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)