Grand Rounds v5(51) is up

Grand Rounds is up at Medic 999. Help! I'm being flooded with links!!!

SurgeXperiences 305 at Amanzimtoti

The next SurgeXperiences 305 is up at Amanzimtoti. Go, now!

Botox? Bollocks!

I had a little chuckle when I saw the Cosmetic Physicians getting upset at what they perceive to be the underhanded tactics of some Cosmetic Nurses.

For the benefit of those who have been living under a rock, there is a movement called Cosmetic Medicine. It is championed by the Cosmetic Physicians Society of Australasia the Australasian Society of Cosmetic Medicine and the so-called Australasian College of Cosmetic Surgery.

In a sense, many doctors practice cosmetic medicine in some way. Some skin lesions aren't likely to be cancers but are removed anyway at the patient's insistence. Some varicose veins are more a nuisance than a risk to life or limb and still get removed. Some footballers have surgery to speed their recovery and short term function when they would have healed on their own anyway. The line between what is truly deserving medicine and what is discretionary (or "cosmetic") is a very fuzzy one.

Nevertheless, cosmetic medicine is a booming industry. They like calling it Cosmetic "Medicine" because it is much more acceptable to pop a pill or have an injection than to have "Surgery" these days.

I have occasionally been caught at the dinner table between a plastic surgeon and a "cosmetic surgeon" having a good go at each other. The plastic surgeon (who, like me, undertakes a minimum of 5 or more years of basic surgical principles and practice after at least 2-3 years of general medical experience, followed by specialist surgical training in plastic surgical and reconstructive surgical techniques, and often further subspecialty fellowships locally or overseas) argues that cosmetic surgeons are not trained in the basics of surgery and surgical techniques, the care of the complex patient, the management of severe complications after surgery, and the wide range of techniques required in modern surgery.

The cosmetic surgeon (who could be from a wide range of backgrounds such as a doctor who has not undertaken any form of specialist training and just decides to set up shop, or a specialist in another field like a dermatologist or a GP who decides to extend their practice into cosmetic fields, or any of these people who choose to undertake a 1-3 year informal apprenticeship with another "cosmetic surgeon") argues that you don't need to learn how to do a microvascular anastomosis in order to inject collagen, do tummy tucks, perform liposuction, or do a boob job. Instead, they say that you need an "eye for aesthetics" which they say plastic surgeons lack, and you need experience in a dedicated cosmetic clinic where finer and more subtle work is done rather than a public hospital where plastic and reconstructive surgeons deal with major deformities and mangled patients.

Obviously I am a little biased, but cosmetic physicians are really in a much bigger mess because firstly they have failed to set common standards for themselves. This is inevitably because they come from very disparate backgrounds, and therefore any attempt to standardise a training program akin to surgical training runs the risk of rendering a whole generation of self-taught cosmetic physicians unable to meet their own standards, without very prolonged and generous "grandfathering" provisions.

Secondly, cosmetic physicians perform a wide variety of procedures, from Botox injections, Collagen or dermal filler injections, liposuction, abdominoplasties, breast enhancements, facelifts, dermabrasion, laser skin therapy, varicose veins surgery, and all sorts of procedures related only in the fact that their goal is to make you look better. There is no common set of skills. There is no fundamental "principle". There is, in short, nothing to base a training program upon other than learning a few tips and tricks here from as many other disciplines as possible. It's like taking a random factory production-line worker off the Boeing production line and saying "Why don't you ask everyone else in the factory a few questions, then we'll give you a building and you can build the new 787 Dreamliner for us?" From all the trouble that Boeing is having, perhaps that is really what is happening!

Thirdly, once you leave the moral high ground and start sniping at your own colleagues and lowering the standards of training necessary to perform these procedures, there is really no limit as to how low it can go. Cosmetic physicians standing up and saying that you don't need to be a surgeon to do cosmetic procedures is only step one. Step two (as described below) is cosmetic doctors supervising procedures done by cosmetic nurses in order to make more money. Step three (also described below) is for Cosmetic nurses standing up and saying that you don't need to be a doctor to do these procedures. Step four is beauticians standing up and saying that you don't need to be a nurse to do these procedures. Step five is some bloke in Mexico who does breast implants with a second hand diathermy machine and a spoon in his garage.

Just like Melissa Blandfort who is a travelling cosmetic nurse performing invasive procedures in patients for cosmetic purposes in various beauty salons, and without the review or approval of a doctor. Her website does not mention Botox by name, but clearly says that she performs:

Injectable wrinkle treatments
Injectable wrinkle treatments have now been in use as a cosmetic treatment for over 20 years. They relax a wrinkle causing muscles, to help improve the appearance of the wrinkle. It is extremely effective in treating crows feet, frown lines and other wrinkles caused by a muscle contraction. It is generally most effective in people aged form 25 to 55 years of age. It takes up to ten (10) days to have full effect and can last up to four (4) months.

Now, last I checked Botox and similar paralytic or neuromuscular blockade agents were prescription-only in Australia, so unless she takes a doctor around with her to write out scripts for these patients, I can't see how she can be legally injecting anybody with Botox. Her website says nothing about her being accompanied by a doctor, and I would hate to be the 20th patient receiving Botox out of her multi-dose vial that mysteriously appeared out of nowhere.


Links:

• Botox trend creating worry lines - Brisbane Times
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  Botox trend creating worry lines
  Jill Stark
  August 23, 2009
  
  DOCTORS groups claim nurses are putting patients at risk by illegally performing cosmetic procedures such as Botox, wrinkle fillers and fat-dissolving injections without supervision.
  
  The Cosmetic Physicians Society and The Australasian Society of Cosmetic Medicine say nurses are increasingly injecting the restricted drugs in beauty salons and at Botox ''parties''.
  
  They claim nurses should administer anti-ageing medication only after patients are assessed by a doctor. But they say people are often injected without medical checks and prescriptions are provided for patients doctors have not met.
  
  Complaints have been made to nursing boards in three states, including Victoria, amid fears that nurses lack the medical expertise to deal with infections, allergic reactions or nerve damage from injections.
  
  One nurse in Victoria is being investigated amid claims she administered Botox and fat-dissolving injections over a 12-month period at regional beauty salons without having patients checked by a doctor. The doctor she claimed to work for is only registered to practice in a neighbouring state.
  
  But nurses deny breaking the law and have accused doctors of a scare campaign to protect their own profits.
  
  The Sunday Age believes two nurses reported to the Nurses Board of Victoria have had cases against them dismissed.
  
  Botox is a schedule four, prescription-only drug. It cannot be advertised directly to the public and must be used under medical supervision.
  
  Nurses board chief executive Nigel Fidgeon said he could not disclose information on hearings but added: ''There is no legislative restriction preventing a nurse from administering Botox as long as they have a doctor's order. There is also no requirement for a nurse to be supervised by a doctor when administering such medicines.''
  
  Gabrielle Caswell, who heads the Cosmetic Physicians Society, said she had no problem with nurses administering the drug if a doctor had examined the patient. But she said: ''We are getting situations where nurses are now holding Botox parties. So you get together with friends and usually there's alcohol around, you have a bit of a drink, no medical history is taken, you just wait your turn, get your Botox and it's all just a bit of a laugh,'' Dr Caswell said.
  
  ''But the moment you've taken a drink, then you're not giving informed consent. There's no doctor there to check if you're psychologically or physically suited to Botox or fillers.''
  
  Melissa Blandfort, a nurse who has been visiting beauty salons across Victoria to inject clients with Botox for nine years, said the claims were nothing more than a ''turf war''.
  
  ''They [doctors] don't like nurses injecting Botox because it means less business for them. This isn't about patient health concern. You can actually have more of a problem taking too many Panadol than you can taking Botox,'' she said.
  
  Ms Blandfort conceded the law on cosmetic treatment was a ''grey area'' and said she would welcome regulation that provided more clarity.
  
  But Alicia Teska, board member of The Australasian Society of Cosmetic Medicine, said nurses were trivialising the specialty. ''These are medical procedures and they shouldn't be trivialised as being of no more importance than having a manicure or having your hair done,'' Dr Teska said. ''It's the standards that are not being met and people should be quite concerned about that.''
  
  Dr Caswell said patients might not have legal recourse if such a procedure went wrong.
  
  ''The nurse is not technically responsible for the treatment, it is the prescribing doctor. If you have never met the prescribing doctor and haven't undergone a medical examination and history-taking, it may be difficult to discover who the doctor is.''
  
  Ms Blandfort said she had full insurance with a reputable provider. ''All the nurses that I know who do this have indemnity as well … I've had people abuse me for not treating them because I thought they might be a high-risk person and I sent them away.''
  
  Victorian Health Services Commissioner Beth Wilson said Botox was a relatively safe drug if used responsibly. ''If a nurse is adequately trained and they understand infection control and they know how to get informed consent, then I can't see a problem with it. However, I don't think alcohol and medicine should ever be mixed and to have people come to a Botox party and get injected is asking for trouble.''

  
  
• Four Corners 2006 Episode "Buyer of Beauty, Beware" - MUST SEE! The reporter for this episode is Jonathon Holmes who currently fronts Media Watch. Watch out of the liposuction procedure gone wrong at about 40 minutes in.
  
  
• A death after liposuction exposes busy illegal clinic - The Boston Globe, 2006
  
  
• Ex-footballer Colin Hendry's wife dies after operation to repair botched cosmetic surgery - Daily Mail UK 10th July 2009
  
  
• Choice Magazine review of Cosmetic Surgery
  
  
• Patients at risk in ugly cosmetic surgery wars - SMH, 2006
  

Clubs and Cartels

The big news this week has been that the ACCC is on the prowl again. Medical work practices are not new ground here - the ACCC has previously stoushed with the RACS over surgical training, as well as Queensland obstetricians and more recently Adelaide heart surgeons (my previous posts ACCC Strikes Again and Bleeding Hearts in Private Hospitals). In fact the ACCC has so much interest in the medical industry that it provides an Info Kit for doctors.

The new case now concerns medical accreditation practices at St Vincent's Private Hospital in Sydney, in particular, the practice of limiting appointment of new anaesthetists to those who already hold appointments at the nearby St Vinnie's Public hospital.

In general, most private hospitals have Medical Accreditation Committees that review the qualifications of any medical staff that wish to work at that hospital. The majority of private hospitals are quite keen to have as many doctors on their books as possible and to make the accreditation or credentialling process as simple as possible, because generally more doctors means more patients (and more business).

In the case of anaesthetists, they generally provide a service at the request of a surgeon. With the exception of staff anaesthetists who are paid directly by a private hospital to be available full or part time for urgent or emergency cases, the majority of private anaesthetists are paid fee-for-service by the patient or their insurance fund. Patients generally choose their surgeons but not their anaesthetists, and therefore the surgeon-anaesthetist team usually comes as a single package.

A surgeon will choose to work with a specific anaesthetist in the private setting because they are competent, they work well with the surgeon and his team (often having worked together for years), and they are available to do a particular set of cases at a particular time. Usually if a surgeon moves to another private hospital the anaesthetist will follow, rather than the other way round. Therefore it makes sense that if a private hospital wants to attract a new surgeon to bring work over that they encourage simple, rapid accreditation by the associated anaesthetists.

In contrast, in a public hospital the surgeon has no say who their anaesthetist will be. It could be a junior registrar, or a seasoned consultant. It could be someone they have never met or worked with before. We have to trust that somebody, somewhere (usually the public hospital's appointments committee), has decided that this anaesthetist is up to the job. In most cases, there are no problems as many aspects of anaesthetics are commonplace and transferable. Having a pool of staff anaesthetists makes it easier to roster for emergency cover, or to squeeze as much work as possible from a smaller group of staff - essential in any cash-strapped public hospital - at the cost of breaking up the regular surgeon-anaesthetist team. Obviously for more complex operations there will be more in-depth decision making and efforts to pair experienced and familiar surgeons and anaesthetists (as well as other theatre staff) together.

So what is going wrong here at St V's? Well, to the frustration of the hospital management and the surgeons, an arbitrary rule has been applied to limit the accreditation of new anaesthetists. This means that otherwise qualified and capable anaesthetists are unable to work at that hospital and surgeons who go to that hospital must choose from the anaesthetists who already work there. It is effectively a closed shop and keeps those anaesthetists who already have appointments busy with private work, and potentially allows them to raise their fees above what might be market rates at a hospital with a more liberal accreditation process.

Unfortunately it means that surgeons are forced to work with anaesthetists that they may not wish to work with, as well as discouraging them from bringing work to that hospital, much to the disappointment of hospital management.

Sadly, this is not the only private hospital in Australia that engages in this type of activity. Sometimes it is instigated by the medical staff, sometimes it is instigated by management as a business decision (usually if they employ the anaesthetists directly). Sometimes the ACCC gets it wrong, but by my reading this is one that they have got right and things clearly have to change.

Links:

• ACCC demands answers from St Vincent's - The Australian
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  ACCC demands answers from St Vincent's
  The Australian
  via AAP | August 17, 2009
  
  THE entire team of anaesthetists at St Vincent's Private Hospital is under investigation by the consumer watchdog for acting as a cartel.
  
  The Australian Competition and Consumer Commission (ACCC) last week demanded the group of 30 doctors, who are allocated nearly all the hospital's anaesthetic work, justify its membership rules, the Sydney Morning Herald reports.
  
  The investigation comes after the hospital applied to the commission last year to rule it could continue the practice of preventing outside anaesthetists from working in its operating theatres, even when requested by a surgeon.
  
  Individual doctors face possible fines of up to $500,000 if they are found to have breached competition laws.
  
  The private hospital's pool is restricted to anaesthetists who also work at St Vincent's Public Hospital.
  
  The process is supposed to be competitive and to benefit public patients, but has been criticised for being skewed towards doctors trained at St Vincent's.
  
  The hospital withdrew its application in December, but the commission is investigating fresh complaints from anaesthetists who say they are still locked out of work at St Vincent's.

  
  
  
• St Vincent's a closed shop, said leading anaesthetist - SMH
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  St Vincent's a closed shop, said leading anaesthetist
  Sydney Morning Herald
  Julie Robotham Medical Editor
  August 19, 2009
  
  THE anaesthetist representing doctors in the St Vincent's Private Hospital cartel investigation told professional colleagues that work allocation practices there would not change, despite a deluge of adverse submissions collected by the competition regulator during its initial, later abandoned, inquiry last year into the scheme.
  
  Minutes of a meeting of the NSW branch of the Australian Society of Anaesthetists, obtained by the Herald, reveal Gregory Deacon's resistance to the idea that closed-shop anaesthetic rostering might breach the Trade Practices Act.
  
  According to the minutes, from February, ''GD reminded committee members that St Vincent's Hospital is a privately owned business and therefore has the legal right to appoint staff, including doctors, as it chooses … GD felt the appointment process at St Vincent's Hospital was unlikely to change as a result of the application to the ACCC.''
  
  At issue is the practice of allowing only the limited number of doctors with an appointment at St Vincent's Public Hospital to work at the private facility. The private hospital argued this ensured adequate anaesthetic cover for the public hospital. However, NSW Health, which funds the public hospital, told the commission that claim was specious because there was a surfeit of anaesthetists in the eastern suburbs willing to work with public patients.
  
  Other doctors told the commission the real intention was to keep lucrative private work within a select group of associates.
  
  The commission last December dropped its first examination of the arrangement when St Vincent's withdrew its application to be exempted from the law.
  
  Now the anaesthetists - who as a formal association manage anaesthetic staffing for the hospital - are again under ACCC scrutiny, following new complaints from doctors excluded from working there.
  
  Dr Deacon, as the public officer representing them, must respond by Friday to the commission's questions regarding the group's history, policies and reasons for refusing work to qualified doctors. He refused to comment last night.

  
  
  
  
• Elite hospital old boys' network targeted by competition watchdog - SMH
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  Elite hospital old boys' network targeted by competition watchdog
  Sydney Morning Herald
  Julie Robotham Medical Editor
  August 17, 2009
  
  THE entire team of anaesthetists at St Vincent's Private Hospital - more than 30 doctors - is under investigation for acting as a cartel.
  
  The Australian Competition and Consumer Commission is moving to end what other doctors claim is a decades-long history of restrictive behaviour by an old boys' network which is bent on protecting its exclusive access to some of Sydney's most lucrative private operating lists.
  
  The ACCC last week demanded the group - a consortium of doctors employed as independent contractors but allocated nearly all the hospital's anaesthetic work - justify its existence and membership rules and defend how its members set patients' fees.
  
  Other doctors said giving anaesthetic shifts to a limited pool of specialists could also compromise patient care, barring surgeons from choosing anaesthetists experienced in particular operations.
  
  The commission's move could see individual doctors hit with fines of up to $500,000 if they are found to have breached competition laws. It comes after the hospital last year applied to the commission to rule it could continue the practice of preventing outside anaesthetists from working in its operating theatres, even when requested by a surgeon.
  
  The private hospital's pool is restricted to anaesthetists who also work at St Vincent's Public Hospital - appointed through what the hospital describes as a, ''competitive process '' intended to benefit public patients, but which others say includes a system of patronage skewed towards doctors trained there.
  
  The application prompted a huge backlash, as individuals and specialists' groups told the commission the closed roster was unjustified and unique in NSW.
  
  In its submission, NSW Health, which funds St Vincent's Public Hospital, said public patients did not benefit from the exclusivity arrangement, because there was no, "current or foreseeable shortage of anaesthetists," in the eastern suburbs, and, "indeed if anything there is an oversupply''.
  
  The hospital withdrew the application in December and is understood to have told the doctors, who effectively run the anaesthetic department and charge some of Sydney's highest rates, to change how they allocate work.
  
  But the commission is now investigating new complaints from anaesthetists who say they are still locked out of work at St Vincent's Private.
  
  Early this year the hospital's executive director, Robert Cusack, signed a rejection letter saying there was, ''sufficient anaesthetic cover within the existing cohort of anaesthetists,'' and the candidate therefore, ''did not satisfy a business need of the hospital.''
  
  Despite this, Mr Cusack is understood to be furious with the anaesthetists' position and to have told them he will not pay their legal costs or any fines.
  
  An anaesthetist, David Bollinger, told the Herald : ''I've had a professional relationship with a surgeon I've worked with for 15 years, and he moved to St Vincent's and they won't let me work there. It's … mean-spirited, and bordering on unethical.''
  
  Another anaesthetist refused work said: ''St Vincent's is very highly regarded in the community [but] the way they do things is not necessarily in the best interests of patients … it's in the best interests of themselves.''
  
  Gregory Deacon, public officer of the St Vincent's Private anaesthetists' consortium, declined to comment, saying the matter was being handled by lawyers. The hospital also refused to comment, citing the ACCC proceedings.

10 Year Challenge

Seasoned readers may recall my previous post "10 Years in Limbo" about the 10 year moratorium placed on overseas-graduated doctors.

The 10 Year Moratorium applies to New Zealanders as well, as despite their special visa status they are not considered permanent residents even when enrolled in Australian Medical Schools, and the only way around this is to obtain permanent residency prior to commencing Medical School in Australia.

Well, Dr Mike Belich wants to do something about that, and he has challenged the validity of the 10 year lockout and is currently going through the courts, as reported in The Australian. To be honest, I don't really understand his argument for seeking an exemption from the current rules... but I guess this is how precedents are set.

No doubt all the New Zealander's over at Paging Dr will be all excited. I better go let them know...

GP goes to court fighting country duty - The Australian
(Click to Expand)

GP goes to court fighting country duty
The Australian
Adam Cresswell, Health editor | August 15, 2009

A NEWLY qualified general practitioner has launched a David and Goliath legal challenge to the head of Medicare, filing a Federal Court action over a ruling he says will force him to abandon his home and partner and spend the next 10 years working in the bush.

Byron Bay doctor Mike Belich passed his postgraduate exams to qualify as a GP three months ago but is on borrowed time in the northern NSW coastal resort because of a retrospective ruling by Medicare that he was an overseas student when he enrolled at the University of NSW in 1999.

The ruling means he is subject to a moratorium set up by the Howard government in 1996 that forces overseas-trained or foreign-origin doctors to work for 10 years in the outback before attaining the right to practise where they like under Medicare.

Belich could not apply for permanent residency when he first moved to Australia with his family at age 14 because as New Zealanders they were considered to be, effectively, permanent residents already. He became an Australian citizen while at university, but later found out that the day he started medical school was the cut-off point used to classify him as an overseas student. He's challenging the ruling as unfair and beyond parliament's original intentions.

If successful his case, lodged with the NSW registry of the Federal Court this week, could affect up to 100 other doctors of New Zealand origin who, it is understood, may be in a similar position.

Belich tells Weekend Health that while at university he was treated the same as a local student, to the extent that he graduated with a HECS debt.

He was first informed of Medicare's decision to classify him as an overseas student when he applied to join the GP training program, more than a year after he had qualified as a doctor and when an Australian citizen.

He says his case is a fight for "natural justice and transparency".

"They have gone against the intention of the law, and have acted in a way to get me and 100 other people into a 10-year binding contract where we had no idea (this would apply)," Belich says. "I'm not going to work where they want me to work ... the government has spent all this money training me as a GP, they are short of GPs and they need a GP here in Byron."

Belich, who has recently bought a house with his partner in Byron Bay, says subsequent attempts to overturn the decision - including direct appeals to then federal health minister Tony Abbott and his successor Nicola Roxon - have brought sympathetic noises but no practical concessions.

The situation has been in limbo during Belich's four-year period of GP training, when he was allowed to continue working in Byron Bay under a temporary exemption from the 10-year rule.

But with his GP fellowship secured, the exemption is due to expire on October 19. Belich says he cannot comply with the 10-year rural service order because his partner is unable to leave the area under the terms of a Family Court order granting her former partner access to their two children.

Belich's solicitor Adam van Kempen, partner with the Byron Bay law firm Bottrill van Kempen, says Belich is asking the Federal Court to make a declaration that Belich is not a former overseas medical student under the terms of the Health Insurance Act.

Further, the case, which cites the chief executive of Medicare Australia as the respondent, seeks a declaration from the court that the act does not prevent Medicare benefits being paid in respect of services Belich provides.

Other doctors who may be affected by the outcome of the case will be New Zealanders who study in Australia under the same conditions as Australian students but who later are told by Medicare that different rules will apply, van Kempen says.

"The contention is that the legislation has captured this group of people and it was an unintended consequence of the legislation," van Kempen says.

Given the October 19 deadline, van Kempen says he expects there will be an application for the case to be heard urgently.

In a letter sent by then Royal Australian College of General Practitioners president Michael Kidd to Abbott in July 2006, Kidd says it is "evident ... that the Department of Health and Ageing's classification of Dr Belich as a 'former overseas medical student' appears to be a contradiction to the information publicly available" from the Department of Family and Community Services,

Department of Education, Science and Training, Department of Immigration and Multicultural Affairs and other agencies.

Kidd concludes that the college believes the moratorium should not apply to Belich and requests Abbott "use (his) ministerial discretion ... to overrule this restriction and allow Dr Belich to practise freely".

A Medicare Australia spokeswoman says it would "not be appropriate ... to comment on foreshadowed legal proceedings".

A Considered Response to Swine Flu?

We all know the swine flu jokes...

• "When will there be a mass outbreak of human/avian swine flu? When pigs fly."
  
• "I think I have the swine flu. I'm coming out in rashers."
  
• "The only known cure for Swine Flu has been found to be the liberal application of oinkment."
  
• "Apparently my mate's got Swine Flu, I think he's just telling porkies, though."
  
• "How do you know you've got swine flu? The thermometer tells you you're bacon."
  
• "Did you hear that Mexico has become a world power? When it sneezes, the whole world gets the flu."
  
• "Two buddies are talking and one guy tells the other: "I’m worried my brother's got Swine Flu!" "Why dude?" the other guy asks. "I haven’t seen him since late Saturday night when he went home with a pig.""
  
• "I have the poor mans version of swine flu… Spam flu"
  
• "I rang the Swine Flu Hotline but all I got was crackling."
  
• "Why did the pig jump off the tall building? Because he read in the news that Swine Flu!"
  
• "How can you tell if your wife might be getting swine flu? She starts hogging the bedsheets."
  
• "Apparently they are worried about a spamdemic of swine flu!!! They think it started as a snoutbreak".
  
• "I need to get tested for swine flu. I've not been to Mexico, but God knows I've slept with some pigs in my time."
  
• "I'm getting tired of all this swine flu news. It's just all a big boar."
  
• "If you develop swine flu, make sure you comply with lockdown or the government will send over the pigs."
  
• "If you have symptoms of swine flu, then immediately call a hambulance, and go to the hogspital for treatment. Smokers please note it is a non-smoking facility, so you won't be able to have a snout. This could be a false alarm, in which case you can trotter off home, but if the symptoms return, you may need to go to your local farmacy for some oinkment."

But this one takes the cake!!

Afghanistan's only pig quarantined in flu fear
Reuters, Tue May 5, 2009 3:32pm EDT. By Golnar Motevalli.

KABUL (Reuters) - Afghanistan's only known pig has been locked in a room, away from visitors to Kabul zoo where it normally grazes beside deer and goats, because people are worried it could infect them with the virus popularly known as swine flu.

The pig is a curiosity in Muslim Afghanistan, where pork and pig products are illegal because they are considered irreligious, and has been in quarantine since Sunday after visitors expressed alarm it could spread the new flu strain.

"For now the pig is under quarantine, we built it a room because of swine influenza," Aziz Gul Saqib, director of Kabul Zoo, told Reuters. "We've done this because people are worried about getting the flu."

Worldwide, more than 1,000 people have been infected with the virus, according to the World Health Organization, which also says 26 people have so far died from the strain. All but one of the deaths were in Mexico, the epicenter of the outbreak.

There are no pig farms in Afghanistan and no direct civilian flights between Kabul and Mexico.

"We understand that, but most people don't have enough knowledge. When they see the pig in the cage they get worried and think that they could get ill," Saqib said.

The pig was a gift to the zoo from China, which itself quarantined some 70 Mexicans, 26 Canadians and four Americans in the past week, but later released them.

Some visitors were not concerned about the fate of the pig and said locking it away was probably for the best.

"Influenza is quite contagious and if it passes between people and animals then there's no need for the pig to be here," zoo visitor Farzana said.

Shabby and rundown, Kabul Zoo is a far cry from zoos in the developed world, but has nevertheless come a long way since it suffered on the front line of Afghanistan's 1992-4 civil war.

Mujahideen fighters then ate the deer and rabbits and shot dead the zoo's sole elephant. Shells shattered the aquarium.

One fighter climbed into the lion enclosure but was immediately killed by Marjan, the zoo's most famous inhabitant. The man's brother returned the next day and lobbed a hand grenade at the lion leaving him toothless and blind.

The zoo now holds two lions who replaced Marjan who died of old age in 2002 as well as endangered local leopards. In all, it houses 42 species of birds and mammals and 36 types of fish and attracts up to 10,000 visitors on weekends.

(Reporting by Golnar Motevalli; Editing by Jon Hemming)

Surgical Principles of Bongi

This is a series of entertaining and very true posts from Bongi over at Other Things Amanzi:

1. to swear does in fact help.
   
2. fear nothing but fear itself.
   
3. all bleeding stops.
   
4. enjoy.
   
5. it is in fact always the surgeon's fault.
   
6. take a moment.
   
7. break the tension, don't add to it.
   
8. we do it to impress the chicks.

Clearly Bongi is more successful at impressing chicks because when I did what he did they all went off for debriefing and counselling.

Grand Rounds v5(31) is up

The Birthday Edition of Grand Rounds is up at Diabetes Mine. This blog scores an entry yet again - woohoo!

Next edition will be at SixUntilMe. Just don't try saying it with a New Zealand accent. Because it would be weird telling you to go check out "Sex 'n Tell Me".

Wellsphere / Healthblogger Doesn't Like Me?

Along with many other health-related bloggers, I have received numerous invitations to join the Healthblogger / Wellsphere network from a Dr Geoffrey Rutledge.

Here is an example (copies of Dr Rutledge's mail-merged posts are commonplace on the Internet, so I do not think I am betraying any trust by reproducing his email here):

Hi ,

Congratulations again for being invited to join the HealthBlogger network. You are just one quick step away from becoming part of the premier network of the best health bloggers! All you have to do is click here:

URL REMOVED

Set your account name/password, and we'll take it from there. We'll connect your blog and begin republishing your articles so they are available to the entire Wellsphere audience.

If you have any difficulty with this process, or if you have any questions, don't hesitate to send me an email to EMAIL REMOVED, or call me at TELEPHONE REMOVED.

I look forward to welcoming you to the HealthBlogger network!

Cheers,
Geoff
--

Geoffrey W. Rutledge MD, PhD
Chief Medical Information Officer
The HealthCentral Network, Inc.
http://www.wellsphere.com

Here is a copy of the invitation we sent you last week:

Hi ,

My name is Dr. Geoff Rutledge, and I am delighted to invite you to join Wellsphere’s HealthBlogger Network, the world’s premier network of health writers, including nearly 2,000 of the Web’s leading health bloggers! We carefully reviewed your blog, and based on the high quality of your writing, the frequency of your posts, and your passion for helping others, we think you would be a great addition to the Network. As a member of the HealthBlogger Network, you’ll enjoy the greatly expanded reach and exposure to Wellsphere’s more than 4 million monthly unique visitors, innovative special features and functionality for your blog, and an exclusive badge to recognize you as one of the Web’s leading health bloggers. You’ll also have the opportunity to share tips and advice about blogging with your fellow health-focused bloggers. Once you join, we’ll begin promoting you and your blog as a great source of health knowledge and support, featuring you in rotation on our homepage (www.wellsphere.com), republishing your posts on Wellsphere, giving you special status on Wellsphere and linking back to your blog. THERE IS NO COST FOR YOU TO JOIN and YOU RETAIN OWNERSHIP of the content that you allow Wellsphere to republish. To be clear, your content is yours, and you are free to do whatever you choose with it.

Let me tell you a bit about me and about Wellsphere. I'm a physician who has taught and practiced Internal and Emergency Medicine for over 25 years at Harvard and Stanford medical schools, and am passionate about helping people get the information and support they need to be healthier. I'm now the Chief Medical Information Officer at Wellsphere.com, where I manage the HealthBlogger Network. Wellsphere, the fastest-growing consumer health website, is revolutionizing the way people find and share health and healthy living information and support. We’ve recently merged with The HealthCentral Network, Inc. (www.healthcentral.com), and together we’re now serving more than 10 million people a month!

I would like to invite you to join the HealthBlogger Network as a featured blogger in the General Medicine Community. Once you join the HealthBlogger Network, we will automatically republish the blog posts that you’ve already written and the ones you write in the future (so you don’t have to re-post them yourself, and there’s no extra work for you!). We will feature them not only on the community pages of the site, but also on numerous relevant WellPages, where we give users a comprehensive view of expert information, news, videos, local resources, and member postings on topics you write about. Each of your articles that are re-published on Wellsphere will include a link back to your blog, and your Wellsphere profile page will show your special status as a featured blogger on Wellsphere (and will include another link back to your blog). By connecting to the Wellsphere platform, you will greatly expand the audience for your postings, attract additional readers to your blog, and receive much deserved recognition for your efforts to improve peoples’ lives.

You will also receive from us a special badge for your blog recognizing you as a Top Health Blogger, and gain access to features and functionality for your blog that we’ve created especially for members in the HealthBlogger Network, including a custom tailored Health Knowledge Finder search widget, a Wellevation widget that provides daily motivational tips for your members, and a Wellternatives widget that offers nutrition information and healthier suggestions at popular chain restaurants.

It’s easy and free to join the Health Blogger Network! Just reply to this message to let me know you would like to participate.

Congratulations on being selected to participate in the Health Blogger Network! If you have any questions, please feel free to send me an email to Dr.Rutledge@wellsphere.com

Good health,
Geoff
--
Geoffrey W. Rutledge MD, PhD
Chief Medical Information Officer
EMAIL REMOVED
TELEPHONE REMOVED
http://www.wellsphere.com
The HealthCentral Network, Inc.

Sounds pretty good, hey? Well, I have done some poking around and Healthblogger does not seem all that popular amongst some health bloggers. For example:

• The Wellsphere Blogging Controversy by John Grohol
  
• A Different Perspective on the Sale of Wellsphere by Trisha Torrey
  
• How The Health Blogosphere Was Scammed by Dr Val

So I decided that if I were to consider syndicating my blog I had better be clear about what I was willing to agree to. I sent Dr Rutledge an email:

Dear Dr Rutledge:

Thankyou for your invitation to join the HealthBlogger / Wellsphere Network. I would be willing to allow the HealthBlogger network to use my blog content on a number of specific conditions.

1. For the purposes of this agreement, YOU refers to Dr Geoffrey Rutledge, HealthBlogger, Wellsphere, and any related parties engaged in business with the above organisations. MY BLOG refers to material published by me on the blog site at http://papermask.blogspot.com.

2. All communication with me should be conducted via this email account. I can give no assurance that correspondence received via other means is from me. Any payment to me should be conducted via a secure anonymous escrow facility which I will advise via this email account on acceptance of this agreement.

3. YOU may only use the first paragraph, or approximately 255 characters, whichever is shorter of any post and must place a direct link back to MY BLOG post entry at the end of that excerpt. This is the limit of my Blogger RSS feed and YOU may not use any other means to source content from MY BLOG.

4. YOU may be granted a temporary non-exclusive license for 6 months to use such content where it is used only on the WELLSPHERE.COM domain. Such license is not transferable and material cannot be republished outside the WELLSPHERE.COM domain or further licensed to another third party.

5. I reserve the right to withdraw permission for my material to be used at any time. Should my permission be withdrawn all material must be removed within 2 weeks of my email notification being sent.

6. There is to be no censorship, vetting, modification, or limitation of material which is reproduced. All supplied material must be published as is, and not subject to editorial adjustment.

7. 25% of any income raised directly or indirectly from use of my content (eg advertising revenue on pages featuring my posts) should be forwarded to me or a charity of my choosing, with adequate evidence produced to my satisfaction of such payment.

8. YOU must not make any attempt to expose my identity or compromise my anonymity. Should such attempt occur then YOU shall make payment to me a sum of USD$100,000 and any consequential damages related to damage to my employment, career or reputation.

9. YOU must not make any claim as to my identity or qualifications, other than what is publicly available via MY BLOG.

10. YOU recognise that material featured on MY BLOG may be incorrect, untrue, fictional, or misleading, and that this may be either intentional, or unintended. It may also contain material which is sourced from other parties whose permission or right to reproduce may not extend to YOU. I do not take any responsibility for the consequences of reproduction or misrepresentation of material sourced from or via MY BLOG.

11. Should there be any breach of these conditions, YOU shall make payment to me or my nominated charity a sum of USD$100 on each occasion of such breach (eg each post which is reproduced after withdrawal of my permission, and each modification within each post against my direction, and each omission of a post against my direction). Each unique URL from which my posts are accessible giving rise to such a breach would be considered an individual breach.

12. I shall not be responsible for any liability, damages, or consequential loss incurred by YOU or any other party as a result of material reproduced on your network.

13. I retain the right to publicly comment on any arrangements made with YOU and reproduce correspondence between us both on MY BLOG and elsewhere.

14. YOU do not have reciprocal rights to publicly comment or reproduce correspondence with me without my express permission, unless such material has already been publicly reproduced by me on MY BLOG.

15. YOU will not require me to agree to any other contract(s) related to reproduction of my material, and that should YOU have records of any other conditions or contracts which have been agreed to outside of this email they will be invalid and considered null and void.

If you agree to these conditions, please let me know and I will make appropriate arrangements. Please note that in the interests of transparency I will be posting my conditions and your response to these conditions to my blog. Should you not wish me to directly quote your response to these conditions then please let me know.

Kind Regards,

Sheepish.

Unfortunately, Dr Rutledge and his team have chosen not to respond to my email. Is this a sign of my unpopularity??? Or am I being unfair with my conditions???

SurgeXperiences 221 at Suture for a Living

The current edition of SurgeXperiences is up at Suture for a Living

Next edition will be hosted by Other Things Amanzi.

Grand Rounds v5(30) is up

Pharmamotion is hosting Grand Rounds this week. Head over there to check it out - even this blog gets a mention this week!

Next week, it will be the turn of Diabetes Mine. Get your entries in early!

What Waiting List? A followup.

I received an insightful comment from Anonymous in response to my post on Waiting Lists. My reply follows.

Anonymous said...
I disagree with the assumption that waiting list manipulation doesn't change how long patients wait for operations.

If we use a lie (using stats) to say there is no waiting list problem then additional resources will not be allocated and ignore attempts at increasing real efficiency. This means that real waiting times may increase along with losses in quality of life, patient productivity, increased complications and increased cost of care. It’s not just the usual cost of the operation but all the related costs before and after that don’t show up in the hospital stats.

Differences in the delay of processing of forms will change the order when patients are seen.

Dear Anonymous (why are there so many people called Anonymous???),

I would agree wholeheartedly with you if the statistics were actually used for resource planning - unfortunately as far as I can tell they are only used as a political football. I am not saying that sitting on waiting list forms is a great thing to do, just that we live and work in a pragmatic world and have to get on with things.

I remember clearly in a chat with a friend who was a government lackey a few years ago why we don't look at more useful KPIs - the response was that there was no interest in measuring a KPI unless it was a number that could be improved upon and promoted in a media release.

Efficiency is squeezed to its limit already - there is no efficiency gain to be realised. Our driver at the coalface is the desire to treat patients as best we can, not to meet arbitrary targets or make the Minister look good. The only thing that can be improved upon is more capacity by capital investment - and this will never happen because placing a chokehold on capacity is the only way to limit ongoing costs! Just like the logic that if we have fewer doctors the health budget will be smaller. Bugger the patients.

As for differences in delay of processing forms... all the forms for our specialty went through me. It didn't matter how long I sat on them, or when I put them on the list, or when I received them. I filled out the forms, I submitted the forms, I reviewed the waiting list, and I booked and scheduled patients into theatre where I then operated on them.

Patients were prioritised by me on the basis of firstly clinical need, secondly resource availability, and waiting time came a very distant third. The patients were more frustrated by delays and cancellations on the day of operation than an extra week after 2 years of waiting. This is what happens every day in every hospital I have worked at. How about yours?

Meeting Fatigue

 
Where hospital administrators meet... and where doctors meet.

One of the discussion boards I attend recently commented on the usefulness of multidisciplinary meetings. These are typically where one unit has a combined meeting with another unit (often to review cases, radiological imaging, or histopathology) in order to reach consensus views on how to manage a particular case. These are quite valuable tools as they allow cross-fertilisation of ideas, multiple perspectives on a single problem, and a chance to air sometimes unusual options or nut out some difficult, challenging cases.

Sometimes, however, you can go overboard with these meetings - in the past I have often experienced "meeting fatigue" where i typically tune out and either stare blankly into the air or fall asleep (especially in radiology meetings held in a darkened room... it is harder to fall asleep while staring into a microscope but not impossible).

I recall as a neurosurgery registrar I used to walk into the end of the neurology-vascular radiology meeting so that we could start the neurology-neurosurgery radiology meeting which then led into the neurosurgery-oncology radiology meeting then followed on by our orthopaedic-neurosurgery-spinal radiology meeting.

When I switched to Thoracics I realised that the oncologists then split off after this meeting to their oncology-respiratory-thoracic surgery meeting, followed by our thoracic surgery pathology meeting upstairs.

The vascular surgeons, on the other hand, did their own vascular radiology meeting before the neuro-vascular radiology meeting, then went on a diabetic and high-risk foot round and clinic with the endocrinologists and orthopods, followed by a dialysis access round with the nephrologists, before doing their own ward round.

Of course, the oncologists followed neuro-oncology and thoracics-oncology meetings with an upper GI-oncology meeting that afternoon, a colorectal-oncology meeting the next day, a breast-oncology meeting and a urology-oncology meeting, before having a big drug company lunch and flying off to Noosa for the weekend gratis to meet up with the cardiologists.

As far as I can tell, the only specialties that did not have multi-disciplinary team meetings were the ED physicians and anaesthetists. Actually, that is not true - the anaesthetists sometimes went to a surgical-anaesthetics morbidity and mortality meeting, so that leaves the ED physicians on their own.

The bigger the hospital, the more time you seem to spend in meetings and not actually treating patients. Sometimes I think that an "MDT" meeting really means "monotonous, dull time-waster".

Grand Rounds v5(29) is up

Grand Rounds Vol 5 Issue 29 is up at Getting Closer to Myself. Make sure you go and check it up for a roundup of the medical blogosphere!

Waiting Lists? What Waiting Lists?

Waiting in Line at the Eiffel Tower - gadl @ Flickr

It is hard to ignore the news in Victoria about waiting list manipulation. Ho hum. This is old news. If you want to know how to manipulate a waiting list, refer to my previous blog entry. Every few months a politician rants on about how waiting lists are down and everything is just dandy. Shortly after the opposition carries on about how waiting lists are going up and the sky is falling down. Then an election happens, and sometimes they swap sides... and guess what, the newly-elected government politician says waiting lists are down and the newly-ousted opposition says waiting lists are up and the cycle goes on.

At the bottom of all of this political to-ing and fro-ing is an army of doctors, nurses, and paramedical staff who try their level best to treat as many patients as possible with the money that they have been allocated. It's not a lot of money, and there are an unending stream of patients, but we do what we can.

And then in between this sandwich is a layer of bureaucrats who fiddle the numbers. The Department of Healthiness, or Human Servicing, or Ageing Gracefully, or whatever (let's call them The Department) look after the politics, and dole out the money. The Hospital Administrators hold out their hands and grab as much cash as they can. The line between The Department and The Hospital Administrators can be very grey and muddy. Some people work both sides of the fence.

It is an area of pragmatism and compromise. The Department asks for good media release material - reduced waiting lists, greater throughput, briefer ED waits. The Hospitals deliver. No-one asks how they deliver... they just do. If you ask for Key Performance Indicators (KPIs) then you will get KPIs. If this means fiddling the books, then you fiddle the books. What does it matter as long as patients are still treated exactly the same as they were before? The media release is just meaningless drivel. At the end of the day youse goes to the hospital and youse gets your operation (after a variable waiting period which is dependent on so many factors that understanding it all would take a PhD or a Masters Degree).

I admit that I have worked in Victorian Hospitals. At the request of Booking Office Managers I have signed off on forms making patients "Not Ready For Care". I have kept waiting list forms in my bag for two or three weeks before handing them in to the data-entry clerks. I have seen waiting list forms sit in a pile for several weeks waiting to be entered. Never has this process made any difference to how long a patient has physically waited for their operation - only the accounting. This is not isolated to a single hospital in Victoria - this happens in every hospital in Australia, and most likely around the world. The same thing happens in every large organisation or company world-wide. Don't be a hypocrite - if you are a manager you are probably doing exactly the same thing to your KPIs.

I once worked in a hospital where my manager would deliberately lose my overtime claim sheet for several pay periods in a row. After a few months she would find them all and pay my overtime, along with all of my colleagues in the same department. We thought she was incompetent until we realised that she got a monthly bonus if the salaries came in under budget. Once a quarter she would pay us out and forgo her bonus - but the other three months made up for it.

Where patients wait a long time for their operation there are generally only a limited number of reasons:

1. Rate-Limiting Steps. There are only so many resources to do a particular operation, and everyone has to wait. This may mean waiting for investigation results, theatre allocations, specialty staff availability for complex operations, ICU beds, or special equipment for a particular operation. Basically all operations need critical planning and preparation steps to be performed first. If one of these steps cannot proceed, then it becomes a rate-limiting step.


2. Administrative foot-dragging. This is where clinical or financial approval for a particular procedure takes a long time, or is difficult to organise. There is no excuse for this except lazy, procrastinating administrators who don't think anything needs to be done any earlier than the next committee meeting in 3 months time.


3. Patient indecision. Some patients just cannot make up their mind. They want to go on the waiting list but they don't want their operation when you ring them up. "It's not convenient." "I'd rather wait until school holidays." "Let me do it when I come back from New Zealand." "I can't get time off work." These patients inevitably get upset that they have been waiting 5 years despite ringing them 20 times and they complain interminably, often to their local MP.


4. Genuine stuff up. Sometimes forms get lost. Sometimes some poor data entry clerk spells a name wrong, or accidentally presses delete. Sometimes the doctor's handwriting is illegible. We don't like it when this happens, but it happens.

Waiting lists are a fact of life. Political maneuvering is a fact of life. Management data fiddling is a fact of life. Media beat-ups are a fact of life. Like Dr Simon Leslie of Shellharbour Hospital, I'd rather just get on with the job of fixing people.

We have an unhealthy obsession with statistics and numbers. Collecting data on every scrap of activity is the reason why hospitals have half the numbers of beds they had 20 years ago - they have all been converted to offices for data-collectors, administrators and managers. The administrators need administrators, and then they need auditors to oversee the administrators, and directors to supervise the auditors.

Why can't doctors and nurses just be given the money and the trust that they can go about their job treating as many patients as possible. So what if the waiting list is a bit longer this year, or a bit shorter? No amount of number juggling can hide a 5 or 10-year trend. Stop focusing on short term goals, stop using health statistics for political gain, and you will get accurate figures and more importantly the trust of your staff.

• Hospital data fiddling raises national concerns - ABC Radio PM (Click to See)
  
  

  Hospital data fiddling raises national concerns
  PM - Tuesday, 31 March , 2009 18:50:00
  Reporter: Simon Lauder
  
  LISA MILLAR: The revelation that a Victorian hospital has been faking waiting-list data for more than a decade has raised alarm bells about how Australia's hospitals are assessed and rewarded.
  
  The Victorian Government has responded by scrapping bonus payments for hospitals and ordering random audits.
  
  Simon Lauder reports.
  
  SIMON LAUDER: After months of allegations and headlines about the manipulation of figures at the Royal Women's Hospital, a Government-ordered audit confirmed it has been going on since 1998. The independent auditor found patient records were falsified to improve reported waiting times by as much as three months.
  
  Although the hospital says it's been years since it received any bonus payments for the falsified data, the Government's responded by shutting down a $40-million bonus fund, used to reward hospitals for meeting performance criteria. It's also ordered random audits of hospitals.
  
  The revelation's prompted others to suggest the Royal Women's Hospital is not the only place where performance data is fiddled with. This surgeon phoned in to ABC local radio:
  
  SURGEON: A number of my patients are regularly made not ready for care once they're placed on the waiting list and they look like they get their operation inside the month but their actual wait from the time the waiting list form is filled out is significantly longer than that.
  
  SIMON LAUDER: Allegations of similar behaviour have also been levelled at Mercy Hospital and Bendigo Hospital; both of which deny they fudge their figures.
  
  The Premier John Brumby says the Royal Women's Hospital case highlights the pitfalls of performance-based pay, which is being increasingly embraced in Australia.
  
  JOHN BRUMBY: More and more of the funding mechanisms that we are seeing across Government now are performance based. If you look at the agreements that come out of COAG, if you look at the hospital and reform commission report, they're all about performance-based funding.
  
  And I think what's occurred here means that we need to make sure that the reliability of the data, all of the measured outputs out of the system are as accurate as possible.
  
  SIMON LAUDER: Associate Professor of medicine at the University of Queensland, Dr Ian Scott, says if hospital data is to be relied on, the Federal Government needs to set the standard.
  
  IAN SCOTT: We're increasingly in an era where there's going to be constraint on health budgets, where expectations are going to have to be reconciled with the fact that we have a limited amount of money to spend on health care and I think that if we get distracted and use money in producing dodgy data, simply not to embarrass the health minister, then I think that's not an appropriate use of resources.
  
  SIMON LAUDER: So is there a warning in the Victorian example for other states and indeed the Commonwealth?
  
  IAN SCOTT: I think there is. I think quite definitely we need to ensure that if data is to be collected, it has to be standardised, it has to have agreed definitions around the data elements that are being collected.
  
  SIMON LAUDER: So if the Commonwealth is to judge the performance of the states and their hospitals on this data, does the Commonwealth need to take more of a leadership role in overseeing the collection of data?
  
  IAN SCOTT: I think that's probably true. I mean at the end of the day I think we do need to move more towards a national data set. I think we need to have some standardisation around the data that we're collecting across the country and to that extent the Australian Government then should play a greater role in helping to define that dataset and to help design and fund the processes by which that data is collected, it's collated centrally, analysed and reported.
  
  LISA MILLAR: Dr Ian Scott speaking with Simon Lauder.

  
  
  
• Nothing but the truth - AMA Vic President Doug Travis (Click to See)
  
  

  Nothing but the truth
  Doug Travis
  April 1, 2009
  
  
  Illustration: Spooner
  
  Patient treatment is being compromised as hospitals try to work the system.
  
  THE Victorian community has been dismayed to learn that a trusted institution, the Royal Women's Hospital, has been falsifying and manipulating reporting data. Yet, as the Victorian Government acts to stamp out the perverse incentives that have led to data manipulation, the Commonwealth is ready to impose reporting requirements across the health system that may reinvent those incentives.
  
  Federal Health Minister Nicola Roxon should therefore be watching this story unfold and considering the lessons learned.
  
  Good information is the lifeblood of good health care. For an individual patient, the more a doctor knows of his or her history and diagnostic profile, the more likely a good outcome. To protect the health of the community as a whole, we need accurate and complete reporting. Manipulated and falsified data means that Government cannot adequately plan for the future health needs of Victorians.
  
  Presenting a rosy picture hides the problems in our health system. For example, because of overstated successes, governments have held back on tackling bed shortages in Victorian hospitals. These shortages have become critical in recent years, meaning that bad data is compromising safe and effective patient care.
  
  Other hospitals may be found to have manipulated data. AMA members suggest that several hospitals have set up systems that appear designed to meet key performance indicators (KPIs) rather than good patient care, such as creating short-stay units attached to emergency departments. The definitions of "time to care" are tweaked in some hospitals to produce a more favourable KPI outcome.
  
  The community expects hospital boards and management to instil a culture that values integrity, long-term vision and whole of community service, not a culture that concentrates on the short term.
  
  A hospital under pressure puts staff under pressure. Nurses and doctors are working hard to ensure that the patients in the hospital are looked after to the best of their ability, despite a shortage of beds and a shortage of staff.
  
  Until Monday, Victorian public hospitals had perverse incentives that paid extra funds to hospitals that reported they met their KPIs. More funding went to hospitals that did well, and less money to hospitals that were struggling with extra demand.
  
  Imagine you are in a highly pressured environment with too many patients and not enough resources. A manager comes in and tells the staff that if they don't meet the KPIs, the hospital loses funding. Staff get a clear message. Meet the KPIs or patient care will suffer.
  
  The suggestion that hospital boards and management are not aware of data manipulation is puzzling — hospital officers must be accountable for the culture in their organisations. Yet as state Health Minister Daniel Andrews professes fury, he elects to hold no one accountable.
  
  If the minister's actions are part of a plan to draw a line under the past and move forward, then his failure to punish can be understood. If the minister is serious about changing the culture and replacing the trust in our hospital system, he needs to back up his words with action.
  
  First, the minister should be congratulated for removing the bonus payments system that has contributed to the problems of data manipulation. This is an important and valuable first step.
  
  The next step the minister must take is to direct all hospital chief executives to report truthfully from now on, or face dismissal. As a representative of the Victorian people, the minister cannot be seen to condone actions that betray the community's trust. The minister must also make public all the data that shows the demand pressures on the health system, including previously secret information on outpatient waiting lists. We need all the data to have a sensible debate about resources for our health system.
  
  However, as the Victorian Government removes some of the barriers to accurate reporting, the Commonwealth Government is considering a host of incentives across the health system that could create more problems than they solve.
  
  Again, hospitals (and states) will have incentives to report success against benchmarks, rather than concentrating on quality care. Roxon has also floated new benchmarks for general practice to improve a range of health indicators for their patients, such as weight, insulin dependence and smoking.
  
  Under these proposals, GPs who help some of the most disadvantaged in our community may be penalised. The incentives mooted appear to encourage doctors not to see sick people.
  
  I hope Roxon is watching the Victorian health system closely to see what perverse incentives can do to resources, planning and quality care. We must report accurately and truthfully to be accountable to the community.
  
  The bottom line problem is that the truth can be embarrassing. Let's address the problem, not by spinning the statistics to avoid embarrassment, but by treating enough patients, so that the truth does not embarrass us.
  
  Doug Travis is president of AMA Victoria.

  
  
  
• Minister orders hospital audits after dud figures - The Age (Click to See)
  
  

  Minister orders hospital audits after dud figures
  April 1, 2009 - 2:40PM
  
  Elective surgery waiting lists will be audited at every Victorian public hospital in response to a widening scandal over manipulated figures.
  
  Victorian Health Minister Daniel Andrews announced on Wednesday a director of data integrity would be appointed to oversee system-wide audits of hospital waiting lists.
  
  The announcement follows revelations the Royal Women's Hospital in Melbourne manipulated figures to make waiting lists appear shorter.
  
  A damning report by the auditor-general has exposed fundamental flaws in hospital data keeping, saying the problem is widespread and figures cannot be relied on for accuracy.
  
  It has also identified figure fudging in the emergency department at the Latrobe Regional Hospital in Gippsland.
  
  Mr Andrews said independent auditors would immediately start checking the books at Latrobe.
  
  Former Victorian public advocate Julian Gardner has been appointed to the Royal Women's and Latrobe Hospital boards to stamp out improper practices, he said.
  
  "I take responsibility for these matters, I am determined to fix these issues, I am determined to stamp these practices out, and I think the measures that I have announced today, along with the reforms I announced on Monday, are a big step forward in terms of fixing these issues," Mr Andrews said.
  
  AAP

  
  
  
• Audit slams phantom wards scam - The Age (Click to See)
  
  

  Audit slams phantom wards scam
  Julia Medew and David Rood
  April 2, 2009
  
  
  Audit slams phantom wards scam
  Julia Medew and David Rood
  April 2, 2009
  
  The Royal Melbourne Hospital. Photo: Marcus Ferraro
  A SCATHING audit of four Victorian hospitals has confirmed staff are creating "ghost wards" and manipulating surgery waiting lists to secure bonus funding and avoid critical scrutiny.
  
  Auditor-General Des Pearson's report on hospital data, tabled in Parliament yesterday, cast serious doubt on the accuracy of Government health system performance reports.
  
  It also shifted the spotlight back on beleaguered Health Minister Daniel Andrews and the Department of Human Services for not providing "effective quality control regimes" and validating data reported to them for funding.
  
  "These conditions have opened the way for inappropriate practices such as data manipulation, which undermine the integrity of hospital performance monitoring," the report said.
  
  Mr Pearson's audit found three hospitals had been inappropriately listing elective surgery patients as "not ready for care" and that one hospital had recorded "admitting" patients to wards when they were still languishing in emergency departments. These practices could be more widespread, the report said.
  
  The report did not name the hospitals involved, but Mr Andrews confirmed Latrobe Regional Hospital had been manipulating its emergency department data and that the three remaining hospitals were the Royal Children's, the Royal Melbourne and Dandenong hospitals. It is unclear which were inappropriately altering surgery waiting lists.
  
  Until this week, public hospitals received bonuses for reaching Government benchmarks, including some that related to emergency department performance and elective surgery waiting lists. But after the discovery of fraudulent data reporting at the Royal Women's Hospital, Mr Andrews has decided to abolish the system.
  
  Mr Pearson's report said in some cases, nurses were retrospectively altering patient data records so the hospital met Government benchmarks. It also found hospitals were inconsistently measuring waiting times for care.
  
  While no hospitals had received funding that would need to be withdrawn, the report recommended sweeping changes to the system, including the implementation of new checks and balances.
  
  The finding comes after The Age revealed allegations in May that hospitals were creating "virtual wards" and fudging waiting times to attract funding. At the time, Mr Andrews said he would investigate the issue but since August, he has repeatedly denied there was any evidence of data manipulation to investigate.
  
  Yesterday, Mr Andrews said although responsibility for the health system rested with him, he did not think he had mishandled the scandal. He said that when allegations of data manipulation were raised with him last year, there was no hard evidence to prove it, and the Department of Human Services had "processes in place".
  
  He is resisting growing calls from the Opposition to resign and said his priority was to fix the problem. "I'm sorry if any patient has been adversely affected by these inappropriate practices; there is clearly a need to improve," he said.
  
  As the crisis gathered pace yesterday, Mr Andrews announced a system-wide audit of elective surgery waiting lists to match an audit already assessing emergency department data. He also announced the creation of a "Director of Data Integrity" role within DHS and appointed former public advocate Julian Gardner as a delegate to the boards of the Latrobe Regional Hospital and the Royal Women's Hospital to ensure their problems would be fixed.
  
  In response to comments from Federal Health Minister Nicola Roxon yesterday that deliberate data manipulation would have serious implications on future funding, Mr Andrews said: "I don't expect that there will be any impact on commonwealth health funding."
  
  In a fiery question time that saw shadow treasurer Kim Wells ejected from Parliament, the Opposition repeatedly called on Premier John Brumby to sack Mr Andrews.
  
  But Mr Brumby defended his Minister, saying he had taken decisive action to ensure tight standards across the hospital system.

  
  
  
• Bullying, bottlenecks and death by a thousand paper cuts - SMH (Click to See)
  
  
  
  

  Bullying, bottlenecks and death by a thousand paper cuts
  March 28, 2009
  
  'At heart, I'm a doctor who likes to look after patients' . . . Simon Leslie's case forms part of the Garling review into the culture of NSW hospitals. Photo: Jacky Ghossein
  
  The story of Shellharbour Hospital's Dr Simon Leslie is a microcosm of the malaise Peter Garling observed on a statewide tour of 61 public hospitals, writes Julie Robotham.
  
  ON APRIL 28, 2006, Shellharbour Hospital boss, Michael Brodnik, distributed an email. A decision had been made, he wrote, to set up a new unit within the emergency department.
  
  "The unit will be … four beds, conceptually down the right hand wall of ED but using the concept of 'virtual beds'," he told colleagues. Patients who arrived at emergency and needed admission would be assigned a virtual bed if no official in-patient bed was available, remaining physically in emergency. Brodnik said he had no control over the change, reassuring staff: "It really is a paper exercise."
  
  The rationale was to get patients off the emergency department's books within eight hours of arrival - a watershed imposed by government as a so-called "key performance indicator" or KPI, amid political pressure over backed-up hospitals and ambulances unable to offload patients.
  
  At Shellharbour Hospital, an outpost serving the cookie-cutter sprawl that straggles down the coast from Wollongong, that target was hard to achieve, because some patients had to be transferred for diagnostic tests.
  
  By May, Shellharbour was still processing emergency patients too slowly, and emails were flying. The head of the hospital's emergency department, Dr Simon Leslie, sent a measured one to Sue Browbank, Brodnik's boss: "We are being asked to run our health service on the basis of the need to treat one statistic," he wrote. "Doctors have not been ignorant or uncaring of the need to manage our resources appropriately … but are driven firstly by patient care and community needs."
  
  For a while, Leslie continued a vocal opposition to the imaginary beds. The directive to reclassify patients "according to any objective look at it was fraudulent", he told the Herald last week. "It required staff in my emergency department to write down records that were incorrect."
  
  Later he tired of battling the fait accompli and settled back to running front-line health care in the hard-to-staff hospital.
  
  That could have been the end of it, but then Peter Garling, SC, came to town. On April 14 last year, at one of the inquiry's 34 public hearings, "Dr Leslie told me the 'virtual ward' was a fiction to compensate for the fact that Shellharbour Hospital does not have a short stay unit," Garling recounted in his report. Leslie's evidence resulted - finally - in the ward's abrupt termination, though this, as he had previously observed to Browbank, was, "easy because it doesn't actually exist".
  
  Three weeks later, Browbank informed Leslie of the appointment of a Southern Hospitals Network Director of Emergency Medicine - which, according to Garling's later deconstruction, "both technically and in reality … effected the abolition of Dr Leslie's position".
  
  Leslie was ordered to stop calling himself director of the emergency department and told he could instead apply for a part-time position. "How is it possible," he asked a human resources manager, "to remove me from the role for which I have a contract and in which I have been acknowledged and satisfactorily functioning for over two years?"
  
  The vaporisation of his job and claim it had never really existed were normal practice during "amalgamations and clinical reviews," the manager soothingly responded. "In many cases roles and responsibilities have changed, staff displaced and new position descriptions written."
  
  Leslie's was a story Garling could not resist. A microcosm of the poisonous malaise he had observed on a statewide road-trip to 61 public hospitals, it comprised four elements the senior counsel had noticed repeatedly: a bottleneck between emergency and in-patient beds; inflexible performance criteria imposed from on high, then middle-management sleights-of-hand to meet those demands; and a yawning gulf of alienation between clinicians and administrators.
  
  So when Leslie updated the inquiry on the personal fallout from his testimony, Garling in late September 2008 ordered five people as well as Leslie to four gruelling days of extra hearings, devoted to the doctor's treatment. They included Debora Picone - in 2006, chief executive of the South Eastern Sydney Illawarra Area Health Service, but elevated in 2007 to director general of NSW Health.
  
  That won Leslie no respite. On the contrary, shortly after Garling's summonses landed on managers' desks, Leslie was cut out of meetings and told to hand back his pager and vacate his office - though ultimately he did not do so, successfully arguing both were essential to his work.
  
  In her sworn evidence, Browbank acknowledged Leslie's job description was signed by a doctor expressly delegated to work out his role and title. Yet she maintained the position could not exist, because the doctor had no authority to create it.
  
  Garling rejected the semantic contortion. Browbank's stance "flies in the face of the obvious facts revealed by the evidence and is wholly untenable," he concluded.
  
  Because Leslie's treatment was "unreasonable, repeated, unwelcome, unsolicited, offensive, intimidating, humiliating and threatening," Garling wrote, "I find it amounted to bullying and harassment in accordance with NSW Health's own guidelines."
  
  Leslie is an unlikely poster boy for victimhood. Affable and easygoing, it is hard to imagine him having the sleep disruptions and obsessive thoughts he says beset him at the time. He simply carried on going in to work. "At heart," said the 52-year-old, "I'm a doctor who likes to look after patients."
  
  Doctors who like to look after patients are the backbone of the health system, but are massively disenfranchised.
  
  Re-engaging them would be the most critical step in reforming NSW Health, Garling said, proposing a Clinical Innovation and Enhancement Agency - under which clinicians would determine protocols for patient care. As well, he proposes an independent Bureau of Health Information to monitor hospital performance, freeing doctors like Leslie from political pressure to fudge the loathed KPIs.
  
  The toughest challenge is how to make hospitals gentler. "The workplace culture in NSW public hospitals is characterised by lack of respect and trust, absence of empathy and compassion, inability to celebrate the success of others, failure to communicate, and a lack of collaboration," was Garling's damning verdict after his journey to the heart of the health system. Its anti-bullying policy had failed, dissent was quashed and persecution was rife.
  
  Garling recommends making individual employees - all 118,000 of them - more directly responsible for their behaviour, reorienting the system away from blame towards constructive criticism and strengthening complaints procedures.
  
  Last July, Leslie lodged a formal complaint about his treatment. Eight months later he has not been told how it will be resolved. Terry Clout, the area health service's chief executive, told the Herald he was seeking more information and would consider "any actions that may be required". He declined to comment further, citing, "procedural fairness" in the "personnel matter".
  
  Leslie said the delay was "a process to wear me down". He understands deliberations will not privilege Garling's account of events - despite the evidence the commissioner collected under unmatched statutory powers.
  
  Perhaps that is unsurprising. Garling said Leslie's situation went unresolved because Shellharbour managers "did not demonstrate … the slightest knowledge of what constituted bullying and unacceptable behaviour".
  
  When is a bed not a bed? Leslie has paid a price for trying to reconcile the internal logic of NSW Health's storytelling with empirical reality, and no one has ever apologised. He will now take his case to the NSW Industrial Relations Commission. If Leslie - with the inquiry's weight behind him - cannot bring NSW Health managers to account, possibly nobody can. "Mr Garling's put a fairly heavy burden on me," he said. "I feel an obligation not to let that go to waste."

Helpcure.Com is a Fraudulent Scam

I can't make it much simpler than that, can I?

It is commonplace that blogs are used for comment spam - some would consider it a valid and respectable technique for search engine optimisation (or SEO, in geek-speak). This is basically where you try to drum up links to your website by posting a whole bunch of comments on various other (more respectable) websites or blogs in the hope that search engines like Google will start ranking your website more highly.

I normally delete such comment spam as soon as I see them as they are usually for things like cheap, illegal, and probably counterfeit Viagra, Cialis, Horny Goat Weed, Rose Hip Oil, or Sniffing Glue etcetera. In this case, though, not only did I find the comment transiently amusing, but after having some time to think about it I found the fact that it was so effective for this website quite offensive.

Let me explain to you how this works:

1. Let us say you are the author of a particularly informative and well-respected blog, who shall remain nameless.


2. One day you receive a comment on one of your blog posts along the lines of "Hey great post! Here is a gratuitously ego-stroking comment just to see whether or not you are paying attention to the comments posted on your blog."


3. You might see a few of these trickle in, and before you know it, you are flooded by more comments: "Hey great post! Here is another gratuitously ego-stroking comment so that your first instinct is to approve this comment and secondly you don't notice the segue to another website that is connected to your blog by the most tenuous of links, such as this fantastic web page at http://fredbrunel.com/journal/2007/10/comment-spam-explained/


4. If you pay attention, you might notice that the comment on your blogpost might look remarkably similar to comments on another web page, or another blog, or that other blog you never read. You might then stumble across more websites with the same comment, even ones that you might normally respect.

Furthermore, you are highly likely to discover that the target website is full of fraudulent bullshit designed to fleece unsuspecting, desperate and vulnerable people of their hard-earned cash. For example, Helpcure.com says:

THIS IS HOLISTIC TREATMENT ! WHAT IS THIS?

THIS IS A COMBINATION OF A BIO MAGNETIC CARD WITH BIO MAGNETIC TAPE ON THE CARD- (OR BIO MAGNETIC TABLETS ALSO CAN BE USED) THIS WILL CREATE NEGATIVE CHARGE IN CD4 CELLS- TO PUSH VIRUS OUT THROUGH BIO MAGNETIC FORCE AND HERBALS TO ENHANCE IMMUNITY -TO PROTECT YOU FURTHER. NO SIDE EFFECTS AND NO PROBLEMS.

Are you nuts???? You are seriously asserting that a credit card will push viral particles out of my body through magnetic force? You bet this is holistic therapy, because I can tell you which hole you can swipe your card through.

If you have HIV (or indeed any illness) please do not fall for this load of codswallop. Just listen to your immunologist and infectious diseases physician. Read the FDA tips on how to spot a health fraud. Discuss any change in treatment with your specialist before lauching into anything. Use your brain and a modicum of commonsense.

If only I could get 1000 other blogs to link here with comment about the truth of HELPCURE.COM, then maybe the Number 1 Search Entry for "HELPCURE + HIV" will say "Helpcure.Com is a fraud". So once more for the benefit of the Google spiderbots: HELPCURE.COM IS A FRAUDULENT SCAM.

The Unwanted Child: Part 3

Thanks to Tracy who pointed out that the latest developments on this - the parents have overturned the judgement on appeal and have won their compensation.

Lesbians win $300K compo over double IVF bungle - The Daily Telegraph
(Click to Expand)

Lesbians win $300K compo over double IVF bungle
February 13, 2009 12:00am

A LESBIAN couple who said having two IVF babies instead of one damaged their relationship have won an appeal against their doctor and been awarded $317,000 in compensation.

In the first Australian case of its kind, the Melbourne parents of the twin girls sued Canberra obstetrician Sydney Robert Armellin for implanting two embryos instead of the requested one.

During the initial proceedings, the ACT Supreme Court heard that following the twins' birth, the mother had lost her capacity to love.

The couple's relationship had also suffered as they became mired in everyday tasks associated with raising two children.

The couple, whose combined income is more than $100,000, sought $398,000 from Dr Armellin to cover the costs of raising one of the girls, including fees for a private Steiner school.

In July last year, Justice Annabelle Bennett rejected the couple's claim and ordered them to pay Dr Armellin's legal costs.

The doctor had not breached his duty of care to the twin girls' birth mother and was therefore not negligent, Justice Bennett said.

But the ACT Court of Appeal has overturned that decision, ABC Television reports.

The three judges of the appeal court awarded the couple, who can't be named for legal reasons, $317,000 in damages and ordered Dr Armellin to pay their legal costs.

The IVF procedure, carried out in Canberra in November 2003, used sperm from a Danish donor.