From the Experts

PUBLISHED : Monday, 01 April, 2013, 12:00am
UPDATED : Monday, 01 April, 2013, 10:00am

Not very long ago, medical care was mostly ineffective, but safe and cheap. Now it is mostly effective, but dangerous and expensive. Unfortunately, it is hard to know exactly how effective, how dangerous and how expensive.

Doctors vs mechanics

Like car repair, medical care is a credence service: the professional (mechanic or doctor) has far more knowledge than the client (car owner or patient), and not only recommends a service, but also provides the service, and then charges for providing it.

The client doesn't know whether the service is needed at all, or, if needed, whether the particular service option is correct, and whether the fee charged is appropriate.

Medical care is a credence service: the professional (mechanic or doctor) has far more knowledge than the client (car owner or patient)

Naturally, this causes great anxiety on the part of the client - especially when it is one's own body rather than one's car which is to be serviced.

How can patients be sure they are receiving the right service at the right price? It is not easy, but economists have some answers.

To avoid over-treatment, economists recommend that you choose a doctor who is busy. A doctor will get into less trouble by providing treatment of some kind (whether it's necessary or only superficial), whereas withholding treatment or providing inappropriate treatment is likelier to cause a lawsuit.

Doctors vs refrigerators

This same simple economic model works for minor or straightforward medical problems, which any doctor of the appropriate speciality can treat. Thus, the medical service can be regarded as a commodity, like a refrigerator.

If your problem is rare or complex, the treatment is no longer a commodity.

Patients wish to avoid under-treatment (or, more precisely, too much of the wrong treatment instead of the right amount of the right treatment).

Some treatments are easy to deliver - for example, painkillers - and some are not, such as large and complex operations or powerful drugs with dangerous side effects.

If the doctor is too busy to sort out your complex problem, or does not have the experience or training to treat it, you hope that he or she will refer you to another doctor who can help.

Unfortunately, your doctor may not know your diagnosis and, therefore, may not be able to refer appropriately, or does not know who to refer you to, because he or she is not aware of the expertise in the medical community.

Under-servicing vs over-servicing

Under-servicing is arguably more of a problem than over-servicing, as failure to receive needed treatment is usually more detrimental to patients' health than receiving unnecessary services. Unnecessary services are usually safe; otherwise, the doctor could end up in court. (There is no big legal or moral difference between providing unnecessary services which are safe versus risky, but there is a practical difference: with risky services there is a greater risk of coroner's inquests and the like.)

Hong Kong has two local problems for which I can offer no good solution. The smaller problem is that doctors are very poorly paid for thinking and relatively well paid for doing, so doctors who perform procedures lose money consulting. This discourages them from spending too much time with a patient with a complex problem. It's better to see a dozen patients with simple problems.

The other problem is medical advertising and the fact that it is banned by the Medical Council. This makes it very difficult for both patients and doctors to find out what services are available. Patients ask around, while doctors refer them to colleagues from medical school or their church or club. It's hard to find out if a particular doctor has just returned from training at the world's best centre for that subject, or perhaps has done extensive research on something that is too complex or obscure for mass media.

The government vs the people

Economists tell us there are significant costs to preventing the free flow of information. These costs are, of course, hidden. The cost of the Medical Council's over-regulation of advertising is paid by the government, which funds it apparently without limit. (It provides figures only on special request, and even then, it buries the big ones.) On the other side are some doctors attempting to circumvent the advertising restrictions, who may end up facing disciplinary inquiries, and sometimes court cases (usually judicial reviews of Medical Council decisions).

Who really pays? Well, if you are a patient, you pay the doctor's costs, and if you are a taxpayer, you pay the government's. So you pay for both sides.

Dr Jason Brockwell is a hip and pelvic surgeon in Hong Kong