Trust is the magical ingredient in the complex doctor-patient relationship, but where does transparency sit in this? The latest Doctors Drum breakfast turned the spotlight on, well, turning the spotlight on – the profession, the patients and the system of institutions and commercial businesses that surround them as they go about the task of restoring health.
The breakfast was held the day after the Minister for Health Roger Cook announced the establishment of a Sustainable Health Review and much of the discussion spoke to what every clinician hoped from it –efficiency and accountability. To achieve that, a transparent process and a transparent system are necessary.
Corruption or inefficiency?
On the panel was the head of the Corruption and Crime Commission who had just released a report into how a pharmacist working at SCGH and FSH could have stolen and consumed Schedule 8 drugs for a period of years without detection. In his opinion it shouldn’t have happened because all the policies were in place to stop it from happening. The failure was in the non-adherence to the policies.
He also cited the investigation into the Health IT contract that was overrun by $43m.
“This was looked at very carefully and it was found there was no corruption just incompetence and failure to follow policy. In my limited time in the job I have seen far more failures to follow policy than corruption.Health constitutes about half the state budget and in my view of the system in WA it’s pretty inefficient.”
“These are not the first reports. I don’t know what it will take for someone to act on them.”
A question from the floor took up the problem of Medicare fraud which was facilitated by a flawed system and the ineffective way in which Medicare investigates the problem. This was echoed by one of the respondents of our ePoll survey who believed it was a significant problem that even Medicare acknowledged through its own research.
While no one took up the Medicare angle it did open a discussion on what one person described as the flawed medical model how doctors were remunerated.
How much do patients know?
And, asked some, how much do they want to know? In clinical practice how practical is it to be completely transparent?
One doctor put the problem onto timed medicine. “We manage people who are diseased or broken and we have 10 minutes to do it. How can we change what we do? We prescribe antidepressants and after a month less than 50%are taking them…because we didn’t tell the patient enough about their condition and what the medication will do. It is completely opaque and it’s not surprising they come back when the wheels fall off.”
The consumer advocate on the panel said most patients made most all of their decisions in a complete vacuum and information needed to be democratised. She praised Dr Google, as flawed as it was, for going some way to address consumer health literacy.
Another said time was the key and it was the thing most denied GPs who were often left to help their patients navigate through their health decisions.
One GP thought transparency was a double-edged sword in the context of the therapeutic relationship.
“There is a high level of uncertainty in what we do in general practice. Should we communicate that uncertainty to our patients? I think that could be counterproductive. In clinical trials, the placebo is a deception, surely? That is not transparency but we need it because we know that it has an important effect. We also know that about half our patients see people who are not science-based (complementary medicines) and what they offer,as well as a lot of time, is an element of certainty about treatment. It is misplaced, of course, but there is a danger for doctors in this area. Full clinical transparency can undermine the therapeutic effect of treatment.”
A panellist agreed: “Australians march with their feet and you may say it’s patronising, but people enjoy going to complementary practitioners because they get certainty. Placebos are a wonderful thing and something that is very powerful. ‘I will give you a pill and it will make you feel better’ are powerful words from your GP, particularly if you have had a relationship for along time. It is not patronising but very useful.”
“That’s why we can’t have complete transparency because there is some magic and some humanism involved in medicine that we have been using since time immemorial. We are stuck with it and our patients demand it.We need to balance, with the evidence, what we can provide.”
The consumer advocate thought the questions doctors asked needed to change. “Some people want to hand over their power and that’s OK other’s need to understand. If they don’t understand the paradigm and it affects your interaction, then it has to change. We are at the dark end of the spectrum so even a little grey would be great.”
A specialist felt patients wanted leadership from doctors.“You can share uncertainty with a patient in a positive way. Frequently I divide my decision on the page: this is an evidence-based decision but some decisions we make in medicine are not evidence based because there is not an answer to every question. I often say, this is my clinical judgement; this is a risk. We are being asked to manage risk.”
Big call, big bucks?
The roles of the pharmaceutical and medical device industries in influencing clinical decisions became the next subject for hot discussion.
While one doctor thought pharma offered excellent education,many others thought that it didn’t come free.
“The evidence shows that pharma do it for one reason and that’s their bottom line and entirely related to selling their product. More harm is done by that than providing a balanced view of what pharma is going to do.”
Several doctors said a spotlight needed to be shone on device companies. “We have gone from a situation where new devices were studied in a controlled environment, outcomes measured then experts determined whether they were worthwhile. Now devices are developed and the companies create the need. Unsubstantiated claims of cures are put on websites and patients come to us demanding that product,” one said.
“Or they come with absolutely no idea that they are having a device put inside them. They are often completely in the dark and they wear it forever,” said the consumer advocate.
Shifting the responsibility
Over-testing and over-investigating raised concerns about waste and the litigious and defensive environment doctors live in.
While many doctors acknowledged it was a big problem, it is a difficult problem to solve.
“There seems to be a trend away from the basic sciences of history and examination to technological verification of our own insecurities.That’s why we lean towards investigation. You’re right we’re a litigious society. I struggle with the idea that we are going to an all-investigation field but Gen Y tends that way,” said one doctor.
Common sense seems to have lost ground and there is no cost accountability or transparency and this wasn’t confined to medicine. As one doctor pointed out, technology has changed sport and the notion of umpire irrevocably.
However, doctors should back themselves more.
“I have been in practice 30 years and now I can say, ‘I’m not going to do that’ but you have to have experience and clinical nous to back yourself and I know many of our young colleagues struggle to deal with that uncertainty. Uncertainty is the hallmark of general practice. We spend our entire time with uncertainty and it’s only as you get older and wiser that you can say, I’ve got no idea.”
Evidence also found itself on shaky ground. It has been reported in the US that 50% of research doesn’t get published (at a cost of$180b a year globally) if it didn’t produce the right answers for its backers and some disease guidelines were based on the work of panels who were financially conflicted.
Outcomes-based funding model
Everyone expressed dismay at the current funding model for general practice and a few advocated the need to change to outcomes-based reimbursement. It’s introduction, should it happen, could be rocky given, as one doctor suggested, “few of us look at the long-term satisfaction of our patients.” However this seems to be the direction policy is going.
One GP said the model only paid for “doing things” – “that’s why orthopods doing quick operations get paid more than anyone else.” He believed an outcomes model would be “much cheaper and save that huge cost of unnecessary testing and give us time to do the job properly.”
Another said a patient’s outcomes were not just clinical but also about quality. “We have too many perverse incentives.” She raised the interesting point that we needed to know what we were measuring.
The work of the International Consortium of Health Outcome Measures (ICHOM) was raised which is likely to form the basis of some of the reforms being mooted. ICHOM, an NFP backed by Harvard Business School and others, has come up with a combined set of outcomes derived from clinical and patient surveys that looked at a range of issues, from patient satisfaction, quality of life and clinical outcomes of over 100 disease sets.
“It allows you to compare across-the-board treatment. So you might have radiotherapy on your prostate cancer versus radical prostatectomy …you are able to not only determine your clinical measures but also satisfaction. It is disease specific, not treatment specific.”
This 360 degree look at outcomes was welcomed but one sounded a caution that if the government was remunerating on outcomes, there had to be an acknowledgement that many of the factors were outside the control of the doctor.
Outcome-measures were OK, said one doctor, as long as the right ones were being measured. He cited the 4-Hour Rule as a policy that go tit very wrong. “A casualty visit is deemed a success if it lasts less than four hours. No-one measures the patient outcome clinically. It’s a cynical and very expensive game.” Patients were shifted from casualty into the laps of other doctors in the system whether it was appropriate or not and the practice was putting unnecessary strain on an already strained system.
Returning to the ICHOM model … a final note was sounded. “What is different about this set of outcome measures is that patients’ outcomes measures were weighted higher than the physicians’ and ultimately we have to remember that it’s not whether we think we’ve done a good job, it’s whether the patient thinks we have.