Feb 2016

After decades in the public system I still experience a thrill each time I’m able to call the brightest minds to the side of a patient who can’t afford his groceries
It was nearing a weekend when I inherited the care of a distressed elderly man. The hospital bed had been pushed against the wall to guard against falls. His hair was plastered in sweat and his limbs jerked involuntarily as he mumbled incoherently. He looked tired, uncomfortable and dehydrated and he was incapable of providing a history although the differential diagnosis ranged from delirium to an unrecognized surgical emergency. Mostly, what struck me was that he had unalleviated distress.
I found his wife standing helplessly in a corner. Despite her stress she spoke calmly and was intelligent and thorough. Combating frustration and tears, she related the story of the past few weeks. He had been admitted to a private hospital for surgery and had failed to thrive post-operatively. There were complications including an infection and then slowly, he had stopped eating and drinking, become more confused and occasionally aggressive. A parade of doctors came past but the patient continued to deteriorate until his wife was told that the best place for him was a public hospital because the private hospital couldn’t manage his disruptive behaviour. Wary of his two private hospital transfers and now a third move, she agreed out of sheer hopelessness.
It took me over an hour to piece the story together, which she concluded thus: “I think they turned us out when he got too hard for them.”
Since there was no medical transfer note, I could hardly judge, but on that Thursday afternoon I said the most important things she needed to hear. I promised her that we would look after her husband. I told her that we would monitor his distress, settle his agitation, call in our geriatrician, involve our psychiatrist and get to the bottom of his problem. I promised to find him a quiet, single room, with one experienced nurse who would provide continuity of care and protect him from unnecessary intrusions. And I promised her that her husband was safe. At this, she burst into tears, unable to contain the mix of exhaustion, adrenaline and fear that had been driving her to increasing levels of despair. I told her that I had complete confidence in the ability of my public hospital to deliver on my promises.
On Friday, the patient had deteriorated and in further discussion with his wife it became obvious that his agitation and decline over the past few weeks had signalled the end of life. He didn’t need an MRI, bloods, a geriatrician or a psychiatrist. He certainly didn’t need a locked ward to prevent him from harm. What he needed was first dignified, compassionate end of life care. Again, I promised her we would deliver and we did. By Sunday, he had died.
After the trauma of her ordeal, his wife expressed gratitude for her final memory of him – clean, calm and peaceful.
If you think this incident pits the merits of private hospitals against public ones, I could just as easily flip the scenarios and describe any number of woeful accounts of the public hospital system betraying the trust of patients. For the record, private hospitals generally serve patients well but the Australian public hospital system does not deserve anywhere near the level of disdain and invective that it attracts. Last week I heard an influential radio announcer publicly question why anyone would ever choose to be treated in the public system – it was not merely ungenerous, it was frankly irresponsible.
Our public system is a magnet for the best minds who seek to work in collaboration with their peers to advance medicine. While private medicine rewards doctors with a fee for service, public hospitals, especially the large academic centres, nurture talent and fuel innovation, discovery and ultimately, life-changing treatments. Safer chemotherapy and transplants; ingenious skin grafts for burns treatment; lithium for mania; airway support for sleep apnoea; foetal ultrasound; the link between how a baby sleeps and sudden infant death syndrome – these are just some of the things that research and collaboration within the public health system has engendered.
But that’s cutting edge stuff, you say. How does the public hospital system serve me, the average patient, when I break a hip, suffer an arrest, have a seizure or find a lump in my breast? As most healthcare insiders will attest, if you are seriously ill your best best is the local emergency department.
Your public hospital is the only place where the first question isn’t about your level of cover but the nature of your problem. It’s the only place with doctors available around the clock. Not just on the phone, but there to see you, in person.
After decades in the public system I still experience a little thrill each time I am able to call the brightest minds at the side of a patient who can’t afford his groceries, let alone a private cardiologist. That broadcaster scoffed that public hospital patients couldn’t even speak to their doctors because of a lack of interpreters. It made patients look silly and doctors, derelict, he said.
Where I work, nearly 60% of the patient population can’t speak English. On any given day, I need a Dari, Khmer, Arabic, Hungarian and Macedonian interpreter. No, they are not on tap but they are easily booked. Mind you, no private hospital houses a Tagalog or Pashto interpreter either! But why would it? The people who need these interpreters inevitably wash up at the shores of their public hospital.
If the private hospital queues for some interventions are shorter, there is little concordance between having an expensive treatment and a good outcome. No critically ill patient I have met really cares about the plushness of the carpet or the provenance of the art – such frivolities are never to be equated with the essence of medicine, which is to provide sound healthcare, with efficiency, dignity and compassion. It’s fallacious to suggest that this aspiration is exclusive to one hospital system, private or public.
Having experienced global healthcare systems, I have yet to come upon a perfect one. Of course, we must address the problems that beset healthcare but lambasting the entire public hospital system is an ill-conceived way of inspiring change. At best, it disillusions patients, at worst, it compromises their care.
Always in the eye of another storm, working in the public hospital system can seem like a Sisyphean task whether you are an orderly or an oncologist. But we stay because we are sustained by a fundamental belief that the true measure of a society is how it looks after its weakest. Medicine speaks to us as a vocation, not a mere job.
The outside world regards the Australian healthcare system as a jewel in our crown. It’s time we realised why.

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