The government loves to erect handsome expectations without the funding to achieve them, then blame the flimsy reality on us.
There is a legend in Russian history that in 1787, Russian field marshal Prince Grigory Aleksandrovich Potemkin decided to impress Catherine the Great as she travelled to the newly conquered Crimea.
Prince Potemkin was apparently concerned about displaying the squalor of the conquered territory, and so he built a series of “Potemkin villages”, entire villages erected as painted façades along the paths of Catherine’s travels.
These villages are now used as a metaphor for strategies that obscure the truth for some form of gain. Usually political gain.
In health, it has never been more obvious that our landscape is littered with them. Some of them are benign, others not so much.
Potemkin healthcare
When a health minister or other dignitary arrives to inspect any facility, healthcare is zhuzhed up with a coat of paint and sometimes a careful choice of patients. This behaviour is expected, and relatively harmless. No one believes the images in the media are a true representation of anything.
But there are the less benign Potemkin villages that are deliberately misleading. Often, you see them in vision statements.
A local example is an institution that has around 33% of its junior doctors experiencing racism, bullying and/or harassment. It has been quite open that certain communities (e.g. Aboriginal and Torres Strait Islander communities, LGBTIQA+ communities) receive less appropriate care than they should. And yet, the vision statement façade tells the community that “we are respectful – we value everyone” and “we are kind – we make everyone feel welcome and safe”.
One could argue that no community is gullible enough to believe vision statements, and I would agree, except that the first of their four statements asserts, “we are reliable – we always do what we say”.
We see this sort of well-meaning hyperbole in education too.
It may be perfectly appropriate to assess procedural skills using competency frameworks, for instance. But assessing the professionalism skills of a medical student using core competencies means we can gloss over the unease we may feel about their character, interprofessional communication or ethics.
It’s not deliberate, but it may not be honest to say that student has demonstrated their trustworthiness and professionalism when we are unable to use the subjective “gut feeling” we all have to prevent a student with poor communication skills or ethics becoming a doctor. Being able to pass an exam and switch on an adequate professional performance does not mean someone is inherently professional in their daily conduct.
While vision statements can be a little, well, overenthusiastic, and curriculum and assessment can be overambitious, I think most people can see where this is coming from. Most of us would see what organisations and educators are trying to do, and although their statements may be exaggerated, they are generally well-meaning.
Where Potemkin villages get really nasty is where they are used for political gain.
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The language of Potemkin policies
We can usually recognise Potemkin research, policy or marketing by looking for “weasel words” — words that suck the life and meaning out of a sentence. Examples are qualifying statements, like “evidence suggests” or “some people say” or even simple words like “may”.
In health, there is increasing use of words such as “evidence-based”, “patient-centred”, “co-designed”, “recovery-oriented” etc. These qualities may be admirable, but when you really look at how they are used, there is often nothing behind them, or what is behind them is “lite”.
We see Potemkin words everywhere. Increasingly, articles presented as research are actually advertorials. Examples include “research” that is used to sell an “evidence-based” product, when the “evidence” is a poorly designed study of under 20 people and none have the disease in question.
However, the more dangerous use is in politics and management.
Ged Kearney, federal assistant minister for health and aged care, recently posted on social media denouncing “medical misogyny”.
“Gender bias in healthcare is hurting women, and it’s time for change,” she wrote, citing a newspaper article on a survey which found that “two-thirds of women feel dismissed, judged, or ignored when seeking reproductive and general healthcare”.
While there is a kernel of truth there, because most women have met at least one health professional in their life who has been dismissive or biased, there is a disturbing Potemkin spin here.
The survey had around 2500 responses from a convenience sample, which is 0.01% of Australian women reporting “misogyny” at some time in their lives. To say “two-thirds of women feel dismissed, judged, or ignored when seeking reproductive and general healthcare” is a bit of a stretch.
Following this assertion with a list of all the things her government has done to address this is spin, and it harms healthcare. I am sure female patients who read this comment from Ms Kearney are likely to be wary of doctors in the future, and this has the potential to impact their willingness to see us when necessary.
What should we do with Potemkin policies?
Doctors are held to a code of conduct that is designed to increase trust in the profession. We are required to be honest, presenting risks and benefits in as objective a manner as possible.
I don’t understand why policy makers, politicians and managers aren’t held to the same standard.
AHPRA disciplines doctors who raise concerns publicly that are seen to undermine trust not only in the professions, but also in governments and policies. So, what should we do when people with influence misrepresent or even lie about the healthcare system? How do we hold them to account?
I think we all need to push back on Potemkin statements, and here are some questions I often ask:
- Can you tell me more about the evidence? Isn’t that a small/biased sample and/or an inappropriate methodology?
- Are there any conflicts of interest behind this evidence? If so, are they clear and declared?
- Which population was represented in the research? Who wasn’t?
- Which patients are “centred” in this policy? Is it appropriate for those with the greatest need, and the lowest literacy/health literacy/digital literacy?
- You say this program is “co-designed”. Who was involved in the designing? Is it still a good program for more vulnerable people?
- Who was on the committee who designed this policy? Who wasn’t?
- You’ve spoken about “medical misogyny”. Apart from the fact that misogyny appears across all institutions in society, can you tell us how policy misogyny is being addressed? Why is the work that women GPs do, like, on average, longer consultations, undervalued by Medicare?
And my most common question, “how do you know this is cheaper/more effective/more efficient/more equitable??”
No wonder we are all struggling with the emotional toll of our work, and no wonder the public distrust clinicians.
It’s not the clinicians who should be held solely accountable for healthcare when it doesn’t meet patient expectations. Managers, politicians and policy makers set those expectations, and then under-resource so none of the expectations are possible. It is not trustworthy to build facades, and then blame clinicians who can’t magically create an entire building.
At the end of the day, I want to walk behind the façade, take a photo, and publish it somewhere visible.
Until policy makers and others with institutional power are held to account for their trustworthiness, healthcare design will be compromised. Building Potemkin hospitals, which advertise gold standard, patient-centred, evidence-based, recovery-oriented and equitable care, means the clinicians on the ground have to deal with the fallout when patients and their families get to see behind the façade.
And that is deeply unprofessional.
Associate Professor Louise Stone is a working GP who researches the social foundations of medicine in the ANU Medical School. She tweets @GPswampwarrior.