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MUCH is now made about appropriate behaviours and being professional.
The health industry has seen the development of many codes of conduct, standards and ethical briefs. The vast majority of the health, medical and surgical workforce adhere closely to these and recognise they have a responsibility not just to the individual patient, but also to serve the broader community as a whole.
Sociologists and experts in behaviour have described the development of the social contract that underpins the obligations that are placed by society on the professions in exchange for many privileges, but particularly for their ability to enjoy autonomy and self-regulate.
Rules or standards are but empty ideals without sanctions. It is easier to spell out the rules by which people should abide but far more difficult and painful for professional organisations to make sure that they are adhered to.
The Royal Australasian College of Surgeons (RACS) has a Code of Conduct that highlights the Pledge that all Fellows make on joining. RACS has done the “nice and easy” bit in writing this Code and updating it. We are now being confronted by the few who breach our code.
RACS has been particularly involved in two parts of our pledge over the past 5 years.
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The first relates to “I will be respectful of my colleagues”. During 2015 RACS has been very involved in a detailed assessment of discrimination, bullying and sexual harassment. An Expert Advisory Group found the problems are substantial and serious. We accepted their recommendations and published an action plan: Building Respect, Improving Patient Safety.
This multi-year initiative will require leadership and cultural change, comprehensive education around discrimination, bullying and sexual harassment, and an approach to complaints management that is transparent and trustworthy. The medical workplace must become a safe workplace for all health workers.
The RACS Council is committed to change and the way forward involves the participation of all Fellows of the College, but also implies that future breaches of the Code of Conduct will be dealt with seriously, in a graded manner to the point of losing the Fellowship.
The other part of the pledge is “I will never allow considerations of financial reward, career advancement or reputation to compromise my judgement or the care I provide”.
Traditionally, RACS has found discussion of fees “too hard” and outside our remit. However, inevitably the charging of inappropriate fees – which has variably been called extortionate, excessive, gouging or rorting the system – is clearly a professional issue. A body such as RACS that aspires to champion standards cannot ignore it, for no doctor should take advantage of the vulnerability of their patients, be they rich or poor.
RACS cannot stand by if members are charging fees that cannot be justified as reasonable, when considered in terms of expertise, resources or time. In a market that is clearly not properly informed or transparent, despite informed financial consent, there is a moral dimension. Professional reputation and surgical standards are at stake. No one should have to seek financial advice, access their superannuation, remortgage their home or resort to crowd funding for a clinically indicated procedure. There is no correlation between the size of fee charged and the quality of the surgery. Most excellent and busy surgeons charge reasonably.
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RACS is also working with a number of insurers and funding bodies to better understand their administrative data sets to enable the provision of clinically relevant feedback to all surgeons.
Reports of high-volume procedures will provide a global view of outcomes such as length of stay, complications and use of intensive care units, but will also show variations in total fees charged or out-of-pocket costs. This will enable individual surgeons to understand their outcomes and fees and to reflect on their own practice.
The greatest change in building respect and being reasonable may be accepting responsibility. Professional bodies need to take the collective responsibility for the behaviour of their members and do this for the benefit of patients and the community.
Professor David Watters, OBE, is President of the RACS. Associate Professor David Hillis is Chief Executive Officer of the RACS.
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The MBS is indexed to rise each year at 2% less than the inflation rate. Therefore if you kept your fees at the MBS rate, after ten years of practice if the work volume stayed the same, you would earn 20% less than when you started.
That is simply unsustainable and is the root cause of the problem.
Unfortuantely, the left leaning members of our profession feel that we should all conform to their self flagellating philosophy. However, I feel that a hard working doctor who has given up the best years of their life to late night study sessions and afterhours work (often unpaid) is entitled to a reasonable and rewarding income.
Ian Hargreaves paints an extremely reasonable view, especially when it relates to complex fracture surgery and all that goes with it. It is probably time for the RACS to indicate what is reasonable and what is unreasonable, and to contribute by acknowledging that fees cover the costs of practice and are not fees direct to the surgeon, rather the surgical business. There are many costs of business, especially in Sydney. Surgeons groups probably haven’t yet highlighted what the effect of the three year freeze on CMBS fees will be for its membership.
The AMA runs a fee schedule that is considered reasonable by its membership, and it would be worth knowing if RACS considers this fees schedule reasonable. If so a clear policy supporting it would help.
By all means encourage market factors to moderate mega-fees. Encourage second opinions. Let patients, and referring GPs, know with confidence that alternates exist. Allow more access to good quality public hospitals and allow more young graduates to be appointed to them. Reduced the numbers of trained surgeons graduating into under-employment and reduce the IMG stream of economic refugees from the NHS and its poor working conditions.
Of course there is a social contract but some of the reasons this has been undermined is worth looking at.
Ian Hargreaves paints an extremely reasonable view, especially when it relates to complex fracture surgery and all that goes with it. It is probably time for the RACS to indicate what is reasonable and what is unreasonable, and to contribute by acknowledging that fees cover the costs of practice and are not fees direct to the surgeon. There are many costs of business, especially in Sydney. Surgeons groups probably haven’t yet highlighted what the effect of the three year freeze on CMBS fees will be for its membership.
The AMA runs a fee schedule that is considered reasonable by its membership, and it would be worth knowing if RACS considers this fees schedule reasonable. If so a clear policy supporting it would help.
By all means encourage market factors to moderate mega-fees. Encourage second opinions. Let patients, and referring GPs, know with confidence that alternates exist. Allow more access to good quality public hospitals and allow more young graduates to be appointed.
I absolutely agree with the comments about doctors having to charge more and more above the MBS fee as it fails to rise with CPI and also the rising costs of education. However, this is not what is being discussed in this article. What is being discussed is people charging 3 to 4 times the AMA fee. I believe that the AMA fee should be used as a guide and specialists charging more than double that should be brought to account.
I do not support the idea of charging fees above those in the AMA list, which I have always believed represent a fair valuation of doctors’ services. But cannot understand how RACS (and others) can comment on fees, without a detailed discussion of the most important factor in the equation – the rebates. It is all very well for people who started their specialist careers in the 1980’s to point out that they charged the “schedule fee” only. Back then the MBS and the AMA fees were pretty much level. But three decades of woefully poor indexation of rebates (and from 2012 to 2018, zero indexation) have made the MBS rebates virtually irrelevant. It is pointless to use the MBS fee as some sort of guide to what should or should not be charged, and the statements we see, along the line of “Dr Bloggs’ fees are x times the MBS”, are useless. In my own specialty (anaesthesia) the MBS fees are less than 25% of AMA, and even with the private insurance contribution it gets up to only about 40%. Each year these figures are lower. People who say I must accept the “schedule” are therefore saying I must accept a pay cut every year. Had there been adequate indexation of rebates, out-of-pockets would be virtually unheard of. These arguments should be put to politicians, bureaucrats, insurers, consumer reps, and most importantly, patients, at every opportunity.
Spot on Ian Hargreaves!
As a recently retired surgeon commented to me last week:
‘My education was free, my College fees affordable, I did no (costly) postgraduate education or skills courses, I was a consultant at 30 and had a successful private practice at 32. Now 68 and retired I had a nearly 40 year career of mixed private and public work always billing patients at scheduled fee. I managed to buy my dream house, send my kids to a dream school… life was pretty good. It’s not the same for you.’
Fast forward and graduates often have hundreds of thousands of dollars in undergraduate and graduate debt, are encouraged by College selection criteria to pursue dreadfully expensive skills courses and postgraduate degrees, pay extortionate College fees ($4000 plus to sit the exam just to be eligible for SET selection) and are trapped in some of the most expensive housing markets in the world. Additionally, ever lengthening training times increase the interest payable on this debt and decrease the years to pay it all off and get ahead.
At the risk of sounding like an ever whinging milennial, (watch out for the ever increasing body of evidence showing just how tough we have it, or simply google Old Economy Steve memes), there is something awfully unsettling about nearly retired surgeons telling young surgeons to charge less.
To a certain degree you reap what you sow and you can’t expect to increase the cost of every measurable aspect of becoming a surgeon, but then control what that surgeon (or any other specialist for that matter) charges.
A family member is having a deep brain stimulation procedure in Brisbane. There is only one centre here where this is performed and I have been told that I will be out of pocket $ 22 – 27,000 dollars, despite being in the highest bracket of my fund (Doctors Health Fund) which pays all in-hospital and implant charges and AMA item number fees.
It is strange that the College would talk about fees, when it does not produce a fee schedule for operations or consultations. However, in recent years my trainees have commented that they have each paid the College over $20,000 in their final year of training. This includes a SET Training Fee of $3275 (the surgeons who do the training do it for free), a Fellowship Examination Fee of $7850 (the surgeons who do the examining do it for free) with a pass rate of a little over 60%, with each subsequent attempt requiring payment at the full rate. Those lucky enough to pass get to pay a Fellowship Entrance Fee of $6105. Given that they are already entered in the College database, it is unclear what “expertise, resources or time” is involved in this, or whether it represents what real estate agents would refer to as “key money”.
The same applies to international medical graduates, who pay a Supervision/Oversight Fee of $7620 ($21,750 if they are ‘remote’), after they have paid a Specialist Assessment Fee of $9405. This contrasts with the fee for fixing a surgeon’s shattered distal radius, including all after-care, filling in of disability insurance company forms, and assessment/certification of his ability to return to work following the injury, AMA fee $1075, Medicare $376.55.
The general public believes that doctors are employed by the government, and that every treatment should be free (consider the furore over the Abbott government attempt at a copayment). At Medicare rates, my current registrar would take 350 new patient consultations in his first year in practice, just to cover the College costs of his final year of training. A race to the bottom will turn ‘6 minute medicine’ into ‘6 minute surgery.’
Congratulations to the RACS for taking a stand on this matter. The excessive charging for surgery often bears little relationship to the skill of the surgeon or the complexity of the surgery. I am particularly saddened to see repeated news reports of men who have been gouged for enormous surgical fees to perform robotic assisted radical prostatectomy and members of the public having to resort to appeals for donations in order to cover the massive fees associated with having urgent surgery for their brain cancers. Is this mainly a Sydney phenomenon?
Because i am a well known retired academc surgeon,I have received many comments and complaints about the “gouging” by some surgeons.Some of the reported fees bear no relationship to the complexity or otherwise of the procedure. Anaesthetists get even more complaints. It is good to see that the College is finally taking action to deal with this metter which is undoubtable harming the reputation and status of all surgeons.
s.
There is an unwritten social covenant between doctors and the population. The sense of it is “that if we look after the population we wil be looked after”. ie., we will be comfortable”. There is a similar unwritten agreement with the clergy of churches and we have all seen the results of that breakdown in trust. Those doctors that have taken advantage of their privelege and rorted our very generous covenant are to blame for the developing mistrust of doctors by our population. I see many doctors, and some are very young, who act like a glutton at a smorgasboard and have an amazing sense of entitlement. I have seen many patients who are insured who have been forced to borrow money to pay outragoeus gaps. Surgeons are not the only ones and many anaesthetists and physicians are guilty of the same overcharging. Our Colleges need to be “socially acountable” and realise that we are there to serve and not to gorge off our community. Patients are not cows to be be milked. If we want Medical Practice to be self regulating our Colleges have to demand ethical and fair behaviour by our practtioners. It is as important as stopping the rorts by some of our unions.