Tuesday, May 26, 2015

I am a Bully (Yes, you read that correctly)

Not long after I gained my RACS Fellowship and became a fully-fledged consultant surgeon, I found myself operating at 3am on a bleeding patient. This young girl’s life was literally slipping through my fingers. I had tried everything: pressure on the bleeding veins, applying clamps and pushing with swabs on sticks, suturing the holes that were getting progressively bigger and bigger, pledgeted sutures, packing the abdomen, clamping the aorta to stem the venous haemorrhage.

Everything I did seemed to make things worse, and I felt this rising tide of frustration beginning to well up inside me. Even worse everything seemed to be happening in slow motion. The retractors I needed weren’t available. The scrub nurse couldn’t find the instruments I asked for. The needle holders didn’t grip. The scissors didn’t cut. The lights weren’t right. The psMonitor was going flat.

I had never experienced this as a trainee. There was always a senior surgeon to turn to, who had the responsibility. Up until then I had not truly faced the prospect that a patient would imminently die because I wasn't up the the task - and then my assistant stuck the back of my hand with a needle.

“What the F!@)(k did you just do?” I exclaimed. The moment after I had said it I had realised what had happened. I had just abused my hard working registrar, who was just as tired as I was, even more nervous than I was, and completely undeserving of my foul-mouthed critique of his left-handedness. The look on his eyes told it all. His face went pale, and he looked like he was about to pass out. But it was too late. I had become a bully.

Anyone who has read my blog before will know how much I love to boast about myself (completely justified, of course). I am, after all, the perfect model of the considerate, caring surgeon. I spend an inordinately long time with my patients in clinic, and they all love me even though they have to wait two hours beyond their appointment slot.  I put up with the incompetence of the constantly rotating stream of junior nurses all the time because I love to teach, and it takes an extraordinary level of medical student ignorance to irk me.

But it has taken a long time for me to become this tolerant. I have had to hone this skill over many years, gradually learning how to refrain from my natural instinct to yell, throw sharp objects, scrunch my face and stamp my feet. This has turned me into the wonderful teacher, leader and all-round nice-guy that I am today (except for Othman who thinks I am a "nasty consultant").

Occasionally, however, something makes me snap. I liken it to a generalised epileptiform seizure. If I am tired, stressed, ill, overworked, underpaid, and forced to work in an underfunded, under-resourced healthcare system, or god forbid going through a divorce, then my likelihood of losing my cool increases. I can keep it in check, but given the right stimuli my inner bully emerges and a torrent of abuse will inflict itself upon whomever is the nearest appropriate target. Sometimes the odd phenytoin-laced movie voucher from hospital administration for unpaid overtime will stabilise my condition but otherwise I am like a coiled viper ready to strike at the next inappropriately metaphorical simile.

Last night, however, I watched the Four Corners episode on Bullying in Surgery and realised that I am not alone. Indeed, there are many latent bullies out there just like me. We are a horde of ugly monsters hiding in a world of reasonableness, tranquility and sincerity, like those damn vampires in Twilight. We do not belong here. We cannot change or adapt to this modern world. We must either destroy humanity and reclaim our place at the Iron Throne of Westeros or fade away gently into the night due to our irrelevance.

Indeed, I expressed this to Mrs Sheepish and she suggested that perhaps I should retire and then we could go all Greece-like and default on the massive debt I used to finance my medical education, specialist training and private practice. It took me a while to realise that she was joking and then she very sensibly pointed out that everybody has the capacity to be a bully in the wrong circumstances and that does not mean that I am a “bad person” who is beyond redemption.

Therefore tomorrow I will ring my ex-registrar who is now a respected and successful neurosurgeon working at an ivory tower and I will apologise for almost destroying his career. And I'll have a quiet laugh at him because he still holds the forceps funny.

PS For those of you with no sense of humour then you have my pity.

Monday, April 21, 2014

AMI Survives Another Heart Attack?

The most recent AHPRA newsletter came with a very interesting story:

Referral from New Zealand’s Health and Disability Commissioner

New Zealand’s Health and Disability Commissioner (HDC) completed an investigation into the Advanced Medical Institute (NZ) Ltd. The Commissioner found that the Advanced Medical Institute (NZ) Ltd had breached the New Zealand Code of Health and Disability Services Consumers’ Rights 1996.
The HDC has published a partly anonymised version of the report on the Health & Disability Commissioner website and has asked the Board to alert medical practitioners in Australia about his concerns.
Long time readers of this blog will know that I hold the business of Advanced Medical Institute in great disdain, outlined in my previous entry here. I thought that they had sustained a fatal blow after the events of 2010, but clearly they have continued to practice in New Zealand.
This Commission finding is clearly a blow to their activities, but we have seen AMI rise snake-like from its ashes before (I deliberately did not say phoenix for... obvious reasons).
If you are interested, you can read all about AMI's practices at the NZ H&DC's website here.

Friday, February 28, 2014

Testify, sister!

Astute readers may have noticed that my last post mentioned three areas about which I am incensed enough to rant about. So here is my Number Two (and all of those who are giggling at the incidental scatalogical reference can stop now).

Throughout 2012-3 AHPRA has been conducting consultation in regards to new Guidelines for Social Media.One would think that this would be an area where extensive debate and discussion would ensue, with input from many experts. The blogosphere took off with criticism and comments, and one would hope that AHPRA paid attention to the online commentary as well as the formal submissions to their consultation process.

On Feb 17th this year AHPRA announced the implementation of new Guidelines to be rolled in from March 17th. The Social Media Policy is generally worded fairly well, and seems, at least to my eye, to be quite reasonable. It primarily warns practitioners to be careful when using social media and to uphold professional principles of confidentiality, impartiality, and ethical behaviour.

Along with the swag of updated guidelines is a new Advertising Guideline which essentially reinforces the current stance that testimonials of health services (ie a patient saying how great their doctor was, or how well their surgery went) is not appropriate and should not be used by health professionals in advertising or marketing. Nothing controversial there.

But these new guidelines go one step further. AHPRA has revamped its Social Media stance and incorporated this into the new Advertising Guidelines. Now not only is it unacceptable to use testimonials on your own website, but you cannot allow others to leave testimonials on your website, or other sites that you control. Furthermore, if you become aware of a testimonial (positive or negative) on a website you do not control then you must take reasonable steps to have that testimonial removed, or else you are liable to be fined under the National Act.

WTF? I am liable for a $5000 fine if someone else writes something about me on a third-party blog or rating site???

Social Media Champion Jill Tomlinson (whose is regularly attributed as being responsible for #Destroythejoint, a concept that I never fully understood, but then again I am not a twitterer, or tweeter, or twit, or twat, or whatever someone who uses Twitter should be called) has launched a solo campaign against these new guidelines with an Open Letter, published at Croakey.

If you think these guidelines are right on, then please let me know. If you think they are way off the mark, then don’t just let me know… let AHPRA know! Or the AMA, or your college, or the newspaper. Heck, you can even spread the word on this new fangled thing called Social Media.

New Advertising Guidelines - Social Media - Excerpts

6.2.3 Testimonials
Section 133 of the National Law states:
(1) A person must not advertise a regulated health service, or a business that provides a regulated health service, in a way that – 
(c) Uses testimonials or purported testimonials about the service or business
The National Law does not define ‘testimonial’, so the word has its ordinary meaning of a positive statement about a person or thing. In the context of the National Law, a testimonial includes recommendations, or statements about the quality of a regulated health service including clinical care, personal experiences of a regulated health service or about the benefits of a particular practitioner or regulated health service by someone who received the service. Testimonials can distort a person’s judgment in his or her choice of health practitioner. They may misrepresent the skills and or expertise of practitioners and create unrealistic expectations of the benefits such practitioners may offer health consumers. Testimonials in advertising include: 
  1. using or quoting testimonials on a website, such as patients posting comments about a practitioner on the practitioner’s business website, particularly when the website encourages patients to post comments and/or selectively publishes patient comments, and/or
  2. the use of patient stories to promote a practitioner or regulated health service.
There are a number of independent websites that invite public feedback/reviews about a patient’s experience of a regulated health practitioner, business and/or service. These websites are designed to help consumers make more informed decisions and increase transparency of interactions.
A review is not considered to be a testimonial or purported testimonial, in breach of section 133 (1)(c) of the National Law when it only comments on non-clinical issues, regardless of whether it is positive, negative or neutral.
Reviews must not contain statements about the quality of clinical care received from the regulated health practitioner, business and/or service.
A practitioner must take reasonable steps to have any testimonials associated with their health service or business removed when they become aware of them, even if they appear on a website that is not directly associated and/or under the direct control or administration of that health practitioner and/or their business or service.  This includes unsolicited testimonials. 
‘Reasonable steps’ include taking action in the practitioner’s power, such as directly removing, or requesting removal, of the testimonials. For example, a review on a social media site that states ‘Appointment ran very late and magazines were old’, is not considered a testimonial as it makes no reference to the clinical care provided by a regulated health practitioner, business or service. However, a review on the same social media site that states ‘Practitioner was quick to diagnose my illness and gave excellent treatment’, is a testimonial which references clinical care and is considered in breach of the National Law.
Once the practitioner becomes aware of the testimonial, they must take reasonable steps to have the testimonial removed (also refer to Section 7.1 on social media).

7.1 Social media
The National Law prohibits advertising in any way that uses testimonials or purported testimonials. Testimonials, or comments that may amount to testimonials, made on social media sites by patients or other people may contravene the National Law (refer to Section 6.2.3 of these guidelines for more information on testimonials).
Social media includes work related and personal pages on social networks such as Facebook, LinkedIn and Twitter.
A person is responsible for content on their social networking pages even if they were not responsible for the initial publication of the information or testimonial. This is because a person responsible for a social networking account accepts responsibility for any comment published on it, once alerted to the comment. Practitioners with social networking accounts should carefully review content regularly to make sure that all material complies with their obligations under the National Law.
These guidelines should be read in conjunction with the Social media policy, published on National Boards’ websites.

Social media

‘Social media’ describes the online and mobile tools that people use to share opinions, information, experiences, images, and video or audio clips and includes websites and applications used for social networking. Common sources of social media include, but are not limited to, social networking sites such as Facebook and LinkedIn, blogs (personal, professional and those published anonymously), WOMO, True Local and microblogs such as Twitter, content sharing websites such as YouTube and Instagram, and discussion forums and message boards.

Monday, February 24, 2014

That Which Does Not Kill Us Makes Us Stronger

“The report of my death was an exaggeration” - Mark Twain, New York Journal, 2 June 1897

Firstly an apology to my long time readers – there has been some upheaval in the ranks of the Paper household and so other issues have taken priority over blogging and social commentary. Therefore this blog may have appeared to be dead or semi-comatose, but instead it has just been in hibernation. It comes back to life for worthy issues, and there have been at least three very worthy issues that deserve some attention. The first is something that should hit close to home for every doctor and health professional, being that of personal security.

Like many other surgeons around the country I was shocked at the senseless, violent attack on a fellow surgeon in Melbourne last week. I do not purport to know the details of what happened, but from newspaper reports and the surgical rumour mill, it appears to have been a targeted attack by a somewhat unhinged patient or relative. It was vicious and unrelenting and the victim has been lucky to survive, probably saved by the fact that it happened at the start of a weekday in a fully staffed major hospital.

I have chosen not to link to news reports of this attack as I suspect this colleague would prefer that his online profile and the rest of his life is not defined by this event any more than necessary.

Security in hospitals has been a hot topic. It has been championed by the AMA particularly in the Emergency Department setting.  Ambulance officers, ED and Psychiatry nurses often bear the brunt of violent behaviour from patients, along with staff in aged care facilities caring for confused and demented patients, as well as the perfectly intact but lecherous ones. GPs take personal security so seriously (especially after the tragic death of GP Dr Khulod Maarouf-Hassan in Melbourne some years ago - link included since I see little harm in doing so) that they now design consulting rooms around quick escapes and duress alarms. The last case I recall of an Australian surgeon being violently attacked was that of Victor Chang who was killed by some thugs with a rather daft plan to make money. There may well have been others that I am not aware of.

Some suggest that the problem of frequent violent assaults on health care staff is due to soaring nationwide crime and the standard knee-jerk response to these assaults is to beef up security, such as arming security guards with guns, putting up plexiglass screens, handing out duress alarms to all staff, and even setting up metal detectors at hospital entrances akin to some US schools after the Columbine Massacre. Obviously this risks escalation of violence and creation of a divide between staff and patient.

Others say that it represents inadequate mental health funding, or the natural outcome of community-based mental health care.

If you ask me, this represents a slow and gradual shift in the degree of respect that the community holds for health care workers in general. The nurse, the paramedic and the doctor are no longer perceived as someone who has dedicated their lives to the wellbeing of patients and the community in general. They become a valid target of outrage and violence.

Modern medical TV dramas (see ER, Chicago HopeGrey's Anatomy) portray us as “real people” who have “real problems”. We are invincible and then we are fallible. We make a few mistakes and then we clock off and go home without a care for the bloke in Bed 22 with the fractured NOF and urinary retention that the overnight cover will sort out (unless it suits the dramatic love-interest plot twist for us to hang around in the on-call lounge).

Industrial bargaining portrays us as replaceable commodities, or heartless negotiators risking our patient’s lives for a 4% pay rise. (See Link 1, Link 2) Admittedly, certain health unions will play the same card back at the Government of the day seeking a similar productivity gain (how on earth do you measure productivity on a ward?).

Health care is no longer seen to be full of altruistic souls in a profession that holds a high moral ground. It is no longer a desirable profession to work in. It pays poorly compared to many careers in commerce or IT. It involves menial and what some might consider degrading tasks on a daily basis that cannot be delegated to some unpaid intern (much as we might try). On an hourly basis my plumber makes more than me and we both have to wade around in wee and poo. Who would want to be a doctor, and why do they deserve our respect?

The reason, I think, should be simple. When you are at your lowest, when your body is flaccid and your soul is shaken, when every skerrick of hope seems to be gone, we are the people to will tend to you, look out for you, and make decisions in your best interest until you recover and can make them for yourself. We have to act for your benefit above any personal benefit to us. And if you don’t respect us, it makes it mighty hard for us to respect you.

Sunday, December 30, 2012

My Second Ever Blog Award

I can't say that I am a prolific blogger. Anyone who spends more than 30 seconds on this site can probably tell that I am hard pushed to scrounge up more than one or two posts a year at the moment. This is probably a reflection of how busy my life has become, juggling all the different hats that I wear. Blogging, enjoyable as it is, just is not a priority in my life.

My second ever dodgy blog award!
Nevertheless, I strive for quality over quantity, and as a result, I am quite frankly amazed that the single post that I managed to produce in 2012 has won me an award for "Top Surgery Website in 2012". Never mind the fact that it was just a video that I found funny with a tangential relevance to surgery. My kids still can't understand why it is dumb to sell both your kidneys on the Internet. Or for that matter what kidneys are, why anyone would want to buy them, and why you need them in the first place. I guess I'm not as good a clinical teacher as I though I was.

Having only ever won one Blog Award in the past from a dodgy self-promoting website, I am as chuffed as ever to have won a second dodgy blog award for doing, basically, nothing. Perhaps this will inspire me to continue to blog as little as possible in 2013... though I think I might have a few things to vent over in coming weeks.

For now, please feel free to bow down and bask in the warm glow of my awesomeness!


I wrote to you previously to inform you that The Paper Mask had been nominated for inclusion on our list of 100 Top Surgery Websites. I'm now thrilled to let you know that it has been awarded a spot on the final list published on OnlineSurgicalTechnicianCourses.com! The full list is available here: http://onlinesurgicaltechniciancourses.com/surgery-websites/

We hope our readers, mostly aspiring surgical technicians, will find this collection of excellent sites about all types of surgery useful and inspiring as they consider their educational opportunities for moving forward in this rewarding health care career.

We've made a badge that you can post on your site if you'd like to share this award with your visitors and readers. You can either use the HTML code below or the attached graphic file.
Congratulations, and please feel free to email me with any questions or other feedback.


(Name Removed)