Things they didn’t teach in medical school: Part 31 Advocacy

One of the things they didn’t teach in medical school is advocacy. There are different meanings for advocacy – in this case I refer to the broader meaning of advocating for patients and communities to achieve an end to their benefit. An example might be supporting the funding of a new drug or campaigning for increased resources for a hospital.

Simplistically advocacy can just be about being vocal but there can be problems with this approach.

To be an advocate it is important to be able to see all points of view so as being able to bring a cogent argument to the table. Often times advocates are dealing with political situations and positions and invariably these become polarised – it is important to diffuse this polarisation to get the party with whom one is lobbying to also be able to see the arguments in favour of your position. Advocates need to be prepared to compromise to achieve small but important wins rather than overnight revolution.

Advocates need to be careful about their motivations for lobbying. For example it is not uncommon for drug companies to ask doctors to provide support for a new treatment. If this happens there needs to be transparency about the reasons for lobbying and full disclosure of any conflicts of interest.

Similarly advocates need to be careful that their lobbying is not seen as some form of whistle-blowing – this is because some employment contracts prohibit this activity. In this case being part of a community of advocates is important. There is strength in numbers.

There are many tools for advocacy – the main one is conversation and the new medium for conversation is social media. Mastery of social media and branding the advocacy message is a new skill for the medical graduate advocate.

Could Taxing Alternative Medicine Help the Health Budget?

Australia, like many parts of the world, has an approach to alternative medicine and therapies that involves turning a blind eye to therapies that at face value seem harmless and able to be regulated with a lower level of rigour than conventional medicines. These therapies provide often provide false hope for patients with life threatening illnesses like cancer. Equally they are misleading for less immediately life-threatening problems. My wife is constantly receiving spam/junk advertising for weight loss programs that promise unrealistic weight loss – some of these have been in the press for serious side effects (and of course no weight loss except that attributable to the complications).

The alternative therapy industry is critical of the profit motive of ‘big pharma’ but these guys could equally be called ‘big herbal’. Australia spends approximately 9-10 billion dollars per annum on conventional medications and direct costs to patients accounts for 10-15% of this. Yet in 2005 more than 3 billion was spent on alternative therapies. If Australia parallels the US then current expenditure on alternative therapies might be 6 billion dollars or more.

A tax on these therapies – which bear minimal costs for development and proof of effectiveness and which rely predominantly on marketing for sales – could potentially raise enough funds to save 5% on the national medicines budget. There is no reason why a tax couldn’t be imposed – the government does it for tobacco, alcohol and luxury goods. And realistically – isn’t alternative medicine a luxury good.

Oncology versus palliative care

So I’ve just read this article in KevinMD about oncology and palliative care: The Tension Between Oncology and Palliative Care

Whilst I agree with the overall sentiment I think we can generally do better. First of all – this isn’t an issue unique to oncology – it is important for all sub-specialties and all patients/consumers where end-of-life is an issue.

Secondly this is a societal issue. Bottom-line is that nobody lives forever and so thinking about these things is important for both individuals and society. Society needs to get beyond the notion that technology trumps death.

Thirdly we need to move beyond palliative care as end-of-life care to the notion that supportive and symptomatic care is useful throughout the whole illness. This will both improve outcomes overall and prevent harm.

In an ideal world there is no oncology versus palliative care, there is just care.

Local, smocal

So apparently Tony Abbott is blocking the referendum on local government http://www.smh.com.au/opinion/political-news/coalition-delivers-blow-to-local-government-referendums-yes-campaign-20130702-2p8we.html

I’m not sure that I have a problem with this.

Australian Government is built on the notion of subsidiarity. The Oxford English Dictionary defines subsidiarity as the idea that a central authority should have a subsidiary function, performing only those tasks which cannot be performed effectively at a more immediate or local level (ripped totally from Wikipedia).

The Rudd healthcare reforms are underpinned by the principle of subsidiarity and yet the reality is the local health districts (LHDs) control some of the decision making yet in reality the State and Federal governments control the dollars and well…you can’t do healthcare without those dollars…so despite decentralised decision making the control is still centralised.

So if Tony is blocking the referendum…think of it in this context….subsidiarity can cause as many problems as the perceived benefits…..for the KRudds of the world it might just be for appearances not substance.

Enough choppy choppy: how about spending a dollar to save a dollar in health

So I work in health and well to be frank health is not exactly thriving.

I am associated with 3 public hospitals with a collective EOFY debt of around 50 million dollars. The way the powers want to catch up is with cuts. But the problem with cuts is that it doesn’t actually deal with the fact that service needs to be delivered.

People being to hospital costs money so the logical way to deuce expense is to stop people being admitting to hospital is to reduce admissions. The only real way to achieve this is to stop people being admitted to hospital. The only way to achieve this is to provide outpatient services that otherwise meet the inpatient demand.

The problem is that ‘new’ outpatient services is a new expense and the system can’t countenance that.

Well I think I fact of life is that sometimes you have to spend a dollar to save a dollar.

The real issue is that health services want business cases: well tell me how much you are willing to spend to save a dollar. I’ve heard one dollar for 3 saved but this is a clowd-cuckoo-land number. I agree 1 for 1 isn’t a gain but 1 for 2 is a tangible benefit

Regardless of the breakpoint let’s get a number to inform our business cases.

Things they didn’t teach in medical school: Part 30 Continuing the conversation after the consultation

One of the things they didn’t teach in medical school is how to continue to the conversation of the consultation after the actual physical consultation is over. Supposedly shared decision making leads to better decision satisfaction and outcomes but what happens once the patient leave the consulting room.

In some cases they leave with a pile of printed information. They may have taken their own notes. Or a carer may have taken the notes and been the second pair of ears. But I know the wrong messages may have been taken away or there will be lots of questions.

One way to deal with the problem is to ensure that the patients have had an opportunity to ask the questions in the first place – question prompt lists can help with this.

Another potential way is to provide a record of the consultation. This can be a written summary or alternately it can be an audio record of the consult. Some doctors are set up to do this but these days it most commonly happens when patients ask me if they can record the conversation and then they use their mobile phone.

An alternate potentially useful method is to develop your own resources to refer the patients to. I’ve just started, albeit extraordinarily slowly due to time commitments, to develop videos using the Explain Everything platform. Hopefully my patients will find these useful both for innformation about their treatment and to inform decisions.

Here is my talk on Xeloda Side Effects

Things they didn’t teach in medical school: Part 29 Building Things (incl. organisations)

One of the things that we can do, regardless of our profession, is build stuff and make things better. For me, this is what people in civil societies do – build stuff and make things better. Most of the time we do this as cogs in the machine but many of us have the opportunity to actually do things that make major changes and one of the ways we do this is through building organisations that support our ends.

You may want to start a new organisation right from the beginning or perhaps you need to change, grow and improve an existing organisation. Nobody teaches you how to do this at medical school.

What I’ve learning being involved with a variety of non-government organisations and businesses is to define the purpose of the organisation upfront. This doesn’t mean the purpose can’t change over time when the organisation needs to adapt to circumstances. Clarity of purpose means being clear about what is the product or the organisation. In recent times the digital revolution has seen a number of companies like Kodak essentially disappear. Kodak thought it was in the business of making film and cameras but actually it was a communications business.

By knowing the real purpose and product of a business one can then focus on the means to achieve the ends. This is strategic things that can be applied to many things that aren’t taught in medical school.

And remember – Rome wasn’t built in a day.

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