When do we draw the money line in medicine? (1 Viewer)

[Medman]

After having spent so many years in medical school I have experienced the mostly ineffective and inefficient public health system of today. Doctors abide the "Hippocratic Oath" of do no harm for individual patients. I raise the ethical issue of what about the population as a whole? If money was not an issue and we had an infinite supply of this resource healthcare would be awesome. However, we live in a society where money is a finite resource and increasing media pressure to achieve best outcomes for all patients.

I pose this scenario to evoke your thoughts on this issue. A 26 year old female who was diagnosed with liver inflammation due to her own body attacking her liver. She was put on drugs to suppress her immune system so her liver could recover. This disease could be a self limiting illness and some people after a few years can be weaned off drugs. She doesn't attend follow up appointments to check on her the status of her liver and does not take her medication. She now presents to hospital with liver failure and is going to die if she does not receive a transplant. The cost of a liver transplant is expensive, ten's of thousands of dollars and given her non-compliance in the past, what if she does not abide by advice once again and end up "wasting" this gift of a new liver.

Taxpayers money are being spent on portion of people who are not listening to doctor's advice yet expect the best treatment to manage their now ailing condition. Right now, we treat these people just like any other person in the public health system, the sickest as our priority. An extremely sick person could potentially spend more than what they have paid taxes in their lifetime to treat their condition. I understand most people do listen and take on board advice and do their best to manage their condition but what happens to the ones that don't listen and end up sick and costing the public health system hundreds of thousands to millions of dollars? Could this money be better spent elsewhere?

I have seen plenty of people being ignorant to advice, a guy who had a kidney transplant which is now failing because he didn't take his drugs, a diabetic whose problems arise from her weight yet refuses to do anything about it, autoimmune patients who don't attend follow up appointments to check their disease and adjust their medication and the list goes on and on.

 

[bangladesh]

You've mentioned a very significant issue, but what do you suggest? There isn't much that can be done about someone who for example as you said has received a kidney transplant and doesn't take his medication causing it to fail. Firstly, how can a doctor determine whether that patient is going to take his medication or not? Secondly, even if the doctor knows that he's not going to take his medication, Should he just leave him and not treat him?(assuming he had the right to do that)

 

[Medman]

I think if the patient has been educated and still refuses to listen and as a result progresses in their disease they should take responsibility for their actions. Meaning the public system should only partially fund their necessary procedures instead of funding the whole amount. If they can't afford it then they can be treated symptomatically and they can be assessed by a tribunal to see whether they should be allowed to once again use public health resources.

There are better ways to use the money, for patients who are willing to go for treatment and want to continue to contribute to society. A hospital recently had to stop surgeries for a cancers because their costs exceeded their budget. What if we could redirect money from the non-compliant patients who put themselves in that situation and treat people who truly want to be treated. This might sound harsh but because resources are limited you need to make these difficult decisions and it can't be to everyone's benefit.

 

[bangladesh]

What if we could redirect money from the non-compliant patients who put themselves in that situation and treat people who truly want to be treated.

I can see your point here but I can't see how that'd be practical? You can't deny someone treatment based on the fact that they might later on decide not to take their medication resulting in a kidney/liver failure and thousands of dollars to go down the drain.

 

[nerdasdasd]

Can I also add that... Why should we treat people who choose to screw up their livers and health... E.g. Obese people, addicts and drugs. Because that does waste $$.

 

[bangladesh]

Can I also add that... Why should we treat people who choose to screw up their livers and health... E.g. Obese people, addicts and drugs. Because that does waste $$.

lol.. not sure if srs.... are you actually legit about this?

So we don't treat them and let them die? What if their death causes grief issues for their relatives requiring them to get therapy and ends up costing the government way more $$ than treating the patient would? What if we treat the 'fat person' and they adopt a healthy lifestyle afterwards and then contribute to the society more than you or me ever could? What if that 'drug addict' has just made the wrong decisions and realises what he has been doing to himself after he develops a serious health issue and changes his lifestyle?

 

[Xt]

As you have mentioned in the beginning of your post- your patient is your priority, not the population. If you feel strongly about the issues you have raised, you may want to move into politics, admin, or public health roles.

 

[Medman]

There's a lot of what ifs, we don't base decisions on what ifs. We base it on statistics and my guess is that statistics would show a certain population contributes way less to society than their value in society. Like I said money is a finite resource and you have to choose where to best put it. amirbang your altruistic nature is respectable but basing decisions on what ifs will not solve any broader issues in society, you need to analyze the issues and make the right judgement.

The problem with denying treatment to patients who are obese, smoke, take drugs etc. are that these cannot be picked up with 100% accuracy. Obese people can still be healthy, BMI is a poor measure of morbidity and mortality. Instead aerobic oxygen usage is a better indicator of health for individuals but again who has the resources to perform this test on everyone and even then it isn't 100% accurate. People who smoke or take drugs can deny taking these drugs, urine screen are not 100% accurate and there are false negatives.

I'm saying we should be basing treatment options on their previous decisions not if it's a new patient. If they refuse the help and ignore advice then we should draw a line somewhere and say sorry we can no longer fund your other treatments.

Politics, admin and public health is a lot of talk and no action. Democracy results in ineffectiveness due to the red tape. Ultimately, I would not like to work in a public hospital so it wouldn't matter to me anyway but I just wanted to raise this issue to see who else has the same thoughts. I would personally like a system that has both a mix of USA and Australian health systems.

 

[Futuremedstudent]

Hi,
sorry if this is irrelevant.
How long does it take to become a specialist and how much would one earn once they become one ?
Thanks

 

[Medman]

Hi,
sorry if this is irrelevant.
How long does it take to become a specialist and how much would one earn once they become one ?
Thanks

8-9 years minimum after graduation if you're smooth sailing. These type of people know what specialty they want to pursue when they enter med school and do research, publish papers and make contacts in their relevant specialties. Even so, these days these people are missing out because pretty much all public hospital consultants need a PHD now. If you include a PHD that's another 3-4 years. I know of a Dux at Monash who trained to be a gastroenterologist, graduated last year is now doing a PHD so he can get a public hospital consultant position. If you don't get a PHD and go private you will probably earn 300-500k a year if you work hard and it also depends on the specialty. If you're a public consultant and also do private work you can earn well over 800k+, but you will have limited time to pursue any other passions.

Due to the lack of specialty training positions now it will only get harder and harder.

 

[Futuremedstudent]

8-9 years minimum after graduation if you're smooth sailing. These type of people know what specialty they want to pursue when they enter med school and do research, publish papers and make contacts in their relevant specialties. Even so, these days these people are missing out because pretty much all public hospital consultants need a PHD now. If you include a PHD that's another 3-4 years. I know of a Dux at Monash who trained to be a gastroenterologist, graduated last year is now doing a PHD so he can get a public hospital consultant position. If you don't get a PHD and go private you will probably earn 300-500k a year if you work hard and it also depends on the specialty. If you're a public consultant and also do private work you can earn well over 800k+, but you will have limited time to pursue any other passions.

Due to the lack of specialty training positions now it will only get harder and harder.

Thanks

 

[Kiraken]

There's a lot of what ifs, we don't base decisions on what ifs. We base it on statistics and my guess is that statistics would show a certain population contributes way less to society than their value in society. Like I said money is a finite resource and you have to choose where to best put it. amirbang your altruistic nature is respectable but basing decisions on what ifs will not solve any broader issues in society, you need to analyze the issues and make the right judgement.

The problem with denying treatment to patients who are obese, smoke, take drugs etc. are that these cannot be picked up with 100% accuracy. Obese people can still be healthy, BMI is a poor measure of morbidity and mortality. Instead aerobic oxygen usage is a better indicator of health for individuals but again who has the resources to perform this test on everyone and even then it isn't 100% accurate. People who smoke or take drugs can deny taking these drugs, urine screen are not 100% accurate and there are false negatives.

I'm saying we should be basing treatment options on their previous decisions not if it's a new patient. If they refuse the help and ignore advice then we should draw a line somewhere and say sorry we can no longer fund your other treatments.

Politics, admin and public health is a lot of talk and no action. Democracy results in ineffectiveness due to the red tape. Ultimately, I would not like to work in a public hospital so it wouldn't matter to me anyway but I just wanted to raise this issue to see who else has the same thoughts. I would personally like a system that has both a mix of USA and Australian health systems.

No

You don't know for what reasons a patient is non-compliant and some of those reasons are far from invalid, as a doctor you are tasked with treating people, and doing no harm to your patient, you are not paid to judge your patient for their actions but to treat them in a way that does not discriminate. A patient might not be compliant with a certain form of treatment due to their cultural beliefs, due to being worried about side effects, not understanding the instructions for it's use correctly, or having a host of stresses that mean it is lower in their priority and they might sometimes forget to take it or not use it frequently.

Patients who opt not to get treatment or use it are completely within their rights to do so, doctors are not the harbingers of justice who choose whether or not a patient "deserves" treatment, all of this is dependent on what is best for the patient and what the patient wants,

 

[Medman]

^You haven't treated any patients have you? You have no idea how retarded some patients are. Cultural reasons and not being to understand instructions aside, it's the ignorance that ticks me off about patients.

So say for example your mother was diagnosed was cancer and they couldn't operate on her cancer because of budget constraints which is partly attributed to treatment being used on people I mentioned above. Would you feel the same?

 

[iBibah]

You have no idea how retarded some patients are

is it really your place to make such a judgement?

 

[Kiraken]

^You haven't treated any patients have you? You have no idea how retarded some patients are. Cultural reasons and not being to understand instructions aside, it's the ignorance that ticks me off about patients.

So say for example your mother was diagnosed was cancer and they couldn't operate on her cancer because of budget constraints which is partly attributed to treatment being used on people I mentioned above. Would you feel the same?

strong assumption to make, i haven't "treated" any patients as yet but i have had sufficient exposure to patients to understand that it is inappropriate to judge the reasons for why they might do things. It is a bit rude to call your patients "retarded", you're judging their decisions which is not your job as a doctor.

Again, that would be a classic case where a conflict of interest impairs your ability to practice, as a doctor, you are not supposed to prioritise your mother over any other patient. In other words, how you feel about a situation should in no way impair your ability to provide treatment to a patient who requires it. You cannot pick and choose who you treat based on who you judge, by some arbitrary measure that works irrespective of a patient's wishes or intentions, to be "retarded" or not.

 

[bangladesh]

please don't take too much offence from this, but the more you post on this forum, the more i start wondering how you got through the interview process and ARE TUTORING MED INTERVIEWS... You certainly would not freaking get a spot with that attitude towards health care and your patients..

 

[Medman]

please don't take too much offence from this, but the more you post on this forum, the more i start wondering how you got through the interview process and ARE TUTORING MED INTERVIEWS... You certainly would not freaking get a spot with that attitude towards health care and your patients..

Medicine creates cynicism. The things you witness astounds common sense. I know what the interviewers look for so I make appropriate suggestions to my students to say the right things.

As for my beliefs it has changed since I entered medicine. Medicine is not glorious, it is frustrating. Medicine is not about helping people, it's about helping patients make informed choices which, most patients agree with. However, there is a minority of patients that constantly ticks you off because they are wasting taxpayers money and are very thick. Do you really think doctors don't judge their patients? You are so ignorant and begs me to wonder what "exposure" you have had.

So who's to decide where the healthcare budgets are directed to? Oh wait that's right there's a board where doctors also contribute. If you think a doctor's job is purely limited to treating patients you are also an ignorant fool.

You guys are focused on the one issue, the smaller picture. I am focusing on the bigger picture, money's impact on the healthcare. That's the difference between doing well in the interview and doing poorly.

This is just food for thought. It may sound Draconian but I'm wondering if there is a way to prevent patient ignorance and let them take charge of their health, scare tactics etc. I'm not saying this system should be implemented but I believe a significant portion of taxpayers money are being wasted on potentially preventable problems. Would like to find out the actual number.

 

[Kiraken]

Medicine creates cynicism. The things you witness astounds common sense. I know what the interviewers look for so I make appropriate suggestions to my students to say the right things.

As for my beliefs it has changed since I entered medicine. Medicine is not glorious, it is frustrating. Medicine is not about helping people, it's about helping patients make informed choices which, most patients agree with. However, there is a minority of patients that constantly ticks you off because they are wasting taxpayers money and are very thick. Do you really think doctors don't judge their patients? You are so ignorant and begs me to wonder what "exposure" you have had.

So who's to decide where the healthcare budgets are directed to? Oh wait that's right there's a board where doctors also contribute. If you think a doctor's job is purely limited to treating patients you are also an ignorant fool.

You guys are focused on the one issue, the smaller picture. I am focusing on the bigger picture, money's impact on the healthcare. That's the difference between doing well in the interview and doing poorly.

This is just food for thought. It may sound Draconian but I'm wondering if there is a way to prevent patient ignorance and let them take charge of their health, scare tactics etc. I'm not saying this system should be implemented but I believe a significant portion of taxpayers money are being wasted on potentially preventable problems. Would like to find out the actual number.

1) lol that is helping people, helping patients make informed choices = helping people. Not to mention you come across as a tad patronising, most medical students I know are under no delusion of glory.
2) Instead of throwing around ad hominems consider the difference between judging a patient's decisions privately to yourself and letting it dictate your treatment of and how you manage that patient. There is a difference that you seem to be failing to understand. There is a difference between thinking to yourself and acknowledging to yourself that you do not feel the decision is the same you would make and it does not seem logical to you and outright controlling the treatment and management of a patient against their wishes (you have no right to refuse them medication and treatment if they want it and it is indicated in the condition they have). I've had enough exposure to patients in a GP and hospital setting to know that doctors who suggest things like you do and have no respect for their autonomy cause them much dissatisfaction and this definitely impacts on treatment and management of their conditions. In fact, this might be a reason they are non-compliant, because such an attitude reduces rapport and thus trust.
3) A doctor's primary purpose in their career is to promote better health outcomes for their patients, this is only possible if you respect a patient's autonomy, because such a nebulous term as "better health outcomes" can only be determined on the basis of what a patient wants, not by what you want for the patient.

Also btw, please do not lecture us about how to pass an interview, some of us did this completely on our own accord, and all this really does is kinda cement my view that you are patronising and arrogant and for little reason too as much of what you have said on this forum has been misguided.

4) If you are really thinking bigger picture then you would be considering prevention, how to prevent patients getting these preventable problems in the first place, rather than judging them with little information as to why they choose not to pursue your management and treatment plan and deliberately withholding treatment from them, which is in complete contradiction to the Hippocratic Oath

tl;dr if you're a doctor you are paid to help promote better health outcomes for your patients, not to be a judgemental dick who arbitrarily holds back treatment for patients they do not like.

 

[bangladesh]

Medicine creates cynicism. The things you witness astounds common sense. I know what the interviewers look for so I make appropriate suggestions to my students to say the right things.

If your students had some common sense and were passionate enough to read some medical journals in their spare time, then the interview process would be a breeze for them.

 

[Medman]

If your students had some common sense and were passionate enough to read some medical journals in their spare time, then the interview process would be a breeze for them.

So please enlighten me on what "medical journals" one should read for the interview. I have never asked my students to read medical journals in my 3 years of training students and they all have done pretty well.

Kiraken. Perhaps I have the surgeon mentality where patient outcomes are proportional to their effort they put in. This being said their lifestyle choices such as smoking, weight gain all effect surgical and medical outcomes. Is it not glorious to defeat disease and to bring a patient back from the brink of death?

Again your definition of a doctor is only about the smaller picture patients. So doctors shouldn't get a say in budgets of health? So doctors should ignore public coffers and treat patients as if we have an infinite supply of money? Normal practice in medicine follows a strict guideline to save the public system money. If we were to only think of "beneficial patient outcomes" all males would get a PSA test, everyone with GI bleeding would receive gastroscopies etc. Why do we not do these things? Money. I can understand you're resolutely against the idea of withholding treatment without understanding the situation but I have not said we withhold treatment but these patients need to come to appointments, receive treatment, get tested or the Government won't fund their treatment in which case they will have to pay a portion themselves. Ad hominem much? Perhaps you should analyse your own responses before accusing me of using ad hominems.

Straw man much? You're making an assumption that I do not give patient autonomy. Well I give them the autonomy to choose their treatment but I don't feel comfortable being doctor who will always "prescribe" them drugs to help them sort out their problems when they have deeper problems. I have met a lady who has visited the GP's office in over 20 occasions and refuses to solve her marriage issues leading to a destructive family life. The GP has consulted her more than 1hr in half of these consultations to get her to realise the root of her problems. She has not changed and constantly asks for antidepressants and other drugs to "treat" her problems. You may have patience for such patients but for me, I would not be able to handle it. I give them the autonomy to choose a different doctor.

I like to bring the issue of organ transplantation. We do in fact withhold organ transplantation for alcoholic patients. Patients in liver failure who has a history of alcohol cannot receive a liver transplant unless they have been 6 months alcohol free. You see my suggestion has already been implemented due to limited supply of resources. Is there not a way to extrapolate this to a broader scale?

GP mentality is great and you're entitled to your opinion. I still think it's a waste of resources to support people who are ignorant to their condition even after doctors have gone to great lengths explaining to them in great detail the consequences and importance of treatment. The problem is implementing a system which can differentiate these people so tbh I don't see it happening but I just wanted to hear what other people thought about this issue.