Teaching and patient payment

To the Editor: A recent interview-based study of the experience of 60 general practitioner teachers in Brisbane1 found that private, fee-paying patients were perceived by a number of participants as being less accepting of active student involvement in teaching consultations than those in bulk-billing practices. Some examples of a perceived relationship between patient payment and patient attitudes — and perhaps obligations (although no participants explicitly related non-payment for health care with an increased patient obligation to assist with doctor training) — in relation to teaching are provided in the Box. Arguably, there is an implication that private fee-paying patients may be more inclined to be litigious in the event of an adverse outcome associated with teaching, and that these patients may choose to obtain their general practice care elsewhere if they are imposed on. These perceptions are likely to influence GPs’ decisions to seek patient consent for active student learning.

The literature does not explore whether fee-paying GP patients have more or less positive views about teaching than those who are bulk billed or treated in public hospitals, although a United States emergency department study2 found no significant difference between patient income and patient consent rates. However, an “uncomfortable sense of obligation” to, and boundary blurring with, patients who assist with teaching has been reported by GPs in the United Kingdom,3 and it is interesting to hypothesise that this sense may be sharpened by patient payment, and relieved somewhat by reducing fees.

In relation to any perceived obligation for (bulk-billed) patients to assist with teaching, for the “greater good” of securing ongoing health care for society, Waterbury4 argues against sacrificing patient autonomy and refutes several arguments for a patient’s obligation to assist. He also argues powerfully against placing any teaching burden disproportionately on community members who are both ill and impoverished. The extent of the “teaching burden” on patients is difficult to assess in the absence of evidence about patient health outcomes in relation to teaching, but both patients5 and doctors1 report that student presence in consultations may be inhibiting. An element of “marginalisation of the patient in the (teaching) doctor’s duties”4 is arguably inevitable.

Further Australian general practice research into private patient attitudes might challenge these GP perceptions. If many of these patients are in fact willing for greater involvement than that anticipated by the GP, both patients and students may be frustrated by the loss of teaching opportunities.