When fees for services become the number one cause of

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when fees for services become the number one cause of personal bankruptcy? 45 Perhaps most importantly, why has culturally relevant research—now 40 years old—been systematically ignored in restructuring health delivery procedures and delivery costing? As the authors of the 1975 study concluded long ago: “Firstly, physicians can allocate the relative time spent taking the history and examining the patient with some confidence, knowing that the extra time spent on the history is likely to be more profitable than extra time spent on the physical examination. Secondly, more emphasis must be placed on teaching students how to take accurate histories in a medical clinic, and proportionately less on showing them how to elicit physical signs. Thirdly, more emphasis must be placed on research into communication between the patient and his physician, and perhaps less emphasis is needed on the development of new laboratory services. Fourthly, there are implications for the planning of medical outpatient departments. There needs to be more emphasis on space for interviewing patients, and proportionately less on space for examining them. Our findings also have implications for the number of follow-up appointments that need to be given to patients who seem to present diagnostic problems. It seems that if the physician is still in considerable doubt about the diagnosis after the history has been taken and the patient has been examined, then laboratory investigations are unlikely to be helpful.” 41 Health economists should quantify the potential savings from allowing clinicians time to gain accurate case histories. Provision of such time would also increase a physician’s sense of worth, and might even help limit the high levels of mid-career disenchantment. However, such savings could have a negative effect on investment in for-profit health, where clinical care is routinely exposed to service delivery models and physicians are sometimes referred to as health-care vendors. As this neglected study made clear, saving time in the short term will not translate into saving money. Despite the age of this study, its findings are still relevant. What health-care delivery culture is being promoted worldwide by emulating business practices that need immediate financial returns on investment without any responsibility for long-term outcomes? We call for a resurrection of respect for caregivers who are wholly capable of saving money and lives, if given the time to show their abilities to do so. Clinical adherence Although competence is generally understood as the ability to implement recognised standards of best practice, what constitutes competence in medicine is far from clear. 46 Martin Talbot, 47 for example, questions the competence model of medical education, claiming that it sometimes rewards low-level or operational competencies at the expense of “reflection, intuition, experience and higher order competence necessary for expert, holistic or well developed practice”. By contrast, Betancourt and
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  • Summer '18
  • Jeanne Hughes
  • Lancet

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