The United States spends over 16% of its gross domestic product (GDP) on health care, and this is predicted to rise to 20% or more over the next 10 years. Although Australia spends only 11% of its GDP on health, our costs are also rising. I do not propose to analyse here all the factors contributing to this rise, but will focus on differences between US and Australian medicine that could help us understand this situation better.

The first factor is that Americans are obsessed with health care. Television is replete with health care programs, much more so than Australian TV. An avalanche of medical dramas bombards the public with all manner of diseases. House is available almost continuously on one cable channel. You don’t know what House is? What sort of a doctor are you? Ask your children — perhaps they will know. Drug advertisements are frequent, promising a cure for everything from depression to diarrhoea. Magazines on health fill supermarket shelves, and doctors advertise on the subway (next to the lawyers). This bombardment of the public with things medical causes a false expectation of perfection in modern medicine. The TV doctor (almost) always makes a brilliant diagnosis and saves the patient. The drug ads scream perfection, as do the doctors’ ads. This is also occurring in Australia, but to a lesser degree.

Another American characteristic is also slowly invading our shores, and I believe this is the second factor inflating costs. When Americans pay for something, be it a meal, clothes or medical care, they expect to get what they pay for, expect perfection and expect it now(!). They will send or take back a poorly cooked steak or a faulty shirt — a fact that anyone who has eaten with Americans in a restaurant or shopped with them will have noticed. In the case of medical therapy, the equivalent is finding another doctor or having another test. Thus, Americans are much more likely to get multiple opinions, go to multiple doctors and have multiple tests for the same problem.

The third factor is that US medicine is much more specialised and fragmented than Australian medicine. You go to a dermatologist for acne, a gynaecologist for a Pap smear and a psychiatrist for your anxiety. The family practitioner has almost disappeared.

A few examples involving relatives of mine in the US serve to illustrate these issues. One, a teenage girl, slipped and hurt her ankle. An expensive visit to the emergency department and a variety of radiological investigations showed no fracture or other detectable abnormality. A sprain or strain, the family was told. But told by the physician’s assistant — the patient was not seen by a doctor. Efficient and reasonable, you think? — so did I. Not so. A second opinion from the family podiatrist (and another fee) was required before the family was satisfied. Another relative visited a gynaecology practice for routine care, which was also provided by a physician’s assistant. Queries about hormone replacement therapy were answered by this person as well. The outcome was a visit to another gynaecologist. You see, although many gynaecologists use physicians’ assistants, the first visit is always with the doctor. Thus to see the doctor you may need to find a new doctor. Furthermore, routine gynaecological care can involve a battery of tests, some of which may be useless in certain cases, such as the rapid plasma reagin test (for syphilis) in an otherwise well 25-year-old woman (my daughter, in this case). A call from the physician’s assistant noted that the test was “slightly positive”, but that she shouldn’t worry, as this didn’t indicate infection. It was suggested that she could follow up the matter with her local doctor (who received no letter about it). A whole new set of investigations was aborted only by Prof dad saying “don’t be ridiculous!”, or words to that effect.

Finally, because of the fragmentation and specialisation of medicine in the US, treatment needs to be effective, efficient, fast and permanent. People in the US move around more than Australians, thus requiring new doctors; specialists often focus almost entirely on their specialty (although, paradoxically, gynaecologists often serve as general practitioners for women); and difficulties with insurance can delay or interrupt care. A friend with hypothyroidism told me she had not had thyroid function tests for 3 years, as a divorce had separated her from both her husband and his health insurance. A visit to an endocrinologist (of course not a GP) and associated thyroid function tests would have topped US$1000, which she decided she could not afford.

So how is it that a country with the world’s best medical facilities and perhaps the world’s best medical and economic brains can’t manage health care costs? I would suggest it is a combination of the traits I have mentioned here. The expectation of perfection and immediate cure results in more tests, more aggressive treatment and more visits to more doctors. This is exacerbated by the requirement to see specialists (indeed, often multiple specialists), even for the most minor of problems.

In Australia, if we are not careful to preserve general practice, with its evidence-based but commonsense approach, in a setting that allows trusted medical professionals to give patients realistic expectations of the outcome of care, we may quickly catch up with the US in the cost of medical care.