Protecting us from ourselves

A friend of mine who has recently become an expectant father, found out that he needed to find out his blood type. For those not aware there can be complications if the mother has an RH negative blood type and the baby has RH positive. The complications can be avoided by some injections, but are also unnecessary if the father is also RH negative as the baby will then always be RH negative as well and there is no risk of reaction. This is the case with my wife and I who are both RH negative.

So anyhow, to avoid unnecessary treatment my friend decided to get his blood type determined only to turn up and discover that they were unable to obtain this simple test without a referral from a doctor, which would of course require an appointment and cash.

Annoyed at this waste of resources he sent off an email to a number of friends, several of whom are medical doctors, complaining bitterly at the waste of his time, his money and the government’s money that was involved in this process.

My immediate (and deliberately provocative) response was that it was due to the closed shop that doctors were running where everything has to be processed by one of the union and I think there is certainly something in that. However I want to explore the response from the doctors.

The response from the medical doctors was that it was important for them to refer patients for further tests as without a good knowledge of risks, benefits and interpretation of the results, it would leave patients open to deceptive conduct by pathology labs and others who may advertise to run screening tests that would be completely unnecessary and potentially counterproductive. The example cited was all body CT scans which because of the radiation dose, the high percentage of false positives (as high as 80%) and the risk entailed in biopsies to clearing up the false positives may provide no benefit to a patient who has little reason to suspect cancer. So while my friend may have been able to ask for this test in a situation where it was necessary what about other less educated people and more complicated tests. The question is where do you draw the line?

Firstly I think its an interesting assumption that doctors are more scrupulous than pathology labs, particularly given the schmoozing they get from drug companies. Still I can accept that you may develop a relationship with your GP that you won’t with a lab so they may have more interest in treating you well.

Putting this aside there are two issue here. The first is the actual situation in question. Accepting the argument made above, there is no question in my mind that we should be drawing the line somewhere above the complexity of a test to determine your blood type if the person is willing to pay the full cost of the test themselves. If it is to be in some way subsidised by medicare then there may be some screening necessary in such simple procedures to prevent unnecessary over usage.

The second issue is a broader one. While I support public health care for reasons I have outlined here, I also stated that I didn’t have a problem with wealthy people buying additional layers of health care. The trickier thing is with treatments that may have little or no demonstrated benefit. I have no doubt that such procedures shouldn’t be funded through medicare, but what about people who wish to pay for full body CAT scans? Should we prevent them from buying such procedures?

In general I think the answer is no. Sure if procedures are genuinely carry high risks and these are not being properly explained to consumers then there is reason to perhaps intervene. From what I read on fully body CAT scans the risk is not that high, less I imagine than many other legal activities. How would it compare to cosmetic surgery? Whether people are wasting their money or not is not really my concern.

People waste money every day on activities I think are virtually worthless. I can’t see the point of spending a couple of hundred thousand dollars on a Porsche, personally I think you’ve been conned given it has less storage space than my Astra, costs around 10 times as much, and has the same maximum speed (legal speed that is!). However I’m not going to restrict them from buying them even though they might increase their risk of dying in a high speed crash (perhaps).

This same reasoning of course applies to alternative medicines and other quackery. In general I think my principle stands. If someone is selling placebos and people are willing to buy them despite there being plenty of information around that they have no scientific effect (other than the placebo effect) then they should be free to do so. If it makes people feel better about themselves then all well and good, just like the sports car. Noting that this does not mean that we should not argue against them.

As for my first statement about doctors running a closed shop. I do believe there is an element of this behaviour going on. Its always seemed to me that the gap between doctors and other medical professionals seems unnecessarily large, and there could be more room for low level specialists bridging the gap. More routine things like injections for immunizations etc could easily be done by someone with a nursing background and a small amount of specialist training rather than your GP. However not having enough detailed knowledge of how the medical system works in practice I’ll defer further comment on this. It could be that this occurs to a greater degree than I realise and my comments are unfounded but certainly I have not encountered evidence of this.

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10 Responses to Protecting us from ourselves

  1. […] Protecting us from ourselves – Steve Edney weighs up the arguments for and against having the right to order one’s own pathology tests (rather than needing a referral from a GP). […]

  2. ozrisk says:

    Steve,
    I agree with what you say, but, on the opening part of the discussion, if you only want to find out your blood type, go and donate blood. Part of the process is to type you. It was the way I found out my type and it accomplishes a social good at the same time.

  3. Steve says:

    Yes, that was also pointed out. (Incidentally it also proves the point about referals to a doctor being unnecessary). Although I must add that when I when through the same experience I was told that the blood bank’s testing would not be sufficient from detering the doctors at the hospital from administering the injection, indeed they were likely to question the parentage and want to give it anyway as they try to avoid all these risks.

    My friend wasn’t told this though, just to find out what it was.

  4. ASR says:

    Steve,

    “I was told that the blood bank’s testing would not be sufficient from detering the doctors at the hospital from administering the injection,”

    The blood bank’s test is enough to determine whether you get anti-D (see http://www.ranzcog.edu.au/womenshealth/anti-d.shtml) but there are many other antigens that can cause haemolytic disease of the newborn. I guess the issue is also non-paternity as we discussed. NHMRC guidelines for anti-d administration can be found in this FAQ word document approved by the ARCBS: http://www.transfusion.com.au/FILES/RhD/Clinical.doc

    “without a referral from a doctor, which would of course require an appointment and cash”
    This is a whole other argument/debate about the decline in bulk billing doctors. Ideally, most GPs would bulk bill and it wouldn’t require shelling out “cash” but due to the inefficiencies in our federal/state system, cost shifting has resulted by the federal govt has resulted in a system where less GPs bulk bill and therefore more people go to “free” EDs.

    I think your article is an excellent summary, and I agree that the line could be drawn at blood type, but I think the point raises a number of issues about access to health and testing as you’ve outlined. Just a few additional points i’d like to add:

    1. In an ideal system there is a role for GPs doing “health prevention” (see http://www.mja.com.au/public/issues/183_02_180705/rus10405_fm.html) so that if a person is “forced” to see a GP to get something they think they want, the interaction should have more quality than to just focus on why the person has come but allow the GP the opportunity to discuss other health issues like hypertension and cholesterol etc so the person might make changes before its too late (i haven’t articulated that well but see: http://www.mja.com.au/public/issues/185_08_161006/har10079_fm.html). Young men are especially bad at focusing on their health before it’s too late.

    2. With respect to whole body scanners, another aspect to consider is that the scan may show something of uncertain significance (because the test is now being used as an unevaluated screen rather than having a pre-test probability for a certain diagnosis) and then the person having the scan will be referred to a GP to discuss the result. Thus if lots of rich people start paying to have these, they may displace poor people from access to GPs, to discuss results which no one knows the significance of.

    3. “Its always seemed to me that the gap between doctors and other medical professionals seems unnecessarily large”
    There is a gap within the medical profession itself and I think it is simplistic to lump “doctors” in one group and “other medical professionals” into another (fostering an “us v them” mentality that is populist but destructive) as both groups are as diverse as each other. For example Steve, have you seen a physiotherapist or speech pathologist lately? Are you aware of the fees charged by allied health professionals? Immunization clinics do exist. As for other things, nurse practitioners are increasingly performing tasks in public hospitals which seems to work well. There are many issues to consider such as getting to a situation where rich people see doctors and poor people see nurses etc and also the issue of liability and insurance but i’ll leave discussing them for another time.

  5. Steve says:

    with regard point 1, if people don’t want to go and get themselves assessed even if it puts themselves at risk should we really be forcing them to go with forced referals? I don’t see this as a black and white issue and obviously there are cases where we do need to help people look after themselves eg in the extreme example the mentally ill. To what degree should we be forcing people for a relatively small risk when they are obviously capable of making decisions. I don’t find this very compelling.

    As to point 2. With a very large false negative rate yes the results need significant expert apraisal and it could generate more GP visits I take this point, but I’m unsure as to what degree this is really would be a problem. Perhaps if people were visiting GP’s less for trivial referals then it would free up enough services. 🙂

    3. As I said maybe more goes on than I appreciate. I didn’t know there were immunization clinics but it is good that there are I quesiton how many there are though.

    My opinion on this is formed from spending time in say a hospital. Obviously you’ve spent more but perhaps from a different perspective.

  6. steve munn says:

    Steve,

    I have long thought that the Government should ban workplace agreements requiring workers to obtain a medical certificate for a sick day UNLESS they are taking 3 or more days off. This is a definite waste of Medicare funds as well as the doctors time.

  7. Rod Clarke says:

    So basically this is all about some poor old lefty complaining about having to put his hand in his own pocket.

    Oh FFS dude your going to become a father so its time to start learning how to waist time and to shell out cash.

    I for one am happy that GPs specialists and surgeons have a closed shop and keep the dregs out.

    If you want to see what an open shop looks like go to a “holistic” birthing centre! estrogen soaked no-responsibility femborg quackery at its best…….. afterall there only risking your kid.

  8. Steve says:

    I think he’s happy to pay for the tests, he’s not happy to have to have all of us pay for a doctors appointment to sign a form for him to pay for the tests.

  9. yobbo says:

    No different than me having to see a doctor to sign a form to get my Asthma prescriptions filled, even though I’ve been taking the exact same drugs for 20 years. There are many, many things that only doctors can do that anyone with access to google could do themselves.

    The vast majority of GP visits are 3 minute jobs where the patient just wants a prescription. It’s a huge waste of time and money.

  10. trisha says:

    My husband and I are also both rh-.I have alot of unpublished information on rh- blood types. Write me at: Born2BearBabies@aol.com

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