A Tricky Question

This article was published in the December 2014 issue of Good Practice, the RACGP publication. I forgot I'd written it, so I'm posting it here now!

I’ve just learnt the most dangerous question in medicine. It’s “Are you a good doctor?”

I am sure, dear reader, that you are a good doctor. You know everything, and you know the things you need to learn. You can see through the twinkle in a drug rep’s eye faster than you can say Vioxx. You are all much better than average, and, even as you know enough statistics to be able to dismiss this as an impossibility, you also know that it is certainly not you who is below average.

Now that we are patting each other on the back in mutual admiration, here come some people to spoil the party. Let me introduce you to Dr Dunning and Dr Kruger

Dunning and Kruger won an Ignobel prize for their work, describing experiments showing that those who were the least competent in various tasks were also the most likely to rate themselves highly competent. They were also the most self-confident. There’s something about not being very good at something that makes you blind to the areas that you don’t know, or even realise that they are there. It’s a good job nothing like that could happen in medicine.

Except, sometimes, research evidence can be as disquieting as a mirror in a brightly lit room. In JAMA in 2006, Davis and colleagues did a systematic review comparing self-assessment with external observation. They tell us that we are not very good at assessing our own competence. Meanwhile, two years later In Medical Teacher, another systematic review by Colthard and colleagues also shows us that we are not that good at assessing our own learning needs.  In both situations it is the least skilled of us who are the worst at self-assessing, and who are the most confident.

And then there’s research that consistently shows we think we’re immune to drug rep marketing, no matter how often it’s shown that we’re not. This evidence is entirely consistent with other sociological and psychological research, which confirms that doctors are part of the human race, no matter how much we want to think our training makes us otherwise.

Apply Dunning and Kruger’s research to our profession, and you can see the danger in asking “Are you a good doctor?” It may be those very areas where we feel highly confident are just those areas we are worst at. It may well be that those of us who think they are expert at seeing through drug rep spin are those most susceptible. What if those of us who say they are good doctors are the ones we need to be most wary of?

Of course, you could dispute the evidence. All that stuff about education and drug reps doesn’t apply to you, or to Australia. But that is just what you would say, wouldn’t you, if you were subject to the Dunning-Kruger effect! To show how competent we are, we might have to admit uncertainty over our competence. In fact, in real life, I have discovered that the doctors I really admire all feel that at any moment, they will be tapped on the shoulder and outed as a fraud!

For any eager regulators out there wanting to put conditions on the registration of anyone admitting they think they are a good doctor, the solution is even more simple. As a profession, with specific knowledge and expertise, self-regulation often means peer review. We need, and should welcome, others around us to help us see our blind spots. Perhaps “Are you a good doctor?” is not such a dangerous question if our answer is “You’re asking the wrong person.”

References

Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments. Journal of personality and social psychology. 1999 Dec;77(6):1121-1134.

Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA : the journal of the American Medical Association. 2006 Sep;296(9):1094-1102

Colthart I, Bagnall G, Evans A, Allbutt H, Haig A, Illing J, et al. The effectiveness of self-assessment on the identification of learner needs, learner activity, and impact on clinical practice: BEME Guide no. 10. Medical teacher. 2008 Jan;30(2):124-145.

Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA. 2003 Jul;290(2):252-255

Let Them Stay

Let Them Stay in Picton - Photo Cath Taylor

We held a small gathering in Picton protesting against the potential return of over 250 asylum seekers to Nauru.
Doctors, churches, writers, State Premiers and many many people around Australia have joined together to protest this, and you'll have seen me talk about this on Twitter.

But what do children think? After all, those being returned are the same age and younger than our children. Imogen, our eldest, has written before on this issue, and is genuinely upset and angry about what we are doing.
She wrote to Malcolm Turnbull after our gathering today. This is her letter.

Dear Mr Turnbull,

Right now, I am at a candle vigil with my church and members of my community. We are sitting in the town square, peacefully showing our support for the asylum seekers currently being faced with returning to Nauru, peacefully showing that we do not agree.

I can’t help but feel slightly useless. Children younger than me are being sent back to the place of their nightmares, women back to the very people they have been abused by, families going to live and grow up in a hell hole. And I am lighting candles.

I mean, is this the best I can do? What can I do? In my own perfect little world, such a contrast to the life that these asylum seekers have and are going to live, I am lighting candles. I feel powerless.

I have heard many stories from these people online. Stories of children younger than me giving up any hope. Stories of seven year olds who want to end their lives. Of children playing with cockroaches and women being abused and families broken apart. And I am lighting candles.

Right now, I feel very little pride in my country. Very little hope in our government. What kind of country are we? A country where babies who have been born here are sent to live in the place of nightmares. Where people who only hope to do good are sent to a place where no good exists? Where traumatised women are sent to their very abusers, hidden from the law, shown that no one cares? And I am lighting candles.

And yet, right now, people all around Australia, just like me, are showing their support for these asylum seekers. And this is beautiful. This is the Australia I am proud of. This is the Australia I have hope in. This is the beginning of a new and kinder, more generous, compassionate Australia. People are starting to realise what Australia is about. And that is not a country where we lock up children, it is a country of love. And I am lighting candles.

I am lighting candles with the rest of Australia, connecting with others I have never met. We are showing Australia’s true side. One I can be proud of.

Maybe it is the lighting of these candles that will change our world. The lighting of these candles that will shine a light on every injustice. The lighting of these candled that will let everyone have a voice, everyone be proud of the Australia we have. This light will let us see sense. The power of peace. The power of a compassionate nation.

Thank you,

Imogen Senior, Age 14

Greg Hunt* gives up smoking

Greg Hunt* is trying to give up smoking.

“All the doctors say I need to give up smoking,” he says, “though science isn’t done by consensus, and I’ve come across some really interesting blog posts. Now, I’m not a doctor, but it’s pretty clear to me that there’s real uncertainty on the question of smoking causing lung cancer or heart disease or lung disease or any of the other things smoking is supposedly “bad” for. Smoking is clearly good for the lungs because it helps you cough up all that junk.”

At this point he pauses to cough up some brown phlegm into a tissue.

“Anyway. I do believe the doctors, and they say I should give up smoking completely. Though, obviously, smoking will be a big part of my lifestyle for a long time to come. I mean, if I stopped smoking immediately, it would cause me economic ruin.

“Eh?” I ask. “How’s that. You won’t be paying for cigarettes any more, and you’ll get healthier.”

“Ah, details.” He says. “Trust me. I have shares in tobacco. I’ll never be able to retire if I don’t prop up the entire industry.”

“You won’t be able to retire if you keep smoking. You’ll be dead,” I can’t stop myself from replying.

“Only two-thirds of smokers die young, and medical care is getting better and better, and, because I’ve had private health insurance for a long time, and shares in private health insurance, I’m much better off economically if I keep smoking, and you don’t look too hard at the numbers.”

“Don’t look too hard at the numbers?”

“So, because I absolutely believe what the doctors say…”

“That you should give up?”

“… Yes, that I should give up, I’m going to take their advice and cut down.”

“Cut down?”

“Yes. I’m setting a target for a 5% reduction in my cigarette consumption based on 2005 levels.”

“How much were you smoking in 2005?”

“Oh, about 50 cigarettes per day. It was only 35 before that, but it went up.”

I examined his face for signs of a joke, but he looked very serious.

“What? So you’re cutting down to 47 cigarettes a day?”

“Yes, I am. But I’m currently only smoking 35 cigarettes a day. Well. 40. But I’m allowed to count it as 35 because of a complex cigarette accounting rule where I can carry over previous cigarette reductions into this year.”

He managed to keep a straight face.

“But that means you can actually increase your smoking.”

“No. Well, yes. But it means I’ve hit my target.”

“But you’re increasing your smoking.”

“Well, frankly, that’s one of the oddest and strangest and I’ve got to say ... desperate arguments I’ve ever heard.”

There was still no sign that he wasn’t taking this seriously.

“So. I’ve hit my target,” he repeated with emphasis.

“But what about stopping smoking altogether?” I ask, a little confused now.

“I aim to cut future smoking by a 26% based on 2005 levels, by 2030. Which puts me way ahead in the middle of the pack of my smoking cessation group.”

“What? But your group are cutting smoking by 40% and upwards.”

“Yes, as I said I’m way ahead of them.”

“What? 26% compared to 40%”

“Yes. Because I’m measuring it per capita.”

“Eh? You’re not making any sense!” I was getting a bit frustrated now.

“Exactly. I’m hitting targets all over the place.”

“But your targets are rubbish. The doctors say you need to stop smoking.”

“Yes, and I’m doing everything the doctors say with my ambitious target of reducing my smoking by 26%, much much more than everyone else in my smoking group.”

I looked at him. He really seemed to believe this. He looked back at me, still straight-faced.

“So how will you achieve this tiny reduction?” I venture nervously.

“Well. I’ll achieve this ambitious reduction with a policy. You know how those so-called experts that I believe say we should tax cigarettes so it becomes expensive to buy them?”

“Yes. Definitely. There’s good evidence that it works.”

“Well. One man’s evidence is anther man’s anecdote…”

“No, it’s not!” I shouted

“… and that policy would lead to me buying fewer cigarettes, and lead to my economic ruin. No, I have a much better policy. The government will pay me for every cigarette I don’t smoke.”

“…. What?...”

“I’ll put in a bid in a reverse auction along with all the other smokers. And If I’m one of the winners, then I get money for each cigarette I don’t smoke.”

“That’s a crazy policy,” I say. “That’ll never work.”

“Oh, that’s what they all say,” he tells me. “But I know it will.”

“How do you know that?”

He waved his hands in the air and just said “Woooooooooooo! See. It’ll work.”

He wasn’t laughing.

“And if you don’t win the auction?”

“I might cut down anyway.”

“What? Well what use is that?” I ask

“It’ll make me stop smoking. Isn’t that what you want?”

“But… but.. what a complete waste of money!”

“Not at all. I get the money. Do you see? I get the money. How can that be a waste? You’re not very bright are you?”

“And what if you get the money and don’t give up?”

“Oh, that’s the really clever part. Listen to this. A man – or a woman, it doesn’t matter – comes round to my house and says ‘Don’t do that again!’”

“What? Is that it?”

“Yes. That’s a strong robust compliance mechanism.”

“No, it isn’t.”

“I’m glad you agree with me.”

“But I didn’t.”

“Thank you.”

I took a long slow deep breath and counted to 10.

“So. Let me get this right. You’ve been told to stop smoking, but instead you can increase your smoking and get money for doing it.”

“No. I hit my targets. You’re concentrating too much on that increasing bit. I hit my targets. And I get money. It’s a perfect system, you see.”

“And what do your doctors say about it?”

“Oh, I don’t believe a word they say. I found this on Wikipedia”

He looked straight at me. Was that a smile playing around the corner of his mouth? Was that a knowing wink I saw? No. It wasn’t.

“Thank you for your time Mr Hunt,” I said as I left the room.

“The pleasure was all mine.”

I heard him start coughing again as the door closed behind me.

*Not Greg Hunt, Minister for the Environment. A different, satirical, imaginary Greg Hunt

Boundless Plains?

Well, Imogen didn't get an answer from the PM to her last letter.. She's phoned his office (yes, really) but heard nothing. She's still really angry and upset about the way we are treating children in asylum detention, so she's written another letter to the PM.

Perhaps we need to listen to children more.

Please feel free to share widely.

To the Hon Tony Abbott PM,
I am usually proud to be an Australian. Proud to live in a country where we have freedom of speech,
proud to live in a country where we won’t be killed for speaking out against the government. But
recently, I have been becoming less and less proud of my home. Less proud of the government that
is supposed to represent our nation’s views. Less proud of a country with ‘boundless plains to share’.
A country that doesn’t seem to be able to help anyone whose life is in serious danger.
Because right now, despite how much you insist that you ‘stopped the boats’, despite the
government’s little tale that you are ‘helping’ these people, despite your continued reference to
these people as statistics, men, women, and children are dying out at sea as they try to reach what
they believe is a safe refuge, here in Australia. Little do they know, the few people who actually
make it here will be locked up in the equivalent of jails, men, women and children alike.
Their crime, you might ask? Trying to find a place where they won’t be murdered for having their
own views, for being a woman, or for having a different religion to their government. Seeking a
country where their children can have a proper life, free of fear of death when they wake up each
day. Is that so evil of them that we have to lock them up in prisons, where they are abused by
guards, where 5 year olds self-harm? A place that most Australians would not think fit for their pet
dog?

I am sure, that in their position, you would have done the same. Because would you stay in a

country where your family could be brutally murdered every day? Where people are whipped, or
worse, for speaking out against their government? Is it such a crazy dream to live in a place where
you can properly appreciate life?

Recently, I heard a story about a 5 month old baby, born in Australia, who was sent back to Nauru.
Yes, we are talking about the place where 5 year olds have tried to commit suicide, guards treat
people abominably, and human beings sleep in tents not fit for a dog. Just think about the situation
from the point of someone other than an Australian who lives a sheltered little life. This baby is
going to grow up in Nauru. It is going to be the only world it knows. Instead of having a normal,
happy childhood, like I am having, and you have had, she will have a broken childhood. Many
experts have said that Nauru is not safe for infants, and certainly not suitable.

I believe that Australia needs to open its eyes and see the horrific things that are being done right
now, because in the future we will look back on it and be ashamed of our inhumane, cruel and just
plain evil things that we have done.

I will conclude with the second verse of our proud country’s national anthem, because it seems as
though our government has forgotten the words.

Beneath our radiant Southern Cross
We’ll toil with hearts and hands;
To make this Commonwealth of ours
Renowned of all the lands;
For those who’ve come across the seas
We’ve boundless plains to share;
With courage let us all combine
To Advance Australia Fair.
In joyful strains then let us sing,
Advance Australia Fair.

I look forward to hearing your response,

Yours sincerely,

Imogen Senior (13 years old)

Children self harming in asylum detention... my daughter writes...

My oldest daughter and I were in the car together when we heard Julian Burnside talking on the radio about children so desperate that they had attempted suicide while in asylum detention. It was heartbreaking.

I discovered today that my daughter wrote to the Prime Minister about it.

This is what she wrote.

To the Hon Tony Abbott MP,

On the 31^st of March, 2015, I was listening to Radio National on my way down to school with my dad. It was a Tuesday, and a normal day. On the radio, a lawyer called Julian Burnside was talking, and he caught my attention. He was talking about the effects of offshore detention on children, my age and younger. Right now, 133 children are being held in immigration detention facilities within Australia, and 107 are held in detention on Nauru. He was telling a story of a young girl and her family. This girl was 11 years old. To put this into perspective, she is 2 years younger than me.  She had come over from Iran to seek asylum in Australia, and had then been sent to one of our detention centres, with the rest of her family, for 18 months. She was horribly mistreated here, abused by guards and under-nourished. They came to live in Australia, because she was in such a bad way that she needed psychiatric help. Here, the 11 year old child hung herself with a bedsheet. They took her to hospital. At hospital, no one was allowed to visit her because ‘visiting hours on Nauru were from 9am-5pm’.

If an 11 year old child is trying to KILL herself, because of what us Australians are doing, what does that mean? Because of Australians, because we lock people away who just need safety and help, because of our law, children are trying to kill themselves.

There is another girl right now, 5 years old, who is in Darwin. She has been told that she has to go back to Nauru, back to the place where she was treated how no child should be treated. Back to her nightmare. This child is also suicidal. This 5 YEAR OLD CHILD is trying to kill herself. And why? Because of what our law has done to her.

Julian Burnside went on to remind us that seeking asylum is not illegal. Nor are these people criminals. You and your government claim that by keeping the ‘criminals’ in offshore detention that you are protecting Australia. Do you think that a 5 year old child, who wants to kill herself, is likely to be more of a danger to Australia or to herself? Do you think that sending her back to Nauru, to ‘protect Australia’, is worth her life?

I can’t get my head around the fact that while I live my life, while I get driven to school by my dad, while I enjoy normal Tuesdays, children younger than me are killing themselves. And there’s nothing I can do. But you can. You have the power to save people’s lives. You can do more than I can.

It is your government that is doing this to human beings. It is your law that makes children kill themselves. It is our narrowed and stubborn minds that mean innocent people die. It is Australia that needs to save lives.

Get your act together Australia.

I look forward to hearing your response.

Yours sincerely,

Imogen Senior, (Age 13)

Why Private Health Insurance won't improve our health

As we play "will-they won't-they" on the GP Copayment – currently rumoured to be dumped, but with the Medicare rebate frozen, that’s just a slow implementation of the co-payment. Health care costs keep rising, and presumably the government know this as they’ve just agreed to allow increases to Private Health Insurance premiums by an average of 6.2%. They rose by an average of 6.2% last year, too. 

Of course, your tax subsidises this to the tune of over $6bn (yes, billion). Governments see Private Health Insurance (PHI) as being an important part of the health system mix in Australia. One of the budget KPIs is to maintain the number of people covered by private health insurance hospital cover. As well as rebates of 30% of the premium, the tax system penalises high income earners who don't take out health insurance. And Peter Dutton, the former health minister, can even be seen spruiking health insurance.

What do the co-payment and Private Health Insurance mean for health policy?

Combining a liking for co-payments and PHI, this is my prediction for the worst case direction of future health policy under the current government:

1. Introduce co-payment somehow for seeing a GP. {Evidence – it’s happening right now}
2. Watch as Private Health Insurers and their members argue that clearly co-payments to see the GP should be covered by Private Health Insurance {Evidence – PHI already lobbying government on this}
3. Bow to this pressure – it’s only what the public want. Allow Private Health Insurance to cover General Practice. {Evidence – Government already allowing trials of this in Brisbane}
4. Private Health Insurers compete for customers by offering favourable access to GPs, and paying GPs more than they get from Medicare. {Evidence – this is the basis of the trial in Brisbane. Admin fee paid to practice, 24 hour access guarantee for members}
5. GPs opt out of Medicare system, as they get better paid and easier access to referral networks {Evidence – compare specialist care in public and private systems}
6. IPA, Private Health Insurance Companies and their customers argue they pay PHI so should be able to opt out of Medicare altogether. {Evidence – this would be the small government libertarian position}
7. Medicare gets progressively underfunded and seen as a second rate safety net rather than a universal health system. {Evidence – it’s already referred to as a safety net}

A look at Private Health Insurance through a lens of who actually needs good health care the most shows why this progression needs to be resisted.

Who has Private Health Insurance?

The Private Health Insurance Administration Council collect excellent statistics about PHI coverage.

Nationally, about 47% of Australians hold hospital insurance coverage. It has gone up slightly each year since 2010, and is fairly constant across the states (with more in the ACT and fewer in the NT).

 

Looking at insurance coverage by age, we see fewer being covered in their late 20s, and a big drop in coverage in the elderly.

 

Who doesn't have Private Health Insurance?

It's a statement of the obvious to say that those who don't have health insurance are those who can't afford the premiums. And that would certainly be true.

 

So, as people are more advantaged, they are more likely to have PHI (orange boxes increasing) and less likely to have a concession card (blue boxes decreasing).

This is all very well, but it is a well know fact that the more disadavntged you are, then the more health problems you have. (I am writing another post all about this, but you can see the stats before I write). 

The area in which this is most well known is in Aboriginal and Torres Strait Islander health, where the statistics are well known. Less well known is that only 15% of Aboriginal and Torres Strait Islander people in non-remote areas have Private Health Insurance. This is Australia's specific example of the Inverse Care Law that applies generally. Those who need health care the most, get it the least. 

Health Costs

Private Health contributes less than 8% of the total health spend (less than half the amount contributed by individuals themselves in out of pocket costs).

 

 What does Health Insurance buy - "For our members"?

Private health insurance have a difficult time selling you something in a universal health system. If the health system is going to give you high quality, timely care when you need it regardless of your ability to pay, what can they offer? This, I suspect, is one reason why the government want to turn Medicare into a safety net, rather than a universal health system - to generate a product to sell for profit. Private health insurance need to be able to convince you you're getting something you wouldn't otherwise get. That's why it's always "For our members." Here are the options:

• Earlier access
  This is the big one. Private Health Insurance companies know that their main selling point is priority access. Waiting times in the public system are subject to a fair amount of political pressure, but everyone knows insurance will get you seen earlier. The boss of Medibank told the AMA that Medibank members should be given priority in the emergency department. There's a trial going on right now in Brisbane between a group of General Practices and Medibank to give priority access. The ability to see a doctor earlier - independently of your need – is the main product sold by Private Health Insurance.
• Access to Allied Health
  This is another major one. Seeing a physiotherapist, or an exercise physiologist, or a dentist or a psychologist can be difficult in the public system, especially if it’s not part of a hospital admission. Medicare will only cover a limited number of these in particular circumstances.
• Higher quality health care
  You will receive high quality health care pretty much anywhere you go in Australia. That is, yes, you will always find people who are unhappy about their care, but health care is complex, and things will go wrong. However, public or private systems have no monopoly on things going wrong. And often, when things go wrong in the private system, people are moved to the public system for it to be corrected.
  It's also worth remembering that in hospitals, it is the public system who is usually involved in education and training of future health professionals, which can make for high quality (and can also look inefficient on a balance sheet!)
• Friendlier staff
  No health professional goes into their job wanting to be rude. It's stress and burnout that make this happen, which comes about from expecting too much of staff while giving them too few resources to do it. That's why staff ratios might be good and cases less complicated. It's easy to be friendly then!
• Nicer rooms
  This is often the case in the private system (though not necessarily if the public system charges your insurer for their services). I don't see any reason for not having nice rooms in public hospitals. It just seems to be that we are happy to see out insurance premiums pay for it, but not our tax. Which seems sort of odd to me.

Remember that having private health insurance doesn’t solve all your health care problems. Most policies are subject to exclusions – are you covered for having a baby? Mental illness? You are with Medicare! There are also significant patient copayments, which are often unclear when the policy is taken out or when you start treatment.

We can see that private health insurance companies, and perhaps politicians who want PHI to take the pressure off the public system, and perhaps health professionals who might be paid more privately than in the public system all have an interest in ensuring that the publically funded system has long waits, limits to the professionals you can see and happens in less pleasant environments. Often this won’t be explicit – it may even be subconscious – but results in thinking of the public system as a safety net, not a universal system.

Summary - why private health doesn't improve population health 

We've seen that Private Health Insurance is mostly bought by those who can afford it, who, by a happy coincidence are also those who are likely to be the healthiest. Clearly, there's not too much profit to be made by paying out on insurance for people with more conditions, or needing more complex case management.

So when we pay over $6bn in tax rebates on private health insurance premiums, that's money going from our tax to those who are already well off enough to afford PHI premiums. But not to those who have most illness or the most need of it. That money can't help Close the Gap, for example, when it has no way of reaching the 85% of Aboriginal and Torres Strait Islander people in non-remote areas without Private Health Insurance.

And when we allow Private Health insurance premiums to rise by 6.2% each year, but freeze Medicare revenues, that's paying more each year for the health care of those who need it least, while ensuring a cut in real terms for those who rely on Medicare, and ensuring they will have to contribute out of their own pockets. General Practices will gradually have to move away from communities that can't pay to those that can.

When we allow Private Health to sell a product that allows us to jump a queue on the basis of our ability to pay, rather than our clinical need, then that moves those better off and less likely to have high health care needs to the front of the queue. This already happens in the hospital system, and will happen in General Practice if we allow it. Freezing Medicare rebates makes this more likely, as the only source of revenue to keep practices viable is patients.

And eventually, if Medicare is a safety net unused by those who are better off (where more political power lies) then it will be allowed to gradually wither as it serves only those without money, power or influence.