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BRITISH MEDICAL JOURNAL VOLUME 28 9 21 JuLY 1984

L e t t e r from... Sydney

A u s t r a l i a n d o c t o r s on s t r i k ePETER C ARNOLD

" A s f a r as t h e members o f t h e m e d i c a l p r o f e s s i o n t h e m s e l v e sa re c o n c e r n e d , t h e r e can b e no d o u b t t h a t t h e nature o f t h e i rc a l l i n g as d o c t o r s , surgeons and nurses i m p o s e s on them am o r a l d u t y never t o s t r i k e or t o engage i n any a c t i o n d e s i g n e dt o r e d u c e t h e l e v e l o f s e r v i c e p r o v i d e d , no matter h ow d e e p orb i t t e r t h e i r sense o f g r i e v a n c e . " 'Many w i t h i n and w i t h o u t t h e p r o f e s s i o n w o u l d agree w i t hP r o f e s s o r M a c f a r l a n e ' s c l a i m . Y e t n u r s e s ' s t r i k e s a re a l m o s tb e y o n d c o u n t i n g . P r e l i m i n a r y r e s e a r c h s h o w s t h a t d o c t o r s h a v et a k e n s t r i k e a c t i o n i n a t l e a s t 1 7 W e s t e r n c o u n t r i e s , i n many o fw h i c h t h e r e h a v e b e e n more t h a n one s t r i k e . Now A u s t r a l i ah a s h a d i t s f i r s t d o c t o r s ' s t r i k e . An u n d e r s t a n d i n g o f t h i s eventr e q u i r e s some k n o w l e d g e o f r e c e n t c h a n g e s i n h e a l t h i n s u r a n c earrangements. Th e system b e f o r e F e b r u a r y 1 9 8 4 h a s b e e nd e s c r i b e d r e c e n t l y . 2 3

A u s t r a l i a h a s a c o m p r e h e n s i v e system o f p u b l i c ( s t a t e o w n e d )a n d p r i v a t e ( c h a r i t y or c o m m e r c i a l ) h o s p i t a l s . Th e currentd i s p u t e concerns t h e c o n d i t i o n s u n d e r w h i c h c o n s u l t a n t s mayt r e a t p r i v a t e , f e e p a y i n g p a t i e n t s i n p u b l i c h o s p i t a l s . F o rd e c a d e s c o n s u l t a n t s h a v e o f f e r e d t h e i r s e r v i c e s f r e e o f c h a r g ei n t h e p u b l i c h o s p i t a l s , t r e a t i n g t h e i n d i g e n t a n d t e a c h i n gm e d i c a l a n d n u r s i n g s t u d e n t s . I n e x c h a n g e t h e s e " h o n o r a r i e s "c o u l d a d m i t p r i v a t e p a t i e n t s . Th e p u b l i c h o s p i t a l s also e m p l o y e ds t a f f s p e c i a l i s t s , f u l l y s a l a r i e d b u t w i t h t h e r i g h t t o t r e a t somep r i v a t e p a t i e n t s .Over t h e p a s t 1 5 years A u s t r a l i a h a s e x p e r i e n c e d a v a r i e t y o fh e a l t h i n s u r a n c e s chemes. Th e c o s t s o f m e d i c a l a n d h o s p i t a lcare h a v e b e e n shared-in v a r y i n g p r o p o r t i o n s , a t d i f f e r e n tt i m e s , i n many schemes-between t h e f e d e r a l government, t h es t a t e governments, and t h e v o l u n t a r y h e a l t h i n s u r a n c e " f u n d s "( B r i t i s h U n i t e d P r o v i d e n t A s s o c i a t i o n type o r g a n i s a t i o n s * ) .E a c h c h a n g e o f government p o l i c y h a s r e s e m b l e d a game o fm u s i c a l c h a i r s , w i t h t h e m a j o r r e s p o n s i b i l i t y f o r c o s t s b e i n gt o s s e d a r o u n d b e t w e e n t h e governments and t h e f u n d s l i k e t h ep r o v e r b i a l h o t p o t a t o . I n New S o u t h W a l e s , w h e r e s p e c i a l i s t sl e d t h e r e c e n t s t r i k e , t h e s t a t e government d e c i d e d some yearsa go on a n o v e l method o f e c o n o m i s i n g on s t a f f s p e c i a l i s t s 's a l a r i e s . I t o f f e r e d them t h e o p p o r t u n i t y o f t r e a t i n g morep r i v a te p a t i en t s i n e x c h a n g e f o r a s u b s t a n t i a l r e d u c t i o n i n s a l a r y .As t h e p a t i e n t s ' f e e s were met t h r o u g h t h e f u n d s , w h i c h were i nturn s u b s i d i s e d b y t h e f e d e r a l government, a c l e v e r New S o u t hW a l e s government was a b l e t o pass t h e b u c k .Th e s p e c i a l i s t s most a f f e c t e d were t h o s e i n p a t h o l o g y ,r a d i o l o g y , and n u c l e a r m e d i c i n e . T h e i r w o r k , as i s u s u a l i nt h e s e s p e c i a l t i e s , c o n s i s t s o f t h e i n t e r p r e t a t i o n o f d a t a o b t a i n e d

*More l i k e t h e B l u e C r o s s and B l u e S h i e l d i n t h e U n i t e d S t a t e s .

w i t h t h e h e l p o f t e c h n i c i a n s u s i n g modern l a b o r a t o r y a n dr a d i o l o g i c a l e q u i p m e n t . I n t h e i r case, h o w e v e r , t h e t e c h n i c i a n swere e m p l o y e d b y t h e h o s p i t a l s w h i c h owned t h e e q u i p m e n t .Th e s p e c i a l i s t s p a i d an a g r e e d percentage o f e a c h p r i v a t e f e ef o r t h e u s e o f t h e s e f a c i l i t i e s . Th e v a g a r i e s o f h e a l t h i n s u r a n c el e g i s l a t i o n were s u c h t ha t p a t ie nt s w i t h p r i v a t e i n s u r a n c ec o u l d c l a i m t h e i r r e i m b u r s e m e n t s o n l y i f t h e accounts t h e yr e c e i v e d were f r o m a d o c t o r . A c c o u n t s s u b m i t t e d b y h o s p i t a l sf o r s e r v i c e s r e g a r d e d as " m e d i c a l " were not e l i g i b l e f o r re-i m b u r s e m e n t . A c c o r d i n g l y , t h e h o s p i t a l s sent ou t accounts f o rx ra y e x a m i n a t i o n s a n d f o r p a t h o l o g i c a l t e s t s i n t h e name o f t h es p e c i a l i s t s wh o had v e r i f i e d t h e r e l e v a n t r e p o r t s . D u r i n g t h i st i m e many " h o n o r a r i e s " were p e r s u a d e d t o accept payment, ona s e s s i o n a l b a s i s , f o r a t t e n t i o n t o n o n - i n s u r e d p a t i e n t s .

1 9 8 4 l e g i s l a t i o nOn 1 F e b r u a r y 1 9 8 4 , t h e Labour f e d e r a l g o v e r n m e n t ' s newM e d i c a r e p l a n ( l o o s e l y b a s e d on t h e C a n a d i a n s y s t e m ) r e p l a c e d

t h e f u n d s i n r e s p e c t o f a l l i n s u r a n c e f o r m e d i c a l expenses. I tb e c a m e i l l e g a l t o o f f e r or t o p u r c h a s e i n s u r a n c e a g a i n s t a nyc o s t s f o r m e d i c a l s e r v i c e s c o v e r e d b y M e d i c a r e . Th e newl e g i s l a t i o n r e q u i r e d p a t h o l o g i s t s and r a d i o l o g i s t s t o s i g n a newcontract w i t h p u b l i c h o s p i t a l s ; p r o h i b i t e d t h e r e i m b u r s e m e n t o ff e e s t o p a t i e n t s t r e a t e d p r i v a t e l y i n p u b l i c h o s p i t a l s u n l es s t h es p e c i a l i s t had s i g n e d t h e c o n t r a c t ; s p e c i f i e d t h a t f e e s must bea t t h e l e v e l s d e t e r m i n e d b y t h e f e d e r a l g o v e r n m e n t ' s f e e s e t t i n gt r i b u n a l ; and a l l o w e d t h e M i n i s t e r o f H e a l t h t o vary a nya s p e c t o f t h e contract w i t h o u t c o n s u l t a t i o n w i t h t h e p r o f e s s i o nand w i t h o u t a ny avenue o f a p p e a l a g a i n s t such v a r i a t i o n s .A l t h o u g h t h e r a d i o l o g i s t s , p a t h o l o g i s t s , and n u c l e a r m e d i c i n es p e c i a l i s t s were t h e o n l y s e c t i o n s o f t h e p r o f e s s i o n d i r e c t l ys p e c i f i e d b y t h e new r e g u l a t i o n s , o t h e r s p e c i a l i s t s - e s p e c i a l l yt h e surgeons-became c o n c e r n e d t h a t t h e y , t o o , m i g h t bea f f e c t e d b y s u c h c o n t r a c t s . As t h e p a t h o l o g i s t s h ad a l r e a d yb e e n b r o u g h t under s u b s t a n t i a l c o n t r o l b y t h e f e d e r a l govern-ment i n 1979-in an ( u n s u c c e s s f u l ) a t t e m p t t o d i m i n i s h " o v e r -s e r v i c i n g " b y u n s c r u p u l o u s p a t h o l o g i s t s p a y i n g " k i c k b a c k s " t or e f e r r i n g d o c t o r s - t h e r a d i o l o g i s t s a n d surgeons d e c i d e d t omake a s t a n d on t h e q u e s t i o n o f t h e new c o n t r a c t s .From 1 F e b r u a r y a l l A u s t r a l i a n s s t a r t e d p a y i n g a 1 % t a xl e v y i n e x c h a n g e f o r cover f o r 85% o f t h e f e e s d e t e r m i n e d b yt h e g o v e r n m e n t ' s t r i b u n a l a s b e i n g a p p r o p r i a t e f o r t h e manyt h o u s a n d s o f i te m s o f m e d i c a l s e r v i c e rendered b y d o c t o r s ,and f o r t h e c o s t s o f h o s p i t a l care i n s h a r e d w a r d s . P a t h o l o g i s t sand r a d i o l o g i s t s were c a l l e d on b y t h e government t o s i g n t h e i rc o n t r a c t s b y 1 M a r c h , a f t e r which d a t e , u n l e s s t h e y h ad s i g n e dup, no r e i m b u r s e m e n t s would be p a i d t o t h e i r p a t i e n t s . Inm i d - F e b r u a r y t h e A u s t r a l i a n Medical A s s o c i a t i o n announcedt h a t - a p a r t from some minor matters t o be decided b y ani n d e p e n d e n t c o m m i t t e e o f i n q u i r y headed b y t h e dean o f t h ef a c u l t y o f m e d i c i n e a t Melbourne U n i v e r s i t y , P r o f e s s o r DavidP e n i n g t o n - i t was i n g e n e r a l agreement w i t h t h e r e q u i r e m e n tt h a t t h e c o n t r a c t s s h o u l d be s i g n e d b y 1 March. Th e A u s t r a l i a n

V a u c l u s e 2 0 3 0 , New S o u t h W a l e s , A u s t r a l i aPETER C ARNOLD, B S C , MBC o r r e s p o n d e n c e to : " N o o i t g e d a c h t , " 2 1 A O l o l a A v e n u e , V a u c l u s e 2 0 3 0 ,New S o u t h W a l e s , A u s t r a l i a .

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1 7 6M e d i c a l A s s o c i a t i o n had not appreciated th e implications of thenew A c t .

R a d i o l o g i s t s ' a nd surgeons' rebellionB u t t h e r a d i o l o g i s t s and t h e surgeons responded briskly. On

2 2 F e b r u a r y t h e r a d i o l o g i s t s announced th at t hey would nots i g n t h e contracts. A few days l a t e r th e surgeons in New SouthWales c a l l ed f o r a stop to a l l but emergency surgery on 1 March.Th e r a d i o l o g i s t s and t h e New South Wales branch of theA u s t r a l i a n M e d i c a l A s s o c i a t i o n took up their c a l l , and on thatd a y no e l e c t i v e p r o c e d u r e s were done in New South Walesp u b l i c h o s p i t a l s . Th e m i n i s t e r threatened t h a t p a tients wouldnot b e r e i m b u r s e d u n l e s s t h e doctors signed t h e contracts by1 March a n d h e requested h i s counterparts in the st ate govern-ments t o l e g i s l a t e f o r t h e control of th e fees t h at doctors couldc h a r g e f o r p r i v a t e work done i n public hospitals. (For constitu-t i o n a l reasons t h e f e d e r a l government i s unable to leg i s l a te ond o c t o r s ' f e e s . Th e s t a t e governments are, however, unrestrictedi n t h i s r e g a r d . ) Th e b a t t l e was on.

Over t h e next f o u r weeks th e public was entertained t o fullpage newspaper a d v e r t i s e m e n t s placed by t h e orthopaedic andg e n e r a l surgeons, t h e r a d i o l o g i s t s , the Aus tr a l i an MedicalA s s o c i a t i o n , and t h e M i n i s t e r f o r Health; to front page head-l i n e s a b o u t d o c t o r s s t r i k i n g a nd h o s p i t a l s closing; to s p iri tedr a d i o and t e l e v i s i o n c l a s h e s between t h e minister and thespokesmen f o r t h e v a r i o u s medical groups concerned; and tocartoons lampooning t h e d o c t o r s , who saw themselves asw o r k e r s f i g h t i n g f o r t h e i r r i g h t s . The Prime Minister joined int h e d i s c u s s i o n s , a t f i r s t s e c r e t l y a nd then publicly, accusing theA u s t r a l i a n M e d i c a l A s s o c i a t i o n of b ei ng comparable to thatmost rumbustious and d i s r u p t i v e of a l l A u stral i an trade unions,t h e B u i l d e r s ' Labourers' Federation. The public joined inthrough p h o n e - i n s to radio stations and through letters to thenewspapers.Some saw d o c t o r s as b e i n g greedy; others agreed t h a t they,too, would r e f u s e a contract that gave their employer unfetteredpowers over t h e i r c o n d i t i o n s of work. The Labour governmentso f New S o u t h W a l e s , V i c t o r i a , South Australia, and WesternA u s t r a l i a l e g i s l a t e d to control d o c t o r s ' fees in public hospitals.S o u t h A u s t r a l i a ' s u n i o n s c a l l e d f o r a boycott of doc tors opposedto t h e new l e g i s l a t i o n .

Meanwhile t h e s t r i k e had begun. Doctors in t h e AustralianC a p i t a l T e r r i t o r y , t h e s m a l l d i s t r i c t that contains the c a p i t a lc i t y o f C a n b e r r a , banned a l l non-emergency public hospitalwork from 1 4 March. At th e same time, New South Walesr a d i o l o g i s t s r e s t r i c t e d t h e i r public hospital work to emergencies.New South Wales public hospital surgeons and other specialistsh e l d an emergencies only s t r i k e one day each week, rotating thed a y o f t h e week so t h a t no operation would be delayed moret h a n a w e e k . D o c t o r s i n other states threatened s tr i ke action.F i n a l l y , t h e A u s t r a l i a n Medical As so c i a ti on announced a fullw e e k ' s emergencies only s t r i k e .Th e A u s t r a l i a n Medical Association called for a public rallyby d o c t o r s , bu t c a n c e l l e d i t when Sydney's trade unionst h r e a t e n e d t h e personal s a f e t y of doctors p a r t i c i p a t i n g in ther a l l y . Th e New South Wales government gazetted regulationsp r o h i b i t i n g d o c t o r s from discussing with their private patientswhether t h e y would be admitted to p u b l i c h o s p i t a l s as privateor a s p u b l i c p a t i e n t s .

Meanwhile t h e s m a l l A u s t r a l i a n Democrat Party, which holdst h e b a l a n c e o f power i n t h e f e d e r a l senate, used i t s numbers toamend t h e l e g i s l a t i o n : nowany changes to t h e contracts whicht h e m i n i s t e r might make can be vetoed by either house ofp a r l i a m e n t . F i n a l l y , t h e minister conceded t h a t he would refera l l t h e contentious i s s u e s to th e Penington inquiry. Both heand the Australian Medical Association, however, have made itc l e a r t h a t n e i t h er s i d e considers i t s e l f obliged to abide byP e n i n g t o n ' s recommendations.W h a t o b s e r v a t i o n s can be made, i n t h i s Penington l u l l , aboutt h e p a r t i c i p a n t s i n t h i s confrontation? The Labour government

BRITISH MEDICAL JOURNAL VOLUME 289 21 JULY 1984a n n o u n c e d , i n b r o a d p r i n c i p l e , i t s i n t e n t i o n s v i s a v i s p r i v a t em e d i c i n e o v e r 2 0 y e a r s a g o when f o r m u l a t i n g i t s p o l i c i e s o nh e a l t h c a r e . A t n o t i m e h a v e t h e s e [ F a b i a n ] p o l i c i e s b e e nv a r i e d . A t e a c h o p p o r tu n i ty t h a t i t h a s had-under W h i t l a mi n 1 9 7 2 - 5 a n d , s in ce 1 9 8 3 , u n d e r Hawke-Labour h a s t r i e d t oi n t r o d u c e a p p r o p r i a t e l e g i s l a t i o n . I t s u n i v e r s a l , c o m p r e h e n s i v eMedibank w a s e s t a b l i s h e d i n 1 9 7 5 , r a n f o r j u s t o n e y e a r a n dw a s t h e n p r o g r e s s i v e l y d i s m a n t l e d b y t h e c o n s e r v a t i v e F r a s e rg o v e r n m e n t f r o m 1 97 6 o n w a r d s . L a b o u r p r e f e r s s a l a r i e d t op r i v a t e m e d i c i n e , v i e w s p r i v a t e d o c t o r s a s m o t i v a t e d p r i m a r i l yb y g r e e d , s e e s n o r e a s o n why money s h o u l d b u y b e t t e r m e d i c a lc a r e f o r s o m e , a n d i s d e t e r m i n e d t o c u t down t h e " t a l l p o p p i e s "i n t h e p r o f e s s i o n .

O v e r r e c e n t d e c a d e s t h e A u s t r a l i a n M e d i c a l A s s o c ia t i o n h a si n my v i e w p r o g r e s s i v e l y l o s t i t s o n c e u n c h a l l e n g e d r o l e a ss p o k e s m a n f o r t h e p ro fe s si o n . I t s members h a v e b e c o m ea n g e r e d b y i t s a t t e m p t s t o r e p r e s e n t t h e i n t e r e s t s o f b o t hs a l a r i e d d o c t o r s a n d s e l f e m p l o y e d d o c t o r s , g e n e r a l p r a c t i t i o n e r sa n d s p e c i a l i s t s , d o c t o r s w i l l i n g t o b e s u b s i d i s e d b y t h e s t a t e a n di n d e p e n d e n t p r a c t i t i o n e r s w i s h i n g t o p r a c t i s e p r i v a t e l y , a n d s oo n . F i r s t c h a l l e n g e d i n 1 9 6 8 b y t h e f o r m a t i o n o f t h e G e n e r a lP r a c t i t i o n e r s ' S o c i e t y ( o f w h i c h I w a s t h e f o u n d i n g s e c r e t a r y ) ,t h e A u s t r a l i a n M e d i c a l A s s o c i a t i o n h a s f o u n d t h a t i t s i n a b i l i t yt o r e p r e s e n t t h e d i v e r s e i n t e r e s t s o f t h e p ro fe s si o n h a s l e d t ot he e s t a bl i s h m en t o f , among o t h e r s , t h e A u s t r a l i a n A s s o c i a t i o no f S u r g e o n s , t h e A u s t r a l i a n S o c i e t y o f A n a e s t h e t i s t s , t h eA u s t r a l i a n S o c i et y o f O r t h o p a e d i c S u r g e o n s , a n d t h e N a t i o n a lA s s o c i a t i o n o f M e d i c a l S p e c i a l i s t s , a l l m e d i c o p o l i t i c a l o r g a n i s a -t i o n s s e p a r a t e f r o m t h e r o y a l c o l l e g e s t o w h i c h t h e i r membersa l s o b e l o n g . Th e r e c e n t c o n f r o n t a t i o n w i t h t h e g o v e r n m e n ts u g g e s t s t o me t h a t t h e A u s t r a l i a n M e d i c a l A s s o c i a t i o n i s n ol o n g e r a b l e t o t e l l t h e g o v e r n m e n t w h a t i t s members w i l l a c c e p t .Th e A u s t r a l i a n M e d i c a l A s s o c i a t i o n m u s t now c o n s u l t w i t h t h ec o m p a c t , i n d e p e n d e n t o r g a n i s a t i o n s r e p r e s e n t i n g t h e r a d i o l o g i s t s( t h e i r R o y a l A u s t r a l a s i a n C o l l e g e , u n l i k e t h e o t h e r c o l l e g e s ,d o e s n o t e s c h e w p o l i t i c a l a c t i o n ) t h e s u r g e o n s , t h e a n a e s t h e t i s t s ,a n d t h e o r t h o p a e d i c s u r g e o n s b e f o r e b e i n g a b l e t o p a r l e y w i t ht h e g o v e r n m e n t .

P r o f e s s i o n d i v i d e dS o m e , s e e i n g t h i s d i v i s i o n o f t h e p r o f e s s i o n , c a u t i o n t h a t

u n i t y i s s t r e n g t h a n d t h a t i f we d o n o t h a n g t o g e t h e r , we w i l la s s u r e d l y h a n g s e p a r a t e l y . O t h e r s p o i n t t o t h e numerouse x a m p l e s o f t h e l ea d er s o f t r a d i t i o n a l n a t i o n a l m e d i c a l o r g a n i s a -t i o n s n e g o t i a t i n g a w a y t h e i r m e m b e r s ' i n d e p e n d e n c e . 4 T h i ss c h o o l o f t h o u g h t e n c o u r a g e s t h e f o r m a t i o n o f s m a l l g r o u p sw i t h common v o c a t i o n a l a n d r e g i o n a l i n t e r e s t s , w h i c h c a n s t a n du p t o t h e g o v e r n m e n t r eg a rd l es s o f a g r e e m e n t s w h i c h m i g h t b ec o n c l u d e d b e t w e e n g o v e r n m e n t a n d t h e A u s t r a l i a n M e d i c a lA s s o c i a t i o n .

A f t e r s o m e i n i t i a l c o n fu s i o n , t he m e d i a t o o k t h e l i n e t h a t ,j u s t a s w o r k e r s i n A u s t r a l i a h a v e t h e i r ( m i n i m u m ) w a g e s s e tb y t h e a r b i t r a t i o n c o m m i s s i o n , s o d o c t o r s s h o u l d a g r e e t o h a v et h e i r (maximum) f e e s s e t b y a n i n d e p e n d e n t t r i b u n a l . Th ec a r t o o n i s t s h a d a f i e l d d a y l a m p o o n i n g t h e t r a d i t i o n a l l y g o l f i n gd o c t o r , more c o n c er n e d w i t h money t h a n w i t h h i s p a t i e n t s 'w e l l b e i n g . Th e p u b l i c , a c c o r d i n g t o o n e s u r v e y , w a s e v e n l yd i v i d e d o n t h e i s s u e , m o s t f i n d i n g i t d i f f i c u l t t o u n d e r s t a n d .A n o t h e r f o u n d t h e p u b l i c t w o t o o n e a g a i n s t t h e d o c t o r s .As t o d o c t o r s g o i n g o n s t r i k e , i t d o e s s e e m , c o n t r a r y t o t h ev i e w s o f P r o f e s s o r M a c f a r l a n e , t h a t d o c t o r s c a n a n d d o s e n s ed ee p a n d b i t t e r g r i e v a n c e s , w h i c h w a r r a n t t h e i r r e d u c i n g t h el e v e l o f s e r v i c e t h e y p r o v i d e . Th e m a j o r it y o f s t r i k e s b y d o c t o r st h i s c e n t u r y h a v e c o n c e r n e d e i t h e r l e v e l s of r e m u n e r a t i o n orm o v e s b y g o v e r n m e n t s , w h i c h w e r e s e e n a s t h r e a t e n i n g r e -m u n e r a t i o n a t s o m e f u t u r e d a t e . E x a m p l e s o f s u c h r e d u c t i o n so f l e v e l s o f s e r v i c e a r e t h o s e t h a t t o o k p l a c e i n A u s t r i a b e t w e e n1 9 5 5 a n d 1 9 6 2 , B e l g i u m i n 1 9 6 3 , C a n a d a i n 1 9 6 2 ( S a s k a t c h e w a n )a n d 1 9 7 0 ( Q u e be c ) , F r a n c e i n 1 9 6 0 a n d 1 9 8 2 - 3 , G e r m a n y i n1 9 2 3 a n d 1 9 7 7 , G r e a t B r i t a i n i n 1 9 7 5 - 6 , I s r a e l i n 1 9 5 0 a n d 1 9 8 3 ,

8/2/2019 Aust Doctor

3/3

BRITISH MEDICAL JOURNAL VOLUME 289 2 1 JULY 1984 1 7 7I t a l y i n t h e 1 9 6 0 s a n d i n 1 9 7 4 , P e r u i n 1 9 8 4 , Sweden i n 1 9 5 7 ,a n d i n t h e USA i n 1 9 7 5 - 6 . One o f t h e f e w s t r i k e s c a l l e d o n am a tt e r o f n o n - m o n e t a r y p r i n c i p l e w a s t h a t l e d b y LudwigHartmann i n Germany i n 1909-a s t r i k e f o r t h e p a t i e n t s 'f r e e d o m o f c ho i c e o f d o c t o r . I t c o u l d b e a r g u e d , h o w e v e r , t h a te v e n t h a t s t r i k e w a s f i n a n c i a l , a s t h e Hartmannbund w a sc o n c e r n e d t h a t some d o c t o r s m i g h t b e e x c l u d e d f r o m t h ep a n e l s w h o s e members w e r e a s s u r e d o f p a y m e n t .Th e A u s t r a l i a n s t r i k e o f 1 9 8 4 f i t s i n t o t h e b r o a d p a t t e r n o ft h e s t r i k e s r e f e r r e d t o a b o v e . W h i l e t h e s p e c i a l i s t s p r o t e s t e dt h a t t h e y a l m o s t i n v a r i a b l y c h a r g e t h e f e e s s u g g e s t e d b y t h eg o v e r n m e n t , t h e i r f e a r w a s t h a t t h e new l e g i s l a t i o n w o u l d g i v et h e m in i s te r t h e p o w e r t o c o n t r o l t h e i r f e e s . U n t i l now t h e yh a v e b ee n c o n t e n t w i t h t h e r i g h t t o c h a rg e h i g he r f e e s , a r i g h tt h a t t h e y h a v e s e l d o m e x e r c i s e d b u t a r e m o s t r e l u c t a n t t or e l i n q u i s h . F u r t h e r m o r e , t h e p r o p o s e d l e g i s l a t i o n w o u l d h a v eg i v e n t h e m i n i s t e r t o t a l p o w e r o v e r t h e p r i v a t e e a r n i n g s o f a l lp u b l i c h o s p i t a l d o c t o r s , w h e t h e r s a l a r i e d s t a f f s p e c i a l i s t s o rv i s i t i n g m e d i c a l o f f i c e r s ( t h e f o r m e r " h o n o r a r i e s " ) .

Are medical s t r i k e s i n e v i t a b l e ?W h e t h e r o r n o t d o c to rs r e s o r t t o s t r i k e a c t i o n p r o b a b l y

d e p e n d s l a r g e l y on community a t t i t u d e s t o s t r i k e s o v e r s a l a r i e sa n d c o n d i t i o n s o f s e r v i c e . A u s t r a l i a h a s a l o n g t r a d i t i o n o fa r b i t r a t i o n a n d c o n c i l i a t i o n i n i n d u s t r i a l d i s p u t e s , w i t h s t r i k e sf r e q u e n t l y u s e d b y u n i o n s t o p r e s s t h e i r c l a i m s . W h i l e e a r l i e rg e n e r a t i o n s o f j u n i o r d o c t o r s w e r e w i l l i n g t o work l o n g h o u r s i ne x c h a n g e f o r t h e e x p e r i e n c e , t o d a y ' s r e s i d e n t s a n d i n t e r n s h a v ebecome u n i o ni s e d , l o d g i ng l o g s o f c l a i m s b ef o r e a r b i t r a t i o nc o u r t s a n d a r g u i n g o v e r a l l o w a n c e s f o r a c c o m m o d a t i o n , m e a l s ,l a u n d r y , a n d c a r p a r k i n g . Y e t i t w a s n o t f r o m t h e r a n k s o f t h ef o r m e r l y u n i o n i s e d t r a i n e e s p e c i a l i s t s t h a t A u s t r a l i a ' s s t r i k ee m a n a t e d . T h i s s t r i k e w a s l e d b y t h e r a d i o l o g i c a l a n d s u r g i c a le s t a b l i s h m e n t , t h e o l d g u a r d t o whom t h e v e r y t h o u g h t o fs t r i k i n g w o u l d h i t h e r t o h a v e b ee n u n t h i n k a b l e .T h e r e c a n b e no d o u b t t h a t t h e i r f e a r w a s o f t h e f i n a n c i a l

c o n s e q u e n c e s o f t h e new l e g i s l a t i o n . I t w a s i n t h e s t a t e w h e r et h e s p e c i a l i s t s f e l t m o s t t h r e a t e n e d , n a m e l y New S o u t h W a l e s ,w h i c h h a s f e w p r i v a t e h o s p i t a l s i n t o w h i c h t h e y c o u l d r e t r e a tf r o m g o v e r n m e n t c o n t r o l s , t h a t s t r i k i n g w a s s e e n a s a p p r o p r i a t e .L a b o u r g o v e r n m en t s u n d er s t a n d s t r i k e a c t i o n a s b e i n g t h ew o r k e r ' s u l t i m a t e w e a p o n . By s t r i k i n g , t h e s p e c i a l i s t s h o p e d t omake t h e f e d e r a l a n d s t a t e L a b o u r g o v e r n m e n t s r e a l i s e t h ed e p t h o f t h e i r o p p o s i t i o n t o t h e l e g i s l a t i o n . I n t h e s t a t e s i nw h i c h p r i v a t e f a c i l i t i e s a r e p l e n t i f u l , s u c h a s V i c t o r i a , Q u e e n s -l a n d , a n d S o u t h A u s t r a l i a , s t r i k e a c t i o n w a s t h r e a t e n e d - a s a ne x p r e s s i o n o f s u p p o r t f o r t h e s p e c i a l i s t s i n New S o u t h W a l e s .I t m i g h t b e t e m p t i n g t o s u g g e s t t h a t m e d i c a l s t r i k e s a r ei n e v i t a b l e i n t h e l o n g r u n i f t h e g o v e r n m e n t c o n t r o l s a l l t h ep u r s e s t r i n g s i n t h e d e l i v e r y o f h e a l t h c a r e . B u t t h e N e t h e r l a n d s 'e x p e r i e n c e s u g g e s t s t h a t s o c i e t y ' s a t t i t u d e t o w a r d s t h e s e t t l i n go f d i s p u t e s i s p a r a m o u n t . Dutch d o c t o r s w i l l i n g l y a c c e p t f e ei n c r e a s e s i n a c c o r d a n c e w i t h c h a n g e s i n t h e s a l a r i e s o f s e n i o rp u b l i c s e r v a n t s . 5 They l e t t h e p u b l i c s e r v i c e a s s o c i a t i o n a n d t h eg o v e r n m e n t n e g o t i a t e a n d t h e y a c c e p t t h e o u t c o m e . S t r i k ea c t i o n b y Dutch d o c t o r s i n t h e s e c i r c u m s t a n c e s s e e m s u n l i k e l y .As r e g r e t t a b l e a s i t ma y s e e m t o P r o f e s s o r M a c f a r l a n e a n dt o o t h e r s wh o s h a r e h i s i d e a l i s t i c v i e w o f t he h ea l i n g p r o f e s s i o n s ,m e d i c a l s t r i k e s h a v e become a p a r t o f t h e a r m a m e n t a r i u m o fg o v e r n m e n t e m p l o y e d d o c t o r s i n many c o u n t r i e s . A u s t r a l i a ns p e c i a l i s t s a r e n o d i f f e r e n t f r o m t h e i r c o l l e a g u e s who h a v e g o n eo n s t r i k e e l s e w h e r e i n t h e w o r l d . P e r h a p s t h e s a d l e s s o n f o r u sa l l i s t h a t d o c t o r s , a s a g r o u p , a r e r e a l l y n o d i f f e r e n t f r o m t h er e s t o f t h e s o c i e t y i n w h i c h t h e y l i v e .

R e f e r e n c e sM a c f a r l a n e L J . T h e r i g h t t o s t r i k e . Harmondsworth: P e n g u i n , 1 9 8 1 : 1 3 8 - 9 .2 G o l d s t e i n SGM. I n s e a r c h o f an o p t i m a l h e a l t h c a r e s y s t e m . Br Med 7 1 9 8 2 ;2 8 5 : 8 2 4 - 8 .3 A rn o l d P C . H e a l t h c a r e f i n a n c i n g i n A u s tr a li a : t h er e i s no s o l u t i o n . Br Med .1 9 8 3 ; 2 8 6 : 1 5 9 - 6 0 .A r n o l d P C . C r i s e s down u n d e r . Br Me d J 1 9 7 9 ; i : 1 0 7 - 8 .G l a s e r W A. H e a l t h i n s u r a n c e b a r g a i n i n g : f o r e i g n l e s s o n s f o r A m e r i c a t n s . Ne w Y o r k :G a r d n e r P r e s s , 1 9 7 8 : 8 6 - 8 .

( A c c e p t e d 1 8 J 7 u n e 1 9 8 4 )

S u n b u r n , p a r t i c u l a r l y i n t h e f a i r s k i n n e d , i s n o w t h o u g h t t o b e l a r g e l yr e s p o n s i b l e f o r t h e d e v e l o p m e n t o f s o m e t y p e s o f m a l i g n a n t m e l a n o m a .I s u l t r a v i o l e t l i g h t s t i l l r e c o m m e n d e d f o r t r e a t i n g p s o r i a s i s ? I s t h ei n c i d e n c e o f c u t a n e o u s m a l i g n a n t n e o p l a s i a h i g h i n p s o r i a s i s ?Th e i n q u i r e r i s c o r r e c t i n s u g g e s t i n g t h a t s e v e r a l r e c e n t s t u d i e s h a v es u g g e s t e d t h a t f a i r s k i n n e d p a t i e n t s who b u r n e a s i l y a r e more c o m -m o n l y f o u n d i n g r o u p s o f p a t i e n t s s u f f e r i n g f r o m melanoma t h a n i na g e m a t c h e d c o n t r o l g r o u p s . T h i s o b s e r v a t i o n w a s r e c e n t l y c o n f i r m e di n t h e W e s t e r n C a n a d a m e l a n o m a s t u d y . ' Th e r e l a t i o n b e t w e e ne x p o s u r e t o s u n a n d t h e s u b s e q u e n t d e v e l o p m e n t o f m e l a n o m a ,h o w e v e r , i s b y n o m e a n s c l e a r a s t h e p i c t u r e o f a " t y p i c a l " p a t i e n tw i t h m a l i g n a n t melanoma e m e rg i n g f r o m e p i d e m i o l o g i c a l s t u d i e s i nt h e U n i t e d Kingdom i s a y o u n g i s h woman (women a r e t w i c e a s o f t e na f f e c t e d a s m e n ) who i s a n i n d o o r w o r k e r a n d o f h i g h s o c i o e c o n o m i cs t a t u s . 2 T h i s i s c l e a r l y n o t t he g r o u p o f i n d i v i d u a l s wh o o v e r a l i f e t i m eh a v e t h e h i g h e s t t o t a l d o s e o f e x p o s u r e t o s u n l i g h t . Many d e r m a t o l o g i s t ss t i l l recommend t h e r a p e u t i c d o s es o f a r t i f i c i a l s u n l i g h t (UVB) a s a n a i dt o t h e management o f p a t i e n t s w i t h p s o r i a s i s who a r e a l s o r e c e i v i n ge i t h e r t o p i c a l t a r o r t o p i c a l d i t h r a n o l t r e a t m e n t . I n t h e p a s t d e c a d eUVA o r l o n g w a v e u l t r a v i o l e t l i g h t i n t h e f o r m o f a t r e a t m e n t knowna s PUVA ( p h o t o c h e m o t h e r a p y ) f o r p a t i e n t s w i t h s e v e r e f o r m s o fp s o r i a s i s h a s a l s o b e e n w i d e l y u s e d . Two l a r g e s t u d i e s o f p a t i e n t s w i t hp s o r i a s i s h a v e r e c e n t l y s u g g e s t e d t h a t d e s p i t e t h e u s e o f UVB o v e rmany y e a r s t h e r e i s n o e v i d en c e o f a n i n c re as e d i n c i d e n c e o f s k i nc a n c e r o r i n d e e d o f a n y o t h e r f o r m o f m a l i g n a n c y b y c o m p a r i s o n w i t ha g e m a t c h e d c o n t r o l s . 3 Thus i t w o u l d a p p e a r t h a t t h e p a t i e n t w i t hp s o r i a s i s wh o r e c e i v e s l o n g t e r m UVB t r e a t m e n t a s p a r t o f h i s a n t i -p s o r i a t i c t r e a t m e n t i s a t no i n c r e a s e d r i s k o f d e v e l o p i n g a n y f o r m o fc u t a n e o u s m a l i g n a n c y , e i t h e r b a s a l c e l l c a r c i n o m a , s q u a m o u sc a r c i n o m a , o r m a l i g n a n t m e l a n o m a . A n o t h e r t i m e h o n o u r e d t r e a t m e n tf o r p s o r i a s i s , t o p i c a l t a r , i s a l s o a r e c o g n i s e d c u t a n e o u s c a r c i n o g e n , b u to n c e a g a i n t h e r e i s n o s t a t i s t i c a l l y s i g n i f i c a n t i n c r e a s e i n c u t a n e o u s

m a l i g n a n c y i n t h o s e p a t i e n t s wh o h a v e r e c e i v e d t a r t r e a t m e n t f o rs e v e r a l d e c a d e s . T h i s a p p a r e n t p r o t e c t i o n o f t he p a t i e n t w i t h p s o r i a s i sf r o m a n y i n c r e a s e i n c u t a n e o u s m a l i g n a n c y d e s p i t e t h e u s e o f t h e s ef o r m s o f t r e a t m e n t i s n o t u n d e rs t o o d . Th e c o n c l u s i o n s o f a r a s PUVAa n d s u b s e q u e n t c u t a n e o u s m a l i g n a n c y a r e c o n c e r n e d i s n o t y e t w e l le s t a b l i s h e d . A l o n g e r p e r i o d w i l l h a v e t o e l a p s e b e f o r e a d e f i n i t es t a t e m e n t o n i t s s a f e t y ma y b e made.-RONA M A C K I E , p r o f e s s o r o fd e r m a t o l o g y , G l a s g o w .Elwood JM, G a l l a g h e r R P , H i l l GB, S p i n e l l i J J , P e a r s o n JCG, T h r e l f a l l W .P i g m e n t a t i o n a n d s k i n r e a c t i o n to s u n a s r i s k f a c t o r s f o r c u t a n e o u s melanoma:Western Canada melanoma s t u d y . Br MedJ7 1 9 8 4 ; 2 8 8 : 9 9 - 1 0 2 .

2 Lee JAH. Melanoma and e x p o s u r e t o s u n l i g h t . E p i d e m i o l Rev 1 9 8 2 ; 4 : 1 1 0 - 3 6 .J a c o b s PH , F a b e r EM , N a l l ML. P s e r i a s i s a n d s k i n c a n c e r . I n : F a r b e r EM , CoxA J , e d s . Ne w Y o r k : Y o r k e M e d i c a l B o o k s , 1 9 7 7 : 3 5 0 - 2 .' A l d e r s o n MR, C l a r k e J A . C a n c e r i n c i d e n c e i n p a t i e n t s w i t h p s o r i a s i s . Br7 C a n c e r1 9 8 3 ; 4 7 : 8 5 7 - 9 .

C o d l i v e r o i l i s a r i c h s o u r c e o f u n s a t u r a t e d f a t t y a c i d . T h e r o l e o fu n s a t u r a t e d f a t t y a c i d s i n t h e p r e v e n t i o n o f a t h e r o s c l e r o t i c a r t e r i a ld i s e a s e h a s b e e n w i d e l y d i s c u s s e d . I s t h e r e a n y e v i d e n c e t h a t , f o r t h i sr e a s o n , c o d l i v e r o i l s u p p l e m e n t s may l e s s e n t h e t e n d e n c y t o d e v e l o pa t h e r o s c l e r o t i c a r t e r i a l d i s e a s e i n l a t e r l i f e ?I know o f n o e v i d e n c e t h a t c o d l i v e r o i l s u p p l e m e n t s l e s s e n t h e t e n d e n c yt o d e v e l o p a t h e r o s c l e r o s i s . Th e amount o f u n s at u r at ed f a t t y a c i di n c o d l i v e r o i l c o m p a r e d w i t h t h a t i n t h e d i e t a s a w h o l e w o u l d , Ii m a g i n e , b e r e l a t i v e l y s m a l l . S t u d i e s h a v e s h o w n t h a t b a b i e s f e d o nm i l ks c o n ta i n i n g f a t s w i t h a h i g h p e r c e n t a g e o f u n s a t u r a t e d f a t t y a c i d sh a v e r e l a t i v e l y h i g h f r a c t i o n s o f u n s a t u r a t e d f a t t y a c i d i n t h e i r a d i p o s et i s s u e s t o r e b u t t h e y r e v e r t q u i c k l y t o t h e u s u a l p a t t e r n when t h e y a r ep l a c e d o n a n o r m a l d i e t . F u r t h e r m o r e , w i t h t h e a d m i n i s t r a t i o n o f c o dl i v e r o i l comes a r i s k o f g i v i n g e x c e s s i v e a m o u n t s o f v i t a m i n D.-D H U L L , p r o f e s s o r o f c h i l d h e a l t h , N o t t i n g h a m .