Tuesday, September 25, 2007

The Unwanted Child

This case disturbs me in the same way that it would disturb much of the community:
  • Should a couple who are unable to have children naturally due to a lifestyle choice be allowed to do so via IVF?
  • Should the birth of a healthy, but unintended child be something for which compensation should be claimed?
  • Should the ACT continue to have medical negligence laws that are out of step with the rest of Australia?
  • Should you be able to sue for relationship stressors which are a normal part of parenting?

What makes me more uneasy is, however, the thought that "There but for the grace of God, go I".

I could be the parent with unexpected twins and a strained relationship and career.

I could be the surgeon who performs or supervises a completely routine procedure while the patient utters something minor, innocuous, or unheard while sedated.

Nobody outside the theatre can profess to know what happened during that procedure, or what the successful conception rates of IVF are now, or whether it is unusual to implant a single or multiple embryos in a mother-to-be who is desperate to have children.

Just imagine - you are about to wheel into the operating room when the patient says "Doc, don't messh up my tatt. Ith really importanth to mee... zzzz..."

The patient is half awake and non compos mentis, there is no way to remove the skin cancer without cutting through the tattoo. You have a signed consent form authorising removal of the lesion. You can't remember whether you discussed the tattoo at the time of consent - but it's hard to believe that you didn't. It's highly likely that the patient won't remember making that comment. Do you cancel the case? Do you proceed?

That may or may not be what happened - but I can imagine it happening to me tomorrow.

I am trying out a new JavaScript function from here. Let me know what you think.

SMH: Lesbian sues over IVF twins (Click to See)

Bris Times: Lesbian IVF case divides community (Click to See)

News.Com.Au: Lesbian IVF case leaves ACT vulnerable (Click to See)

Sunday, September 23, 2007

Where Do All The Good GPs Go?

I have had a running discussion (well, running may not be the word... let's say a slow-paced stroll) with an Anonymous commenter about my previous post Ann Bolch Meets Doogie Howser.

One of my criticisms of Ann Bolch's executive summary of the GP workforce was that describes (emphasis added):
At present this occupation has a high vacancy level, with 71 per cent of the vacant positions stemming from staff turnover within the industry

I think that this is an inaccurate portrayal of an industry where firstly, GPs are generally self-employed. Therefore while there is a shortage of GPs, not many of these are as employees - so how can you have vacant positions when such positions are rarely as an employee, and as such are not advertised?

Secondly, once a GP has completed training, they do not generally move from practice to practice in the same way that, for example, an accountant might. I would consider "turnover within the industry" to mean that a GP is poached from one practice to another. Someone please correct me if I am wrong, but I don't think this is commonplace.

Lastly, Anonymous states that:
There is significant turnover of General Practitioners. Many go off into other careers. These are the people that go onto specialize, namely in fields such as psychiatry and O & G.
1:10 AM, September 15, 2007

My response was, and remains:
I stand by my statement that it is unusual and uncommon for a GP to do anything other than work until they retire from medicine. Perhaps a small number of GPs give up medicine because it is too frustrating and decide to run hobby farms, play the stock market, or start up non-medical businesses instead - but you can hardly call that staff turnover.

Perhaps we are disagreeing over the semantics of the term "turnover". I see turnover as when someone gets fired, or leaves to go to another job (as Ann Bolch says, "within the industry"). Generally I don't think you can have staff turnover when GPs are not usually "staff" anyway - but clearly if we are to make any sense of her description we must try to read between the lines rather than taking Ann Bolch's words literally.

As for Anon's concept that a large and significant proportion of GPs go into other careers or specialise... I can't find anything to back this up. Instead, there is a plethora of workforce studies citing the impact of age-related retirement on attrition in the GP workforce.

While Schattner & Coman did find that "Fifty per cent of respondents had considered leaving their current workplace and 53% had considered abandoning general practice because of occupational stress" this does not translate to GPs actually leaving practice. Rittenhouse et alia (No Exit: An Evaluation of Measures of Physician Attrition. Health Services Research 39 (5), 1571–1588) writes:
The strongest predictor of both intention to leave clinical practice and actual departure from practice was older age. Physician dissatisfaction had a strong association (OR=5.6) with intention to leave clinical practice, but was not associated with actual departure from practice.

The closest that I could find to support Anonymous' point of view was this section of the Health Workforce Study Report (PDF, Dec 2005):
And in the area of general practice, the Australian College of non-VR General Practitioners said that because of the differential treatment of their members (that account for 10 per cent of the total GP workforce) who receive less than 70 per cent of the Medicare rebate available to vocationally registered GPs:

Non VR GPs have been leaving general practice ... and moving into other sub-specialities such as women’s health, cosmetic surgery, skin clinics, insurance companies and workcover clinics where the rate of pay is more attractive.
(sub. 128, p. 1)

To Anon - I don't disagree that GP work can be financially and personally frustrating, and that GPs may choose to expedite their retirement as a result of this. Many other specialties share your frustration. I also agree that GPs may choose to subspecialise into areas of interest such as Sexual Health, Mental Health, Obstetrics, GP Anaesthesia, Rural GP practice, Chronic Pain, Acupuncture, Erectile Function, Cardiac Screening, or Skin Cancer treatment. But these GPs are not undertaking recognised Specialist Training (especially as far as the Federal Government is concerned) and they continue to provide services within the realm of General Practice.

I think there is little to be gained in you or I escalating this tiff over the definition of the word "turnover", but I suspect you will respond anyway.

Thursday, September 20, 2007

Ten Out of Ten? I Don't Think So.

Over the last few years, I have seen a steady increase in the number of websites that name and shame doctors. Perhaps that is a little unfair - they start out with the stated aim of rating doctors and allowing patients to find the good ones, but over time they are inevitably overwhelmed with criticism rather than commendation.

The first ones I saw were in web forums and bulletin boards, asking innocent enough questions like: "Which doctor would anyone recommend for condition XYZ?".

Then I started to see websites dedicated to specific conditions and listing, recommending, or rating doctors in that area.

Now there are a growing number of websites that rate or rank doctors in multiple areas and multiple specialties.

Personally, I just have a look to see if me or any of my friends have anything bad said about us, but it is amazing how often you see entries that are just plain vindictive. More than once I have seen people that I know who are perfectly good doctors effectively slandered on one of these websites. Sometimes these are from people that I recognise who just plain have it out for someone for personal reasons.

Thankfully, I don't believe that many people take these seriously, but you never know. It doesn't take much to ruin a reputation these days.

Friday, September 14, 2007

Train Nurses in Hospitals? You Must Be Joking!

John Howard and Tony Abbott have come up with an amazing idea... perhaps we should start training nurses in hospitals?

The Australian: Nursing to lead PM's fightback
Dennis Shanahan and Patricia Karvelas | September 14, 2007

... The new nursing schools will be modelled on the Government's 24 Australian Vocational Training Colleges, built by the commonwealth but run by community groups working with employers. The trainee nurses will provide immediate relief to hospitals suffering staff shortages.

The courses will run for three years and students will emerge with a nationally recognised TAFE qualification - equivalent to university-based study.

While they study, the commonwealth will subsidise their wages and also pay bonuses in the middle of their courses and at the end of their studies, to encourage their completion.

Doctors, hospital administrators and private hospital employers will have input into the training programs to ensure the nurses emerge with skills sought by their industry.

According to a 2004 Australian Health Workforce Advisory Committee report, Australia will need up to 13,500 new registered nurses each year to meet the demand for nursing services over the next 10 years. In 2004 only 5631 nurses completed their training. Despite the shortfall, 2408 eligible applicants were turned away from university nursing courses last year because there were not enough places.

The Government's move is likely to be welcomed by the medical community because university training is often criticised as producing book-trained nurses with inadequate practical experience. The Government has already raised the plans with some hospitals and its announcement will come as the Australian Nursing Federation launches phase two of a four-week TV advertising campaign outlining the negative impact of the Howard Government's industrial relations laws on nurses working in aged care. ...

Hospital doctors and nurses have been saying this for years. The lack of clinical experience and focus in University-based nurse training has led to a major shift in the focus of nursing graduates. Actually looking after a patient's physical needs, helping them get out of bed or go to the toilet, changing dressings, washing and showering, administering medication, physically checking for pressure sores - these have become non-core duties which are beneath that of nursing staff.

Nurses have now become managers, psychosocial carers, patient advocates and protocol pushers. I find that often the job of nursing has been delegated to Ward Assistants, and Orderlies. In fact, a whole new profession has sprung up called Patient Care Assistants or Patient Services Assistants. I think that perhaps we should give all the PCAs / PSAs badges that say "I am really your nurse today".

I am not alone. Kim from Emergiblog and the vast majority of hands-on hospital-trained nurses would wholeheartedly agree that we need a return to fundamental nursing. Moving nursing training out of the wards and into the Universities has been a disaster for patient care. It has produced a generation of "nurses" who do not want to nurse patients. They don't want to train to become doctors, so they have created a new job - the "Nurse Practitioner".

Perhaps the most revealing part of the current state-of-play is that the most vocal opponent to a return to hospital-based, apprenticeship-style on-the-job training for nurses is the Australian Nursing Federation.

Govt announces hospital training plan for nurses
AM - Friday, 14 September , 2007 08:11:00
Reporter: Peta Donald

PETER CAVE: The Federal Government will be hoping to put the leadership turmoil of the past week behind it today, with an announcement about a return to hospital-based training for nurses.

The Prime Minister will announce the new system in Sydney. It will see an extra 500 nurses a year trained in hospitals, rather than universities, as part of back to basics approach.

From Canberra, Peta Donald reports.

PETA DONALD: If the Federal Government wins the election, nurse training will be done in hospitals again, not just in universities. Twenty-five privately operated nursing schools would be built in hospitals around the country, as part of the $170-million plan.

Five hundred extra nurses would be trained each year, according to the Health Minister Tony Abbott.

TONY ABBOTT: It will be based on hospital training in the old style, because one of the real problems with nurse training in recent years is that too much of it has been the classroom, not enough of it has been in hospitals, and it's important that nurses come out of their training program understanding patients and ready to help from day one.

PETA DONALD: Well, they already have a clinical element to their university training, and in the '90s, it was thought to be the way to go to train nurses in universities.

TONY ABBOTT: Mmm. Yes well, I think that we're a little wiser now than we were then, and I think that the pendulum's swung a bit too far and this will be an additional nursing pathway, which will be entirely hospital-based.

Now, it doesn't mean that they won't be doing their classes, but the classes will be in hospitals, the training will be in hospitals and when they come out of their training, they will be absolutely, thoroughly familiar and acclimatised to work in hospitals.

PETA DONALD: But the Australian Nursing Federation is not impressed. It hasn't been consulted about the plan, and believes it's a big step backwards for the profession.

Lisa Fitzpatrick is the State Secretary of the Federation's Victorian Branch, and she remembers what it was like to be trained in a hospital.

LISA FITZPATRICK: Look, it was a wonderful experience, but it was very difficult trying to study and to work full-time, and you did make up the workforce and it was an apprenticeship scheme. Nursing and the skills required for nursing nowadays has changed since the 1980s when we had hospital-based training.

The acuity of the patients is much greater, the skills and the expertise that is required by nurses, their assessment skills, their understanding, their work with inter, ah, other professions is much greater than back in '80s and I do really think that this is very disappointing that the Prime Minister is attempting to take nursing back into the last century.

PETA DONALD: Well, what is the advantage of university-based training for nurses then?

LISA FITZPATRICK: It is a very good preparation for them to work in any health (inaudible) not just a hospital setting. Nurses aren't just found in hospitals. And it's important because it exposes nurses to research, for example, a research culture so that they can improve the practice of nurses into the future.

To take nurses away from the university sector and go back to the days where doctors and hospital administrators and employers were conducting and had input to their training programs is a huge setback for nursing, and one that won't be accepted by the profession at all.

PETER CAVE: Lisa Fitzpatrick from the Australian Nursing Federation.

That's right, Lisa - the nursing landscape has changed a lot since the 1980s... for the worse! But your agenda finally becomes clear:

To take nurses away from the university sector and go back to the days where doctors and hospital administrators and employers were conducting and had input to their training programs is a huge setback for nursing, and one that won't be accepted by the profession at all.

This is not about quality of patient care - it is about a bunch of power-hungry ANF officials keeping other stakeholders out of improving the quality of nursing. These "nurses" don't want to be part of a team... they just want to run the team. Perhaps when they start wearing the moral, legal and financial responsibility of doing so, they will change their minds.

PagingDr and EBM

I have recently discovered a very interesting web forum for Australian Medical Students, Potential Medical Students, and Doctors at http://pagingdr.proboards61.com/index.cgi.

There is a thread at the moment entitled I hate EBM stemming from one student's frustration at the varied evidence base for the management of stroke and stroke risk.

Perhaps I am just scraping the bottom of the barrel for material, but here is my contribution to this thread:

As I have written previously (somewhere in a comment on someone's blog - can't find it now), consultants and senior registrars are often very knowledgeable and up-to-date, but their teaching skills can be limited which means that medical students don't quite get the concept that the consultant is trying to convey.

There is a reason that medicine is sometimes considered more an art than a science - EBM is great for telling you what is the statistically best treatment for a large cohort of patients (e.g. male 60-75 year olds with SBP between 140-180), but it is very bad at telling you what to do with the patient that is sitting in front of you right now (e.g. female 76 year old with SBP of 138, major renal impairment, dilated cardiomyopathy and bedbound in a nursing home).

Look carefully at the inclusion and exclusion criteria of most of the RCTs that you review: these make or break a study and can define whether they obtain a statistically significant result or not. You may well find that the patient sitting in front of you does not strictly fit into the inclusion criteria of the trial, or on subgroup analysis failed to reach statistical significance in that study. Perhaps they have qualities that bring them in line with two conflicting studies.

Just because you are armed with one paper to support your point of view does not mean you are right, or that you have treated the patient's problem - all you have done is answered the question of whether to prescribe drugoxidil or pharmacoxib, or whether to perform a serum rhubarb level vs a radio-labelled hairy cell scan.

Two of my favourite quotes:

- Metanalyses are to Analyses as Metaphysics is to Physics.
- Doctors treat patients, not statistics.

Wednesday, September 12, 2007

Barcode This

I hate bad reporting. Even worse, I hate the way that news.com.au uses bullet points that have little or no basis in the full article. Where does it say that patients are to be stamped with barcodes? The closest is this line:

"In the US veterans' health system, basically every patient has a barcode on the normal hospital wristband as well as their name and date of birth," he said.

For your information, Dr Wakefield, this is common practice throughout many hospitals in Australia and New Zealand. Perhaps Queensland is lagging behind? Mind you, the barcode is quite useless unless you have an army of staff wielding barcode scanners prowling the hospital. It's generally much easier just to check the name, hospital number and date of birth against the operating list, x-ray request slip, drug chart etc. It also doesn't stop people putting the wrong label on the wrong patient (and no, two wrongs do not make a right).

Wrong side, wrong site, wrong procedure or wrong patient surgery is a serious issue, and is not helped by sensationalist reporting. It is also not prevented by single step "solutions" like patient barcodes (which actually make identification more difficult rather than easier). Just like in aviation safety, errors are avoided by multiple layers of protection (The Swiss Cheese Model), and acceptance that responsibility for safety lies amongst all hospital staff, as well as patients themselves. Air crash investigators do not point fingers at individuals, and neither should health safety committees.

Barcodes for patients to stop medical bungles
By Janelle Miles
September 12, 2007 07:37am

  • Patients to be stamped with barcodes
  • 31 wrong operations performed last year
  • Patient misidentification main problem
HOSPITAL patients in Queensland are to be stamped with barcodes in a move to prevent operations being performed on the wrong body parts.

Last financial year 31 mistaken procedures were performed, including three cases of the wrong tooth extracted and two operations on the incorrect part of patients' spines.

In another instance, a person's left tonsil was removed in error and a separate patient had botox injected into the wrong body part.

Queensland Health's Patient Safety Centre senior director John Wakefield presented the figures to a Royal Australasian College of Surgeons state meeting near Cairns.

They represented a huge increase on 2005-06 numbers, when six such cases were recorded, but Dr Wakefield said the centre had been actively encouraging public hospital staff to report incidents.

"You might think: 'Oh gosh, how do these things happen?' " he said.

"But as medicine has become more complex and we get people through the system quicker, there's more opportunities for mistakes to be made.

"It usually happens in very busy hospitals. A major Brisbane hospital when I was working there three years ago had 22 operating theatres. That's a surgical factory."

Dr Wakefield said although the mistakes were rare, with more than 800,000 patients admitted to Queensland public hospitals in 2006-07, they were all preventable.

"For the vast majority, there was very little harm but we regard all these errors potentially as leading to serious harm," Dr Wakefield said outside the meeting.

"We're unearthing a problem, a risk in our system, which we've got to fix."

An analysis of the cases found patient misidentification was a significant cause of the problem.

Dr Wakefield said Queensland Health planned pilot projects to eliminate the problem, including a study into the benefits of barcoding patients.

"In the US veterans' health system, basically every patient has a barcode on the normal hospital wristband as well as their name and date of birth," he said.

"It's a big technical investment but we'd like to explore that.

"It doesn't just protect against patient misidentification, it protects against the wrong drug being administered as well."

Tuesday, September 04, 2007

Ann Bolch Meets Doogie Howser

Does anybody remember the TV Show Doogie Howser, about the 16-year-old doctor? Well, Ann Bolch believes that Doogies are commonplace - after all, look at Balamurali Ambati, Sho Yano, and Akrit Jaswal.

Nevertheless, there are very few, if any GPs aged 20-24 in Australia, and given the current trend towards postgraduate medical degrees, they will become fewer and fewer. That doesn't stop Ann quoting this demographic in her comprehensive summary of the pertinent facts relating to General Practitioners. Ann, check your facts, please.

Most medical schools will not routinely accept undergraduate students under the age of 17. With generally a 5-6 year course, this means that minimum age to graduation is 22 or 23. Add an internship and 3-5 years of GP training, and you have someone who is 25-28 years old before they can call themselves a qualified GP. Mind you, any medical graduate could theoretically go out and set up shop as a GP, but I doubt they would earn $1117 a week before business expenses and tax.

Apart from this, Ann does not understand that there are Medical Practitioners, General Practitioners, and General Medical Physicians. They are different.

And what the hell does "staff turnover in the industry" mean? GPs work until they retire. They don't go off to other careers. They don't get fired. There is no turnover. Either not enough train to be GPs or too many retire, and let me tell you - there is very little turnover in the GP industry, except for those that worked, worked and worked until they died, and are now turning over in their graves over your uninformed article.

Saturday, September 01, 2007

House, Go Home

I made the terrible mistake of watching House on television recently. I think that my brain is starting to turn to mush.

Apart from the fact that he and his staff are somehow capable of performing and administering any and every test and procedure in the hospital, feel that they have the right to invade and inspect patients' homes at will, and have no qualms at talking patients into experimental and dangerous therapies that have little likelihood of doing them any benefit - they seem incapable of taking an adequate history, performing a physical examination, or ordering investigations appropriately or safely.

The plot tries to account for this by placing him in a Department of Diagnostic Medicine that handles all the difficult cases - but many of his cases are far from difficult, or are completely contrived. He and his team are just incompetent.

I better stop watching before I become as incompetent as he is.