Tuesday, September 01, 2009

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.


  • Botox trend creating worry lines - Brisbane Times
    (Click to Expand)

  • 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

Monday, August 24, 2009

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.


  • ACCC demands answers from St Vincent's - The Australian
    (Click to Expand)

  • St Vincent's a closed shop, said leading anaesthetist - SMH
    (Click to Expand)

  • Elite hospital old boys' network targeted by competition watchdog - SMH
    (Click to Expand)

Tuesday, August 18, 2009

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)

Thursday, May 07, 2009

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)

Tuesday, April 28, 2009

Friday, April 24, 2009

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".

Wednesday, April 22, 2009

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:


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!


Geoffrey W. Rutledge MD, PhD
Chief Medical Information Officer
The HealthCentral Network, Inc.

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,
Geoffrey W. Rutledge MD, PhD
Chief Medical Information Officer
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:

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,


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???

Tuesday, April 14, 2009

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!

Saturday, April 11, 2009

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?

Friday, April 10, 2009

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".

Wednesday, April 08, 2009

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!

Wednesday, April 01, 2009

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)

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

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

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

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

Thursday, March 26, 2009

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:



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.

Tuesday, March 24, 2009

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)

Monday, March 23, 2009

Caught out by Media Watch

God I love Media Watch!

Here is their take on the misquoting and misattribution of an imaginary plan to "seize" obese children from their families after an article in the MJA part-authored by Westmead's Obesity Maven, Dr Shirley Alexander.

PDF of the original article is available here via Media Watch.