BRETT SUTTON: You know, it’s a false dichotomy to say that you either do acute care or you do preventive health, but you should be absolutely clear about the benefit that population and prevention health can bring at the most extraordinary value for money.
MIC CAVAZZINI: You’re listening Pomegranate, podcast of the Royal Australasian College of Physicians. I’m Mic Cavazzini. Today we’re reflecting on the moral obligations of being a physician—a theme that was explored at Congress, the annual meeting of the RACP.
BRETT SUTTON: And so, within medicine we feel very passionate about certain interventions and of course, great differences are made. But the real drivers of health and wellbeing are at a much more fundamental level; they relate to the distribution of wealth, power and resources, and so they’re complex and they require arms of government and all of society to work hand-in-glove.
MIC CAVAZZINI: Dr Brett Sutton is Deputy Chief Health Officer of Victoria and has a background in emergency medicine and humanitarian work. He was one of the invited speakers at Congress in a session discussing the role of physician as advocate. I caught up with him and Professor Ross Upshur, who opened the forum with a history of our changing ethical codes, and also talked about the future of big data in targeting social remedies.
ROSS UPSHUR: Yes so, I’m Ross Upshur. I’m a professor in the Dalla Lana School of Public Health and the Department of Family and Community Medicine at the University of Toronto.
MIC CAVAZZINI: Ross, you talked about allocation of resources and how context is just as important as the evidence base in determining utility. What kind of contexts are you referring to there?
ROSS UPSHUR: Well I’ll give you an example from one of my students, who came from a low-income country and was charged with setting up a mammography program. And you know, all things considered, she was kind of worked up about this. She said, “You know, I really don’t think that what our country needs is mammography; we’ve got large parts of the country that don’t have access to potable water. How do I go back to my ministry and say, ‘With all due respect, minister, there are bigger fish to fry?’”
So, this is going to be fast upon all high-income systems as well. We’ve got a revolution in genomics and precision medicine and it’s not going to be cheap. So if we believe that it’s the right of every oncology patient to have their own humanised mouse avatar to get precision signalling of precise treatment, I can only assure you that the inequities will grow.
SUE WOOLFENDEN: And I just want to differentiate inequity from inequality. An inequity is an inequality that is unjust, unfair, systematic and avoidable. You know, there’s a moral judgment made about that. It immediately brings in concepts such as social justice. So when we’re talking about inequities we are being quite deliberate in saying, “These are inequalities for which there is no biological reason for them to occur”—that they’re not OK.
MIC CAVAZZINI: That’s Associate Professor Sue Woolfenden of the UNSW School of Women and Children's Health. She’s a paediatrician in the Sydney Children’s Hospital Network and participated in the closing discussion of Congress, on how doctors can set an example for tackling the social determinants of health.
SUE WOOLFENDEN: So I think a lot of people understand that, you know, people who are really poor, have really poor housing, have poor health outcomes. I don’t think that’s a hard sell; I think most people see that. However, what they don’t tend to understand is that people in-between also have variable health, and if you really want to change a population’s health you need to understand the social gradient—because there’s a huge middle group that you want to try and improve as well.
So, often you’ll get people debating universal versus targeted services—actually, you need both. And the word that Michael Marmot used is ‘proportionate universalism.’ What you actually have to do is make sure that the amount of services you provide is proportionate to the need.
MIC CAVAZZINI: And can you illustrate, perhaps, the slide you showed that compared SES postcodes in Melbourne to the location of speech pathology services?
SUE WOOLFENDEN: Oh, yeah. That was kindly given to me by Professor Sharon Goldfeld who—she runs an equity research group down at Murdoch Children’s Research Institute, where she’s looked at postcodes. Postcodes have a link to a socio-economic status measure—it’s quite rough, but ABS puts it out. And so, she looked at how advantaged or disadvantaged a neighbourhood was and then looked at the supply of speech pathologists both private and public.
And pretty much what it showed was that the majority of speech pathologists—and I’m sure if we did the same thing for private paediatricians—were actually based in the areas that had the most advantage as a neighbourhood. The more disadvantaged the neighbourhoods were, the less access there were to services. And that makes sense because often those areas are more regional, they’re more outer-metropolitan. I don’t think that’s a surprise to any of the College membership, I think they know how there’s less services available generally.
MIC CAVAZZINI: So, is the onus on practice managers or health workers themselves to go into those less lucrative suburbs, or do the incentives need to come from the health system?
SUE WOOLFENDEN: Oh man, that’s a hard one. And I don’t know if I can answer that. I think the onus is on all of us to look at our health services that we provide and how do we make them more accessible. I think there is definitely an onus on us in working in partnership and thinking more about outreach of our hospital-based services.
BRETT SUTTON: I think we need to make better use of big data. We’re in the era of big data, and it means we need to trawl that for as much analysis as it can provide and we need the appropriate local-level feedback. You know, in Australia maybe it’s the Primary Healthcare Network, maybe it’s the local government area, but some version of that to say, “These are our local issues.” Once you identify them you’ve already got the motivation to do something about them, and you’ve provided half the tools to do so because they know where to place the focus and within the resources that are available they prioritise accordingly.
ROSS UPSHUR: I started as a rural physician and I used to tell my residents, “If you want to go and be a rural physician, you can negotiate a bronze statue of yourself in front of City Hall and they will do that to get you to come up and work.” But even areas in Toronto are considered under-serviced, right. And I think we have an obligation to—on grounds of equity or justice or whatever you like—to redistribute, and if we need to incentivise to do that, do that.
The government has a further kind of lever. They’ve put a lock on the number of new family health teams that can be introduced. They’re using it to say, “OK, if you want new grads to work in these teams they’ve got to locate here.”
BRETT SUTTON: But you know, it’s not just about the provision of health services; you need to look at whatever else is required in those spaces. It might be opioid substitution therapy, it might be needle and syringe exchanges, et cetera, in order to match it with the prevalence of illness as you see it. So you know, some will be hotspots for hep C, some will be hotspots for hypertension, and you just need to match.
And I think practices, they need to understand all of those dimensions that relate to, you know, pure distance—but also appropriateness and affordability.
MIC CAVAZZINI: And so, that is somewhere that physicians themselves should be driving, rather than waiting for government to realise there’s a gap.
BRETT SUTTON: But I think it needs to be built from the bottom up, so you need to understand what the concerns are of the community you’re trying to serve, and you have to understand the barriers that they experience individually and as a community. And I’d say the community should be driving it and the physicians should be listening and leading.
ROSS UPSHUR: Exactly. And what we need to think about is from—I like to talk about “from preconception to bereavement.” It’s how we envision the population. So, it’s not just over when the patient dies because there are survivors and we have to provide appropriate care. And good health of a child starts in the preconception.
SUE WOOLFENDEN: It’s very intergenerational, not surprisingly. It all begins before birth. So, one of the things we know is that the more disadvantaged you are, the less likely you are to access antenatal care visits. Usually you want to have at least five visits, because in antenatal care it’s when there are discussions about nutrition and immunisations and being safe, and it’s where parents first start to understand about child development. There’s also some data out there that’s shown how the less antenatal care visits you have, the more likely you are to have a low-birthweight baby. If you’re born low-birthweight or pre-term, that can have impacts on your development and your growth all the way up into adulthood.
So, definitely there’s an example where we could improve things to make sure the way we’re providing services doesn’t become a social determinant in itself. And I think often people get to that argument where they say, “Well, they didn’t come” and then they get the word “Did not attend” written on their file. And rather, I think the question is, “Well OK, why didn’t they come? What is it about the way we provide our service that makes it not a service that people who are at-risk come to?”
MIC CAVAZZINI: Now, you’ve published some research about the awareness of and experience of early years care among disadvantaged and culturally diverse groups in Sydney. What did you find out of that?
SUE WOOLFENDEN: Yeah, you know, you should always do research in an area that makes you cross. And I was getting cross because I was having children aged four who were turning up to my developmental clinic with clear features of autism spectrum disorder, and the first time they were turning up was four. And I was going, “Well, how?” You know, it wasn’t like these kids were children that people would miss the disability.
And it’s very easy again there for you to blame the parents and go, “Oh, the parents were in denial” or whatever, and I thought, “Well, let’s ask. Let’s just find out what is going on from parents from culturally and linguistically diverse backgrounds, and healthcare providers and non-government organisations who run playgroups.”
And it was interesting because the providers—again, we got a lot of stories about stigma: “There’s a lack of awareness in the community,” “People just don’t know where to go.” And even if you did find a problem—and often there were speech problems—people couldn’t afford to go to the private speech pathologists. “There are waiting lists,” “It’s hard to get into a GP,” “We don’t all work together,” “We’re not trained in this.” All those kind of things.
And then from the parents we were kind of getting the story—yes, of a lack of community awareness, a lack of awareness themselves; it was their first child often. But also we were getting a story of “I was worried and I either didn’t know where to go” or “I was worried and I kept saying I was worried and everyone said, ‘He’s fine. It’s because English is the second language.’”
And really the rules are always the same—you have to have two-word combinations at two. You know that’s the rule, regardless of what language you speak, it’s two-word combinations at two. Usually at preschool or day-care someone was saying, “This isn’t OK.” But you’ve got to remember, a lot of these kids don’t actually make it to day-care or preschool because it’s actually not affordable.
MIC CAVAZZINI: Well, you’ve not waited for the system to change to make it easy for you. Can you describe your initiative in attracting disadvantaged young mothers to development surveillance programs?
SUE WOOLFENDEN: Actually, we didn’t push it forward—the playgroups did. The playgroups then went, “Right, we need to something now to train the child and family workers in the playgroups in how to undertake development surveillance,” because we knew these families weren’t going to child and family health nurses. And then we gave them a referral pathway to link them to a child development clinic.
And that did mean we detected quite a few more children with difficulties, and so we managed to get some money to get a speech pathologist who would also go to the playgroups. And rather than her doing one-on-one with every child, which was just going to be beyond the resources, looking at helping the playgroups support language as well. So, we’ve done some education with the parents and the playgroups about what’s normal, when to be concerned, what the Blue Book is. And then we’ve trained the playgroup leaders in sort of, “OK, this is how you ask the questions around child development and this is where you can refer them if you have a concern.”
I mean, the ideal model is hubs and one-stop-shops. So for example, for our Aboriginal clients in the La Perouse area we don’t expect them to come to our outpatients at the hospital because there’s issues with trust. LAPA is seen as their place. We run a clinic out there that essentially runs the same way as a general developmental clinic will run. But the difference is we have often caseworkers from Barnados floating around, who we can engage to help families who are struggling. We have a social worker now we can link them up with who’s there. We have speech pathologists. We have a preschool next door. We have a parenting group next door. And I guess it’s just another example of, if people aren’t coming to you, thinking how you can go to them.
MIC CAVAZZINI: In that closing session at Congress, Peter Connaughton gave a lovely example of the work of the CINI Institute in Bengal to empower women in communities to tend to the public health needs of the village. And he said that empowerment doesn’t mean showing people how it’s done. It requires giving up some of your own authority. Is this a message that can be applied even by the inner city physician?
SUE WOOLFENDEN: Yeah I do. I think, so, in the community where I am, we work in a family partnership where we acknowledge our expertise, but equally we acknowledge the expertise of the parents. Because no one knows their child better than them. But also the other person you must consider, and I think you can start talking to them fairly early on, is children themselves. They’re the experts in their health that I talk to first.
And then I think the message I was trying to get over is that there are many opportunities between being a blip in their mother’s womb all the way to being an adolescent where, even if they have risk factors pushing them down such as poverty, their mother’s isolation or not doing well at school, that the health service has an opportunity to act as a buffer. And children will have buffers too. Their innate temperament might be a buffer, they might have a grandmother that really cares about them, that’s a buffer. They might have family that’s not particularly wealthy but reads to them, and that’s a buffer. So I think, too often we think only in terms of risk, and what instead we need to think about is for each child are what are the risk factors in their lives and also what are the protective factor in their lives, and how can we make sure how we provide health services is a protective factor as well.
MIC CAVAZZINI: It’s estimated that socioeconomic factors are responsible for half of the population’s health and wellbeing status. By comparison all the medical services provided might determine only a quarter of health outcomes. Better targeting of limited resources is crucial to addressing this, but it’s just not a macro-level problem, according to Ross Upshur. He says that merging medical records with socioeconomic markers will help physicians address inequity at every consultation.
ROSS UPSHUR: So, we incentivise practitioners in Ontario to do preventive manoeuvres like flu shots, you know, basic vaccinations, colorectal cancer, pap smears and mammography. But we don’t report on equity. So you can say, “I’m doing a good job, I’ve gone from 60 to 80 per cent coverage,” but if you don’t look at that according to SES, you know, recent immigration, poverty status, blah, blah, blah, and—“Oh, my God, that 20 per cent that I’ve missed are all low socio-economic.”
If you ask the right question, and you’re cued to ask the right question as a matter of course, like I said if you know their postal code, if you ask about income adequacy, isolation—Michael Marmot was talking about “isolation kills.” So, I’m trying to develop a tool right now that permits general practitioners and family docs to identify the frail, isolated individuals.
So, we need to have some investment in research that allows us to figure out how we can make all of this a default practice, just like it is now when you come in: “Here’s your weight, here’s your this, here’s your that, here’s your presenting complaint.” So, we need to change the way that information is shown to clinicians so that the social determinants are present to the mind of the clinician when they’re seeing that patient. We call that the “bifocal vision.” So, I want population health or public health to look one level down, and clinicians to look one level up, and in that intermediate space there’s a shared common goal of improving population health. And then the final cherry on top is addressing equity.
MIC CAVAZZINI: I like big data generally from a scientific background but we’re talking about, in a way, academic understanding of these problems as opposed to what the doctor can do themselves. So, David Beaumont today gave the example of the unemployed patient who comes along with hypertension and his doctors say, “Well, I can treat the hypertension but what can I do about the unemployment?” So, at a practical level how can doctors plug in better to social services where they are provided, and should they be standing up and shouting to government where they’re not provided?
ROSS UPSHUR: So, you have to say being unemployed is like saying, “And I’m also drinking, you know, 26 ounces of whiskey a day.” You have to see it as actionable towards health and then you need the tools. So, what’s the first thing that comes to mind? You know, “Are you getting benefits? Do you know what benefits you’re entitled to? Have you spoken with a vocational counsellor? I’m going to send you to these people. I want to see you back in two weeks to see if we’re making any progress,” right?
We actually have now software that has all of the government benefits for income support and security and we can write—just like you’d refer to a chiropodist for a diabetic foot, or you know, “You need a cath,” you send them to a cardiologist. We need to see these as practice-level interventions that benefit the health of the patient.
BRETT SUTTON: What’s been referred to as social prescriptions?
ROSS UPSHUR: Yeah. We want social precision medicine.
BRETT SUTTON: Yeah. And I think big data shouldn’t be in the realm of academics alone; it needs to be utilised at that service level. You know, again in Australia we’re working with public health networks now to try and help map out all of the notifiable diseases, the infectious diseases according to burden by public health network, and then they can focus on those diseases that are particularly high-burden in their areas. You know, now in Victoria we’re getting better vaccination coverage for some of our Aboriginal Victorians than for the non-Indigenous population, so you can get there.
MIC CAVAZZINI: That’s a great example of collecting the data and feeding it back to where it’s needed, but what about the physician who’s counselling their patients? They’ll tell you, “I’m not a psychologist, I’m not a social worker, I’ve not been trained and I’ve got 10 minutes to write these social prescriptions. Is it that the time and the training isn’t available, or the value of those interventions isn’t fully recognised yet?”
BRETT SUTTON: I think it’s both and I think the selling point is that you can’t afford not to. The people that you will see recurrently, the people that you will see with escalating health issues and hospitalisation, you know many of these things are preventable through more basic, earlier focused interventions, and you know you can—it’s not stealing from Peter to pay Paul, you will save yourself in the long run, but it needs to be understood in terms of how all those causal pathways line up.
ROSS UPSHUR: Yeah. And we do truly need to work towards a fully integrated health and social services system. What we have is a lot of uncoordinated services. So you know, one, we have to really think hard about we unburden the time-burden on clinicians—that’s another thing I’m very worried about. And that’s a human-created problem, right. We’ve created this, we can un-create it.
So, we know that not every rank-and-file practising physician is going to want to be a data hound. If you don’t have the time we create a cadre of people who can do it. And I’m just going to say, as much as I love epidemiologists, it can’t be epidemiologists—it’s got to be someone with a clinical sensibility. If they have a group of people who take public health and preventive medicine, they understand data and its use for policy and planning, they work with family physicians, so they would say, “OK, you’ve got a EMR, I know how to mine your clinical data in your EMR.”
Eventually it’s all going to have to be aggregated and sent to the province anyways. We need to get it remunerated. So, I think there’s, you know, if we’re successful in the next decade we’ll affect this revolution. All this is possible with political will. We actually know what the problems are, we just need to organise ourselves and marshal the will. And I can tell you after four years it’s hard work, because my clinician peers say, “I see one patient at a time,” and my public health peers say, “Well I’m up here doing inter-sectoral work, I don’t deal with patients.” I say, “C’mon guys, let’s get together here and make something really cool happen.”
MIC CAVAZZINI: A common theme to emerge from these discussions at Congress was the esteem and influence doctors have in advocating for patients and communities. It’s not always easy, however, for physicians to put themselves in the firing-line over divisive ethical issues.
ROSS UPSHUR: So it’s interesting, in Canada they’ve created this CanMEDS framework which takes eight qualities and characteristics where physicians need competency—medical expert, manager, collaborator—and advocate is one of them. And interestingly, it’s the one when you’re doing work with specialist physicians or primary care physicians that they feel the least comfortable with. And so, it does take a little courage to be an advocate. You have to be prepared for a massive amount of pushback.
MIC CAVAZZINI: In your session, Brett, you said that doctors carry a level of respect in society that means that they do tend to get listened to if they speak out, but it’s also a fine line about maintaining credibility.
BRETT SUTTON: Yeah look, I think it’s very true. They have a privileged position; they should reflect on that in terms of the privileged position really to be able to move some of those levers of policy-making and of political interest. But they do need to maintain the respect within which they’re held, and you know, that sometimes means meeting policy-makers, meeting politicians in the right space, not going in necessarily with a radical agenda at a time. You need to wait for those hooks. Sometimes they’re about individual case stories, sometimes they’re about very prominent news items that become your entry point for a policy change.
SUE WOOLFENDEN: So, again I can’t speak for all doctors, I can only speak from my experience. Yeah, I think responsibility does weigh heavily and I have certainly struggled with my ambivalence about that level of responsibility, and sometimes feeling like I’m letting people down because I can’t possibly fulfil that level of responsibility. Having said that, we see directly the impact of the social determinants of health every day, so I think we are in the right spot to advocate, and the level of respect that we’re held in too, and use that.
I guess you have to think about how can you be the most effective advocate. I think you will lose vast waves of the population and their support if you show your political colours too much. You can get a bit strident. And you when you’re so passionate about children’s rights I think you can then imply that other people aren’t, and put them offside. You have to think about what matters to different people and what values do they have.
I think the moral argument for managing inequality works for some people; it doesn’t work for everyone. Some people do see the world as having always been unfair and that’s just the way the world is. I think for those people you probably need to have an argument about how expensive inequalities are, you know, through the loss of sort of the human capability but also the effect on things like crime and productivity in society. That is an argument in itself, in terms of the money we would save if we addressed inequalities.
MIC CAVAZZINI: Gillian Triggs referred to the 2016 case of Baby Asha, an infant from Nepal who was burnt at the Nauru detention camp, and her treating physicians at Lady Cilento Hospital in Brisbane refused to discharge her for fear she’d be sent back to a damaging environment. The reaction of the media and politicians was mixed. You could argue that the doctor’s action was in the interests of the patient’s health alone, but others would say that it was overstepping into a more political statement.
SUE WOOLFENDEN: In the end, we have undertaken the Hippocratic Oath, which is to first do no harm and secondly, you know, to help mankind. So, it’s pretty simple really in the sense that you treat your patient, you make sure that they are well, and when they’re ready for discharge you make sure they can go to a setting where they can get good outpatient care and nothing is going to contribute to difficulties with follow-up. That’s our job.
BRETT SUTTON: People can argue the point, but I think if you feel a personal ethical imperative you’ll push against whatever, and I think the point to reflect on is, is it going to damage their clinical relationship and their clinical standing within the hospital going forward? And that’s a worthy consideration, because our professional lives are, you know, how we do good in the world. And so you don’t want that to come to a crashing halt.
By the same token, you know, the things that you stand for define your character and so, there’s always the tension, and you know, we’re in an era where nanny state-ism has become a terrible thing. And yet we forget how we’ve internalised putting on a seatbelt as our obligation to everyone’s health even though, you know, 4,000 people need to wear a seatbelt to prevent one significant injury. So there are cultural elements about what we accept or don’t accept as constraints on our individual freedoms, and so part of it’s the pitch and part of it’s those slow cultural shifts with repeated messaging and the evidence and data behind them.
For population-level interventions we’re talking about invisible gains, and to try and have people emotionally engaged with saving theoretical lives is a harder task. But you know, we’ve done it with smoking, we’ve done it in road safety in Australia so successfully and we can do it for other things, I’m sure.
ROSS UPSHUR: Just to pick up on what Brett was saying, and support it, for me it’s a matter of the clarity and reasoning and your justification. And when you’re advocating you need your argument to be as lock-solid as possible. And I think when physicians are working from their value base, that they’re there for the goals of medicine, which is to improve people’s health, and there’s not anywhere where you can sort of pry underneath that and find an ulterior motive, right. So, if anybody can impugn and suggest, “Oh, well, you’re not speaking as a doc, you’re really—“
BRETT SUTTON: “—your hidden agenda—“
ROSS UPSHUR: “—your hidden agenda is for the auto-industry and seatbelt manufacturers right, which came up during the seatbelt debate. So, if the motives are good, the reasoning is clear, the evidence is as good as it can get, then you’re in a pretty good place for advocacy.”
MIC CAVAZZINI: Ross, a point that you made in your lecture is that ethics isn’t taught to medical students in an effective way anymore. That it’s been replaced by a concept of professionalism, rather than ethics. How is this different? Why is this a problem?
ROSS UPSHUR: Well, I think it relates to the self-understanding of physicians. I think they’re much more comfortable with this language of professionalism than they are with ethics. A profession, by definition, is self-regulating, which means that the standards of where we embody and live our obligations to communities and to our patients is done by us. The one reason I think it’s important to maintain ethics outside of professionalism is because you cannot resolve certain issues that I think lean towards public health ethics, and other macro-level things like resource allocation, through mechanisms of professionalism alone.
BRETT SUTTON: And I agree that ethics is a much broader church in that regard. And I think the other point about professionalism is it’s also defined by the norms, historical and cultural and personal norms of the individuals that make up the profession, and so sometimes ethical behaviour needs to push against those boundaries. You know, you can take gender norms within sometimes very conservative colleges and they might regard those individuals who challenge those norms as unprofessional. Whereas, in fact, they’re following an ethical imperative to see gender equity or appropriate gender representation within that professional body, and so I think it’s important to recognise that some components of professionalism also relate to the baggage and inertia of history.
MIC CAVAZZINI: That was Brett Sutton ending this episode of Pomegranate. Thanks also to Ross Upshur and Sue Woolfenden for their contributions. The views expressed are their own and may not represent those of the Royal Australasian College of Physicians.
Today’s guests appeared at RACP Congress alongside other eminent speakers such as Sir Michael Marmot, Associate Professor Peter Sainsbury, and Emeritus Professor Gillian Triggs. You can see these sessions in full at the College’s YouTube channel, RACP1938. To find other resources mentioned in this podcast or claim CPD credits, visit the Pomegranate website and send any feedback to the address firstname.lastname@example.org. Please share this story with colleagues, and join the conversation on line using the hashtag RACPpod.
I’m Mic Cavazzini and I hope you can join me again next month.