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ONE of the challenges for my specialty of emergency medicine, and for medical specialties generally, is how to avoid being too insular.
It’s a topic I raised late last year in a speech to a meeting of the Australasian College for Emergency Medicine (ACEM).
An organisation set up by and for Fellows with responsibility to maintain specialty standards and the training and assessment of future Fellows appropriately has a focus on its own Fellows, but it is also important to remember the role we play in the community at large.
In providing a service to the community, we need to understand what the community needs. In the past, deciding on these needs tended to be based on Fellows or members bringing their own understanding and experience to inform how the organisation responded.
Increasingly, though, this is seen as inadequate and even wrong. In particular, there is the risk of trying to align the organisation’s interpretation of what the community needs with the organisation’s (or particularly its members’) goals.
I would argue that it needs to be the other way around, whereby the organisation bases its goals on what the community needs. This requires medical organisations to be more outward-looking. One way to do that is to engage the community at large in the organisation’s decision-making processes.
All colleges now have some form of formal engagement with their trainees, and in many cases have trainees represented on almost all their committees. My challenge to ACEM, and to all specialist colleges and other medical organisations, is to have a similar level of engagement with health consumers, and the community in general.
Some organisations already do this well. I have been particularly impressed with the way the Australian Medical Council has done this for a number of years, with health consumer members on many of its committees, and even on accreditation teams for specialist colleges and medical schools.
In my experience input from consumer members is both invaluable and often a useful counter to the insularity often observed in medical organisations. For example, we often concentrate on the technical aspects of how a skill is obtained, whereas the community’s concern is rather that the skill is available and is used appropriately.
However, there are concerns and difficulties expressed about how to make this work.
One concern regularly raised is that health consumers don’t have the expertise to understand the technical aspects of a medical specialty or the training of specialists. Yet the point is that they are being included precisely because they are not medical experts. Their role is to bring their own understanding of the community’s health needs and experience, something that we as doctors have a tendency to exaggerate based on our own expertise
Sometimes there is uncertainty as to where to find a suitable and relevant group of health consumers to engage with. This is particularly the case for specialties such as critical care which, by their nature, do not form long-term relationships patients. Nonetheless, it is worth seeking out organisations and individuals who are willing to engage.
Another concern is that the engagement will be dominated by a person’s personal experience or biases. This is a risk for health consumers and doctors alike. It can be an opportunity to resolve an issue or to bring a shared understanding on both sides, and should not be an excuse to not engage.
I hope specialist colleges and all medical organisations will make community engagement a priority, as I can only see benefits both to the organisation and the community in general.
Associate Professor Andrew Singer is the principal medical adviser to Acute Care and Health Workforce Divisions, Department of Health, Australian Government, an adjunct associate professor at the Australian National University Medical School, and a senior specialist in emergency and retrieval medicine at Canberra Hospital and Health Services.
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Increases in medical specialisation have evolved in line with ever-increasing advances in medicine, science & technology. Doctors have taken advantage of these leaps in knowledge by undertaking to be the best they can be through increasing medical knowledge.
Patients have kept pace too though, and can help make healthcare safer, cheaper & more accessible.
Patients don’t specialise. We’re right across an organisation. We know the ripple effects that will result from treatment decisions. We know that Dept A has a waiting list that we’ll now need to get on, we know that Dept B requires Dept A be seen within x amount of weeks. We know that Pharmacy can only supply the meds you’ve prescribed in 2 wk lots, but we’re going away for 4 wks. We know which clinics consistently run late & we also often know why. We know that the Equip Dept closes early on Fri so we can’t get the equipment you’ve prescribed in time to meet Discharge. Hello, you’ve now got us for the whole weekend. We know your ward hand hygiene rates are good – but do a survey of your outpatients clinics, you may be surprised. We know why you have to call security services a lot. We know how you can fix that. We know that often what is a priority from a health perspective needs to come second to quality of life.
In addition to having a pulse, we’ve also worked in engineering, safety, research, admin, strategy, media, facility mgmt, IT, customer service, fund raising, education, policy devt, HR, Trades, Finance & Communications. We’re also patient families.
History shows we only advance when we are driven to doing so. Consumers aren’t just your patients, they’re the answer to smarter healthcare.
I agree with Leviathan and David De Leacy. The appropriate response to your feelings of “alienation”; is to introduce a rotation into general medical practice as an essential part of FACEM ongoing training, to keep FACEM specialists in touch with patients’ needs, goals and wants, the values-based side of medical treatment, management and engagement. Similarly, those on the AMC or Boards ought also engage in community service and peer review while on these Boards/Committees in order to ensure relevance of their engagement. “Open engagement” recognises that as doctors we are advocates for our patients’ rights and wishes. We do not need committees, that are not “open” but “closed” and act generally and at arms length, which does not serve the public interest, but which as you infer, serves self interest, to do this for us or oversee us. It is the “doctor-patient relationship” that needs to be valued. Combined efforts are needed to promote open engagement, which is mutual and based on integrity and trust, without agenda or self-interest, and which is open to independent, objective and prospective evaluation and assessment.
Hi Andrew, may I take a somewhat wider iconoclastic view about what you undoubtedly profess in good faith? There really has been massive exercise in poltically correct group think in western culture over the last few decades. Specialist College Committees by definition express their own ‘group think’; surely that is their whole reason d’etre. I ask the quetion at the end of the day, aren’t we all fully functioning members of the wider community with much the same cross section of personalities, strengths, weaknesses, family types, ‘internet access’ and personal proclivites for good and bad. Selecting an outside individual for a specialist committee whose only real qualifiation (apart from a pulse) seems to be a propensity for sitting on a committees is surely just another exercise in forelock tugging tokenism so as to appease the left of politics. If so, we should it least have the honesty to state this openly.By the way the guild wars have long been lost (apart from the legal fraternity who are apparently immune from public scrutiny by fiat). Exactly what real and objective evidence can you provide in terms of outcomes to support your argument and to assuage my natural reticence in agreeing to expand the size of any damn committee ?
Thanks for the article, Andrew. IN the specialty we share, I believe our funders and regulators are pressing us to do the OPPOSITE of what the community wants. Emergency Departments seem to be victims of our own success, but stuck in the perpetual federal-state funding split. We provide a service that patients want to use and community practitioners want to refer to, and yet we are constantly pushed to try to ”limit demand”. In most other specialties, demand is a measure of success. We provide the services, tests, procedures, second opinions and reassurance that patients want, and yet we are seen as providing ”inappropropriate” care. The community values the service we provide – we should not be forced into the paradox of providing our service safely, quickly and thoroughly, as the community wants, but somehow discouraging people from accessing it.
I believe we are too eager to pander to pressure groups and this sends the message that we do not have an understanding of our patient’s needs. Nothing could be further from the truth. Clinical doctors engage many times per day directly with patients and nobody can be a better advocate for the medical needs of our community than those who hear every single day directly from those with that need.
Our colleges are not the board of a corporation which of necessity seeks the views of lay investors. I have served at meetings and watched the well meaning “community representative” completely bamboozled by the poroceedings because they simply don’t understand what it’s about. They are often startled when asked for an opinion. Seeking the input of someone whose only qualification is that they must be ignorant, given the only opinion they are likely to bring is based on their very limited personal experience, is of absolutely no use in formulating policy and it is patronization at its worst. “Avoiding being too insular” may be a problem when a committee is composed purely of non-clinical academics, but if clinicians are heavily represented it is unfathomable how the community’s needs can be ignored.