On asking the clinically-relevant questions

There's a question out there in medical land that apparently asks whether you are racist or not. The question is: "Do you identify as of Aboriginal and/or Torres Strait Islander background?" Now, the response to this question  – which in Australia IS of clinical relevance – is not what matters, but the fact that some people are unwilling to ask this question in this first place for fear of "offending" a person who isn't of this background.

Fear of offending a racist person is the reason some people give as to why they feel uncomfortable asking the question. They imagine they may encounter a racist person who'll take offense at not clearly being identified as non-indigenous. More specifically, though, they fear that they'll meet a non-indigenous person who they will offend by implying the negative stereotypes associated with people of Aboriginal and/or Torres Strait Islander backgrounds. But who's given this question that connotation? The racist person who holds those prejudices – and that is the person fearing to ask the question! You don't know the strangers mind that you'll be asking, only that you imagine it may believe what you (either consciously or subconsciously) believe yourself.

And briefly before I leave this topic, let me explain why I say that it is clinically relevant to know whether a person is of Aboriginal and/or Torres Strait Islander background. In Australia, there is difference in the life expectancy, the mortality rate, and the burden from disease between indigenous and non-indigenous Australians. This difference is commonly referred to as “the gap” between indigenous and non-indigenous Australians. Clinically, a person may be more likely to suffer from one or another illness (e.g. diabetes mellitus) if he comes from an indigenous background than if he doesn’t, and his/her symptoms may be more likely to be caused by a disease that is more prevalent in those of indigenous background than those that aren’t. This is turn is relevant to both the adequate diagnosis and treatment of this person’s illness. Further to that, the government may have incentive programs aimed at “closing the gap” in the health of indigenous and non-indigenous Australians, some of which can be quite helpful in allowing indigenous persons to overcome some other indirect/social difficulties in accessing adequate health care. So, asking whether a person is of Aboriginal and/or Torres Strait Islander background needs to remain a relevant clinical history-taking question, and one devoid of prejudice from the person who has been tasked with the job of looking after the health of a community consisting of people of all types of backgrounds. And perhaps we should stop fearing to encounter a racist person if it will only make us become the racist one ourselves.

On money and healthcare: Rights & Priorities - Part 3/3

As a doctor you often see people in a very vulnerable state of health walk into your room. Your job is to provide some sort of health care to that person. It is a paid job just like anyone else’s job for which they trained and invested time, effort, and money. Why any of us decided to become doctors and not hairdressers, teachers, politicians, carpenters, etc., is different for everyone and that is not the point. The point is we are workers same as anyone else doing any job. You do the job for a certain amount of hours, you get paid for doing that job, and then the money is yours to do as you wish. That’s the essence of working in a capitalist, democratic country like Australia and the U.S.A. regardless of what your job actually entails, right?

The doctor is a bit like a hairdresser or an accountant or a lawyer or a politician in that he doesn’t physically sell you a product, but rather a service. A patient walks in, you carry out an assessment, work out what he needs, and advice or give that treatment required. Patients don’t leave the room with a new bag filled with products they’ve purchased, but the same thing happens once you leave your hairdresser or accountant – and yet you are aware you need to pay for the service provided to you. And yet you could say that the service provided to you is at least a little more essential than a haircut or advice about things other than your health. One of these things could potentially be the difference between life and death. I have never heard of anyone who risked death by having long or unkempt hair…

So here is the dilemma I wanted to get to: health, or the access to health care is an essential human right; it is a right every human being regardless of who they are or what they possess deserves for the simple act of having being born human. In countries where there is widespread poverty and having no money really means having no money (i.e. none to spare on food or clothing or housing, and not just meaning poor as in having no money for a tv, a car, a haircut, a holiday, or entertainment, etc.), having a right to free access to health care is one of the great achievements of humanity.

So why am I singling out ‘poor’ countries as separate to developed countries like Australia? Because in developed countries like Australia, we believe that if we can’t afford a holiday or a car or costly entertainment that we are poor. And we don’t want to miss out on these things! To a person in a wealthy country like this, we believe that these things are our rights too - and God forbid that we miss out on these things to pay for what we now consider non-essentials, such as our health care. And that is the cause of the dilemma in wealthy countries: we have for the most part changed our priorities as to what is considered essential and non-essential. Yet we all have a sense of what our human rights are. I will tell you that in Australia we see time and time again people who hesitate and complain about having to pay an out-of-pocket fee to have their health tended to, but will without hesitation hand over large amounts of money for haircuts, for manicures, for holidays, for fancy cars, for video games, movies, etc. And yet, only one of these things could potentially be the difference between life and death…

I don’t know what the right answer is. And I don’t know what the best system of health care is. Surely everyone deserves the right to access health care regardless of what they have or who they are or what they do with their lives. Yet, surely, we have also come to some concerning conclusions when tending to our health is considered less of a priority than funding our non-essential commodities. Personally, I have only ever considered the doctor’s role as equivalent to the mechanic’s, to fix the machine so the machine can go where it chooses and do what it chooses. Doing our job doesn’t make us special people, we just do a special task. But it is a job same as being a mechanic is a job - and in this society, a job implies compensation. Doctors eat too and pharmaceutical companies are not charities, so the reality of it is that health care has become a business. It’s not ideal, but it is the reality.

On money and healthcare: Work & Subsidies - Part 2/3

In Australia, up to 80% of general practitioners accept the rebate provided by Medicare as the total cost of their medical consultation service. Essentially that is to say that they provide to Australian citizens with a Medicare card a “free” consultation service with no out-of-pocket cost to the patient (excluding medications sold through a private pharmacist). That’s a great thing for patients! They can’t use the ‘I don’t have enough money to go see a doctor’ excuse too often since most GPs will see them for "free". Of course, the doctor has to get paid, too – because medicine is a job, not a charity – and Medicare will pay him for doing his job. However, remember, how Medicare is a rebate and not meant as full payment of the doctor’s service?...

There is a big group of people in non-government health care systems (e.g. private allied health professionals, private medical specialists, and around 20% of general practice doctors) who don’t accept the Medicare rebate as full payment for the service they provide. Are they the “better” health professionals, worthy of more money than Medicare provides for? Are they greedy ‘fat cats’ like some politicians will call them? No. They are the same as other health care professionals providing similar services. Often they are the same people who will see some patients at a fully-subsidised cost or charge an additional fee on top of the rebate. They’re not bad people; they are just people in paid employment. They’re people working in a private system practising within their legal right to set their own fees for their service, often actually very realistic fees to cover the true costs of doing their job. Unfortunately, because both types of practitioners operate within the same country, the one who charges what he or she has deemed his service is worth is seen as some sort of evil, money-hungry, exploitative person. Conversely, the one who provides “free” (to the patient) services is often considered less than – and this is what most general practitioners in the eyes of the public are seen as.

On money and healthcare: Rights & Systems - Part 1/3

Rights

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services”  (Article 25, The Universal Declaration of Human Rights). The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. Of course, to the majority of the world’s population, complete attainment of our human rights and of health are only ideals and not reality. Nevertheless, they are ideals worthy of our consideration.

Ideals

In an ideal world every time someone fell into an unhealthy situation (physically, mentally, or socially), he should be able to access medical health care, mental health care, or social care and have his “health” restored. He should be able to access these things regardless of the amount of money he has, his sex or age, his political or religious affiliation, his ethnicity or language, his sexual identity or practice, his birthplace or site of residence, his employment status, etc. Basically, his right to health care is universal and his human right. That’s the ideal; reality is very different for a lot of reasons.

Reality

Every country has different health care systems, which impact on the way patients access health care. Some countries will have a health care system that is exclusively government-funded and all you may need to access it is proof of citizenship to that country. Usually that means that there is no cost to the patient for an “encounter” (i.e. every time you access health care) as funds are usually derived from a portion of pooled taxes payed by that country’s citizens. Other countries may have a system where accessing health care requires payment to a private health care facility or a private company that coordinates provision of health care (e.g. supplying and paying for the medical staff’s wages, the medical equipment, the facility fees, etc.). A lot of developed countries, Australia included, operate both of these public and private health systems concurrently where the public system is the default for all citizens unable to afford private health care. The private system exists and thrives because it promises certain perks and advantages like your choice of health care provider, faster access to elective surgery, more ready access to specialist medical reviews and allied health services, and often newer premises, medical equipment, and technologies. And yet other countries have a third system, like a lot in South and Central America, a “worker’s” health care system that provides health care services exclusively to that country’s citizens whose employers pay for access to this service. The worker’s health system is closer (or equivalent) to the private health care system than to the public system. I don’t intend to argue which system is better or which worse or which country does it best, but it’s interesting to consider what’s out there.

Australia

Australia has a dual system of public and private healthcare, the public system funded from federal money and managed (for the most part) at a state level. Medicare can be considered a pool of federal monies reserved for funding certain medical services (including surgical fees and the payment for medical staff), medicines, medical aids, etc. All citizens have access to those Medicare funds provided certain criteria are met, but generally it is a default system for everyone.

An often misunderstood peculiarity of the Australian government’s Medicare system has to do with the way a doctor bills his or her patients. The Australian government decides which medical services are worthy of a Medicare rebate, the amount of money allocated to it, and the conditions under which a service qualifies for a rebate. For example, anybody may approach a general practitioner for medical care and Medicare will provide a certain benefit to the patient to pay for that consultation. The patient may also approach a specialist doctor and pay for the full cost of seeing him in his private clinic; or he may present to his GP first and obtain a written referral to the same specialist and then become eligible for a rebate from Medicare to help pay for his medical specialist appointment. (A patient not wishing to access the private medical system at all for any reason may also be referred to a specialist in one of the state’s hospitals where it is available and obtain medical specialist review free of charge.) Importantly, the Australian government decides which medical services qualify for a Medicare rebate and how much money it allocates to each service – however, how much money Medicare allocates to a service does not always reflect how much money a service actually costs to provide. Medicare in fact operates as a rebate, a subsidy to the total cost of health care, not (at least not always) as the absolute cost to cover the service. Think of it as a discount voucher, not as a voucher for a “free” service.