Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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22 Surgery and Healing in the Developing World
duced a Medibank scheme that had mixed popularity, leading to over-servicing by
both patients and doctors. In 1975, when a conservative government was elected,
private medical insurance with tax-deductible premiums was introduced, and this
system continued until 1983, when the government again changed to labor. With
this election came the introduction of Medicare, another money rather than health
system. Doctor’s fees are paid to the level of 85 percent from a 1.5 percent tax on
gross income, and the tax deductibility of the premium has been withdrawn, which
largely eliminates health from the cost-of-living indices. Hospital insurance is legal.
Medical fee insurance is not. Therefore, to be operated upon by the surgeon of
choice, patients must pay their levy and also pay for private insurance; for all practical
purposes they are doubly taxed, so the option to choose is not encouraged.
The legislation that introduced Medicare brought about other restrictions that
produced a profound disaffection between doctors and government. This alienation
led to a number of problems involving the withdrawal of surgeons from teaching
hospitals and some consequent instability in the system.
A major effect of the expansion of Medicare has been the reduction in public
hospital funding; it also had a decided impact on teaching hospitals. There has been
a profound reduction of elective surgery, and the term elective has become equated
with unnecessary. The cost-related reduction in bed numbers and attendant reduction
in the number of nurses have placed the teaching of undergraduates under
severe stress; it is fundamentally impossible to train an appropriate number of postgraduate
students in the current setting.
Despite widespread dissatisfaction with the system, the commitment of the teaching
surgical professionals has been gratifying. Many of these individuals have made
special arrangements to teach after having resigned hospital appointments. However,
the major problem in the teaching of undergraduate surgery is the reduction in
volume of standard elective surgery and surgical beds in hospitals.
The changes in the system have emphasized certain subspecialty areas as major
concerns. Patients from one to 40 years of age who are traumatized constitute the
most common admissions, and the whole field of trauma represents the cutting
edge of the treatment of surgical disease. With respect to diagnostic evaluation and
technology, the surgeon can ignore economics only at extreme peril.
Medical school admissions are being lowered by 20 percent and the Australian
Medical Association requested a 30 percent reduction. At the same time that there is
a mixed reduction in elective major and general surgery in public hospitals, there
has not been a significant rise in private hospitals. Although the number of surgical
admissions has remarkably diminished, the number of medical admissions has not
decreased proportionately. All operations appear to have diminished with the possible
exception of vascular surgery, which has increased minimally.
It remains for those of us in surgical teaching positions to capture the enthusiasm
that our students have for learning and to promote surgery in its art and science
in a manner that will foster and maintain that enthusiasm throughout the surgical
careers of those who have chosen that path. Surgeons must not be deterred by aberrations
in government policy from giving the best possible care to patients. To teach
surgery is our special role. We cannot do so without paying attention to clinical
detail, best demonstrated in that competent surgeon who shows concern for the
patient, who is committed to the patient’s care, and who maintains a good communication
in a confidential atmosphere for all those involved.