What happened to common sense

Last week, at the final meeting of the My Health Record Expansion Program steering Group, we spoke about trust. Or better, the lack of trust people have in big databases, governments in general and many other institutions.

This global trend is described by psychologist professor Barry Schwartz, who says:

“(…) the disenchantment we experience as recipients of services is often matched by the dissatisfaction of those who provide them. Most doctors want to practice medicine as it should be practised. But they feel helpless faced with the challenge of balancing the needs and desires of patients with the practical demands of hassling with insurance companies, earning enough to pay malpractice premiums, and squeezing patients into seven-minute visits – all the while keeping up with the latest developments in their fields.

Schwartz says that we seem to respond to any problem with the same answer of sticks and carrots. There is a widespread belief that more and better rules and incentives will solve our woes. There is one issue. Rules and incentives deprive us of the opportunity to do the right thing. They undermine empathy, creativity and the will to figure out what moral right means.

The My Health record offers great opportunities for healthcare in Australia. However, even though 90.1% of Australians now have access to the My Health Record, this cannot be the end of the line. A system that is responsive, has means to listen to users and learn from errors, mistakes and imperfections, is key to an effective and trustworthy digital health solution into the future.

Kindness, care and empathy are an essential part of my job – and everyone else’s. But it’s unlikely that this will ever be translated into key performance indicators or expressed in My Health Record upload percentages, practice incentive payments or MBS fees.

People are inspired by great examples, not by incentives. Above all, most people want to do the right thing. Trust may be a rare commodity these days but it remains an essential ingredient of effective healthcare delivery. It’s common sense, really.

5 reasons why health providers don’t trust each other

Trust is an essential ingredient of effective healthcare delivery. It’s important for interprofessional as well as inter-organisational collaboration.

A 2018 literature review concluded that collaboration leads to more job satisfaction, improved morale and a better working atmosphere. Unfortunately, health providers don’t always trust each other. The authors of the review found 5 sources of distrust:

  1. Doubting the other’s motivation in providing care and the perceived benefit for him/her
  2. Feeling threatened by the other’s involvement and being afraid of losing some territory
  3. A difference in philosophies and scope of practice
  4. Negative images of the profession
  5. Lack of confidence in the other’s skills and lack of awareness of the other’s role in patient care.

Other ingredients of effective collaboration include adequate communication, respect, mutual acquaintanceship, equal power-distribution, shared goals, congruent philosophies and values, consensus, patient-centeredness and environmental factors.

The authors did not explore the level of importance of each factor but I am putting my money on trust as the secret ingredient. If we continue to distrust each other, collaboration will remain a challenge. The question is, how to change this?

If only we worked together (instead of competing)

Many GPs feel disempowered in the current climate of cuts and freezes. It is indeed hard to comprehend why governments slash funding to the most efficient and cost-saving part of the health system.

We are all concerned about the lack of continuity of care and increasing fragmentation in our healthcare system, but what about the divisions within our own ranks?

Part of what makes general practice attractive is its diversity, but it also makes general practice prone to divisiveness. Think, for example, of the stereotypical dichotomies: generalists vs partialists, private practice vs corporates, rural medicine vs metropolitan general practice, etc.

GPs are highly respected in the community, but have become an easy target because of marginalisation and fragmentation. It is a well-known secret that governments play different GP groups off against each other, choosing to include or ignore organisations in their deliberations and negotiations.

Lack of unity also opens the door for disruption by third parties.

Our culture

It is clear that general practice needs an urgent cultural change. Just like surgeons are working on improving the bullying culture, we must address the disharmony and division that afflicts us.

How good would it be if practices worked together instead of competing? If GPs could get together and agree on issues important for their area? If peak bodies would team up and better coordinate strategy, policy development, campaigns, conferences and membership services?

There is a whole generation of GPs that don’t understand why we have so many representative organisations. These young doctors are concerned about the disadvantages. Why don’t general practice organisations support each other, why are there multiple memberships and so much duplication? I believe they are right.

We have much more in common than what sets us apart, so why are we so tribal?

Why tribalism?

I can think of a few reasons. The first that comes to mind stems from social psychology; our brains may be programmed to organise us into small tribes because of evolutionary advantages, such as social bonding and survival.

There are also economic motivations, for example, GP clinics currently compete for patients. Our peak bodies are based on membership and need to offer benefits; this encourages competition rather than collaboration.

Reform fatigue may be another reason why some of us have stopped caring about achieving common goals. Experienced GPs can tell us the tales of the many system changes they have witnessed over the years; reform comes and goes and often disrupts our day-to-day practice. The risk is that we become cynical about what our profession can achieve in Canberra.

Perhaps there is also a selection bias. It is possible that GPs prefer more autonomy than our hospital colleagues, and although we work increasingly in teams, we may be less group-oriented or prefer smaller tribes.

Finally, doctors are trained to be leaders. We’re masters in problem solving and good at making difficult decisions, often in challenging and stressful situations.

We’re independent thinkers, skilled at arriving at our own conclusions and giving strong opinions. But we are not a profession of followers. The success of organisations depends on how well their leaders lead and how well their followers follow.

More unity

United General Practice Australia (UGPA) could connect the dots here. It’s an umbrella group for all the main groups, including the RACGP, ACRRM, AMA, RDAA. Those taking part have shown a desire to put aside their differences to a certain extent.

However, the status and governance of UGPA is somewhat vague. There is also no website or official spokesperson. But it is a start, and I would love to see this organisation be given the opportunity to grow and represent us all.

Lastly, we need to find common ground and partner with patient health organisations, as governments listen to the public more than they do to doctors.

The time has come to stop and think about where we want to go. More unity would require a cultural shift, excellent skills in following others, trust and willingness to compromise — not just from our leaders, but from all of us.

This article was originally published in Australian Doctor Magazine.