A patient, only described as aggrieved, is ushered into my room before I have had a chance to find out more. She is a woman in her early 30s, accompanied by a frazzled husband who is responsible for minding twins in a pram and jotting down notes. By the way she grips her chair, I can tell that her emotions are barely controlled. I introduce myself, and her opening salvo is: “And how much will you charge to hear my story?”
“Nothing”, I reply, puzzled by her biting tone. “You are in a public hospital”, I add, by way of explanation.
“So, there is no bill?”
“No, your taxes keep me going”, I smile, but my attempt at levity elicits only a burst of tears. “I didn’t mean to upset you”, I apologise.
“It’s not you”, her husband sighs.
She had recently discovered a breast lump that resulted in her local doctor sending her to a surgeon who ordered a host of tests to confirm a cancer diagnosis. Every single test was expensive, she says, and I immediately know where this is going. I hear the rest between sobs and curses.
Surgery was scheduled for a week later and was subsequently marred by a complication that required a second operation. Her basic private insurance proved too restrictive, and her stress grew in line with the mounting cost. On discharge, she lacked adequate wound care or communication.
The final straw came when she begged her neighbour for help, who told her that she could have had the same surgery at no cost in the public hospital and been followed by a nurse on discharge.
Through more tears, she flings a flurry of questions at me. “Tell me, did I just lose thousands of dollars on shoddy treatment? Why wouldn’t someone tell a patient that down the road there is a public hospital that would do the same thing for free? What happened to a doctor’s morality?”
Pausing to order my own thoughts, I tell her that I am sorry for her experience. Having never met her surgeon, I can’t account for his thinking, but her surgery itself wasn’t shoddy and the complication might have occurred anywhere. I observe that it is the rare patient who doesn’t want a breast cancer instantly gone – some women view the cost of rapid access to a private surgeon as necessary and worthwhile; other women, through circumstance and choice, rely on the public system, where incidentally, they are treated with the utmost urgency too although the wait can be somewhat longer. Whether a small delay impacts survival is debatable but when it comes to cancer, facts can take second place to emotion and visceral fear and surgeons can feel particularly pressured to “do something” to mitigate this.
She looks skeptical; I think to myself that in treating her, the surgeon made certain assumptions, namely that a patient referred to him, and not to the public hospital, had already had this discussion with her doctor. That she would be aware of, and willing to, meet the considerable expense of surgery. But actually, the patient had no basis on which to work through these layers of complexity. She had cancer, she wanted it out and was willing to do whatever it took. This isn’t unusual. According to a recent ABC investigation, a quarter of patients who responded to a survey had out-of-pocket expenses of more than $10,000. A third had not been informed of these expenses prior to surgery. This happens in a country that has a generous universal healthcare system with some of the best outcomes in the world.
“Doesn’t this bother you?” she asks defensively. “Doesn’t it bother you that your colleagues are unethical?”
I can’t tell her how much it bothers me that more money did not buy her better care. It bothers me that there was an egregious lack of informed consent. And it especially bothers me that the conduct of a few tars the many in medicine who are motivated by service, not avarice. While some people think steep medical fees are unscrupulous, others call it doing business. After all, if the market will bear it, why not charge? But in my opinion, doctors have a duty to know that the business of healthcare is like none other. There is such gross asymmetry of information between doctors and patients that it is near impossible for a patient to wade through the options. Is robotic surgery better than the traditional way? It depends. Is it better to wait and watch or operate now? It depends. Is the surgeon who charges six times more than his counterpart worth it? It depends.
This reminds me of an apocryphal story that is both humorous and telling. Once there was a specialist who grew old and wanted to close his practice, but such was his eminence that the patients kept coming. So, in order to stem the tide, he doubled his fee. But the patients showed no sign of slowing down so exasperated, he doubled his fee again, thinking that no patient in their right mind would brook such excess. But to his dismay, he noted that this led to a surge in referrals as people assumed that the more expensive the advice the better it was. Disbelievingly, he went back to the original idea of putting up a sign saying he was closing for good.
Regulatory bodies can’t regulate the way patients think any more than professional medical groups can police individual ethics, but the Australian Competition and Consumer Commission offers sage advice to patients – know your needs, know your options and shop around. It is worth setting aside panic and heeding this advice.
As for doctors, it is not enough to yearn that society weren’t so disillusioned with us. Medicine really doesn’t need the bad publicity, and it is up to each one of us to scrutinise our actions, behave with integrity, and act collectively in the best interest of the patient. The ancient counsel of Hippocrates should ring loudly in our ears: Make a habit of two things – to help, or at least to do no harm.
• Ranjana Srivastava is an oncologist and a Guardian Australia columnist
