Bridging the gap between rhetoric and reality: can the law enforce quality patient-centred care in Australia?

Abstract

This thesis investigates a perceived gap between the medical profession’s rhetoric that the welfare of the patient is the medical practitioner’s first priority, and the reality of patient experience. The Medical Board of Australia’s Good Medical Practice: A Code of Conduct for Doctors in Australia mandates the duty of medical practitioners to make the care of their patients their first priority. This code also confirms that good medical practice is patient-centred.

Patient-centred care should therefore be central to patient experience. However, despite promotion of this goal by medical professional authorities, patient-centred care is not always being achieved as well as it might in practice. This thesis is an attempt to understand the reasons why this divergence between rhetoric and practice is occurring, paying particular attention to the role of the law as a potential and actual promoter of, and barrier to, practices which are recognised components of patient-centred care, and consequently of good medical practice. This aim is developed through two case studies, the way valid advance directives are observed or not, and the responses of medical practitioners to injuries to patients sustained during medical treatment.

The methodology used includes analysis of hard law regulatory processes together with the development of and increasing reliance on the soft law documented in codes, guidelines and other regulatory standards which reflect the evolving ideals of medical professionalism. In turn, an examination of disciplinary cases of tribunals and courts shows how conduct is interpreted in accordance with what is or is not professional behaviour.

There is evidence that observance by medical practitioners of patient-centred care is often being overwhelmed by the scientific and technical aspects of medical practice and other pressures on medical practitioners, such as concerns about legal liability. The necessity for the observance of respect for the human being who is the patient is discounted to these priorities despite extensive evidence of improved outcomes for patients when patient-centred principles are implemented. The reasons for this discount are complex but a major contributor to the less than optimum observance of patient-centred principles is medical professionalism as fostered by the current methods of socialisation and training of medical practitioners. Bullying and humiliation of medical students in their training leads to desensitisation and a consequent lack of attention by medical practitioners to the necessity for patient-centred approaches to practice.

An exploration of the direct and indirect impacts of the law upon the medical profession shows the domination of medical practitioner interests over the interests of their patients. Therefore, this thesis considers whether the existing Australian legislative regime can be applied to achieving the promotion of the observance of quality, patient-centred practices by medical practitioners to the mutual benefit of doctor and patient. It argues that medical disciplinary authorities can use the provisions of the Health Practitioner Regulation National Law together with soft law regulation to more completely embed a patient-centred culture in medical practitioner behaviour.