Personal values and medical practice

I want to reflect on how personal values and attitudes can impact on professional decision making in the health and allied health fields. This thought has been in my head for some time due to various incidents that I have either witnessed as a practitioner or as a 'patient'/client or have been relayed to me by a friend.

I believe that it is important to be cognisant of our values and attitudes in all aspects of life. It is critical, however, when we are responsible for the welfare of another. In psychological and counselling practice, this is usually emphasised in professional supervision which is strongly encouraged for any practitioner, if not mandatory if you are employed in government or non-government organisation (as opposed to working in your own private practice).

Why does this matter?

Well, the observations I've made or heard told would indicate that self-awareness in the medical professions especially seems to be lacking. Not only are certain attitudes expressed hurtful to the patient at the time, and thus could indeed stop a person from seeking medical attention in the future; but I am also concerned that the decision-making process in deciding treatment could also be adversely affected.

A couple of examples:

Olinda* was told she could probably do with losing weight when she presented at an emergency department after throwing up for several days, and after giving her an anti-nausea drug intravenously and then sent Olinda home. The anti-nausea drug was only effective for a few hours once home. Olinda continued to vomit for another three days.

Frank was asked if he had sex with men, and when he said he didn't then the GP said he didn't see the need to test him for sexually transmitted infections. I believe that the GP knew that Frank's partner had other sexual partners.

I've had a GP speculate that perhaps I was a lesbian, and my partner likes 'that sort of thing', when I wanted to stop the contraceptive pill some years ago. I was too gobsmacked to be able to give an intelligible reply but needless to say that I didn't return to see this doctor again.

I can think of countless others, including ones where I have been either the patient or a support person for the patient but these are a little too distressing to go into.

As a professional, the most common situation where personal attitudes and values raised my concern was when clients with particular presentations and/or diagnoses came into contact with medical or psychiatric triage. I am thinking of, in particular, people who present at a hospital emergency department or call the psychiatric crisis assessment team. Those who have worked within the 'pointy end' of public mental health are probably all too familiar with the types of responses that clients can receive, that can often be experienced as rejection and uncaring. I am not going to pretend that supporting these types of presentations is easy but a whole team approach, along with solid supervision, can help.

Which leads me back to a question: what sort of training and supervision do those in the medical professions receive? Are they encouraged to reflect on their personal values? Is this changing? Are those who have been trained more recently encouraged to consider these kinds of matters when practicing while older professionals were left to just feel their way through?

I wanted to write this without doing any particular research, as I often have ideas but I have found in the past year or so that feeling that I need to undertake research puts a halt to my writing and hence the long time between posts.

I am sure that there are plenty of other examples that people reading this could share, some far worse than those examples above too.

*names and some other details have been changed.

The reality of existing on Centrelink payments

Abstract: This article summarises the amount of income that the major Centrelink payments provide and then presents the cost of rent, food and utility bills. Depending on the payment type, Centrelink payment recipients are paid between $1,047.30 and $1,717.45 per calendar month (including Rent Assistance). Taking into account the basic costs of existence, the outcome results in a range of -$510.52 to +$159.63 before adding other costs generally considered essential.

Introduction

I was inspired to write a post about the economic realities of existing on Centrelink payments after feeling frustrated with medical professionals telling me their gap fees after the Medicare rebate for their services (note, I was told that I would have to pay the full fee up front and then organise the rebate myself). This information was after I had mentioned that I have a Pension Card. In this instance, the gap fee totalled $240 ($40 for initial consultation and $200 for the gastroscopy). I also have been asked if I have private health insurance, which in my current financial circumstances, I could not hope to afford. I know that I am not the only person who receives Centrelink payments who finds themselves in similar circumstances, so I hope that sharing some quick statistics on the current rates of payment along with the costs of existence, will provide some better understanding to those who are fortunate enough to not have to know this reality. In doing so, I further hope that people do not have to experience the sense of humiliation, frustration or indignation in response to professionals offering services that the patient or client cannot hope to afford.

 

Centrelink payment types and rates of payment 

Per fortnight

Age Pension $712.00
Carer Payment $712.00
Disability Support Pension $712.00
Newstart $492.60
Abstudy 407.50, if aged 16-21; $492.60 aged 22 or older
Austudy $407.50
Youth Allowance $402.70

Notes: all payment rates quoted above were current at time of publishing, and are based on the single with no children rate. The Youth Allowance rate cited is that of someone who is over 18 and has to live away from home. Newstart payments are given to people who are either unemployed or deemed unfit for work but deemed to not meet the criteria for the Disability Support Pension (DSP). One of the criteria is that the condition is being treated but is not expected to improve further over the next two years. This prediction is particularly difficult with regards to mental/psychiatric illness. More information on eligibility for the DSP can be found here. A Carer Payment is given where caring duties involve ongoing daily care and stops the carer from being able to maintain employment.

If the recipient happens to be living in private rented accommodation, they may be eligible for Rent Assistance from Centrelink too. Again the single with no children is quoted.

Single occupancy $121.00, or
Per person in shared household $80.67

This maxium amount of Rent Assistance is paid if the recipient is paying more than $268.73 in rent per fortnight. With the average prices of private rental properties in the capital cities of Australia currently greater than this amount, I would imagine that there are very few Centrelink payment recipients being paid less than the maximum amount of Rent Assistance.

Thus, if a person is renting and receiving any of the above Centrelink payments, their total income will be as follows (lowest to highest, using the share Rent Assistance rate*):

Per week $241.69 - $396.34
Per fortnight $483.37 - $792.67
Per calendar month $1,047.30 - $1,717.45
Per annum $12,567.62 - $20,609.42

*The shared rate of Rent Assistance was chosen, as most people receiving Centrelink payments for any period of time beyond their savings cannot afford to keep paying rent in a single occupancy, as will be demonstrated next.

Basic costs of existing

As the concept of the 'poverty line' is sometimes viewed as contentious, I thought I would simply report the basic costs of rent, food and bills. I have done my best to find the most recent and representative data that is readily publicly available, which happens to be a crowd source International database called 'Numbeo'. In preparing this section I searched for other possible sources, such as the Australian Bureau of Statistics or research bodies like the Melbourne Institute, however, I could not locate the basic data that I wanted to present in this paper.

As I am based in Melbourne, I will present data for this city, as well as the National average. For the sake of simplicity, I will present only one time period, which is the per calendar month (PCM) cost for each of the basic costs per person.

Private housing rental

The price listed here is that of a three bedroom apartment in the suburbs outside of the city centre. Unfortunately, I have not been able to find the price of houses, however I would argue that these would be more expensive than an apartment.

Melbourne $666.66
National average $1,000.00

Food

The balanced diet estimate only covers the basics and does not include other household items, such as toiletries and cleaning products. The costs listed here are per person.

Melbourne $379.48
National average $357.82

Utilities

The prices below only include the cost of gas, water and electricity.

Melbourne $191.09
National average $200.00

Summing it up

The total cost of paying for the basics per calendar month are $1,237.23 and $1,557.82, for Melbourne and the National average respectively.

The total amount of income received from Centrelink payments per month range from $1,047.30 to $1,717.45.

In Melbourne, the lowest rate of payment results in a $189.93 shortfall and the highest rate leaves $480.22 in 'savings'. The National average figures are worse, with the lowest income resulting in a $510.52 shortfall and the highest income leaving $159.63 in 'savings'.

Bear in mind, these costs do not include many other items which we in Australia have come to see as 'essential'; such as cleaning products, toiletries, transport (private or public), telephone (landline or mobile), and medical expenses (including medications). Any so-called savings that the upper end of Centrelink payments would be used to pay for these 'essentials'.

Those on the lowest payment (Youth Allowance, students) are able to earn up to $405 per fortnight through employment before the rate of payment is affected. Anyone who has undertaken full time study however, will appreciate how difficult it can be to maintain employment while also trying to undertake full time studies and do well.

Those receiving Newstart can earn up to $65 per fortnight before payments are affected.

I would point out however, that this December there were 61,483 recipients of Newstart, and 4,642 Youth Allowance recipients who were deemed incapacitated and thus not required to undertake job search activities. This means that a person is deemed unfit for any employment, which means that they could not undertake gainful employment and thus unable supplement their payments. Over half of these recipients of both payments have been receiving them for more than 12 months. Whilst it is not apparent how many of these people receiving short or long term Newstart or Youth Allowance payments have been deemed incapacitated temporarily or long term, there is an argument that a high proportion of those on long term support and incapacitated should be receiving Disability Support Payments.

Likewise, those in receipt of Disability and Age Pensions are unlikely to be able to supplement their payments for health or other personal reasons. In addition, as pointed out by a friend when preparing this blog, the cost of medications required to maintain health can be very high, particularly if the medication is not PBS funded.

Finally, as one of the eligibility criteria for the Carer Payment is that the person being cared for requires at least 20 hours of care, Carers are also unlikely to have the capacity to supplement their payment.

Notes

All figures quoted were accurate at the time of publishing, 29 December 2012.

I welcome any input or feedback, especially suggestions for data that is sourced from more reliable sources. For those interested, the Australian Council of Social Services (ACOSS) published a report on poverty in Australia, which includes an analysis of those receiving Centrelink payments. The latest report section can be accessed here. ACOSS have also published a factsheet about Newstart payments which includes their own analysis of living costs for someone living in Brisbane.

I have used the word 'existing' in this article, because words such as 'living' imply that more than making sure that there is a roof over one's head and food in one's belly is possible.