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Quality, Health Professions, Patients and the Market

Doctors do not share the same understandings about quality of care as the marketplace or as patients. This www page expands on the relationship between doctors, the market, the community and patients as it effects quality. Doctors are repeatedly criticised for their failings and undoubtedly some of these criticisms are valid. To what extent can they be blamed for this?


Samuel may be thinking of the professions rather than the market when he talks of being unresponsive to consumers in regard to quality issues. He clearly sees "quality" in terms of what the consumer wants or demands. This is how the market thinks. Health care professions see "quality" in a rather different way. This confusion arises because quality is an imprecise word and has different meanings for different people in different situations. Standards is a better word as it requires that the content, parameters, and limits of applicability in each context be defined. The latter word is more threatening and is seldom if ever used in the marketplace.

I partly agree with Samuel but do not think that it is a valid criticism? It is easy to see why the market has failed. We can readily identify profit, competitive pressures and the lack of power of the consumer as the reasons why the market in health care has failed citizens and the community. We need to look at why professionalism has failed or apparently failed to respond to consumers.

The profession has a much broader social responsibility than simply to meet market or consumer expectations. Its responsibility is to detect serious disease, treat serious disease, discover the causes of serious disease and whenever possible prevent serious disease. If people thought about it the most important thing they possess is their lives, their physical and mental well being. The professions prime concern in its interaction with the public is to pick out those cases where there are serious problems and something can be done or needs to be done. Every doctor's fear is that she will miss something and that someone who has placed their trust in her will die as a result. This is not to suggest doctors be rude, unsympathetic or non responsive to the wishes of the patient who will still be given final choice and responsibility.


The hard reality of medicine and the retrospectoscope is that missing diagnoses which would have saved a life will happen not once but a number of times in the career of each doctor. This will be associated with feelings of guilt and sometimes blame by the patient. Medicine is not yet an exact science and it is easy to look back and say "of course". Each doctor is ethically required to confront this honestly, personally and before colleagues in an attempt to keep these situations to an absolute minimum. This to them is the real face of medicine

I am naive enough to believe that when you have established an honest relationship you can do exactly this with the patient as well. You can talk about the decisions and where you went wrong. I have never been sued for doing so, but have been threatened when I have been unable to do so. Behind my idea of an integrated health service run cooperatively by community and profession is a belief that this sort of honesty and trust is a far better basis for building a health system than the marketplace proposals which seek to "reform" health care by fostering distrust. I like to think that the community would respond to this.


The vast number of medical encounters are for comparatively minor problems which the public experiences and for them this is the face of health care. Only once or twice in a lifetime will the patient confront a serious threat to his life and sometimes he will not realise that it was. If the treatment is effective the doctor who has correctly made the diagnosis will simply say that the treatment will cure it without creating alarm. She may occasionally have to be very confrontational and upset the patient to get the treatment message across. He will not like having his cherished but unrealistic beliefs overruled and may be unhappy even if cured.

The patient is unaware that the doctor is more concerned with this wider responsibility for his wellbeing than in responding to his particular whims and interpretations. From a marketplace perspective this demotion of market principles is unpardonable but from a professional perspective the doctor is meeting her responsibility to the patient and society. This is not to suggest that she should not be responding to the patient to the best of her ability, but responding to the demands of the "consumer" may not be in the "patients" best interests. The patient whose "demand" is not met may be very angry. It is the professional's responsibility to accept that anger and the financial impact a disgruntled patient has on her practice if she is doing so in his best interests.


The corporate director has a prime responsibility to shareholders rather than customers or patients. Many if not most company directors will not allow care considerations to stand in the way of responsibility to share holders. This is clear from the US experience. They do not do it deliberately. They develop explanations which allow them to do so without experiencing discomfort. The corporate director will not tolerate doctors who upset patients by refusing to meet their demands. Unhappy patients don't help the bottom line. These doctors are "disruptive".

The health care professional has a prime responsibility to the patient's ultimate physical and mental welfare and to the welfare of the society which has entrusted her with this responsibility. She will not allow the demands of patients or fashionable public perceptions to override this responsibility.

There are therefore good reasons why the profession does not always respond to the marketplace or the desires of the customer or the public, and why on occasions it should strongly resist these. The response of the profession to managed care in Australia is an excellent example.

Professionalism does have a responsibility to challenge and explain. It should give way when contrary arguments are logical, sound and supported by good evidence. Marketplace medicine is not sound or logical. The evidence presented is derived from areas which are not comparable and the evidence from health care itself is ignored.

Society's desires are not the ultimate determination of what is desirable. To suggest this is to suggest that the profession should have acceded to antisemitism in Germany and to apartheid in South Africa. While it certainly bent to these forces, much as it has bent to market forces, a hard core of professional values maintained a constant challenge to the ideologies which dominated these societies. The professions have provided a hard core of resistance. They continue to do so in the face of economic rationalism.


There are other problems which have caused the medical profession to retreat behind a protective laager. I have already mentioned the unprecedented attack on the profession by market advocates and politicians, frustrated by the professions unwillingness to abandon its professional heritage in the face of their demands.

There is another problem and this is the problem of knowledge and expertise. It is simply no longer possible for one doctor to know enough and have enough skills to provide the service each patient requires, yet the patient often expects this and the doctor feels that she is supposed to know. Even a specialist in an area may not recognise or know of a condition with which another is familiar. The doctor's sense of self and the patients confidence place strong pressures on the doctor to be the authority and "know". The consequence of this is that members of the profession are repeatedly found to have failed. Patient's get told one thing, which is then contradicted by someone else. They go on a merry go round. Another doctor or perhaps a practitioner of alternative medicine eventually becomes the hero. The others are labelled as incompetent, and the professions standing is eroded.

This same problem means that pharmacists, physiotherapists and others are also repeatedly confronted by perceived deficiencies in members of the medical profession in their particular area of medical expertise. They become very critical. Clearly doctors cannot all be well informed about each of these areas, but it is human to be defensive. At the same time these paramedical groups do not always see things from a broad perspective. When these groups try to remedy the deficiencies they see by moving to offer their services this is seen as a threat and a turf war can result - particularly when there is strong market competition.


What I have suggested is an integrated system which can bring the various groups out of their defensive laagers to address these problems.

With speech recognition now a reality computer based records are in my view essential. Technology, while it is a long way from replacing doctors does provide a means of screening what is happening and prompting when necessary. It does not replace judgement. The potential to assist clinicians is enormous.

The organisation of care along the lines of clinical services with technological communication threads into each geographic situation would go a long way to addressing these problems. A single GP in a rural town would be a peripheral meeting point and represent all services in her area. She would have access to each service for assistance and each service would be there monitoring to support, prompt, and help her in what is an extremely difficult task. Because the community would be involved in such a system they would have access to and be part of what was happening.

It is clearly wrong for doctors to be providing services when these can be done equally well and at less cost by less trained people. I don't have difficulty in the blurring of roles in a system which can accommodate that and ensure that those carrying out care are capable, by training or experience. I don't have difficulties with movement between the health professions. The new medical courses where nurses and physiotherapists are training as doctors is a step in the right direction.


Samuel claims that competition will facilitate public information. Experience from the USA shows that competitive pressures discourage the provision of any information which compromises corporate interests, and encourages the provision of information which presents a positive image of the corporate group and is in their business interests. Education is an important vehicle for recruiting patients and is therefore often skewed in the interests of the corporation.

The extent to which corporations will misinform is revealed by the way in which they have used "front organisations" which profess to represent citizens to lobby politicians, market their point of view, and develop a pro-market feeling in the community. Citizens have no idea that what they are seeing on TV or the www is a corporate funded marketing exercise. Citizens accessing one of the largest educational sites on the www are not told that it it owned by the hated Aetna Healthcare.

The way the market informs is well illustrated by the psychiatry books published for public use by Tenet/NME. They were intended to generate a market by increasing anxiety. They were marketed to psychiatric hospitals as "books as hooks" on the basis that by selling these on to families they would secure more psychiatric admissions. I have already mentioned their school fairs and other educational seminars - all very popular in the community.

In 1986 while visiting the USA my wife was spooked by all the publicity about drugs spreading across the world. Much of this probably emanated from the psychiatric corporations. She bought an advertised book. It was written by a psychiatrist, a Dr Gold. Its title and content simply stimulated anxiety and marketed an 800 hot line for help and advice about drugs. It was widely praised in the community and promoted by a number of community groups. Dr Stuckey who died on his boat in New Jersey in 1992 before giving evidence blew the whistle on this doctor. The hot line was one of NME's strategies for persuading unsuspecting and wealthy families all over the USA to fly their teenagers to the highly credible and well advertised Tenet/NME substance abuse hospitals in New Jersey and Florida. Dr Gold and a colleague commuted between them. Dr Stuckey described the care which was actually provided. Both doctors were eventually charged by authorities but I do not know the outcome.

I have already described the "why stop here" marketing by Columbia/HCA, the misinformation by Sun Healthcare and the failure of HMO's to properly inform medicare patients.

I suggest that my proposal for the community and the profession working together for the benefit of citizens would provide a vastly superior system of education to one which works for the benefit of shareholders.


One of the benefits claimed for managed care is its greater focus on preventive medicine. The Australian Consumer Association saw this as one of the benefits and they did not at the time oppose managed care which they called "managed scare". In the USA the market focus was on disease and profit from treating it. Its health service was therefore focussed on treatment rather than prevention. Managed care has it claims addressed this problem, but at the same time it found these preventive health activities a good place to market its policies to healthy people less likely to need them - it helped in cherry picking. HMO's market in health clinics but not in aged care homes or bars where people smoke and drink.

Australian medicine is also accused of paying too little attention to prevention and this is a valid criticism. Attempts are being made to address it. I like to think that the sort of system which I have hinted at as an alternative to the market would perform much better as a medium for practising preventive medicine. The involvement of the community would be a big plus.



This page examines the issue of quality and the market. It considers the different meanings attached to the word quality by different groups in different contexts. The use of the word "quality" is a problem in itself and symptomatic of something much deeper. The page points out that the only groups which have acquited themselves credibly in the face of severely dysfunctional conduct have been the patients, their relatives, the community, and a number of more junior employees. In the marketplace these people are powerless and lack credibility. If we are to design an acceptable health system then these people should be intimitely involved in all parts of it.

CLICK HERE -- to examine the impact of marketplace competition on "quality"

Trust,The Market and Professionalism

This page examines the way in which the market has corroded the values and ethics of the professions and induced doctors to place care for the corporation ahead of care for the patient.

CLICK HERE -- to examine the impact of the market on professionalism

Professionalism - response to economists criticisms

This page acknowledges that professionalism has failed on a number of occasions and more so recently. It explores the reasons for this and argues that the meaning systems and the values which form the basis for professionalism are sound. Professionalism has failed when confronted by powerful forces which introduce meaning systems which are not congruent with professional values.

CLICK HERE -- to explore professionalism and the market at this level.

Understanding the corporatisation of health care

How we understand the situations in which we find ourselves has a profound influence on the way in which we behave. This page explores this issue and develops a framework of understanding from which to examine the corporatisation of health care. This provides a frammework of understnding from which to examine the behaviour of the market, the profession, patients and the politicians who make decisions.

CLICK HERE -- to explore this perspective

Central Map ..... Initial Map ..... USA Map ..... Australian Map ..... International Map ..... Corporate Practices Map..... (to print)
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This page created October 2000 by Michael Wynne