16 FEBRUARY 2024 ausdoc . com . au

Insight

Dr Sue Ieraci Emergency physician in Sydney , NSW .

Limiting access may be the real fix to doctor and patient harm .

In medicine , unlimited growth is the hallmark of cancer , in which cells continue to multiply without the normal controls .

In economics , we understand growth as an expansion of demand and / or market share .

We know that marketing is employed to encourage more demand and to increase market share .

But ultimately , in free markets , there is no rational sense of a certain amount of a product or service being ‘ enough ’ — it is simply a product of demand and supply .

What can be said , then , about an expectation for unlimited growth in healthcare services ?

At a time when large sectors of the healthcare workforce are burnt out , is it appropriate to question the concept of unlimited growth in healthcare provision ?

Do we need more and better of everything ?

And how do we factor in the concept of diminishing returns ?

There is plenty of good evidence

that preventive health measures — such as smoking cessation , immunisation and addressing social disadvantage — lead to better health outcomes .

What they don ’ t do , though , is necessarily lower healthcare costs .

This is due to a combination of the system having to address previously unmet needs and of ever-increasing expectations about what healthcare can do .

But instead of arguing for unlimited growth — more resources , more money , more staff — is there a rational way of arguing for limiting growth in services ?

Can we employ the concept of diminishing returns to this consideration ?

Broadly , healthcare services can be classified as consultations , investigations and procedures .

All three of these categories of services can be rationalised .

Doing so requires both the medical and general communities to tolerate some uncertainty and imperfection .

It also requires a balanced and realistic understanding of risk — the magnitude of the risk , the relative risks and who is the holder of the risk .

Instead of seeing referral as a transfer of risk away from the referrer to the accepting clinician ( whether between community providers or hospital teams ), we need to view the

If I refer this patient for admission or for a procedure , could that treatment cause more harm than good ?

Life expectancy

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risk as being held by the patient . If the pressure to never ‘ miss ’ a potential diagnosis — no matter how unlikely or rare — leads to the creation of side-stream harms , these need to be measured and made explicit to patients .

Instead of , “ My doctor was so caring that he ordered all the tests

Life expectancy vs health expenditure from 1970 to 2018

and sent me straight to the hospital ,” our patients could be saying , “ My doctor was so caring that she explained to me it was better to wait and see how my symptoms developed rather than just ordering a whole lot of tests and sending me to a long queue in ED .”

If AI does come to assist clinical practice , it could be designed to do some complex calculations for us .

If I order this test for an unlikely diagnosis , what is the chance of a false positive ?

If I offer surgery for this condition , how do the potential benefits compare with the risks ?

Could this person with chronic illness avoid having to see me if they had a stock of the medications they might need for an exacerbation and a good plan for how to use them ?

If I refer this patient for admission or for a procedure , could that treatment cause more harm than good ?

We could reconsider blaming each other for imperfections and instead create better decision partnerships with our patients .

We could let kindness substitute for unrealistic fear , help our patients understand how their bodies work and look after not only them but also ourselves and each other .

Pull Quote here Si odi totatiatem faccusa erovid magnimus , sitatum asitiis eariatio es qui cuptiorDolupid quam , sunt . Nis ne as recto et facia qui ut quiam , quis ma nullorest inctum ligendaerum

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