Specialists versus generalists: A commentary on John Menadue and Peter Brooks

Jun 7, 2017

John Menadue and Peter Brooks have mounted powerful critiques of private specialist medical practice in a series in Pearls and Irritations. The nub of their positions is the high fee structure in (private out-patient) specialist practice is out of kilter with community expectations. 

Peter Brooks cites the high median figures of $270 for immunology/allergy and $250 for neurology consultations and the disparities in fees charged for knee replacement – the Medicare rebate is $1318, the AMA recommended fee is $3690 and some surgeons charge $5500 and others possibly more. John Menadue points to ATO data showing the 12 highest paid jobs in Australia are medical specialists. They both criticise the fee-for-service system.

It must be a problem, when, even the AMA is critical of ‘celebrity specialists’ charging prohibitively high fees compared with the average for their discipline.

Inequity is the essence of the issue. Low-income patients, uninsured patients, the broad run of patients who need the public system, are denied timely and reasonable access to specialist care. In outer metropolitan and rural areas, very many patients simply can’t afford the out of pocket expenses to see a specialist. Out of pocket expenses are higher, and the gap between specialists and GPs wider in Australia, than other OECD countries. 20% ($23 billion per year) of Australian health expenditure is for out-of-pocket-expenses compared with 7% in France.

Peter Brooks proposes some ways to deal with the high out-of-pocket-expenses: mandated transparency of doctor’s incomes, use of second opinions and a requirement to fully inform patients of all expected expenses. He recommends the Government consider adopting the Canadian approach, which requires doctors to charge at approved rates at the risk of losing access to Medicare if they don’t.

The demand for recognition of new specialties is seemly insatiable as biomedicine advances and patients look for the ‘best specialist’. The Medical Board of Australia now recognizes, 23 medical specialties, 63 fields of specialisation and 85 specialist titles. Increased specialism leads to fragmented care and patient confusion at a time with the most pressing need is for generalists and GPs. This is an increasing problem in western health care systems and is repeatedly commented upon in editorials in US medical journals.

Specialist fees reinforce divisions in medicine between – highly rewarded specialists, especially procedural specialists, and underfunded primary health care. The unequal fee structures and the contested Commonwealth/State funding responsibilities, create barriers between tertiary (mainly hospital) care and primary community-based care, where there should be none. They shape the future of the health system as medical students see that status and money flow to the medical/surgical – proceduralist – interventionist – end of medicine whereas the burden of community care is undervalued and underfunded. On average, specialists earn 2 to 4 times more than GPs.

This bifurcation may be an unreasonable characterisation of the medical profession, but it makes the point, that as a society, and medical profession, we undervalue the efforts of those responding to suffering in the day-to-day lives of people where they live and work.

The first medical specialties grew out of the health problems of population groups and epidemic disease; then came the organ system specialists – cardiologists, neurologists, thoracic surgeons and so on. And today specialisation is driven by new patterns of disease e.g. HIV/AIDS and addiction, and especially by advances in pharmacology, immunology, genetics, molecular medicine, transplantation, imaging, intervention techniques and robotics. In turn the new disciplines put pressure on hospitals to provide more resources and higher levels of remuneration, further distorting the health system away from community-oriented primary care.

It is a paradox that the prestige, and status, of front-line practitioners is inversely related to the contribution they make to the community’s health and welfare. GPs, and their primary health partners, operate in settings of the premonitory and early manifestations of disease and disabilities, when problems are ill-defined, but where preventive measures and early interventions are most effective. Medical specialists, on the other hand, deal with more advanced, more clearly defined, difficult to reverse, organ pathology and often use expensive technology.

As the population ages and medical treatment enables more people to survive injury and illness, and substance use and mental illness increase, the complexity and intractability of medical problems is increasing. This means the task becomes not so much to cure a disease but to focus on the quality of a person’s life. These are the typical problems which land back in the GP’s patch.

15 years ago, in the NSW Health Council report, John Menadue wrote,

So much of our work and so much of the health debate is really about hospitals and sickness, rather than health. The desire of many clinicians and managers to shift resources and provide more care in the community with an increased emphasis on both early intervention and keeping people well, gets lost in the clamour for more beds and more expensive facilities and hospitals.” 

Services should be based primarily around where patients and consumers live. The autonomy and dignity of each patient is best served by providing services wherever possible outside hospital. So, a shift to community multidisciplinary health teams is a major issue still ahead of us.”

The National Mental Health Commission, in its 2014 report to Government, made an abortive attempt to shift mental health funding from the hospital to community; their recommendation was summarily rejected.

The shift to better care in the community is still ahead of us, especially if increasing numbers of young people are choosing to become specialist clinicians rather than generalists and general practitioners

Ian Webster is Emeritus Professor of Public Health and Community Medicine at UNSW.  

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