The last remaining closed shop union, the AMA, is resisting moves by the federal Labor government to introduce a national register for medical doctors. Union boss, Dr Rosanna Capolingua, has been quoted warning of “remote Canberra bureaucracies”:
And in fact, [it] may be more removed, more distanced from the coal face and work less actively, more slowly when it comes to acting where there is a doctor that is a rogue doctor.
There are very good public policy arguments in favour of federalism - including the principle of subsidarity which, given her allegiances, Dr Capolingua would be more than familiar with. But such arguments also include the principle of innovation and trial and error where different jurisdictions can experiment with novel policy approaches, which if successful, could be adopted nationwide.
Assessment of the qualifications and competence of doctors is not a matter for experiment, nor a matter where there can be a legitimate divergence of approach.
All the evidence is that recently publicised incidents of appalling malpractice, alleged with regard to surgeons such as Dr Jayant Patel in Bundaberg, took such a long time to bring to light because medical solidarity - the upper middle class version of the noxious police culture which used to riddle the Queensland cops - prevented any questioning of his credentials. His alleged malpractice was covered up despite the strong representations of nurses.
Medical registration, surely, is one area where some distance between the bureaucratic authorities and the profession itself brings a compelling and persuasive public benefit. There’s no legitimate argument to be made against it - except the self interest of a profession unable to regulate itself. The former government, under Immigration Minister Kevin Andrews, sought to centralise such powers in order to reinforce racist narratives of fear about foreign doctors. Little was heard from the AMA then. It’s significant that an initiative by the current government which would reduce their vice-like grip over entry to their profession creates such angst, particularly when an objective scan of the record shows that the unwillingness of doctors to countenance others’ better informed view of their colleagues’ competence has led to appalling suffering.
Cross-posted at PollieGraph.
Umm, what is the point to this post? That the AMA is slack about the standard of practitioner it allows into the country?
Or that a closed shop should not be allowed?
To digress, isn’t the Law Society more or less a closed shop guild also? (though were doctors to be held to the same standard of comptence as lawyers there would no end of Jayant Patel type doctors butchering the public)
In Queensland, the Law Society’s powers to discipline its own members were removed by legislation after several cases of gross embezzlement were met with the disciplinary response of a slap on the wrist.
The point of the post, surely, is that the AMA’s arguments are self interested in that the alleged conduct by Jayant Patel was covered up by other doctors and the checks made or not made by the state based registration authorities on him and other dodgy medicos were made by bodies controlled by the profession - which was certainly “slow to act”. As were the doctors at the top of Qld Health and Peter Beattie for that matter. So it’s hard to see how this sort of system works, and what reasonable objection can be made to Roxon’s proposal.
And it’s ironic that the Federal Opposition is also siding wth the AMA, considering that Nelson was a former President, and that the Libs were hell bent on destroying Unions with Workchoices, but are protecting the most militant union of the lot.
Medicine and Law are the two most unionised occupations in Oz (and the UK, as well). All the arguments against closed union shops like the MUA pre-Corrigan pertain against lawyers and doctors - and I say that as a lawyer. Not sure that this is necessarily the best regulatory mechanism, but I’m not is Oz so it’s hard to evaluate. Milton Friedman made some excellent points about doctors and lawyers and their appalling rent-seeking in Free to Choose. May be worth revisiting some of them (I don’t have the book to hand, it’s in a shipping container somewhere in the Atlantic right now).
May your books sail safely, SL!
(I don’t have the book to hand, it’s in a shipping container somewhere in the Atlantic right now).
And when it turns up you can thank the ISO 47 and 55 range that ensures 20 foot equivalent TEUs turn up on time with content integrity when shipped by the lowest bidding TDL companies.
Another reason why the ISO is one of the world’s most successful and trusted transnational bodies. It’s not owned by any government and it’s not run for profit. A true globalisied organisation that makes things work. Like the Red Cross, IATA or ICCAN.
That’s what effective libertarian socialism is really all about.
Medical review and discipline definitely needs to move outside the profession, at least in terms of oversight (some doctors will be needed as advisors/panel members).
I am a little confused about the definition of “closed shop” - I had thought that this term typically referred to situations where people must be union members in order to find work. Can someone please clarify? Thanks.
There are very many good reasons for (and a few against) a national system of registration for all health professionals, but claiming it’s main value will be to stop a Reeves or Patel is populist spin.
As far as I can see no one at Bega even checked if Reeves had a car licence before hiring him and letting him butcher people. No national system will stop anything if hospitals do not use it to check on people. A national system might have stopped Patel getting here as a cleanskin if it had turned up his USA demerits, but then a middling sized health service with a middling skilled admin officer on a credentialling committee could have contacted a few medical boards in USA - if they had wanted to.
Both these guys were recruited by rural services that were only too eager to have surgeons performing procedures on patients that should only be performed in larger hospitals in more experienced teams. Jeez Patel was cutting off limbs in Bundaberg!
Until small services get rid of the idea that any procedure can be performed anywhere by anyone we will always have these cowboys mutilating and even killing people.
I’m with Lauredhl. On the definition of “closed shop” that is.
I find “Bundaberg” defined as “rural” to be most interesting. Bundaberg is a city.
Back to the point of the post:-
How does a “national register” or anything else, suddenly start medical professionals into a culture of dobbing in those of their number who are bungling incompetents?
Certainly in the case of Patel, and maybe also in the case of Reeves, nurses were submitting reports regarding their concerns to the so-called appropriate review systems. Because the review committees were managed by the doctors’ organisations without external oversight, medical solidarity kicked in and nothing was done - it was only nurses complaining after all, and/or a few whiny patients/families, not anyone worthy of proper attention like another doctor.
Some system involving multidisciplinary and external bureaucratic oversight is at least likely to check the worst excesses of such medical solidarity.
Which is now being subverted by Microsoft so it can achieve vendor lock-in [link]
On the closed shop thing:
AMA, not a member. The majority of my colleagues are not members. Membership of the Doctors Reform Society is almost as high. The problem with the AMA is external recognition rather than the extent of internal support. Governments treat it as the sole representative body in industrial matters and, as all of our income flows from government, it becomes such.
The AMA itself denies being a union. This means that if I have an industrial dispute with my employer they are more than happy to advise but not willing to represent, certainly not collectively. This makes the awards for junior doctors something of an optional document. The NSW junior doctors are represented by the single most effective union in the country, the ANF, hence get paid and treated infinitely better than their Victorian counter-parts. The AMA obviously is a union but they can get quite huffy about it if anyone mentions the word.
Also thought it worth mentioning, there are closed shops in medicine but it is the specialist colleges who run them rather than the AMA. Can’t hang out my shingle unless the Physicians say I am an upright and decent chap. Although, no-one is quite sure what happens if I then fail to keep up my membership.
As to disciplinary procedures in medicine I can only comment on the Victorian situation. In a public hospital my practice is subject to investigation by:
1)The Medical Board of Victoria. This polices my fitness to hold ongoing registration.
2)The administration of the hospital in which I work. This would usually involve morbidity and mortality committees, an office of patient advocacy and ad-hoc administrative responses to any medico-legal issues or serious complaints.
3) The office of the Health Services Commissioner
4) The civil and criminal courts
Of these the most important, rapid and flexible is the administration of the Hospital itself. There are inevitably doctors involved in any investigative process as it is otherwise difficult to establish a standard of care. Having said that, my peripheral experience of these processes is that they are primarily driven by administrative concerns and staff. Quite frankly, this Patel character should have been sacked and charged. In most hospitals, he would have been. Is leaving this to hospital administration as the first tier of response appropriate? No, but leaving service provision decisions to local administration is equally flawed.
As to the national registration issue, I think the main beef from the AMA was getting lumped in with people they view as beneath their status under the same registration body. The idea of sharing a professional body with those oiks the physios brought them out in a bout of fake aristocratic cold sweat.
National registration is a perfectly sensible idea. Having said that, the chances of it stopping a repeat of Patel are Buckley’s. The main advantage is going to be inter-state travel, particularly on a locum basis.
Word, both.
I am reminded of the tragic tale of Ignaz Semmelweis, whose 19thC campaign to get Viennese doctors to wash their hands in between the dissection table and the labour ward foundered on their disdain for the fact that he was a mere Hungarian peasant. Numberless women died of puerperal fever as a result, their begging to be allowed to give birth in the gutter rather than in the hospital having fallen on deaf fake aristocratic ears.
Thanks Dr S, interesating to hear from a non-aristocrat-who-knows
At least national registration could give pause for thought to a chap who had been struck off (in Victoria, say) and was contemplating hanging out his shingle in Merimbula (say).
There have been plenty of well-publicised recent cases of malpractice other than the Patel imbroglio, bad as that was.
I dips me lid to patient/victims who find the strength to speak out.
Why thank you Ambigulous, I shall choose to feel complemented. The cross-border nasties are a real, if small, issue. I am not a great fan of federalism and see no particularly compelling reason for state control of anything.
I think your comment about the dipped lid brings up a particular issue. Complaining about your doctor, or more frequently your mum’s doctor, is a fairly confrontational process. Although there are lots of avenues, they are all adversarial. This means that people need a great sense of being personally wronged, as opposed to merely unlucky, to get involved in such a thing. Consequently there is quite a degree of selection of the querulous inherent in the process. Bottom line, most people complain because you irritate them rather than because you failed to heal them. Some people are easily irritated and some doctors are particularly irritating.
For instance. There is a man of my professional acquaintance who spends his life deluged in a waterfall of complaints. He is actually a highly skilled surgeon who I would be pleased to have operate on me. He is also, quite frankly, a prick. Consequently the Health Services Commission has him on speed dial.
This is similar to expecting the civil courts to develop consumer protections rather than having a government supported standard. The punished actions are those most complained of rather than most damaging overall.
So. How do you oversee medicine in such a way that it is not so onerous that no-one can get anything done nor so invasive that we all de-camp to New Zealand in a collective huff? I am not entirely sure, actually. Some branches you can simply count things. The vascular surgeons have run a program for a decade monitoring complication rates in routine surgery and mandating re-training if they go off. Auditing and protocol are very successful in anaesthetics. Radiology would perhaps benefit from one in a thousand films being double-read.
How one monitors the performance of the diagnostic sub-specialties without adopting trivial indicators I do not know. Oh, and anyone who suggests a neurologist should have clinical pathways and diagnostic protocols foisted upon them has never been to a decent neurologist. Some kind of oversight not based upon resolution of complaint appears inevitable and, indeed, desirable but exactly what that should be is one of the many things I am glad is not my problem.
Totally agree that medicine is a ‘closed shop’ in several colloquial meanings of the term - the Colleges and their presiding over specialty admission (at least general practitioners have a choice of Colleges/CME providers now); and the Medical Board being administered from the inside.
From a unionisation point of view, however, they’re nowhere near a ‘closed shop’, if you consider the AMA the union. I’ve been employed by a variety of hospitals and private practices, and been through a formal training programme, and no one has so much as asked whether I was an AMA member, let alone altered my employment or training chances because of it. I don’t know of anyone, not on the rumour mill or anyone else, who has been denied work opportunities due to lack of AMA membership.
I dont’ have numbers to hand, but I’d be surprised if more than half of the docs in Australia are AMA members, and would be at all surprised if it’s significantly less.
Not one, but two eejity spleling/grammar errors. Sorry.
Aren’t registration and problems with malpractice two separate issues. If it’s true that the AMA does not represent even half of Aus Dr’s then hopefully the govt will ignore them.
The issue of mistakes/malpractice, I thought the issue is that Dr’s seem to close ranks far to readily, rather than admit to errors.
Thanks for all the comments - I may have been a bit wide of the mark with regard to the Jayant Patel stuff being sorted through registration, but it does appear to me to be the case that there’s a common thread of medical solidarity running through a few disparate issues many of which are collapsed together in Capolingua’s remarks.
Not exactly. Malpractice claims can of course be pursued through the legal system, but at the same time, complaints about impaired and dangerous doctors are also dealt with through the State Medical Boards, who decide whether a doctor should be deregistered (permanently or for a time period), and/or whether conditions should be placed on their practice. The State Medical Board system, doctor-controlled, is what would be thrown out if a National Medical Board system were imposed.
Currently, at least two state medical boards have places reserved for AMA appointees. It’s not too surprising that the AMA is opposed to any erosion of that aspect of their power.
The main explicit objections I’ve been reading within the medical community against the proposed national registration system are objections to being registered in the same system with inferior beings like nurses, optometrists, physiotherapists, and so on. But I haven’t caught up with this week’s mednews reading yet.
Thanks Dr S, I was insufficiently clear.
I didn’t mean complaints by the querulous, I meant very serious transgressions such as (say) doing an unnecessary clitorectomy that had not been requested by the patient, while carrying out a separate procedure the patient HAD consented to. Malcious malpractice, not routine and minor errors, or irritating a patient.
Yes: it’s a very difficult task, to check on professional work without becoming very onerous or using “trivial indicators”. Ask some University researchers about the flaws in the 2007 trial audit of research performance - since then dropped by Senator Kim Carr. Sounds as if parts of the medical sorority are already much more closely monitored… and with some success.
**allegedly**
Mark, two words; sub judice. Dr Patel has been charged with offences in relation to his medical practice in Bundaberg and awaits an extradition trial in the US. He is entitled to the presumption of innocence before those charges are disposed of. I know you referred to the alleged malpractice of Dr Patel, and I know that your intention is only to open up a general discussion on the need to find ways of ensuring that doctors are properly medically credentialed and competent, but Dr Patel is entitled to be presumed innocent until placed before a jury for its decision on the evidence placed before it in court.
GregM, thanks for that. I’ve tried to be careful to restrict myself appropriately, but in this context I’d also note that much of the events which transpired in terms of how the situation developed and the actions of whistleblowers and relevant authorities are documented on the public record in the privileged proceedings of a Royal Commission. I’m a very strong supporter of the presumption of innocence, and if anyone has any suggestions as to how I could modify the post to better reflect that presumption, I’d be more than happy to consider them.
Mark, I accept completely your efforts to be fair and to stay within the constaints of proper commentary but I would not have used the headline. I would have, in my text, drawn specific attention to Dr Patel’s right to the presumption of innocence. I would then have drawn attention to the Royal Commission Report’s findings on the failures of others to have carried out their duties in establishing his qualifications and competence (based on his prior experience) and have made reference to how common that problem is.
It is such a common problem in all professions and all occupations that it deserves the widest exposure and it it amazing how easy it is to do a proper reference check if you are not too lazy to get around to doing it.
Thanks again, GregM. Those are good suggestions. Probably I wrote the post in too much haste but you’ve prompted me to try very hard to pause and think carefully about how to refer to these problems when similar cases invite a post.
SATP[1]:
Well, actually, both. Oh yes, and there’s also the matter of so many good people being killed, maimed and impoverished by organized gangs of greedy plundering rats pretending to be doctors.
“Doctor Bashing”? You bet!! Should have happened years ago …. then a lot of good people would still be alive today …. and a lot of decent caring young Australians would now be looking after our health.
Lauredhel [7 and 17]:
No need to be confused about the closed shop aspect . A racket is a racket whether it it run by mafia, triads or by specialists’ “colleges”. No doubt you are already aware of exactly what happens when a bright, hard-working, enthusiastic young doctor wants to become a specialist in a particular field of medicine.
The sooner the specialist “colleges” racket is made illegal, the sooner we will have an efficient health care system.
Debbieanne [19] and Mark [20]:
Registration and Malpractice are two very different – though related - issues. It is bloody annoying when the news media mix up the two.
Pavlov’s Cat [14]:
Thanks for mentioning that great hero, Dr Semmelweiss.
Dr S [13 and 16]:
Thanks a lot for your own insights.
There’s an interesting parallel between medical practitioners and war veterans: The news media always focusses on the Australian Medical Association and very very rarely on the Doctors’ Reform Society just as they always focus on the R&SL and vary rarely on any other exservice organizations – the result of this skewed focus is that, in the public’s mind, there is only one authorative organization speaking for the whole class ….even though that well-publicized group might be as useless as an ashtray on a motorbike and though the unpublicized groups might have been the ones that gotthe results. Worse yet, bad behaviour by the highly-publicized organization then reflects badly on everyone in the whole class.
Everyone;
There was one issue in the last federal election that went way below the radar of the parties and the pundits but was on everyone’s lips whenever industrial relations was mentioned …. that the Howard government was bashing trade unions at the same time it was mollycoddling the worst union of all - the union of rich doctors.
Even dyed-in-the-wool, union-hating Coalition supporters detested the hypocrisy of that and hoped Howard would put an end to the practice when he got re-elected. [Of course, they said, The Milky-Bar Kid would give the **** doctors heaps more of our money if we were stupid enough to vote him in].
Where my confusion arose was that the original post started: “The last remaining closed shop union, the AMA,…”
To me, this implied that the author thinks that doctors need to be AMA members in order to find work and training opportunities. Nothing could be further from the truth, in my experience.
Lauredhel [30]:
I didn’t get that impression myself but if you did then any momentary confusion by you on that point is perfectly understandable.
By the way, I’m not opposed to specialists’ organizations as such. I’m all for any body that preserves and enlarges a body of specific knowledge, that pushes the boundaries of our understanding, that transmits particular valuable skills, that encourages and protects its members, that ensures that nobody can make false claims of having high-level skills in that specialty …. all wonderful stuff.
The objection is to such an organization degenerating into an exclusive racket that hinders new entrants, that only pretends to encourage research, that is obsessed with making the racket as profitable as the public will bear.
A massive, radical and fearless review of our entire health system is long overdue - if that means that some hitherto prominent players in this game are upset and peeved over it then so much the better; [my own preference is to see them jailed but there’s fat chance of that ever happening].