Angry Doctor

Tuesday, March 20, 2007

Confidence Goods 5

angry doc repeats himself, he knows, but he thinks this point bears (pun intended) repeating...

A reality check on how hospitals view subsidised patients
Letter from GOH KIAN HUAT

I REFER to Associate Professor Lee Wei Ling's letter, "It's not a numbers game" (Mar 13).

Patients should feel relieved that public hospitals and doctors are not recognised first and foremost for the number of private patients they bring in, and that institutions like the National Neuroscience Institute (NNI) always accord quality of patient care the first priority.

We should recognise, though, that not every health plan, hospital, doctor or nurse gives high quality care. Quality varies, for many reasons.

Quality healthcare means doing the right thing, at the right time, in the right way, for the right patient.

In public hospitals, the waiting time to see a specialist is generally long, while the time spent in consultation with a doctor is usually very short — maybe five to 10 minutes.

In the process of delivering patient care, doctors must look through a patient's history, then check the patient and prescribe a treatment plan in the presence or absence of a nurse. Under such circumstances, how would the hospital know the level of quality of patient care delivered by their doctors?

How is healthcare quality measured? How are patient satisfaction and treatment and prevention of an illness measured? How are errors detected and rectified?

Generally, subsidised patients are assigned to junior doctors. If they are lucky, they may get to see a senior doctor. Private patients, if they do not specify the doctor of their choice, are assigned to a senior doctor automatically. In addition, they enjoy shorter waiting times.

Ideally, healthcare should be non-discriminatory, providing the same quality of service regardless of race, ethnicity, age, sex, health and financial status. However, it is common knowledge that private patients enjoy better facilities and services than subsidised patients.

By and large angry doc acknowledges the concerns raised by Mr Goh. They are relevant to all 'stakeholders' in the healthcare partnership: doctors, patients, and administration.

However, angry doc makes a distinction between the quality of healthcare provided and the quality of service provided.

angry doc cannot deny that private patients may enjoy better facilitites and *services* than subsidised patient, and that these advantages (shorting waiting time, longer consultation time, ability to afford more expensive drugs and treatment) do translate to better care, but that does not mean that subsidised patients receive low-quality *care*.

How do we measure the quality of care then?

Well, it depends on whose angle you are looking at it from, doesn't it?

Mr Goh gives a good definition: "Quality healthcare means doing the right thing, at the right time, in the right way, for the right patient."

But even if we can all agree on this definition, one can easily imagine the difficulty we will have in agreeing on what 'the right thing', 'the right time', 'the right way' and 'the right patient' mean. We can try to be objective, we can track objective data like waiting times, costs, clinical parameters and so on, but unless we can agree on what constitute 'right-ness', we will just be gathering a lot of data and not convincing anyone.

Healthcare being a confidence goods, angry doc prefers to rely on the good old-fashioned concept of medical paternalism, and a 'separation of powers': a discerning patient may be the best judge on quality of *service* received, but a good doctor will be the best judge on the quality of *care* delivered. He is not quite sure where the administrator comes in though...

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