Dual practice of hospital staff doctors: hippocratic or hypocritic?

Introduction

According to health economics, physicians who respond to ‘third-party payers’ for healthcare are expected to establish a ‘principal–agent relationship’ with patients, ¹ which implies mutual trust. Physicians’ dual practice, a combination of public and private practice, may raise potential conflicts of interest in this relationship. ² It might even lead physicians to ‘predatory behaviours’, in which self-gain is pursued to the detriment of colleagues and/or patients, ² while at the same time de-legitimising public services and jeopardising the population’s trust.

Dual practice has long existed in most healthcare systems around the world, ³ regardless of a country’s wealth. Canada is the only highly developed country where it is strongly discouraged, and even forbidden in some provinces. ⁴ It is widely accepted that dual practice plays very different roles in low- and high-income countries,^5,6 since, in the former, governments can hardly manage universal coverage for health and thus are unlikely to play a dominant role in healthcare provision and regulation. A common feature in countries where dual practice flourishes is that public employment is remunerated with fixed compensation (usually wages), while the private sector offers tailored incentives (mainly fees). ⁷

The potential for dual practice varies a lot according to a physician’s specialty, and experience too. The relationship with patients may be stronger for medical and surgical specialties, which ‘have patients’, rather than for support ones like pathology or radiology. ⁸ Thus, dual practice is likely to be practised more in the former (e.g. cardiology, dermatology, orthopaedics, obstetrics and gynaecology). Since it takes time for a physician to build up a good reputation and attract patients for private practice, ⁹ dual practice is usually also related to a physician’s age. ¹⁰

Here we summarise the historical background to dual practice in Western European countries, focusing on doctors employed in the public sector. Then we analyse the main critical issues of dual practice in Europe and discuss it in a global perspective, finally offering a very simple proposal for debate.

Dual practice

Literature search

We first searched the PubMed international database to select all the articles including dual practice in their title/abstract, published in this millennium (2000–2018). We found only 42, confirming that the international literature on dual practice is scant, ⁶ with a decreasing trend of articles in developed countries (Figure 1) and a rather low proportion published in medical journals (Figure 2).

Figure 1.

Trend of articles including DP in the title/abstract.

Figure 2.

Articles including DP in the title/abstract by type of journal.

European background

Most European physicians employed in public hospitals are also allowed to work in private facilities (clinics and/or hospitals), even in the public healthcare systems of the wealthier northern countries. ⁴ For instance, almost all public staff doctors also practice privately in Austria and Ireland, and around 60% in the UK, with a cap on private income whether full-time (10% of their public income) or without limitations if part-time. ¹⁰ Ceilings on private income are also set for public staff doctors in France (30% of total income). ¹¹ In Finland, public doctors provide most private sector services and dual practice is quite common among senior consultants in Sweden and Norway too, although with a lower proportion in the latter, probably on account of the high public doctors’ wages. ¹² In southern countries like Greece and Portugal, where dual practice was formally forbidden up to the end of the last millennium, many hospital staff doctors used to practise privately even before the lifting of the ban. ¹¹

Dual practice can also be regulated by encouraging public staff doctors to practise privately in their hospitals (e.g. in Austria, France, Germany and Italy), paying them part of the sums received by hospital administrations for the private use of hospital facilities. ¹¹ Patients can pay for greater comfort and/or the choice of doctor,^13,14 although the latter is often not a real choice for highly specialised services because many hospitals have only one physician who can provide them. In Italy, hospital staff doctors can refuse such dual practice (so-called ‘intra moenia’) and opt to practise privately outside ¹⁴ ; in that case, they are not allowed to reach leading positions in their departments and have their wages cut by 10–15%. Similar regulations are in force in Portugal and Spain. ⁴

Critical issues

To split arguments on dual practice roughly as positive or negative, the latter largely prevail in the European literature. Dual practice is expected to enhance private practice at the expense of public healthcare provision, as a result of the higher earning opportunities. ⁶ Early in their careers, doctors looking for dual practice may be keen to foster their reputation in public facilities, in order to attract more private practice in the future. ¹¹ Then they have potential incentives to skimp on work hours and divert patients to private clinics, with a negative impact on service provision in the public sector.^4,7 Financial incentives seem to be the main thrust of dual practice, even in countries with high public wages like Norway. ¹²

Another expected consequence of dual practice is on waiting times, since doctors are interested in boosting demand for their private care, redirecting wealthier patients from public waiting lists to earlier appointments in their private practice.^6,7 In wealthy markets like the Western European ones, this behaviour is supported by economic theory, ¹⁵ since the lower the labour supply to the public sector, the higher the demand for private practice where consumers can afford to switch from public to private care. A positive association was found in the British NHS between physicians’ mean private income and public waiting lists across specialties. ¹⁰ This raises potential inequity of access, since patients able to pay can queue-jump the others, irrespective of their different clinical needs. ⁷

A more sophisticated form of dual practice is that directly encouraged by health authorities to commit further and retain highly qualified medical staff in public facilities. ¹¹ However, this has been recently associated with the ethical concept of ‘institutional corruption’, ¹³ a situation in which the institutional setting introduces incentives to enhance (legal) behaviours that may eventually undermine the institutions’ ability to achieve their primary goals.^16,17 In fact, this kind of dual practice may raise potential conflicts of interest and inequity too, since public staff doctors have an extra ‘reward’ again for treating patients willing to pay for elective services bypassing public waiting lists. ¹⁴ According to the latest survey in Italy, ¹⁸ the average waiting time per service in the last three years was almost 11 times shorter for intra moenia than for public services (6 days vs. 65). In addition, managing public and private activities separately (without blurring them) is likely to be resource diverting (and time-consuming) for public hospital administrators. ¹⁴

Despite the arguments against dual practice, remedies proposed in the literature hardly ever include its ban. The most frequent justification for not forbidding dual practice is that it would reduce the appeal of public hospitals and favour the migration of more skilled physicians to the private sector.^7,11 Professional self-regulation in European countries is supposed to be strong enough to deter undesirable behaviours associated with dual practice, ⁷ which should be further discouraged by raising physicians’ public salaries. Further analysis is usually recommended in conclusion, to assess the real impact of dual practice on public health services. ⁶

Discussion

Dual practice is a scantily debated subject in the European and international literature despite its potential importance, especially − and maybe not by chance − in medical journals. A plausible explanation might be that dual practice hardly ever harms patients directly in developed countries and its potential negative effects are mainly indirect, i.e. inefficiency and inequity of healthcare systems, an apparently ‘victimless offence’. Thus, the public and the media are less interested. ¹³ This argument can be roughly extended to the broader concept of institutional corruption, which is usually neglected because individual corruption predominates in the collective imagination and the lack of real solutions to eradicate the institutional type is a common perception. ¹⁹

According to labour theory, employees willing to work more hours in their main job only look for a second one when the first provides a steady but lower income, and the second can offer higher but variable earnings. ⁷ Thus, if the second job is better paid and the employee benefits more from extra money than from leisure time, dual practice is likely to increase the total labour supply. ⁶ For physicians, it is generally agreed that the patient’s healthcare is their primary interest, and financial gain should be secondary. ¹³ This was recently confirmed in a Dutch national survey, ⁸ in which hospital doctors perceived ‘helping patients as well as possible’ as their primary interest, with ‘good income’ only fifth among nine secondary work- and life-related interests, well below the second (‘good work–life balance’).

The interest of public staff doctors in dual practice is usually justified by the predominant perception of low salaries in the public healthcare sector. ¹³ This was indirectly confirmed by a local English survey ²⁰ : most dual practice staff doctors stated they would be willing to give up private practice in exchange for a pay rise. However, dual practice doctors are often suspected of concentrating on their private practice at the expense of the public one, ⁶ so this undermines their professional reputation. Some harsh reactions which followed the introduction in 1999 of dual practice restrictions in Italy (‘public hospitals associated with ‘Nazi camps’ for doctors’) ¹⁴ and Canada (‘[reforms] rival those of Cuba and North Korea’) ²¹ may indirectly support this suspicion and even betray a guilty conscience.

It is worth noting that it takes longer to graduate in medicine than in other subjects (six years in most European countries) ²² and newly graduated physicians are likely to earn a limited income during their long training for a specialty. Although the pay of Western European staff doctors is usually considered high compared to the wages of other qualified workers, ¹² it is hard to find reliable analytical figures on their incomes by country. For instance, in Italy, the estimated average income per staff doctor (€77,140 in 2015) ²³ is more than twice the broad (and rough) income per employee (€35,900 in 2016), ²⁴ while it was estimated as four times higher in Germany in the 2000s. ⁵ However, any mean medical income can reflect very wide ranges by specialty and seniority. As remarked very recently in England, ²⁵ pay disparities among physicians can be really striking and the peaks are hard to justify in public opinion. Income is particularly high for some specialties open to dual practice (e.g. cardiologists, orthopaedic specialists and ophthalmologists),^10,12 raising inequities inside the medical profession (for instance, intensivists hardly ever practise privately).

A different approach to analyse dual practice could come from business administration and human resource management. First, it is very odd for an employee to work for two firms at the same time, ²⁶ so it can be considered even stranger that a company manager deals privately with the same clients in her/his spare time, as happens for physicians with dual practice. Second, hospital clinical professions (nurses included) are burdensome jobs, which often require night and weekend work, ²⁷ so staff doctors would benefit much more from long service leaves than stressful second jobs. Accordingly, an organisational culture rooted in teamwork and collaboration (‘clan culture’) ²⁸ would fit public hospitals much better than one built on competition (‘market culture’). Last but not least, such a culture would make it much less problematic to allow patients to choose their preferred doctors inside a public service.

Policy implications

Physicians’ primary interest is expected to be their patient’s health so their primary activity is direct care. ²⁵ This should be the major motivation for a student choosing medicine at university and the prime goal of medical training later. While medicine is a mission aimed at serving patients and not practiced as a standard business for maximising income, the profession should not involve limitless sacrifice. ²⁹ Thus, we can argue for quite generous remuneration in a civilised society. Given a work pace consistent with arduous commitment, we may also envisage early retirement, especially for the more stressful specialties at serious risk of burnout, such as surgery or psychiatry.

If the physician’s role should not be that of an entrepreneur from the supply side, ¹³ then patients too cannot be considered common consumers shopping around for their best deal from the demand side ¹ : illness undermines their health, making them vulnerable and often prone to ‘financial blackmail’. Health is basic in the hierarchy of human needs ³⁰ and illness threatens people’s dignity, so healthcare should not be too expensive in a civilised society. ⁴

From theory to practice, it is still hard to imagine, even in highly developed countries, a fully equitable healthcare system, where wealthy patients have no advantage over poorer ones. That may be simply unrealistic, like in any other domain. Here, we just argue that private and public healthcare services can co-exist, but separately, without overlap. Particularly in this era of permanent financial crisis, public providers should be able to respond economically and promptly to the health needs of the vast majority of people.

Unlike many other authors, therefore, we conclude that any form of dual practice should be forbidden in European countries and future analysis should focus only on how to find fair solutions for managing and rewarding at best a socially important profession like medicine in the public sector, leaving private practice only to market rules.