Informed, engaged communities for health

Search
Generic filters
Filter by Categories
@WePublicHealth2021
#CroakeyLIVE #Budget2021Health
#MHReform
#OutOfTheBox
#QldVotesHealth
#RCIADIC30Years
#RuralHealthJustice
#ShiftingGearsSummit
#TRIPSwaiver
2021 Floods
Budget2020Health
Bushfires
codesign
community control
COVID-19
Croakey Conference News Service
#2020ResearchExcellence
#21OPCC
#BackToTheFire
#GiantSteps21
#Govern4Health
#HealthReImagined
#HearMe21
#IndigenousClimateJustice21
#NNF2021
#RANZCP2021
#SAHeapsUnfair
#ValueBasedCare
#WCepi2021
#YHFSummit
Croakey Professional Services
#BetterCareCOVID
#CommunityControl
#COVIDthinktank21
#HealthClimateSolutions21
ACSQHC series
Lowitja Indigenous knowledge translation series
Croakey projects
@WePublicHealth
@WePublicHealth2020
#CommunityMatters
#CoveringClimateNow
#CroakeyLIVE #USvotesHealth
#CroakeyREAD
#CroakeyVOICES
#CroakeyYOUTH
#HealthyCOP26
#HousingJusticeAus
#JusticeCOVID
#LookingLocal
#MRFFtransparency
#OutOfPocket
#TalkingTeeth
AroundTheTraps
Caring for the Frontline
COVID SNAPS
COVIDglobalMHseries
Croakey longreads
CroakeyEXPLORE
Gavin Mooney
Inside Story
Journal Watch
PIJ Commissions 2020
Summer Reading 2019-2020
The Conversation
The Health Wrap
TOO MUCH of a Good Thing
CroakeyGO
#CroakeyGO #NavigatingHealth
#GamblingHarms
#HeatwaveHealth
Mapping CroakeyGo
CroakeyNews
Cultural determinants of health
Digital platforms
Elections and budgets
Federal Budget 2019-20
Federal Budget 2020-21
Federal Budget 2021-22
Global health and climate change
2019-20 climate bushfire emergency
asylum seeker and refugee health
Climate emergency
disasters
Ebola
extreme weather events
flooding 2011
global health
NHS
NZ Election 2017
WHO
health
Health workers
Healthcare and health reform
abortion
adverse events
aged care
allied health care
Australian Medical Association
cancer
cardiovascular disease
child health
Choosing Wisely
chronic diseases
co-payments
Cochrane Collaboration
complementary medicines
conflicts of interest
death and dying
diabetes
digital technology
disabilities
e-health
emergency departments and care
Equally Well
euthanasia
evidence-based issues
general practice
genetics
health & medical marketing
health and medical education
health and medical research
Health Care Homes
health ethics
health financing and costs
health reform
health regulation
health workforce
HIV/AIDS
hospitals
HRT
infectious diseases
influenza
international medical graduates
journal articles
LGBTIQ
medical marijuana
Medicare Locals
men's health
mental health
MyHospitals website
National Commission of Audit 2014
National Health Performance Authority
naturopathy
NDIS
NHMRC
non communicable diseases
nurses and nursing
oral health
organ transplants
out of pocket costs
pain
palliative care
paramedics
pathology
Pharmaceutical Benefits Scheme
pharmaceutical industry
pharmacy
Pregnancy and childbirth
primary health care
Primary Health Networks
private health insurance
quality and safety of health care
rural and remote health
screening
sexual health
social media and healthcare
suicide
surgery
swine flu
telehealth
tests
TGA
trauma
women's health
youth health
Indigenous health
#CTG10
#NTRC
Acknowledgement
cultural safety
Indigenous education
Lowitja Institute
NT Intervention
social and emotional wellbeing
Uluru Statement
WA community closures
News about Croakey
PIJ Commissions 2021
Public health and population health
#PreventiveHealthStrategy
#UnmetNeedsinPublicHealth
air pollution
alcohol
consumer health matters
COVIDwrap
environmental health
Fetal Alcohol Spectrum Disorders (FASD)
food and nutrition
gambling
Government 2.0
gun control
health communications
health impact assessment
Health in All Policies
health inequalities
health literacy
human rights
illicit drugs
injuries
legal issues
marriage equality
Media Doctor Australia
media-related issues
nanny state
National Preventive Health Agency
obesity
occupational health
physical activity
plain packaging
prevention
public health
public interest journalism
road safety
sport
sugar tax
tobacco control
transport
vaccination
violence
Web 2.0
weight loss products
Royal Commission
Social determinants of health
discrimination
education
housing
justice
Justice Reinvestment
NBN
Newstart
poverty
racism
social policy
Summer reading 2020-2021
Tasmanian election 2021
The Croakey Archives
#cripcroakey
#HealthEquity16
#HealthMatters
#IHMayDay (all years)
#IHMayDay 2014
#IHMayDay15
#IHMayday16
#IHMayDay17
#IHMayDay18
#LoveRural 2014
Croakey Conference News Service 2013 – 2019
2013 conferences
Australian Centre for Health Services Innovation Forum 2013
Australian Health Promotion Association Conference 2013
Closing the Credibility Gap 2013
CRANAplus Conference 2013
FASD Conference 2013
Health Workforce Australia 2013
International Health Literacy Network Conference 2013
NACCHO Summit 2013
National Rural Health Conference 2013
Oceania EcoHealth Symposium 2013
PHAA conference 2013
2014 conferences
#IPCHIV14
AIDA Conference 2014
Congress Lowitja 2014
CRANAplus conference 2014
Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014
National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
2015 conferences
#CPHCEforum
#CRANAplus15
#HSR15
#NRHC15
#OTCC15
Population Health Congress 2015
2016 conferences
#AHHAsim16
#AHMRC16
#ANROWS2016
#ATSISPEP
#AusCanIndigenousWellness
#cphce2016
#CPHCEforum16
#CRANAplus2016
#IAMRA2016
#LowitjaConf2016
#PreventObesity16
#TowardsRecovery
#VMIAC16
#WearablesCEH
#WICC2016
2017 conferences
#17APCC
#ACEM17
#AIDAconf2017
#BTH20
#CATSINaM17
#ClimateHealthStrategy
#IAHAConf17
#IDS17
#LBQWHC17
#LivingOurWay
#OKtoAskAu
#OTCC2017
#ResearchTranslation17
#TheMHS2017
#VMIACConf17
#WCPH2017
Australian Palliative Care Conference
2018 conferences
#6rrhss
#ACEM18
#AHPA2018
#ATSISPC18
#CPHCE
#MHED18
#NDISMentalHealth
#Nurseforce
#OKToAsk2018
#RANZCOG18
#ResearchIntoPolicy
#VHAawards
#VMIACAwards18
#WISPC18
2019 Conferences
#ACEM19
#CPHCE19
#EquallyWellAust
#GiantSteps19
#HealthAdvocacyWIM
#KTthatWorks
#LowitjaConf2019
#MHAgeing
#NNF2019
#OKtoAsk2019
#RANZCOG19
#RANZCP2019
#ruralhealthconf
#VMIAC2019
#WHOcollabAHPRA
Croakey Professional Services archive
#bettercareseries
#CommunityControl Twitter Festival
ACSQHC series 2019
Croakey projects archive
#IndigenousHealthSummit
#IndigenousNCDs
#JustClimate
#JustJustice
Croakey register of influence
Croakey Register of Influencers in Public Health
Croakey Register of Unreleased Documents
Naked Doctor
Poems of Public Health
Summer Reading 2016-2017
Summer Reading 2017-2018
The Koori Woman
Wonky Health
CroakeyGO archive 2017 – 2018
CroakeyGo 2017
#CroakeyGO Adelaide 2017
#CroakeyGO Melbourne 2017
#CroakeyGO Newcastle 2017
#CroakeyGO Sydney 2017
CroakeyGo 2018
#CroakeyGO #QuantumWords 2018
#CroakeyGO #VicVotes 2018
#CroakeyGO Albury 2018
#CroakeyGO Callan Park 2018
#CroakeyGO Carnarvon 2018
#CroakeyGO Marrickville 2018
#CroakeyGO Palm Island 2018
Elections and Budgets 2013 – 2019
#AusVotesHealth Twitter Festival 2019
#Health4NSW
#HealthElection16
Federal Budget 2009-2010
Federal Budget 2010
Federal Budget 2011
Federal Budget 2012-2013
Federal Budget 2013-14
Federal Budget 2014-15
Federal Budget 2015-16
Federal Budget 2016-17
Federal Budget 2017/18
Federal Budget 2018-19
Federal Election 2010
Federal Election 2013
Federal Election 2016
Federal Election 2019
NSW Election 2015
NSW Election 2019
NT Election 2016
Qld Election 2015
Victorian Election 2014
WA election 2021
Support non-profit public interest journalism
Search
Generic filters
Filter by Categories
@WePublicHealth2021
#CroakeyLIVE #Budget2021Health
#MHReform
#OutOfTheBox
#QldVotesHealth
#RCIADIC30Years
#RuralHealthJustice
#ShiftingGearsSummit
#TRIPSwaiver
2021 Floods
Budget2020Health
Bushfires
codesign
community control
COVID-19
Croakey Conference News Service
#2020ResearchExcellence
#21OPCC
#BackToTheFire
#GiantSteps21
#Govern4Health
#HealthReImagined
#HearMe21
#IndigenousClimateJustice21
#NNF2021
#RANZCP2021
#SAHeapsUnfair
#ValueBasedCare
#WCepi2021
#YHFSummit
Croakey Professional Services
#BetterCareCOVID
#CommunityControl
#COVIDthinktank21
#HealthClimateSolutions21
ACSQHC series
Lowitja Indigenous knowledge translation series
Croakey projects
@WePublicHealth
@WePublicHealth2020
#CommunityMatters
#CoveringClimateNow
#CroakeyLIVE #USvotesHealth
#CroakeyREAD
#CroakeyVOICES
#CroakeyYOUTH
#HealthyCOP26
#HousingJusticeAus
#JusticeCOVID
#LookingLocal
#MRFFtransparency
#OutOfPocket
#TalkingTeeth
AroundTheTraps
Caring for the Frontline
COVID SNAPS
COVIDglobalMHseries
Croakey longreads
CroakeyEXPLORE
Gavin Mooney
Inside Story
Journal Watch
PIJ Commissions 2020
Summer Reading 2019-2020
The Conversation
The Health Wrap
TOO MUCH of a Good Thing
CroakeyGO
#CroakeyGO #NavigatingHealth
#GamblingHarms
#HeatwaveHealth
Mapping CroakeyGo
CroakeyNews
Cultural determinants of health
Digital platforms
Elections and budgets
Federal Budget 2019-20
Federal Budget 2020-21
Federal Budget 2021-22
Global health and climate change
2019-20 climate bushfire emergency
asylum seeker and refugee health
Climate emergency
disasters
Ebola
extreme weather events
flooding 2011
global health
NHS
NZ Election 2017
WHO
health
Health workers
Healthcare and health reform
abortion
adverse events
aged care
allied health care
Australian Medical Association
cancer
cardiovascular disease
child health
Choosing Wisely
chronic diseases
co-payments
Cochrane Collaboration
complementary medicines
conflicts of interest
death and dying
diabetes
digital technology
disabilities
e-health
emergency departments and care
Equally Well
euthanasia
evidence-based issues
general practice
genetics
health & medical marketing
health and medical education
health and medical research
Health Care Homes
health ethics
health financing and costs
health reform
health regulation
health workforce
HIV/AIDS
hospitals
HRT
infectious diseases
influenza
international medical graduates
journal articles
LGBTIQ
medical marijuana
Medicare Locals
men's health
mental health
MyHospitals website
National Commission of Audit 2014
National Health Performance Authority
naturopathy
NDIS
NHMRC
non communicable diseases
nurses and nursing
oral health
organ transplants
out of pocket costs
pain
palliative care
paramedics
pathology
Pharmaceutical Benefits Scheme
pharmaceutical industry
pharmacy
Pregnancy and childbirth
primary health care
Primary Health Networks
private health insurance
quality and safety of health care
rural and remote health
screening
sexual health
social media and healthcare
suicide
surgery
swine flu
telehealth
tests
TGA
trauma
women's health
youth health
Indigenous health
#CTG10
#NTRC
Acknowledgement
cultural safety
Indigenous education
Lowitja Institute
NT Intervention
social and emotional wellbeing
Uluru Statement
WA community closures
News about Croakey
PIJ Commissions 2021
Public health and population health
#PreventiveHealthStrategy
#UnmetNeedsinPublicHealth
air pollution
alcohol
consumer health matters
COVIDwrap
environmental health
Fetal Alcohol Spectrum Disorders (FASD)
food and nutrition
gambling
Government 2.0
gun control
health communications
health impact assessment
Health in All Policies
health inequalities
health literacy
human rights
illicit drugs
injuries
legal issues
marriage equality
Media Doctor Australia
media-related issues
nanny state
National Preventive Health Agency
obesity
occupational health
physical activity
plain packaging
prevention
public health
public interest journalism
road safety
sport
sugar tax
tobacco control
transport
vaccination
violence
Web 2.0
weight loss products
Royal Commission
Social determinants of health
discrimination
education
housing
justice
Justice Reinvestment
NBN
Newstart
poverty
racism
social policy
Summer reading 2020-2021
Tasmanian election 2021
The Croakey Archives
#cripcroakey
#HealthEquity16
#HealthMatters
#IHMayDay (all years)
#IHMayDay 2014
#IHMayDay15
#IHMayday16
#IHMayDay17
#IHMayDay18
#LoveRural 2014
Croakey Conference News Service 2013 – 2019
2013 conferences
Australian Centre for Health Services Innovation Forum 2013
Australian Health Promotion Association Conference 2013
Closing the Credibility Gap 2013
CRANAplus Conference 2013
FASD Conference 2013
Health Workforce Australia 2013
International Health Literacy Network Conference 2013
NACCHO Summit 2013
National Rural Health Conference 2013
Oceania EcoHealth Symposium 2013
PHAA conference 2013
2014 conferences
#IPCHIV14
AIDA Conference 2014
Congress Lowitja 2014
CRANAplus conference 2014
Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014
National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
2015 conferences
#CPHCEforum
#CRANAplus15
#HSR15
#NRHC15
#OTCC15
Population Health Congress 2015
2016 conferences
#AHHAsim16
#AHMRC16
#ANROWS2016
#ATSISPEP
#AusCanIndigenousWellness
#cphce2016
#CPHCEforum16
#CRANAplus2016
#IAMRA2016
#LowitjaConf2016
#PreventObesity16
#TowardsRecovery
#VMIAC16
#WearablesCEH
#WICC2016
2017 conferences
#17APCC
#ACEM17
#AIDAconf2017
#BTH20
#CATSINaM17
#ClimateHealthStrategy
#IAHAConf17
#IDS17
#LBQWHC17
#LivingOurWay
#OKtoAskAu
#OTCC2017
#ResearchTranslation17
#TheMHS2017
#VMIACConf17
#WCPH2017
Australian Palliative Care Conference
2018 conferences
#6rrhss
#ACEM18
#AHPA2018
#ATSISPC18
#CPHCE
#MHED18
#NDISMentalHealth
#Nurseforce
#OKToAsk2018
#RANZCOG18
#ResearchIntoPolicy
#VHAawards
#VMIACAwards18
#WISPC18
2019 Conferences
#ACEM19
#CPHCE19
#EquallyWellAust
#GiantSteps19
#HealthAdvocacyWIM
#KTthatWorks
#LowitjaConf2019
#MHAgeing
#NNF2019
#OKtoAsk2019
#RANZCOG19
#RANZCP2019
#ruralhealthconf
#VMIAC2019
#WHOcollabAHPRA
Croakey Professional Services archive
#bettercareseries
#CommunityControl Twitter Festival
ACSQHC series 2019
Croakey projects archive
#IndigenousHealthSummit
#IndigenousNCDs
#JustClimate
#JustJustice
Croakey register of influence
Croakey Register of Influencers in Public Health
Croakey Register of Unreleased Documents
Naked Doctor
Poems of Public Health
Summer Reading 2016-2017
Summer Reading 2017-2018
The Koori Woman
Wonky Health
CroakeyGO archive 2017 – 2018
CroakeyGo 2017
#CroakeyGO Adelaide 2017
#CroakeyGO Melbourne 2017
#CroakeyGO Newcastle 2017
#CroakeyGO Sydney 2017
CroakeyGo 2018
#CroakeyGO #QuantumWords 2018
#CroakeyGO #VicVotes 2018
#CroakeyGO Albury 2018
#CroakeyGO Callan Park 2018
#CroakeyGO Carnarvon 2018
#CroakeyGO Marrickville 2018
#CroakeyGO Palm Island 2018
Elections and Budgets 2013 – 2019
#AusVotesHealth Twitter Festival 2019
#Health4NSW
#HealthElection16
Federal Budget 2009-2010
Federal Budget 2010
Federal Budget 2011
Federal Budget 2012-2013
Federal Budget 2013-14
Federal Budget 2014-15
Federal Budget 2015-16
Federal Budget 2016-17
Federal Budget 2017/18
Federal Budget 2018-19
Federal Election 2010
Federal Election 2013
Federal Election 2016
Federal Election 2019
NSW Election 2015
NSW Election 2019
NT Election 2016
Qld Election 2015
Victorian Election 2014
WA election 2021

Does the AMA really want to put clinicians in an “ethically invidious and untenable position”?

Health economist, Professor Gavin Mooney, writes:

The AMA recently came out in criticism of the government’s plans on the proposed membership of Lead Clinician Groups. It is fair enough that Dr Andrew Pesce, the AMA President, sticks up for his membership on that front. Here I do not want to get into a debate about turf wars between different clinical groups.

Where I do get concerned, however, is when Dr Pesce gets into questions around the roles for clinical doctors with respect to efficiency and equity. He states: ‘Specifically, doctors should be involved in decision-making about funding for infrastructure, staffing and training within their hospital to ensure it is allocated efficiently and equitably.’

It is an issue that was returned to by Adam Cresswell recently in the Weekend Australian.

But before getting into the question of the rights and wrongs of doctor involvement in issues of efficiency and equity, let me muse on defining these terms – and perhaps challenge Dr Pesce also to muse on them.

To me, as an economist, efficiency is about value for money. Is this use of scarce resources on this group of patients in this hospital better than using the resources on this other group of patients in the hospital? If it is, then it is “more efficient”.

Of course there are value judgments involved in judging “better”. Answering the question of whether within a hospital $X is better spent on 5 heart transplants (largely length of life health improvements) or 100 hip replacements (largely quality of life improvements) cannot be done without using value judgments. Certainly these also involve judgments about medical effectiveness and clinicians’ technical judgments are needed on such effectiveness.

Beyond that, the value judgements in weighing up the benefits of these different options are not for clinicians. The question becomes: after we hear from the doctors about the health improvements from these two options – in other words their effectiveness – which of the two provides the greater benefits, which is better?

This judgment, this value judgment, is not for doctors to make. It is a social value judgment.

Equity is about fairness. But it is a social concern and in the end just how to define fairness has to rest with society at large. It might be seen in terms, for example, of equal access for equal need or of equal health. It might incorporate simply treating equals equally or it might have concerns for positive discrimination.

Now how many medical clinicians are trained in such matters? Some public health doctors are – but hospital clinicians? No. These clinicians can advise on the effectiveness of care – how much health improvement will be delivered – and I would defend to the death their right to do so.

But efficiency? No.

Equity? Again not clinicians’ territory. Certainly the policy on the equitable use of hospital resources is something that clinicians will have to be involved in implementing. Defining and designing what is meant by equity? No.

There are three issues here. First there is the question of competence. Medical clinicians are not trained in such matters. Secondly there is the question of what might best be termed “social legitimacy”. The values medical clinicians bring to judgments about efficiency and equity are only relevant in so far as they reflect the values of the community. (They might – but why not go to the community directly?)

Thirdly, and in some ways most worrying to me as a potential patient (and I would guess most worrying to Dr Pesce), is the ethical issue. When I am seeing Dr Chua about (say) my prostate, I want Dr Chua to be concerned only about me (although I accept that he or she will have a concern for the patients whom he or she might be keeping waiting). In economics jargon Dr Chua can rightly (I believe) be left to judge the “opportunity cost” – the benefit foregone – in treating me as compared with treating his or her other patients.

What I do not want is for Dr Chua to be asked to form judgments about the relative values of treating my prostate versus Fernando Smith’s melanoma or Jeannie Artells’ psychosis. There is or I believe ought to be a limit on how widely a medical clinician – indeed any clinician – should be asked to see and interpret “opportunity cost”.

It is in my view simply not fair to ask a clinician to be an advocate not only for their patients but also for society or even the hospital as a whole. It is not fair on them and it is not fair on their patients.

Yet asking medical clinicians – as Dr Pesce seemingly wants – to be involved in advising not just on effectiveness of care but ‘efficient and equitable use of hospital resources’ is, I would submit, putting them in this ethically invidious and untenable position.

I’d prefer not to do that, and I’d prefer that when my doc is treating me, he or she has to worry only about his or her patients (including me!), and not also about society’s resource use – and that he or she sticks to what he or she is trained to do.

Comments 8

  1. Murf says:

    Contrary to your stance on doctors and knowledge of resource use, I would be very happy if my doctor had the economic consequences of treatment at the back of her mind! Although I am only a student of public health at the moment I can see that all the small decisions by individual doctors can have a huge effect on particular sectors of the health budget – the biggest chunk in Australia’s federal budget. There are formulae for estimating the relative efficiency and opportunity costs of various actions [see http://www.appliedeconomics.com.au/pubs/papers/pa03_health.htm%5D, so that individual value judgments are not forced to surface and to genuinely guide decision-making. Although I find some of the conventional “values” unpalatable, their application would allow at least hospital funding to go to the patients [& their doctors] most likely to get the most life “mileage”. At the moment we have some groups of surgeons and physicians who are “fans” of particular treatments which aren’t necessarily based on outcomes or economic equity for patients. For example, a group of cardiac surgeons at a hospital develop a [expensive] technique which they find can save very old patients from death or major disability, so they use it more. By applying their expertise and the hospital’s resources in this way they are depriving middle-aged patients of an equally good procedure which would give these guys a much better pay-off in length and quality of life. The real crunch comes when you try to persuade a cardiac surgeon to become a “champion” for the procedure on the younger men vs. the old guys. I’d like to see the economic considerations play far more of a role in medical decision-making than they do currently, but IN THE BACKGROUND. Individual patients shouldn’t have to argue their cases.

  2. ihaywood says:

    It’s true top-level ‘macro’ funding resources require balancing different sectors and doctors aren’t particularly good at that, everyone wants to advocate for their own sector.
    But the reverse is true: bureaucrats are very bad at ‘micro’ decisions around clinical care of individual patients, unfortunately this doesn’t seem inhibit them.

  3. Andrew Pesce says:

    Thanks Gavin, this is a very articulate presentation of your perspective. Now perhaps I might put mine.

    You refer to an unbearable burden of responsibility that doctors are asking for when lobbying strongly for a role in participation in the management decision making processes in the hospitals where they work. I agree that it is a heavy burden we are contemplating but I can suggest some existing ones which are even heavier.

    It is the burden of a doctor given the responsibility to care for his/her patients, but with no authority to make any real decision in the hospital processes which control his/her ability to deliver that care.

    It is the burden of doctors being told they must implement decisions made by people they have never met, who have never been seen in the departments, wards and clinics where they care for their patients. Those people who – by the way, Gavin – have no more training in the ethics of equitable use of health care resources than doctors, and certainly don’t have the direct experience to appreciate the immediate let alone distant consequences of their decisions. They certainly aren’t any more likely than doctors to objectively assess the efficiency of closing outpatient clinics or cutting hospital operating lists whist employing more administrative staff not directly involved in patient care.

    It is the burden of internal conflict visited upon complex organisations, where those who actually have to deliver the services are excluded from governance structures, and who consequently are more likely to undermine attempts to impose top down decisions rather than, by having some sense of input and ownership of those decisions, commit to implementing them.

    The AMA has not said doctors should make the decisions in hospitals by themselves. It acknowledges the need for managers and financial officers to impose necessary disciplines on our hospitals. But the corporate and clinical governance structures MUST have hard wired mechanisms for doctors, nurses and other health professionals providing the clinical care in our hospitals to also have real input into their hospitals’ decision making processes. Lead Clinician Groups offer an opportunity not for doctors to control the hospitals, but for them to take their rightful place at the decision making table from which they have been increasingly excluded to the detriment of the public hospital system.

    Only then might all of us who are committed to public hospital care contribute to the challenges we must face of providing equitable access to quality care for all Australians, other than by just turning up to work.

    Andrew Pesce
    President, Australian Medical Association

  4. rhwombat says:

    Well put, Andrew.

    It’s a little hard to accept generalised accusations of incompetence in ethics or understanding on the part of we clinicians (many of whom are not only capable of understanding the finer points of both, but have spent a working lifetime implementing them) from a member of a craft group (economics) with a somewhat chequered history of the same qualities (the group, not the member). We don’t just look after one patient (despite Gavin Mooney’s fantasy of being the the sole focus of our skills) – we (and, in the Public Hospital System, it is always several clinicians working together, never a single unsupported person) look after many, simultaneously: how is that different from having the knowledge, skills and compassion to see where we should put our collective efforts across several overlapping systems?

    To reverse the charge, what gives a non-clinical Health Economist the right to exclude the clinicians from the process? Gavin Mooney seems to argue for exclusion of those of us who are ready, willing and (perhaps, disconcertingly) able to get involved in more than the individual patient in front of us. I know it is disconcerting for an economist to consider values and benefits other than the financial, but it probably behoves a member of one craft group not to disparage the input of others who have always had a large stake in the equitable and efficient delivery of health care in hospitals with full cognisance of their competency and ethical concerns. I’m reminded of the Monty Python skit (written, BTW by Graham Chapman MBBCh) about the machine that goes Ping!, and plaintive question of “what do I do?” from the patient in labour. The response (from Chapman) was: “Nothing, dear – you’re not qualified!”. Ping.

    Richard Lawrence MBBS PhD FRACP.

  5. Gavin Mooney says:

    Thanks Andrew for your very full, reasoned and eloquent response. Three things. First I believe these issues need to be debated much more than they currently are. By implication you would seem to agree. Second the fact that the AMA National President is willing to debate them (semi) publicly on Croakey is delightful. We need more voices to enter this debate however.
    Lastly I did not mean to imply (and I certainly do not believe) that doctors should be excluded from either valuing or deciding. But the issue for me remains: with respect to what? So the questions of ‘whose values on what?’ and ‘who is to decide on what?’ need more debate – and resolution.

    PS to Dr Lawrence
    First can I gently ask you please to read what I wrote? Secondly you might like to take a leaf out of Dr Pesce’s book in how – in a reasoned and eloquent way – to debate such issues.

  6. Andrew Pesce says:

    Thanks Gavin. I also wonder whether you have read the AMA submission to the DOHA consultation paper on Lead Clinician Groups(LCGs) or are commenting on media reports. Our submission can be found at
    http://ama.com.au/node/6424
    You will see there that our view is not that doctors assume a management role, rather to incorporate a meaningful role in the governance structures for doctors and other health professionals. It specifically suggests that LCGs will provide advice to hospital management and Local Governing Councils. After consideration, that advice may be accepted or not accepted, and the whole process should be made available to the public and hospital staff by appropriate communication including the LHN intranet and public website.
    I hope you and other readers will appreciate this is a considered attempt to redress the imbalances I referred to in my original response to your paper

    Andrew Pesce

  7. rhwombat says:

    Professor Mooney,

    Thank you for taking the time to post on this topic, and to respond to comments. I did indeed read what you wrote, together with Andrew’s eloquent (and I suspect unexpected) reply, which prompted me to respond, publicly and identifiably (which is not without risk), because your post seemed (perhaps intentionally) provocative – in a public forum with the capacity for feedback. What I take from your initial post is that you object to Andrew’s public comments on the proposed membership of Lead Clinician Groups, on the grounds that clinicians lack appropriate training, competence or judgement in community values, the “definition” and determination of efficiency and equity, and ultimately, the ethics of allocation of limited clinical resources. To quote: “Yet asking medical clinicians – as Dr Pesce seemingly wants – to be involved in advising not just on effectiveness of care but ‘efficient and equitable use of hospital resources’ is, I would submit, putting them in this ethically invidious and untenable position”. You seem to me to argue fairly vehemently for exclusion of clinicians from resource allocation decisions because they are not health economists. In your response to Andrew’s reply you seem to repudiate yourself fairly comprehensively. You are less gracious in your response to my “voice entering the debate”.

    Despite your claim about not wanting to get into a “turf war between different clinical groups” (…by which I suspect you mean professional, as in economists vs clinicians), the bones of your comments seem to be just that: we clinicians should keep out of what you see as your turf – value, efficiency, equity and ethics, because we are not trained for it. Furthermore, you see some ethical dilemma in clinicians being involved. On the contrary, I suspect that most of us who practice in hospitals (or other large cooperative health care organisations) have far more grounding and experience in these areas than the average economist. I wasn’t aware of Ethics and Public Health (including specific teaching in Statistics and Health Economics) being essential subjects for a degree in Economics: they are for Medicine. Ongoing, reflective professional education (including ethics) is mandatory for clinicians: I’m not aware of that being the case for economists. Many of us have been active in professional bodies (like the RACP and AMA) with specific resource allocation perspectives at local, state and national levels for many years. Decisions about resource allocation and access to limited resources are our daily experience, and we get quite good at it: Who gets theatre time, and for what? Are we going to dialyse this 41 year old “developmentally delayed” woman with diabetes? How can we help the 190kg diabetic with respiratory failure? Can we circumvent the 10 week “queue” for chemotherapy for this 39 year woman with 2 young kids and lung cancer – and which service are we going to defund to get the chemotherapy waiting time below 10 weeks? These are real situations, involving real people, and we clinicians make similar decisions with profound consequences daily, without the benefit of a health economist’s lordly objectivity.

    In fact I suspect that the issue of objectivity is the elephant in the room here. Perhaps you really do think that acting as a remote and unapproachable authority, capable of stark, impartial utilitarianism, on whom can be blamed the economically unimpeachable decision to withhold limited resource, thus sparing the noble clinician and (probably more importantly) the bureaucrats and politicians who may have to face public blowback. In reality, we clinicians have to communicate those decisions to the individual patient (or consumer if we are to keep to econospeak) anyway, and, as pointed out, have well developed ways of doing so.

    The other end of the elephant is the tradition of domineering clinicians (particularly, but not exclusively, from some of the surgical tribes), who obstinately insist that what’s good for them must be good for everybody. We acknowledge (and, usually, try to avoid being) them, but have also had more experience in effectively dealing with such beasts on a personal level than your average bureaucrat (or health economist). Granted that we clinicians must prove that we are not wreckers, but please also acknowledge that resource allocation is a political as well as a quasi-rational process.

    In summary, to reject the interest and experience of clinicians offering to try to help resolve some of the thorny issues of health budget allocation on the grounds of saving us from ourselves seems to me both churlish and counterproductive. Is that “reasoned and eloquent” enough debate for you?

    Richard Lawrence

  8. ianhargreaves says:

    One thing clinicians have to do is explain complex issues to people from all walks of life.

    Take this simple analogy. Prof Mooney, due to your economic expertise in making value judgements about equity, efficiency, and effectiveness, you are appointed to the Australian Astronomical Review Board, to allocate funding for our new federal telescope.

    Astronomers are like doctors – each a professional with fervently-held beliefs and opinions.

    The Board asks astronomers to advise and give technical judgements on effectiveness.

    One group insists on Cassegrain optics. One group prefers Coude. Some advise a single telescope of maximum size to see further, but others see wisdom in getting two smaller telescopes to observe two areas simultaneously. One submission says the money would be better spent on a radio-telescope for quasar studies, while another advocates not building anything, but using the budget to buy time on the Hubble telescope.

    The Australian Astronomical Association president Dr Escep says: “Specifically, astronomers should be involved in decision-making about funding for infrastructure, staffing and training within their observatory to ensure it is allocated efficiently and equitably.”

    Now, place your hand over your heart, (and your other hand over your styloid process) and say that you want no involvement from astronomers: “Yet asking astronomers – as Dr Escep seemingly wants – to be involved in advising not just on effectiveness of observation but ‘efficient and equitable use of observatory resources’ is, I would submit, putting them in this ethically invidious and untenable position.”

    Furthermore, your preference would be, as I understand it from the article, to have no astronomer on the Board itself.

    To put it another way, you would recommend the spending of millions (or billions) of dollars of taxpayers’ money to buy equipment and employ professionals, and not one person on the board making the decision has ever personally used any comparable equipment, or has any personal experience in understanding the arcane terminology used in the professional submissions. How will you find NGC 1301, or even your own styloid process?

    The real answer lies hidden in your original post: “It is a social value judgment.”

    The people most skilled at judging would probably be neither economists nor clinicians, but judges. There is already an Equity Division of the NSW Supreme Court, and it would be preferable for a judge to take submissions from all parties, then make a judgement based on the laws made by the people’s elected representatives. The process could be simpler if inquisitorial rather than adversarial.

    Politicians may well campaign on specific health issues – funding for the Royal Hobart Hospital cost the ALP its majority at the last election – and pass specific enabling legislation, eg the UK government legislated specifically on waiting times for outpatient visits and treatment. This allows more transparency as I can think of no better individual or committee than the electorate as a whole, and the elected MPs, to prioritize hip replacements or heart transplants. An experienced equity judge would resolve the inevitable conflicts.

    The salary of a judge is trivial compared to the cost of a non-clinician committee’s buying a CT scanner that doesn’t work because it is cheaper (my hospital did that), or designing a new building without access to wheel a bed to the old building, to get to the X-Ray department or a lecture theatre (two of my hospitals did that).

    Alternatively, if the frugal NSW government wants to save money, your post alludes to a cheaper yet equally satisfactory option. In demonstrating how easy it is to make complex value judgements, for even ordinary people who juggle work and family lives without formal ethics or economics training, consider Dr Chua’s workday.

    As he arrives at his surgery, his motherly receptionist says: “Mr Smith thinks he may have another melanoma, so I’ve squeezed him in for 2:45. Mr Artells is worried his wife may be suicidal.” Dr Chua nods gravely: “And who’s that on the phone?” “An economist with a prostate problem – I’ll book him for Thursday week. Here’s your bag and the Artells’ address. I’ll have a strong coffee and a full but placated waiting room for you when you get back.”

    $30 an hour.

    Employ that mother.

Leave a Reply to ihaywood Cancel reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Search by: Categories or tags

Search
Generic filters
Filter by Categories
@WePublicHealth2021
#CroakeyLIVE #Budget2021Health
#MHReform
#OutOfTheBox
#QldVotesHealth
#RCIADIC30Years
#RuralHealthJustice
#ShiftingGearsSummit
#TRIPSwaiver
2021 Floods
Budget2020Health
Bushfires
codesign
community control
COVID-19
Croakey Conference News Service
#2020ResearchExcellence
#21OPCC
#BackToTheFire
#GiantSteps21
#Govern4Health
#HealthReImagined
#HearMe21
#IndigenousClimateJustice21
#NNF2021
#RANZCP2021
#SAHeapsUnfair
#ValueBasedCare
#WCepi2021
#YHFSummit
Croakey Professional Services
#BetterCareCOVID
#CommunityControl
#COVIDthinktank21
#HealthClimateSolutions21
ACSQHC series
Healthdirect Australia series 2019
Lowitja Indigenous knowledge translation series
Croakey projects
@WePublicHealth
@WePublicHealth2020
#CommunityMatters
#CoveringClimateNow
#CroakeyLIVE #USvotesHealth
#CroakeyREAD
#CroakeyVOICES
#CroakeyYOUTH
#HealthyCOP26
#HousingJusticeAus
#JusticeCOVID
#LookingLocal
#MRFFtransparency
#OutOfPocket
#TalkingTeeth
AroundTheTraps
Caring for the Frontline
COVID SNAPS
COVIDglobalMHseries
Croakey longreads
CroakeyEXPLORE
Gavin Mooney
Inside Story
Journal Watch
PIJ Commissions 2020
Summer Reading 2019-2020
The Conversation
The Health Wrap
TOO MUCH of a Good Thing
CroakeyGO
#CroakeyGO #NavigatingHealth
#GamblingHarms
#HeatwaveHealth
Mapping CroakeyGo
CroakeyNews
Cultural determinants of health
Digital platforms
Elections and budgets
Federal Budget 2019-20
Federal Budget 2020-21
Federal Budget 2021-22
Global health and climate change
2019-20 climate bushfire emergency
asylum seeker and refugee health
Climate emergency
disasters
Ebola
extreme weather events
flooding 2011
global health
NHS
NZ Election 2017
WHO
health
Health workers
Healthcare and health reform
abortion
adverse events
aged care
allied health care
Australian Medical Association
cancer
cardiovascular disease
child health
Choosing Wisely
chronic diseases
co-payments
Cochrane Collaboration
complementary medicines
conflicts of interest
death and dying
diabetes
digital technology
disabilities
e-health
emergency departments and care
Equally Well
euthanasia
evidence-based issues
general practice
genetics
health & medical marketing
health and medical education
health and medical research
Health Care Homes
health ethics
health financing and costs
health reform
health regulation
health workforce
HIV/AIDS
hospitals
HRT
infectious diseases
influenza
international medical graduates
journal articles
LGBTIQ
medical marijuana
Medicare Locals
men's health
mental health
MyHospitals website
National Commission of Audit 2014
National Health Performance Authority
naturopathy
NDIS
NHMRC
non communicable diseases
nurses and nursing
oral health
organ transplants
out of pocket costs
pain
palliative care
paramedics
pathology
Pharmaceutical Benefits Scheme
pharmaceutical industry
pharmacy
Pregnancy and childbirth
primary health care
Primary Health Networks
private health insurance
quality and safety of health care
rural and remote health
screening
sexual health
social media and healthcare
suicide
surgery
swine flu
telehealth
tests
TGA
trauma
women's health
youth health
Indigenous health
#CTG10
#NTRC
Acknowledgement
cultural safety
Indigenous education
Lowitja Institute
NT Intervention
social and emotional wellbeing
Uluru Statement
WA community closures
News about Croakey
PIJ Commissions 2021
Public health and population health
#PreventiveHealthStrategy
#UnmetNeedsinPublicHealth
air pollution
alcohol
consumer health matters
COVIDwrap
environmental health
Fetal Alcohol Spectrum Disorders (FASD)
food and nutrition
gambling
Government 2.0
gun control
health communications
health impact assessment
Health in All Policies
health inequalities
health literacy
human rights
illicit drugs
injuries
legal issues
marriage equality
Media Doctor Australia
media-related issues
nanny state
National Preventive Health Agency
obesity
occupational health
physical activity
plain packaging
prevention
public health
public interest journalism
road safety
sport
sugar tax
tobacco control
transport
vaccination
violence
Web 2.0
weight loss products
Royal Commission
Social determinants of health
discrimination
education
housing
justice
Justice Reinvestment
NBN
Newstart
poverty
racism
social policy
Summer reading 2020-2021
Tasmanian election 2021
Testing Croakey News category 1
The Croakey Archives
#cripcroakey
#HealthEquity16
#HealthMatters
#IHMayDay (all years)
#IHMayDay 2014
#IHMayDay15
#IHMayday16
#IHMayDay17
#IHMayDay18
#LoveRural 2014