RP Dispensing with doctors? [Letter to the SAMJ 2003]

To the Editor: South Africans have been fortunate beyond belief in their access to doctors, widespread poverty notwithstanding. They are unaware of their good fortune, taking it for granted, but all good things must come to an end.

Other health care professionals cannot replace doctors at a lower cost. True, the work done by doctors can be divided up among several classes of professionals, but doing so increases the costs of care severalfold - the British and American experiences serve as proof of this.

The South African public does not think of a visit to a doctor as one for information or a diagnosis, but rather as one for treatment. This mistaken belief has meant that many attend doctors inappropriately, but it has also meant that the public has not paid for the true cost of care.

South Africans are about to discover that they cannot afford doctors, and their doctors are about to discover the same. Already highly sought after by developed economies, circumstances will force their flight, however regretfully. South Africa will find itself in the same situation as other sub-Saharan countries with regard to the numbers of doctors in relation to the population. The ratio will be woefully inadequate.

Less than 3% of any age cohort in this country is capable of studying medicine. This group must produce our accountants, lawyers, statisticians, actuaries and engineers, among others. It cannot do so completely, and of all the career options, medicine probably falls at the bottom of the scale. We already produce fewer doctors per year than we did in the past, and that number will only get smaller.

It now takes 22 years of study to produce a doctor in South Africa. Which intelligent person is going to make such a commitment in order to be paid as much as a secretary - and to have his or her place of work and residence decided on by the government? I thought the constitution outlawed slavery? And I thought that the USSR proved conclusively that a central command economy does not work? Even the Chinese

acknowledge this. 

The government is changing doctors' scope of practice while calling it something else. This can only end badly for all concerned if the government fails to listen to an important constituency, viz. doctors in South Africa. Pearl Harbour was not a bolt from the blue, nor was 9/11: in both cases those in authority failed to pay attention to the necessary information until it was too late.

Hegel may have been right that history teaches only that we learn nothing from the past.

E Hassen

BMJ Rapid Response

 

The role of the doctor is four–fold:

 

• To preserve health
• To manage disease: treat, mitigate or palliate
• To act as patient advocate
• To educate: self, colleagues, patients and the public at large

 

The nature of medicine is changing much faster than the practice of medicine: we are human and as such the older we get, the less flexible, the less malleable. The role of the doctor cannot be tied up in specifics because life is complex, uncertain and – at the individual level – entirely probabilistic.

 

BMJ Rapid Response: Workforce planning a wicked problem

There seem to be several peculiar assumptions underlying the arguments made:

 

• Workforce planning is a science
• The future will be like the past
• Change is easy
• Equity matters
• Cost is not a consideration
• Consequences can be accurately vectored

 

People make decisions that serve their own perceived interests; governments do the same.

 

Should UK graduates be preferred? Yes, that is fair. Should foreign graduates be locked out? No, but the rules should be stated clearly and commitments already made should be honoured.

 

[BMJ]

Problem Based Learning

A letter to my consultants:

I am committed to being better. This is not an occasional goal or aspiration: it is me. Kaizen. I am not in competition with my future self but I am driven by an ideal self that may not be realised.

I have a great deal to learn and my learning progresses day by day. Learning is what I do.

I understand that protocols exist to standardise safe practice. Both standardisation and safety are important severally and together for many reasons. Standardisation should not mean petrification.

Auditing my own practice more intensively over the past 6-9 months, one of my goals has been to reduce my admission rates and to do so safely. So, I have paid more attention to the numbers and been more aggressive with treatments: keeping in mind that more aggressive action needs finer feedback, more acute monitoring – time is a resource that acts.

I have said many times that I am not invested in specific acts; I am invested in process.

We agree that practice should be informed by evidence and that evidence is sparse; however, we do generate evidence and don’t use it to inform our practices. When evidence exists to change practice and you don’t, it would be helpful if you could say what (achievable) evidence would be necessary to change practice. As consultants, ultimately responsible for safe practice in the unit, it would be considerate if in changing the management of my patients you did so because you believed it necessary rather than preferable. Art is always arguable: your interventions should benefit me as well as the patient. If you don’t change my mind about my course you won’t change my practice – and so you do me and my future patients a disservice if a change in practice is necessary.

Medicine is experiential; no book learning can substitute for treating patients. And guided, moderated experience always beats trial-and-error learning.

Thanks!

A Letter to The Editor, EMJ

It is a wonderful circumstance that when a professional publication will not publish something, one can always self-publish. It may not have as wide a readership as a professional publication but time is a factor that could change that considering that web publishing is not ephemeral.

Admittedly, the letter below was part rant and part therapy, it still raised an issue that is generally important. (IMNSHO)

The Editor,

I was to sit the SAQ (Part B) on Monday 18^th December. I didn't because I arrived (18 minutes) late.

I left home at 0515 to take the 0700 BA flight from Manchester to Heathrow. The flight boarded timeously but departed late (0731). From Heathrow I took the next Heathrow Express (0848), arrived Paddington 0904 and immediately took a taxi to the Barbican.

After several consultations amongst the invigilators I was told that the 15 minute rule could not be relaxed because to do so would set a precedent.

I stayed outside the doors until 1043 when the first candidate left.

I reflected.

The exception discussed could in no way be binding on any future invigilators. "Precedent" was contextually a malapropism. The exception would have done no harm and would have benefited me tremendously.

Beneficence, too, as an observed principle was conspicuously lacking.

For a professional speciality tasked primarily with the urgent, the emergent and the critical, an inflexible adherence to the letter is a cause for concern.

A society's resilience is entirely dependent on the initiative and flexibility of its constituent members....

My disappointment and frustration are salved somewhat by this letter, but the issues I raise above are material to the profession (sic) of Emergency Medicine.

Sincerely,

E. Hassen

On Crime, Safety and Fairness

I was approached recently by a home security company about having my street patrolled for 12 hours daily at “a reasonable cost for peace of mind”.


Peace of mind cannot be bought. And guards, dogs and cameras cannot provide security. For some, I expect that they do provide “peace of mind” – for a while.


Guards, dogs and cameras do provide a cue: only valuable things need protecting and valuable things are worth stealing, particularly because there are willing buyers. And so the circle goes.


I ask myself continually how these cycles can be disrupted, countered, destroyed and always I come to this same conclusion: I need only do the right thing. Only me, not everyone else and not all the time, but only as often as I can manage it. It is a simple thing. And it is so incredibly difficult – not in the conception of it or even in the doing of it from time to time but in the additional requirement of constancy.


To do the right thing.


I am not selfless, I am not extraordinary and I am no hero. Life is a struggle and I have lost my illusions of control. I have not lost my anger.


I have an unremarkable anger: ordinary, because I have learned that all South Africans have it: it is formless and without a target, without a clear cause excepting a marrow-in-the-bone sense of injustice. Some blame apartheid and Bantu education, but it is an anger that cuts across race and social strata. I have no doubt that you have it.


I have it despite my education, my material comfort and my loving family. I have been a victim of crime several times and of ingratitude that hurt and angered as much and yet that is still not sufficient reason because I had it before and after.


The poor have it too. The hungry, ignorant poor have it in abundance shielded by a moral righteousness. My anger has no shield, my relative privilege leaving me without the moral high ground and yet it persists. I cannot blame the poor for their poverty as I cannot blame the sick for their debility. I have not caused the problems, but I find myself labouring under a presumed obligation to fix what I did not break.


I did not suffer? I did not cause the suffering!


A friend speaking plainly said that the world did not owe me a living. He was right.


Life is not only about obligation. We are built to be fair and nothing cuts as acutely as the accusation of unfairness, but fairness is not enough, our humanity, our sympathy is bound up in generosity.


We need to gift. Not charity, which creates a barrier between the receiver and the giver. We need to extend our circles of friends through gifting – little things will do as well as great because it is the exchanges that matter: they show that we care and they free us of the burden of fixing that which we didn’t break.


Only in our caring – our visible caring – can there be peace of mind because only in our caring can we demonstrate equity. The poor are oppressed by their poverty, but they blame the “rich” because there are few connections between them and so, little evidence of caring.


To be a good husband or wife is the same as being a good parent or neighbour. And it is the same as being a good friend. It is caring, visibly. It is many little things, often. We are so often disastrously misunderstood by those closest and dearest to us and yet our relationships endure because we care. How much greater the misunderstandings across culture and race? How intractable in the perceived lack of caring?


Necessity is the mother of invention and there is no greater necessity than self-preservation. I know without doubt that if my talents and opportunities had not been enough for survival, I would have been a criminal – there, but for the grace of God, go I.


Without equity, without caring, there can be no security, no peace of mind.

[Letter to the Editor, Daily Newspaper in South Africa, Oct 2003]

Baby Rape

All rape is horrendous. All violations of person are horrendous.

There is no acceptable rape and no gradations of unacceptability.

One writer observes that we are a Godless nation, another that the government has it’s priorities skewed and all find themselves incapable of expressing the full extent of their horror especially as parents of babies and toddlers. And yet none states what (s)he will do personally to end this sort of event: society should do something or the government or the police.

It is this sort of thinking that preserved apartheid, that made Hitler Fuhrer and that makes our problems apparently intractable. It is thinking that someone else must solve the problem.

Schelling points out that the good gets done if individuals act alone to do the right thing: no central command, no over-arching authority or organisation is needed to accomplish the apparently Herculean; only ordinary people acting on conscience.

We condemn. We complain. We pray.

Do we act? Not to punish but to prevent? Have readers and listeners asked themselves what they will do to prevent this happening to someone else?

One must know despair and desperation first-hand. Those who suffer do not do so vicariously….

I am indeed my brother’s keeper. And in this we are all guilty, all diminished, our horror notwithstanding.

[This letter appeared in The Star (South African Daily, Johannesburg) in October 2003.]

[Context: there had been a report of a rape of a 1 year old baby with significant physical injuries. Rape is common in South Africa and survivors of rape are getting younger because of the mistaken belief that HIV/AIDS can be cured by having sex with a virgin. Younger age is a proxy for virginity.]

Letter to the British Medical Journal: A Palliative

Socioeconomic imbalances have a habit of exacerbating themselves: we call them virtuous and vicious cycles. And it is near impossible to change the one into the other.

The world is increasingly one integrated system and costs and benefits are not directly linked. Those who benefit are not those who pay.

Conscience may persuade some – some of the time – to pay for the value they receive. These discussions serve as part-payment, a salve to conscience, but no pragmatist expects or believes that the brain drain will be reversed.

The convenient solution is to introduce friction to the free movement of health professionals: the health professionals pay, the benefiting countries say, “See we have made it difficult for them.” And the losing countries are left with nothing.

The entire argument seems misplaced. Seen as a unit, the whole world suffers from a dearth of health professionals.

Poor countries – Developing countries – need more health, not more healthcare or more health professionals. Below a recognised threshold, health equates with income, both direct and indirect (the entire focus of public health initiatives: potable water, sewerage systems, electrification, telephones, roads, mass immunisation, etc.) and yet still the health of nations focuses on the movement of health professionals.

A cardiothoracic surgeon or interventional radiologist can do nothing for the health of a nation sitting on a dune in the Karoo or looking off a cliff in the Himalayas. Implants of NGF producing cells for Alzheimer’s are irrelevant to a population dying of cholera for lack something simple and inexpensive: potable water.

The health of a nation has very little to do with the movement or the numbers or the training or the remuneration of health professionals: America and Cuba are the proof of that.

I am in favour of dialogue and I will award myself Brownie points for this piece; I know that it will make no difference to the health any nation, but I will feel better and that will certainly be good for me.

Competing interests: health professional

[This letter appears in the online edition of the BMJ April 2005 and will appear in the print edition in June 2005.]