Our health care would benefit from this fix in how we pay doctors
Doctors who improve people’s lives over extended periods of time, from months to years, attract the lowest pay
Atul Gawande, surgeon, author and advisor to President Clinton on US health care reform, has a dark secret: as he paved his brilliant medical career, he was seduced by the glamour or “heroism” of surgery compared with the humdrum banality of what he calls “incremental care”.
Today, he complains that the US medical system is skewed and wasteful because of bias in which doctors flock to those areas of medicine in which dramatic, heroic interventions make them look like saviours and attract the majority of public attention, and most of the medical dollar.
“When illness was experienced as a random catastrophe, and medical discoveries focused on rescue, insurance for unanticipated, episodic needs was what we needed,” he said in a thoughtful paper, “The Heroism of Incremental Care”, in January’s Annals of Medicine: “Hospitals and heroic interventions got the large investments; incrementalists were scanted.”
He noted that the five highest-paid medical specialties in the US are orthopaedics, cardiology, dermatology, gastroenterology and radiology – these earn an average of US$400,000 a year: “All of these are interventionists,” he said: “they make most of their income on defined minutes- to hours-long procedures – and then move on.”
By contrast, doctors attracting the lowest pay – about half the average earnings of the top five – are all “incrementalists” – paediatricians, endocrinologists, family medical practitioners, geriatricians, immunologists, headache specialists, psychiatrists, rheumatologists – who “produce value by improving people’s lives over extended periods of time, typically months to years.”
His point is that it is these humdrum “incrementalists” that actually contribute most to our communities’ wellness – in short, who do most good – rather than the adrenaline-fuelled gladiators engaged in charismatic, glamorous “rescue medicine”.
I was reminded of Atul Gawande’s thoughts as I read this week about the Food and Health Bureau’s 256-page compendium “Strategic Review on Healthcare Manpower Planning and Professional Development”. The report is awesome in its encyclopaedic review of 13 professions in the medical sector, modelling future supply of, and demand for medical professionals, and mapping the worrying shortages that are expected to get steadily more severe over the coming decade.
But it is frustrating in devoting virtually no attention at all to the reasons for emerging shortages, how severe they will be, and what the consequences would be of failing to bridge the supply-demand gaps. It identifies the main challenges – the rapid ageing of the population, the explosion of “lifestyle-related” diseases, and the relentless rise in medical costs – and doubtless builds assumptions about these shifts into its demand-side models. But it wholly fails adequately to discuss these shifts.
Even more important – and this is where Atul Gawande’s thoughts are so pertinent – it takes as a given our medical model which, like the US, is built around hospitals, random catastrophes, rescue interventions, and heroic gladiatorial surgeons.
For sure we face massive shortages of medical professionals in the coming years – but if you look towards a medical system built around community-based primary care, the preservation of wellness, and the neighbourly treatment of chronic ailments like high blood pressure or diabetes, then the shortages will be different. Fewer firefighters and gladiators, more unglamorous “incrementalists”. Fewer heart surgeons, and more paediatricians, family medical practitioners, geriatricians and headache specialists. And many, many more nurses, and others modestly trained to provide palliative care for the elderly.
As a sidebar, this reminds me that we cannot properly build models of supply shortages without taking account of the massive informal role played across our economy by the hundreds of thousands of home helpers from the Philippines and Indonesia. As more and more of these miserably paid workers spend their time here caring for the elderly and infirm rather than looking after kiddies or house cleaning, so they must surely be seen as an important part of our medical supply side.
The Food and Health Bureau tome notes that we have over 52,000 nurses working in Hong Kong today – almost 30 per cent up on 2011 – but that the “best guesstimate” of the nursing manpower gap by 2030 will be over 1,600 a year. What would that shortfall really look like absent the hundreds of thousands of Indonesian and Filipina elderly carers working silently – and often without recognised medical training –providing 24-hour care to infirm elderlies?
On balance, this humongous report is a valuable first step in tackling the medical sector skills shortages that are getting increasingly severe. At least we have an authoritative government source formally admitting the shortages, and acknowledging that steps must be taken if the quality of our health services is to be maintained.
But still there is gross timidity as it turns to its recommendations for filling the gap: train more doctors and nurses (of course); explore more self-financing (of course): retain existing professionals, including bringing the retired back into work (yes, but surely palliative): put lay-people on medical boards and councils (is this pivotal?): insist on continuous education (of course): improve complaint investigation (yes, and?).
Just two stand out as meaningful: recruit many more non-locally-trained professionals; and improve data collection on manpower projections. On both, I think the government – and the still-highly-protectionist medical professional groups in Hong Kong – is profoundly reluctant to move beyond baby-steps.
In APEC for the past five years we have been trying to persuade the Hong Kong government to provide data into a region-wide skills database that would help us see the skills shortages as they emerge across the region (not just in the medical profession). Still the Hong Kong government has failed to provide input. If it is so robustly reluctant to provide data for APEC’s skills map, why is it suddenly likely to discover enthusiasm for data in the medical sector where so many vested interests have scant interest in tackling our skills shortages?
But let me not be so curmudgeonly. This report is an important step in the direction of tackling a major challenge to our health system. But our medical leaders need to remember Atul Gawande’s warning: the shortages we face need to be filled by unglamorous “incrementalists”, not the hero gladiators that today maintain a stranglehold on our many protected medical professions.
David Dodwell researches and writes about global, regional and Hong Kong challenges from a Hong Kong point of view