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THE ROLE OF DOCTORS* IN HEALTH SERVICES PLANNING AND MANAGEMENT:ALTRUISM, EXPERTISE AND LACK OF ENGAGEMENT AS PERCEPTUAL DISORDERS

The following comes from Enrico Brik an anonymous self-employed consultant and sometime writer and blogger who has worked for over a decade in various roles in health services policy and planning.

“The name and pretence of virtue is as to self-interest as are real vices.” Francois de La Rochefoucauld

On 20 July 2011 Dr Steve Hambleton, a Brisbane general practitioner and President of the Australian Medical Association (AMA), gave a speech to the National Press Club in Canberra on Fixing Health.

In that speech he said, ‘Evidence shows that where doctors run the management of hospitals, results improve and morale is better’, and added that, ‘if (deeds and actions) are bad for doctors, then they will be bad for patients and bad for our health system’.

In a speech to the AMA Parliamentary Dinner on 17 August 2011, Dr Hambleton reiterated his views and added that, ‘You cannot improve the health system by ignoring the opinions and advice of doctors’…‘(doctors) have the knowledge and experience to make the system work better’, and ‘they are (the) best possible health policy advisers.’

So, what is an intelligent impartial person, concerned about health policy and public administration, to make of these views? Having had some years’ experience dealing with medical practitioners in health services policy and planning and, to a lesser extent, hospital management, I thought I could assist a wider understanding by offering something in the way of explanatory analysis and comment.

But first, a thought experiment.

Imagine if you will a very smart eighteen-year-old, freshly out of high school and off to university. This kid has been told for years they are among the brightest and the best. Academically, they have performed in the top 0.5% of their state. They decide to study medicine. Why? The usual reasons – status, calling, intellectual interest, psychological suitability, family pressure, future wealth, or maybe a combination of some or most of these drivers.

What they are taught and learn, above all, is how to be a highly-skilled technician. As they progress and specialise, their status, wealth, intellectual satisfaction and sense of purpose and achievement rise accordingly. Of all the technical careers one can choose, medicine and surgery rank among the best-regarded. These are demanding careers of great human worth and social value, and their practitioners are rewarded handsomely, in both financial and non-financial terms.

But how do medical practitioners perform at all the other things we require of senior policy thinkers, health executives and leaders? Well, in my experience, and in the experience of just about everyone I have talked to in this business (including some doctors), no better than the rest of the population. And, on average, not as well as other intelligent, well-rounded people who have studied and worked in the wide range of areas that comprise a complex modern health system.

Not surprisingly, what most doctors are good at is doctoring. Intelligence comprises a complex set of qualities. It is passing rare for most aspects of intelligence to be optimised in any one individual; even in those who as teenagers ranked in the top academic 0.5% of their peers.

The qualities of medical practitioners we value are these: diagnosis, rectification and prevention of problems associated with complex psycho-physiological entities, AKA us. Most are employees, or self-employed, or partners or directors of small to medium enterprises. A few have entrepreneurial or high-level management skills, and some show fine leadership qualities – but many of them would struggle to run a school tuck shop without ‘support’. As health managers, they make great doctors.

Yet the problem here is not only about the qualities that most doctors lack – it’s about the ones they have. And what they have, as we all do, is baggage.

The encumbrance in this case is an egregious confirmation bias toward their group.

What evidence, for example, does Dr Hambleton allude to in support of his claim that, ‘where doctors run the management of hospitals, results improve and morale is better’? None, of which I am aware. Of what would such evidence comprise? A survey of doctors?

And what of the claim that (doctors) ‘have the knowledge and experience to make the (health) system work better’. What is Dr Hambleton’s evidence for that? Feedback from AMA members?

But most revealing is his statement that, ‘you cannot improve the health system by ignoring the opinions and advice of doctors’. This at a parliamentary dinner at which Federal Ministers from the Prime Minister down were seated at tables of AMA members…access not ordinarily enjoyed by any other part of the health system.

To pretend that the opinions and advice of doctors’ is ignored by health service executives and planners is risible in the extreme. Numerically one of the smallest parts of the public health system, no other group comes remotely close to exercising as much professional influence and economic coercion on health service systems and delivery. Doctors are, as a rule, engaged to standstill.

So, how could Dr Hambleton seriously arrive at his conclusions? Is it just advocacy of group interests? No. It is that, of course, but it is more.  Because many doctors actually believe they should be running all health services. (Indeed I have had one senior VMO surgeon tell me during a surgery planning session – when he wasn’t entirely getting his way – that doctors will just have to run the hospital.)

The AMA’s only plausible complaint could be that doctors are not in complete control.

Being told over and over again for years that one is brilliant, outstanding, or exceptional; it must be very seductive. Only those with the most robust sense of equanimity would fail to be flattered. Being surrounded by and accepted into a revered clique of similar standing, awash with arcane practices and near insuperable barriers to entry, only serves to reinforce a sense of meritocratic hierarchy.  Little wonder some doctors – particularly senior specialists – behave as if they’re God’s gift…

Doctors who move into senior health management and policy leadership ultimately must go through a moment like Charles Erwin Wilson, the General Motors (GM) President appointed in 1953 as US Secretary of Defense. When asked in a hearing if he could make a decision adverse to the interests of GM, Wilson answered yes, but added that he could not conceive of such a situation, ‘because for years I thought what was good for the country was good for General Motors and vice versa.’

Yet it appears that Dr Hambleton would, at least at present, fall short of even Mr Wilson’s meagre threshold. Other than demonstrating that the AMA President is, perhaps ex officio, unfit for senior health system management or service planning leadership, what do his statements tell us about doctors compared, say, to other technicians?

Plumbers, on the whole, are unlikely to think that town planning is a complex bureaucratic system developed solely or mainly to provide plumbing services to households, businesses and institutions. Whatever their intellectual limitations (as a group) may be, plumbers are neither so silly nor arrogant enough to think that their function is the only or principal purpose in planning new developments. Important, yes. Indeed, essential for a safe and clean environment. But not the main game.

If only doctors were as sensible and proportionate in their expectations. But alas, they are not and most cannot be, because for them medicine is health and vice versa. And so, mutatis mutandis, they cannot conceive of a heath system other than as a grand structure to support and deliver medical practices. But most of us know that health is way, way more than this. Just as defence is not just about who builds and supplies jeeps, trucks and other vehicles. Not even in 1953.

What’s good for medicine, and for doctors, is not necessarily what’s good for the health system. What’s good for patients is not necessarily what’s good for doctors. Even leaving aside the obvious financial considerations and matters of malice or incompetence, interests sometimes coincide and sometimes conflict. Whatever their merits, health complaint systems are full of such cases.

It is a fact now quite widely known and well-evidenced too that many doctors, when confronted with the option to undergo the same procedures they typically recommend to their patients, choose to forego them. Any doctor who fails to understand this point about divergent interests is frankly unworthy of a senior role in a public health service.

Confusing the part for the whole is known in analytic philosophy as a mereological mistake.

Smart people avoid being tripped up by such altruistic illusions, unless their baggage is blocking the view. The best way to get over your baggage and take the trip that wisdom asks of us – the journey to abstraction – is to leave the old suitcases where they are and move on without them.

Abstraction is a crucial quality for those in senior management, planning and leadership of services for the public good. It is the capacity not just of looking beyond self-interest and putting oneself in the shoes of others (the altruistic position), but of moving to an impartial point of view that considers the overall public interest and prepares one to take a position that may be detrimental to oneself or one’s group.

Only doctors who no longer especially care about the interests of doctors are capable of abstraction. There are some; but they are few.

And Dr Hambleton and those who think like him do not count among them.

* By ‘Doctors’ it is of course meant, doctor doctors (ie medical practitioners), not real doctors (ie people with a doctorate), apart from those who are also medical practitioners. In this article, vets, dentists and other clinicians are not included in the category of Doctors.

Mr Brik currently resides outside Sydney in NSW. He is not a clinician. His blog is at http://enricobrik.blogspot.com/

Comments 10

  1. Duggy the DC3 says:

    I am really saddened by this post in Croakey. Mr Brik you have not done yourself nor Health Service Planning Professionals a service by this rant.

  2. Enrico Brik says:

    Dear Duggy

    I am sorry, it was not my intention to sadden you or indeed anyone else. However, I feel I should point out that those who read the article closely, particularly the closing paragraphs, might well adduce that it was not my intention do myself or health service planning professionals either a service or disservice.

    As to the article being a rant, I’ll leave it others to judge, other than to note that the noun ‘rant’ is defined as an ‘extravagant or violent declamation’, and the verb ‘rant’ means ‘to rave, or talk wildly, as in delirium’. I have nothing more to add as you made no substantive comment.

    Yours in service planning,
    Enrico Brik

  3. ron batagol says:

    I couldn’t agree more-frankly Mr.Brik’s comments beggar belief and frankly I’m not sure if he is serious or just having us on. Does he REALLY think that doctors ( or other health professionals- hey I’m a pharmacist/drug information consultant- am I in his elite bunch too?), as distinct from professional generic health management people are so narrow-minded and gain no insight and knowledge as to the from many years on health advisory committees as to the needs and checks and balances of the braoder health system? Oh, I get it! Only health administrators are intelligent enough to gain that knowledge!! And years of clinical experience, including balancing risk versus benefits in patients cout for bought? oh, please, you can’t be serious as the saying goes!!

  4. Enrico Brik says:

    Oh Ron,

    Let me put your mind at rest. I’m serious. My comments, as the article’s title suggests, are about doctors and not other health professionals. Indeed, that was rather the point. In my experience, and the experience of many others with whom I deal in the health business, the qualities of allied health clinicians, nurses and others are very well adapted to health policy, planning and management. The article was also not written from the perspecitive of a health administrator, as you imply, because I am not one.

    Cheers anyway,

    Enrico

  5. ron batagol says:

    BTW- tthe last bit should say “And years of clinical experience, including balancing risk versus benefits in patients count for nought?

    But Mr.Brik is so terribly clever, I’m sure he’s already worked that out!!lol!!

  6. ravenm says:

    One of the key roles of the AMA is to function as a trade union, so of course it is not surprising that AMA presidents continue to advocate in this way.
    One key issue that is routinely overlooked is that there are many more nurses than doctors in the health system, and they also have vast experience and knowledge and wisdom that should be respected and harnessed in the management of hospitals and the broader health system. Nurses also tend to be more systemic in their thinking (a crucial skill in management) – of necessity, because they are not at the top of the pecking order. [No, I am not a nurse, or a doctor.]

  7. AlexN says:

    I am a medical student in my last month of medical school. In the last five years, I have had countless discussions with doctors, other health professionals and general hospital staff on how simple changes could lead to dramatic changes to patient health, cost to the taxpayer, and workplace relations. I am constantly amazed at the effect that poorly-constructed policy has on patient outcomes. I’d be interested to know how much of this policy has passed through Mr. Brik’s hands.

    The Health System and how it could be improved are constantly in the minds of people who work within it.

    I find Mr. Brik’s oversimplification of clinicians pejorative and insulting.

  8. ihaywood says:

    I think the plumber/town planner analogy is a good one. In our current health system “town planners” do their job at the macro level just fine, but also want to micro-manage the actual delivery of care too. They determine what taps to install, what spanners plumbers may have, how long each job will take, etc. Complaining that the spanners are metric and the taps Imperial sizes is denounced as a reactionary closed-shop mentality.

  9. Duggy the DC3 says:

    Interested in Mr Brik’s “take” on the Gillard Governments “Lead Clinician Group” that contains at least two Ex AMA presidents.

  10. Bd J says:

    Great provocative article, of course no-one is perfect that’s clear. Actually having bean counters/Administrators run hospitals is a failure. We need to return to the days when a senior doctor and nurse ran hospitals with finsnce/administrators to assist. Actually I see that doctors – and nurses have very little power in hospitals these days. Good clinical care happens only because unusually caring individuals. Eg my Close relative broke their hip in the ACT in 2011 and waited 3 days in a hospital bed to get it fixed, private health care no help either. Apparently this isn’t unusual in the ACT. Lucky she didn’t get pneumonia and die. I could think of many many ways to expedite her care and save the hospital system money and free up the bed she occupied for 9 days instead of 3-4. There are lots real problems in the public hospital system and too much power influence by doctors isn’t one of them. Having said that humility and ethics are always to be admired and supported.

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