Bully for You, Bully for Me

Since the 4 Corners "At Their Mercy" episode this week, there has been some discussion about bullying over at PagingDr Forums, a great source of medical chat for those who are interested. Occasionally I go on a bit of a rant there, and obviously this issue has riled me up somewhat. Interestingly the 4 Corners episode was preceded by a very powerful and relevant episode of Australian Story on Retired Lieutenant-General David Morrison.

My last post was a rather personal piece, with relevant identifying features altered. It was about my experiences as a bully, but I have similarly experienced it differently as a victim. I have received some feedback that it does not help the cause of eliminating harassment and bullying from the workplace. I respectfully disagree, since I think that identifying and rehabilitating the bully is just as important as identifying and helping the victim. I also believe that there is a complex personal interplay in these situations which deserve more than a simple "I'm right. You're wrong" approach. That is a recipe for sudden, knee-jerk changes that can cause far more damage to a system than the benefits it may bring.

I can imagine the objections now, that medical bullies are heinous individuals that deserve to be stripped of their qualifications, their right to care for patients and to teach, and that they should be publicly named and shamed, or even executed. If you found out today that the surgeon who saved your life was a bully is that seriously what you would want to happen to them?

Also the other argument that is made is that the destruction of any career or the loss of life from suicide is tragic and that even if that happens once it is once too many, let alone four times in the space of a few months. Well that is absolutely true, and I agree completely, but we also accept that there is a road toll for the benefit of being able to zoom at speed around the country. We accept that there is a terrorist risk for all of the freedoms that we enjoy. Callous as it may sound, why do we now not accept that some people will not make it through training and might even be harmed in order for the general public to enjoy quality healthcare from highly-trained experts?

The question is how do we go about preventing those preventable incidents? What cost are we willing to bear in the pursuit of preventing them? These are hard questions, and they are questions that we as a society fail to answer, in the same way that we all want the best healthcare using the most expensive drugs and technology, but we also don't want to to pay greater taxes to cover the cost (currently ~9% of GDP).

This question was posed by an aspiring medical student over at PagingDr Forums:

I'd be interested to know how much infrastructure there is to teach doctor's working through the ranks leadership, mentorship and people managements skills... or even teaching skills? (Beyond observing those around them?). I realise doctor's are time poor but I wonder if formal development of these skill would go some way to improve things.

The Royal Australasian College of Surgeons runs training courses in professional and non-technical skills which encompass these areas of leadership, team communication and teaching.

• Non-Technical Skills for Surgeons
• Safer Australian Surgical Teamwork
• Supervisor Training Courses (SAT-SET)
• Keeping Trainees on Track (KTOT - to help struggling trainees)
• Training in Professional Skills (TIPS)

Some might argue that these should be taught earlier. Several other Colleges run similar programs.

Another comment was from a doctor:

An issue that came up was question/answer method of teaching, and that this was bullying. I must admit I do this all the time and never felt like I was bullying anyone. Are medical students saying that ANY questioning is making them upset or is it just contextual, ie. Don't ask me in front of patients/other people?

Speaking for surgery, the Q&A type teaching mirrors the format of the final surgical exit examinations. You are in a closed room with two examiners who basically ask you questions until either they run out of time or you give up (for more information see here). Even if you answer all their questions they think of more until the bell rings. It is not practical to simulate that scenario in private on a regular basis during a working job, so the scenario is simulated at the bedside, at the operating table, or in unit/department meetings. The questioning is not intended to be malicious or threatening, but they are intended to be challenging, to tease out lines of logical thought or consideration, to highlight areas of deficiency and to promote motivation to self-study.

Unfortunately generations of doctors have been brought up with this myth (perpetuated in the media along with lots of other bad work practices because, heck, it's entertaining) that the questioning (or "pimping" which I think is a terrible term) should be used as a chance to mock trainees on their errors, to get them to "harden the F(*#@ up" and that it is most effective if they are pushed to the brink. It is also easy to forget that it is a public forum in front of other co-workers and not a private one like the exams. Lastly if there is a power imbalance then the questioning/teaching process is an opportunity to reinforce that, which sadly some seniors find irresistible. This practice has become so much a part of medical folklore that it is seen as a bit of a joke.

Thankfully the vast majority of surgical teachers realise these limitations and are very sensible in how they employ this teaching strategy. A small number do not and need to read this article.

As for modern education theory that recommends that confronting trainees with their errors is wrong, and should be done in a safe, private, comfortable teaching environment after you have assembled a mountain of data about their errors and prepared a comprehensive performance management plan... well you can imagine the challenges of implementing that in a busy, service-oriented workplace.

The sexual component of the 4 Corners episode is what really kicked everything off, with Gay McMullin's rather inappropriate and deplorable comment that "What I tell my trainees is that, if you are approached for sex, probably the safest thing to do in terms of your career is to comply with the request". RACS has proactively worked to address bullying and harassment for many years, but the public seems to care more when it is sexual harassment, not just regular run-of-the-mill workplace bullying. This is very unfortunate because workplace bullying and harassment is a form of disruptive interpersonal conflict that is made possible by a power imbalance, and exacerbated by chronic and short-term stressors that develop amongst both the harasser and the harassee.

Remember that most definitions of bullying or harassment (and most certainly sexual harassment) is one that is based primarily on whether the harassee has taken offense or feels threatened. The intent of the harasser may not be relevant and harassment can be unintentional (see this Parliamentary document Section 1.55 "Intentional versus Unintentional Bullying"). Therefore factors that increase the harasser's aggressiveness and factors that increase the harassee's sensitivity will logically play into its manifestation. (I am trying to be polite here).

Sexual harassment is however seen as something that arises because of an innate "evil" within the harasser or workplace which is part of their nature and cannot be remediated. This is not a constructive way to view things. It is effectively shaming hard-working supervisors and teachers who have made a terrible mistake without offering them any form of salvation.

I think what is more relevant is the concept that there is occasional harassment that occurs in settings of heightened workplace stress (whether contrived or not) and there is harassment that occurs as a deliberate and repeated pattern of sociopathic behaviour. Regardless of whether there is a sexual component these are two very different scenarios which require two very different approaches. The former is a combined human factors and systems issue ("culture change" or changing the structure and methods of hospitals/teaching - realising of course that this could be very expensive both in terms of financial cost and time cost to surgical training and patient care systems) and the second requires identifying and rehabilitating the individuals involved (this may also involve punishment and/or compensation).

Ultimately the cases described in 4 Corners were tragic, but hopefully they represent a tiny number of the daily surgeon-trainee interactions throughout Australia and New Zealand. For those that are proven, they should not have happened. For those that are just allegations, they deserve to have their investigations completed without intererence. For the rest of us, it is a salient lesson in what not to do. More importantly it highlights what we should speak out about because as Ret Chief of Army Lt-Gen David Morrison said "The standard you walk past, is the standard you accept."

Testify, sister!

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

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

• 4/9/2012 Impacted Nurse - New AHPRA social media policy: we may be in big trouble here.
• 6/9/2012 Croakey Blog - Is AHPRA on the right track re social media use by health professionals? A chance to let them know your views…
• 7/9/2012 Croakey Blog - More feedback to AHPRA on planned social media policy for health professionals (get with the times…)

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

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

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

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

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

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

New Advertising Guidelines - Social Media - Excerpts

6.2.3 Testimonials

Section 133 of the National Law states:

(1) A person must not advertise a regulated health service, or a business that provides a regulated health service, in a way that – 

(c) Uses testimonials or purported testimonials about the service or business

The National Law does not define ‘testimonial’, so the word has its ordinary meaning of a positive statement about a person or thing. In the context of the National Law, a testimonial includes recommendations, or statements about the quality of a regulated health service including clinical care, personal experiences of a regulated health service or about the benefits of a particular practitioner or regulated health service by someone who received the service. Testimonials can distort a person’s judgment in his or her choice of health practitioner. They may misrepresent the skills and or expertise of practitioners and create unrealistic expectations of the benefits such practitioners may offer health consumers. Testimonials in advertising include: 

1. using or quoting testimonials on a website, such as patients posting comments about a practitioner on the practitioner’s business website, particularly when the website encourages patients to post comments and/or selectively publishes patient comments, and/or
2. the use of patient stories to promote a practitioner or regulated health service.

There are a number of independent websites that invite public feedback/reviews about a patient’s experience of a regulated health practitioner, business and/or service. These websites are designed to help consumers make more informed decisions and increase transparency of interactions.

A review is not considered to be a testimonial or purported testimonial, in breach of section 133 (1)(c) of the National Law when it only comments on non-clinical issues, regardless of whether it is positive, negative or neutral.

Reviews must not contain statements about the quality of clinical care received from the regulated health practitioner, business and/or service.

A practitioner must take reasonable steps to have any testimonials associated with their health service or business removed when they become aware of them, even if they appear on a website that is not directly associated and/or under the direct control or administration of that health practitioner and/or their business or service.  This includes unsolicited testimonials. 

‘Reasonable steps’ include taking action in the practitioner’s power, such as directly removing, or requesting removal, of the testimonials. For example, a review on a social media site that states ‘Appointment ran very late and magazines were old’, is not considered a testimonial as it makes no reference to the clinical care provided by a regulated health practitioner, business or service. However, a review on the same social media site that states ‘Practitioner was quick to diagnose my illness and gave excellent treatment’, is a testimonial which references clinical care and is considered in breach of the National Law.

Once the practitioner becomes aware of the testimonial, they must take reasonable steps to have the testimonial removed (also refer to Section 7.1 on social media).

7.1 Social media

The National Law prohibits advertising in any way that uses testimonials or purported testimonials. Testimonials, or comments that may amount to testimonials, made on social media sites by patients or other people may contravene the National Law (refer to Section 6.2.3 of these guidelines for more information on testimonials).

Social media includes work related and personal pages on social networks such as Facebook, LinkedIn and Twitter.

A person is responsible for content on their social networking pages even if they were not responsible for the initial publication of the information or testimonial. This is because a person responsible for a social networking account accepts responsibility for any comment published on it, once alerted to the comment. Practitioners with social networking accounts should carefully review content regularly to make sure that all material complies with their obligations under the National Law.

These guidelines should be read in conjunction with the Social media policy, published on National Boards’ websites.

Social media

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

Who needs a stethoscope?

I posted an entry some time ago about the move to digital stethoscopes under "Listen to me..."

Now I see that we can dispose of the stethoscope and just use our iPhones.

This is one app that I am definitely not purchasing.

I used to have a consultant physician who taught me that "The most important part of a stethoscope is the bit between the earpieces."

Sage advice.

iPhone set to replace the stethoscope - The Guardian
(Click to Expand)

iPhone set to replace the stethoscope
Amelia Hill, guardian.co.uk, Monday 30 August 2010 16.51 BST

The stethoscope – medical icon, lifesaver and doctor's best friend – is disappearing from hospitals across the world as physicians increasingly use their smartphones to monitor patients' heartbeats.

More than 3 million doctors have downloaded a 59p application – invented by Peter Bentley, a researcher from University College London – which turns an Apple iPhone into a stethoscope.

Last week, Bentley introduced a free version of the app, which is being downloaded by more than 500 users a day. Experts say the software, a major advance in medical technology, has saved lives and enabled doctors in remote areas to access specialist expertise.

"Everybody is very excited about the potential of the adoption of mobile phone technology into the medical workplace, and rightly so," said Bentley, who initially developed the app "as a fun toy".

"Smartphones are incredibly powerful devices packed full of sensors, cameras, high-quality microphones with amazing displays," he said. "They are capable of saving lives, saving money and improving healthcare in a dramatic fashion – and we carry these massively powerful computers in our pockets."

Bentley's iStethoscope application is not the only mobile phone programme lightening doctors' bags and transforming their practices: there are nearly 6,000 applications related to health in the Apple App Store. The uptake has been rapid. In late 2009, two-thirds of doctors and 42% of the public were using smartphones – in effect inexpensive handheld computers – for personal and professional reasons. More than 80% of doctors said they expected to own a smartphone by 2012.

The trend looks likely to gain pace as younger doctors enter the workplace. Some medical schools issue students with smartphones. In America, Georgetown University, the University of Louisville and Ohio State University are among those requiring undergraduates to use one.

However, experts say they are being prevented from exploiting the technology's opportunities. Bentley says that he is unable to launch a new range of applications because of out-of-date regulations.

"It's much easier to develop technology than it is to get permission to use it," he said. "I could create a mobile ultrasound scanner and an application to measure the oxygen content in blood, but the regulations stop me. We're not allowed to turn the phone itself into a medical device, and what that precisely means is currently a grey area in terms of regulation. That's the only reason we're not seeing a flood of these devices yet."

Professor Ian Wells, head of the scientific computing section in the department of medical physics at the Royal Surrey County hospital in Guildford, agrees that innovation is being hindered by regulations that are "still in their infancy".

He said: "The approach of the regulators is not well worked out yet. There's a wonderful new world out there but we need to find a way for regulators to protect patients and doctors, while not impeding innovation, research and development."

The Medicines and Healthcare products Regulatory Agency (MHRA) – the government body with responsibility for standards of safety, quality and performance in healthcare – recently set up the Medical Device Technology Forum, a group of industry representatives, regulators, users and scientists, to help establish how to regulate novel technologies.

"This is such a complex area that we are currently looking at every application on a case-by-case basis," said an MHRA spokesman. "We want to ensure that these new technologies are effectively regulated – thereby protecting health and avoiding unnecessary deterrents – while at the same time removing any unnecessary obstacles to manufacturers who wish to exploit new technologies for the benefit of patients."

European regulators are also striving to bring their guidelines up to date. A group of regulators from Austria, Belgium, Denmark, France, Ireland, Sweden and the UK was set up last December to develop guidance for software under the European Medical Device Regulations. They are expected to report at the end of the year.•

Appliance of science

• Star Analytical Services has developed an app that allows patients to cough into their phone, and tells them whether they have a cold, flu, pneumonia or other respiratory diseases.

• OsiriX lets doctors look at x-rays, ultrasounds, CT and MRI images on handheld devices or mobile phones with special software, enabling radiologists, for example, to diagnose acute appendicitis from remote locations.

• ERoentgen Radiology Dx helps radiologists identify the most appropriate radiology exam for a patient by searching a large database of signs, symptoms and diagnoses to help them make quick assessments.

• Instant ECG is just one app that analyses the most common ECG results. It distinguishes the difference in various myocardial ischemia or injury patterns. Using the iPhone's interactive touch screen, the app offers "real-time" films to make rhythm analysis similar to the clinical setting.

• AirStrip OB, an iPhone app, gives obstetricians real-time remote access to foetal heart tracings, contraction patterns, nursing notes, and vital signs. Obstetricians can monitor different stages of labour even when they are not by a patient's side.

e-Health, Telemedicine, and Elections

HP and Dreamworks' Halo Videoconferencing Solution.
Completely unnecessary for doctors, but it sure looks cool.

I love e-things. I am a gadgety sort of person – and yes, I do have a fancy super-duper iPaddy kind of thing. I consider myself to be techno-savvy, and run my private practice with an almost paperless electronic records system. I am an early adopter of many technologies, and will always try new things. But I am not so convinced on e-Health. Why?

e-Health is all the rage. The federal government even has a special taskforce called NEHTA (National e-Health Transition Agency) which is dedicated to wasting investing money in this area. It is all about "transforming and revolutionising" the way we practice medicine.

I don't want to transform and revolutionise anything. I just want to be able to treat my patients better and more easily. This does not require me to have access to every piece of medical documentation on a patient since they were born. It does not require me to be able to access a full medication list and prescribe remotely to a patient on the other side of the country. It also does not require me to videoconference with every patient or doctor in the country.

We have many, many technologies today which make things easier. Often they are the simplest things, and usually they are so pervasive and useful that we take them for granted, like the telephone.

Now, it would be remiss of me not to point out that we are in the latter half of a Federal Election campaign here in Australia. What prompts this post is not the lack of comprehensive health-care policy discussion from either major political party so far, nor the incessant, disproportionate focus on mental health whenever any health funding is mentioned. Julia Gillard's health policy is "Doctors are expensive so let's replace them with technology, physician assistants, nurse practitioners and allied health." Tony Abbott's health policy is "It's too hard let's just hand it to local communities."

But it does bug me that Julia Gillard can stand up and say that she will fund a revolutionary new "Online Consultation" service with a new Medicare Item Number. This is a government whose Health Minister, Nicola Roxon, has been trying very hard to slash item numbers such as those for Cataract Surgery, Obstetric Services, Coronary Angiography, Joint Injection, and Injection Sclerotherapy for Varicose Veins (MBS Website). There is no doubt that this is merely an "election sweetener" for rural GPs and rural voters, and those employed in the technology infrastructure sector.

Steady uptake in Telepsychiatry.

An item number already exists for Telepsychiatry consultations (Items 353-370), and uptake has been gradual - pushed primarily by a small number of psychiatry groups. One might think that psychiatric consults are ideal for videoconference but remember that a great deal of patient interaction is via non-verbal communication and behavioural cues, which even videoconferencing cannot replicate. The RANZCP has guidelines as to how they recommend Telepsychiatry be used.

But much as videoconferencing might be the poster-boy of this type of technology, it ignores the fact that there are many simpler and commoner means by which clinical information is communicated between patients, GPs and specialists, such as email and the telephone.

For example, this policy announcement outlines a scenario whereby a patient might conduct a combined GP visit with an online videoconference to an oncologist. Presumably this is encouraged by the GP and the Oncologist both being able to claim an item number for this consultation.

The key parts of this conference are that first of all, the patient knows that the oncologist exists and is not a figment of the GP's imagination (but there are other means of achieving this) and secondly, the GP is able to discuss the patient's individual treatment plan with a distant oncologist (which is best done in private away from the patient). Given that the private conference is the most important, why restrict any Medicare benefits to a combined patient-GP-specialist consultation?

Currently, patients who will not or cannot travel to see an oncologist can be cared for by a GP or local physician, with instructing care issued by a remote oncologist by much more prosaic technologies as mail, or telephone. Video-conferencing is sometimes used for multidisciplinary team meetings. Realistically, the video adds very little to such meetings or discussions, so it is silly to think that an item number must insist on the conference occurring via video-link. In that setting, should Medicare benefits be available for specialists who spend their time giving advice over the telephone, or reviewing patient files and sending a letter of advice?

If that is the case, then I should be paid Medicare benefits for all the GP queries that I get over the phone, and all the paperwork that I perform organising a patient's care in between physically seeing them. Instead of seeing review patients, I could just check their results, give them a phone call, and lodge the Medicare claim. Is that good or bad? It sure would make my job easier. I could see more patients. It would be significantly cheaper and more convenient for the patient. Even better, if the new Government were to fund practice nurses for specialists, then I could delegate the job to my nurse!

First patient to survive a stroke without side effects?
BULLSHIT! What a way to blow your own trumpet!

Why is it that when you slap a computer with the Internet on it, everything suddenly becomes "Telemedicine"? Since the telephone was introduced doctors have been giving instructions from remote. Is that "Telemedicine?" For years I have been reviewing photos of patients and their X-Rays via email from distant GPs. Am I on the cutting edge of Telemedicine? I have had remote PACS access to a number of hospitals and reviewed films from home. I have advised surgeons and GPs in other towns how to perform surgical procedures over the telephone. Should I be on the news because I am a frontier Tele-surgeon? I don't think so... this is just part of the pervasiveness of communications technology into common life, as well as medicine.

I don't know about you, but this thing
would scare the crap out of me.

My advice, Julia – scrap the "Online Consultations" rubbish and bring in an item number that pays doctors for all the organisational work involved in-between face-to-face patient visits, allow doctors to be paid for telephone consults, advice and services, and don't bother wasting money on teaching doctors to videoconference when they will use it perhaps once of twice a year just for fun. Spend the money on secure integrated email for all doctors and practices. Oh, and funding for specialist practice nurses please.

nhsblogdoc retires from blogging

It is with great sadness that I note that Dr John Crippen aka nhsblogdoc has decided to stop blogging, and furthermore remove all of his previous posts.

He has been a major force in medical blogging, and inspired me to begin blogging in the first place. Numerous posts by me have been stimulated by his lead.

• I don't understand this
• Hospitals Behaving Badly
• Sister, I'm Speechless

It is certainly the end of an era, and I am especially sad that I have only noticed this fact 3 months down the track due to my inability to keep up with the medical blogging scene.

The impact of his blogging is reflected by the farewells that he has received, and I humbly add myself to the list of bloggers sorry to see him go.

• NHSBLOGDOC. Dr John Crippen - Ward87
• Farewell, friend - The Jobbing Doctor
• Crippen would have loved it - Dr Grumble
• nhsblogdoc - GruntDoc
• And now for something completely different - The Road to Hellth...
• Dr Crippen has gone, please come back? - Northern Doc

Sadly, there are those that are happy to see him gone:

• Letter to the Guardian Re: Dr. Crippen - Dancing with the Sandman
• Centre for Nursing Advocacy

But he lives on, even if only in the faint memories of the internet:

• NHSBlogDoc Cached - UK Web Archive
• NHSBlogDoc Archive - Wayback Machine

Dr Crippen - hopefully we will see you reappear, either as yourself, as a new identity, or if nothing else then in the memory of those who continue to blog, and may our influence and spirit continue to guide us to incisive, critical, entertaining and humorous medical blogging.

On Jurisevic, Ross, Knight and Anonymous

I must say that I really have no idea what it is about my posts on this topic, or perhaps this whole issue in general, that has caused such a heated response.

I thought this was just an innocent comment on the activities of the ACCC and my own conjecture as to what might or might not have happened, and the wider implications of the ACCC's actions. I must make clear that I do not know Craig Jurisevic, Iain Ross, or John Knight, or anyone at the ACCC. I have never met them, have no inside information about what happened, and don't have any opinion on their character or skill.

Nevertheless, a series of anonymous posters seem to think that I am a dyed-in-the-wool Craig Jurisevic-hater when this is not the case. Why should some lowly general surgeon working in the middle of nowhere have anything to do with a high-flying, TV-appearing, book-writing, decorated cardiothoracic war surgeon? I don't know what his book is about - it could be about bird-watching for all that I care! What does that have to do with me? He could walk past me in the street and I would not know or care. I neither like nor dislike Craig Jurisevic - so Anonymous, please stop accusing me of being out to get him. I am not out to get Craig Jurisevic but I am not here to defend or promote him either.

In order for everyone to see clearly what I am being accused of, here are links to the two relevant blog posts and the amalgamated comment exchange on this topic.

ACCC Strikes Again, August 2007
Bleeding Hearts in Private Hospitals

Comments:

Milk & Two Sugars said...

Ah, but 'desirable' is not the same as 'required', is it? Do you think it's possible that the problem stemmed from Ross and Knight's inability to formally take action to prevent a surgeon they considered inexperienced and therefore dangerous from being allowed to take such a position? I'm not familiar enough with the College of Surgeons practices to know whether such an avenue was available.

6:18 PM, August 20, 2007 

Anonymous said...

The surgeon in question had several years as a trauma surgeon on top of his cardiothoracic training and had a Masters I Surgery in the field of cardiac surgery, so experience was never an issue, nor was patient safety.

9:39 PM, August 22, 2007 

Sheepish said...

You make a good point, M&TS. Ross and Knight may have felt that way for reasons apart from CJ's professional qualifications. There is no practicable means to limit someone's activity in private, as the whole point is that the market decides whether such qualities are a problem.

I have written a further post about my opinions on this.

Thanks for your insight, Anonymous. Please keep reading, and letting me know what you think.

2:20 AM, August 24, 2007 

Anonymous said...

Sheepish,
Why no response to posts that highlight the fact that CJ was more than qualified and competent??

9:53 PM, September 13, 2007 

Sheepish said...

Hi Anon - I assume you are the same Anon from the postACCC Strikes Again on this topic.

I don't claim to know CJ personally or professionally, so I can't really comment on his qualifications. My observations didn't relate to how skilled or competent he is, and I assume that he is appropriately trained to the level of an FRACS(CT). They were about the issues around the ACCC's actions and private hospital accreditation.

By the way, if you comment again it would be nice if you gave yourself a nickname or logged in to Blogger - it's a bit weird replying to "Anonymous".

10:31 PM, September 13, 2007 

Honest Doc said...

Dear Sheepish,
I am not the Anon from other posts referred to. This is my first time on this site. I have recently developed an interest in the case as I have worked in SA all my life, and I , and most other docs in the public and private hospital system know of the past behaviours of the two surgeons charged by the ACCC. The finding is of no surprise as these "Old Adelaide" exclusive practices have destroyed many a young medico in Adelaide.
Lets see what the Medical Board, our independent aribiter of professional conduct, has to sy about the actions of Messrs. Ross and Knight!

10:49 PM, September 13, 2007 

Anonymous said...

Hi to all- I have read enough peoples opinions and views of those who support Knight and Ross or try to make it seem that they were doing nothing wrong. I do personally and profesionally know Dr Craig Jurisevic, and in the past have worked under Dr Knight as a theatre nurse. Let me say that there are clear and distinct differences between these two individuals. While they are both immensly tallented and educated surgeons, the motivation behind Knights and Ross' actions were not in the interests of patients who might in future require the services of Dr Jurisevic. In my time working with Dr Knight, It was clear that money was a large motivator for him, while he is an excellent surgeon, and his patients are always the priority, money comes in at a very close second. This is not the case with Dr Jurisevic, while he may be earning a significant salary, and may be launching civil action as reported in the Australian, he has every right to do so. These men have attempted to tarnish this surgeons reputation in a decietful and pathetic manner, even making him believe that he was not qualified to work as a CT consultant surgeon. To Dr Knight and Ross, what you did was intentional, Dr Knight has at various times been very callous and decietful individual to get his way, and obviously has not changed since I have worked with him. While I do not directly work under Dr Jurisevic, I have assisted him in Surgery many times and saw first handedly what an experienced and caring individual he is. Money is not a motivator for him, nor is the position or titles. His main and only motivator is knowing that he is saving or greatly improving the life of another human being.

8:42 PM, October 31, 2007 

Anonymous said...

Why do you hate craig jurisevic so much? Have you read his book yet? now that you see he was MORE than qualified and Ross and Knight were being c**ts do you admit you are wrong?

2:41 PM, May 21, 2010 

Sheepish said...

Dear Anonymous:

I assume that you are referring to a series of posts that touch on news reports involving an ACCC finding regarding the failure to appoint Craig Jurisevic to an Adelaide private hospital. (Now I sound like Sir Humphrey!)

They are ACCC strikes again and Bleeding Hearts in Private Hospitals from August 2007.

Firstly it is helpful if you provide a name as many other commenters use the same pseudonym "Anonymous" and it makes it impossible to tell whether you are the same Anonymous as has commented on those posts.

Secondly, you may wish to post your comment on those posts rather than this one, as otherwise no-one has any idea what you are on about without me coming to your rescue.

Thirdly, I have never said, and can confirm that I do not, hate Craig Jurisevic nor bear him any ill will. I have not read his book nor do I have any immediate urge to go out and buy it as I don't have the faintest idea what it is about yet.

I have merely passed comment on the general issues raised in this ACCC case and theorised on what might possibly have happened. As I passed no judgement on Craig Jurisevic I really don't have the faintest idea what you are accusing me of, or what I could possibly be wrong about.

Next time I would appreciate it if you could write a comment that at least made sense, rather than a paranoid rant.

Sheepish.

11:56 PM, May 21, 2010 

Anonymous said...

Dear Sheepish,

I have read all those posts about the ACCC, and I am very close to the case of Mr Jurisevic and Mr Edwards. I know it well. Far better than you'd like to think you are - you are a nobody. You have no idea what you are talking about and you elude to the fact that Ross and Knight were shafted in some way. You need to go f*** (edited) yourself!

1:51 PM, June 10, 2010 

Sheepish said...

Dear "Anonymous":

I don't claim to know the case or any of the doctors involved well or at all, other that what I have read in the paper. I may well be nobody but I am entitled to pass comment and express an opinion. It is, after all, my blog.

I do not allude to anyone being shafted, but you are not doing your case any justice by your irrational, unjustified finger-pointing. I think it is fair to say that your attack on my comments is, to say the least, paranoid behaviour. If you have inside information then please feel free to share, as raving and ranting is clearly not doing much good for my education, nor your pent-up frustration (which may well be solved by the same action that you have asked me to perform).

8:40 PM, June 10, 2010 

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".

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.

I Don't Understand the NHS

This is probably the domain of Dr Crippen but the more I read about the NHS the worse it seems to be.

What does the NHS Centre for Involvement do?


And do they really really need a National Knowledge and Question Answering Service?. I thought that's what AskJeeves, Universities and libraries were for. Before you know it there will be a Ministry of Truth.

Too bad the NHS' Jargon Buster service doesn't explain what "Involvement" and "Question Answering Service" mean, because it sure as hell has redefined what a Spine is!

Perhaps it is a function of the fact that the NHS is one of the largest employers in the world (over 1.5 million) that they have to find pointless activities for people to do? I vote that they shut down one of these departments and hire more doctors and nurses.

Happy New Year Blah Blah Blah

After a long break, I have decided to resume my intermittent blogging. I know that it has been some time, and that many of you may have moved on to more regular and more exciting blogs, but nevertheless, I still have the urge to vent.

So I hope that you have all had a good Christmas, Hannukah, New Year, and New Year.

Part of the reason that I have been quiet is that I now find myself on both sides of the fence. All of a sudden, I have been planted inside a palace of power, a domain of dominance... an institution of influence. But enough of the alliterations. I have frequently complained about the powers that be - now even though I may be a speck or a fly on the wall I can see some of the machinations that lead to my complaints, and I am not impressed.

Partly I am not impressed by how bureaucratic and slow large organisations work. Partly I am not impressed with my own lack of enthusiasm at changing any of this. Nominally I may attend a committee that can change things. But I realise now how competing interests dilute progress. And I also see how committees have to justify their own existence.

So I am conflicted - I have better things to do with my time, but I still want to be on the inside, looking for an opportunity to improve things, even a little. Perhaps I am merely a pawn being played by others, but it means that I must be even more careful about what I write and blog about, lest I inadvertently divulge state secrets, or even worse my identity.

And so I leave you with two little tidbits for today:

1. This blog has been nominated for the Inaugural Australian Medical Blog Awards set up by DrCris at AppleQuack and Scalpel's Edge. If you think I deserve it, vote for me. Otherwise feel free to nominate another Australian Medical Blogger, like The Girl.

2. A fascinating piece from The SMH on the fraudsters allegedly dodgy dealings at Advanced Medical Institute. You may recall that these are the group that run are associated with the Heart Check group from my post here and here:

• Authorities launch investigations into sex ads company - The Sydney Morning Herald
  (Click to Expand)
  
  
  

  Authorities launch investigations into sex ads company
  Kelly Burke, Rachel Browne and Alex McDonald
  The Sydney Morning Herald, February 1, 2009
  
  

  Erectile dysfunction king … Jack Vaisman, founder and owner of Advanced Medical Institute and (inset) one of his controversial former billboards. Photo: Jacky Ghossein from SMH

  
  
  AUSTRALIA'S king of erectile dysfunction, "Dr" Jack Vaisman, is being investigated by government agencies in two states.
  
  The NSW Office of Fair Trading and Victorian Consumer Affairs confirmed last week they were examining the operations of Mr Vaisman's company, the Advanced Medical Institute (AMI).
  
  NSW Fair Trading Minister Virginia Judge has asked dissatisfied customers to come forward with their complaints of alleged unconscionable contracts and undeliverable guarantees.
  
  Mr Vaisman claims almost 500,000 men over the past decade have responded to AMI's billboard-sized promises of longer lasting sex.
  
  The NSW regulator believes the disaffection is probably much higher than the actual complaints received as men are too embarrassed to lodge formal complaints over the $4000 contracts which commit them to 18 months of "treatment" and severely limit their access to the company's money-back guarantees.
  
  The thriving business predicated on men's sexual-performance anxiety has delivered millions of dollars to AMI coffers and spawned more than 20 clinics in Australia and New Zealand, and, most recently, a discreet consultancy in London.
  
  Last year AMI, registered as a public company on the US NASDAQ, posted an almost 50 per cent increase in gross profit, from $8million to $12million, in the July to September quarter alone - profit the company attributed to its more effective advertising campaigns (at a cost of $500,000 a quarter), increased brand name recognition, and the effectiveness of its products.
  
  Yet AMI's founder and owner Mr Vaisman, a portly Ukrainian migrant in his early 60s with a good suit and a comb-over, denies he is a very wealthy man. Comfortably off, he'll concede. But far from accumulating personal wealth, Mr Vaisman claims he is delivering savings worth millions of dollars to Australian taxpayers every year.
  
  "All my consultations, we never use Medicare," he said. "Can you imagine if 90,000 impotent patients went to their GP every year? At $45 or $50 a consultation, what would happen? The Government would lose millions of dollars."
  
  Sexual dysfunction, says Mr Vaisman, is a quality of life condition and if you want quality of life you have to pay: "It's like if you want a better car or you want a better house, you pay more money."
  
  Mr Vaisman is under fire from multiple corners, but that is hardly new. In 1996 his former company, On Clinic Australia, was prosecuted for importing $500,000 worth of unregistered drugs - the charges were proved but no conviction was recorded, with the Court of Criminal Appeal acknowledging the probably inadvertent nature of the offences.
  
  Aside from much-publicised run-ins with the Advertising Standards Bureau, there has also been attention from the Australian Competition and Consumer Commission over allegedly misleading claims relating to his controversial treatments and AMI's promises of guaranteed results or money back. Mr Vaisman rejects the latter allegation outright: "We cannot guarantee a result but we always guarantee money back."
  
  Meanwhile, the chorus of caveats and criticisms from the medical fraternity multiplies monthly.
  
  Dr Chris McMahon, associate professor of the Australian Centre for Sexual Health, has dealt with former AMI patients, and alleges the majority have not received what they thought they paid for.
  
  AMI's apomorphine-based nasal spray has not been the subject of clinical trials, so its efficacy remains untested, he says.
  
  "There's a certain logic to it," he conceded. "I could also argue that because Panadol is effective as a tablet for a headache we could crush it up and put it into some K-Y Jelly and rub it into the scalp. Now we all know that is ridiculous - the way that you would prove or disprove that is to do a clinical trial."
  
  The non-profit Impotence Australia receives on average about five complaints about AMI each week. When patients fail to respond to the nasal spray, lozenges are offered but invariably the patient ends up facing injection therapy, the association's chief executive, Brett McCann, says, which is where many men will draw the line.
  
  "[I've seen] one guy who had only one arm … It is pretty difficult to inject when you've only got one arm. He said he would never have agreed to it had he known."
  
  But formal complaints are comparatively rare, says Professor Basil Donovan, from the University of NSW's National Centre in HIV, Epidemiology and Clinical Research.
  
  "Men are too embarrassed to come forward," he said. "It is an area prone to exploitation."
  
  The Australian Medical Association has expressed concern that some of AMI's initial customer contact does not involve a registered medical practitioner. Moreover, the company's practice of conducting phone consultations is unlikely to identify health issues such as heart disease, stroke, obesity and diabetes that can often be underlying causes of erectile dysfunction, AMA president Dr Rosanna Capolingua says.
  
  Dr David Malouf, the vice-president of the Urological Society of Australia and New Zealand, says the treatments AMI offered at large mark-ups could be provided at a much cheaper rate by a GP.
  
  "But the reason [GPs] don't is because these treatments are less effective than others, such as Viagra, Cialis and Levitra."
  
  Such mainstream treatments are also largely without the horror side effects sometimes associated with injectibles, says Dr Malouf, warning that 30 per cent of men may develop local pain at the site of the injection.
  
  "I've seen bruising, scarring, curvature of the penis and priapism [persistent painful erection]. I had one patient who was treated with one of these agents. He was given a sheet of paper with a number to call if anything went wrong, which it did. He was effectively told [by AMI] 'there is nothing we can do, you have to go to a hospital emergency department' … That case of priapism was so severe, it permanently damaged his erectile function. He went from having a mild erectile problem to having a non-functioning penis. And he was a young guy, too."
  
  Dr Malouf says he also had a 17-year-old boy who was prescribed treatment for premature ejaculation from an AMI clinic: "I would have thought that was entirely inappropriate."
  
  When The Sun-Herald put this to Mr Vaisman last week, he said: "If a patient asks for help, does it make any difference of the age?"
  
  The following day, public relations firm Wilkinson Media issued a statement saying AMI had a policy of not providing treatment to people under the age of 18.
  
  Mr Vaisman has never been registered as a medical practitioner in Australia, a sacrifice made, he claims, to stay in this country. With a mother, wife and daughter to support - the former two suffering serious health problems - a year-long hospital internship was out of the question when the Ukrainian-trained doctor arrived in 1987: "This was the price I had to pay for my freedom."
  
  That much of the clinics' work with clients takes place over the phone is logical, Mr Vaisman argues, as erectile dysfunction is very much a self-diagnosed condition.
  
  "If a patient says to the doctor, I cannot get an erection, there is no test that can prove or disprove this, you have to take his word."
  
  It is also an effective technique, he says, in protecting anonymity.
  
  With the exception of occasional crustiness or bleeding around the nose, Vaisman says his nasal sprays have practically no side effects. The risk of priapism is no more prevalent with the use of injectibles than with more conventional treatments such as Viagra, he adds, while AMI's 24-hour hotline is available to advise in such emergencies.
  
  Mr Vaisman says Impotence Australia, one of AMI's most vocal critics, is in direct competition and accepts sponsorship from large pharmaceutical companies such as Viagra's manufacturer, Pfizer.
  
  Impotence Australia declares it accepts sponsorship from pharmaceutical companies on its website, but denies the direct competitor claims made by Mr Vaisman.
  
  "We're not offering any treatment," said Mr McCann. "We refer people either to GPs or sex therapists or we give general information."
  
  Mr Vaisman describes himself as a pioneer: "We have a lot of criticism. But I am fighting for what I believe is right. I am a fighter."

  
  
  
• Why erectile dysfunction client wanted his cash back - The Sydney Morning Herald
  (Click to Expand)
  
  
  

  Why erectile dysfunction client wanted his cash back
  Kelly Burke
  The Sydney Morning Herald, February 1, 2009
  
  AT THE age of 35, Nick* was appalled when he started experiencing difficulty maintaining an erection during sexual intercourse with his partner.
  
  The Advanced Medical Institute's "Want Longer Lasting SEX?" billboards seemed to be screaming at him from every corner.
  
  Nick succumbed to their promise. He confessed to the first male AMI consultant that the "open relationship" he had been coerced into by his girlfriend - she could seek other sexual partners - might be the underlying cause of his physical problem.
  
  The consultant listened and left. Next came a female consultant who told Nick that regardless of his relationship status, there would be no improvement unless he received drug treatment. She left. Then came the "deal closer".
  
  "She was upbeat, articulate and very pushy. When I baulked at signing a 12-month contract committing myself to drug treatments worth around $3000 … she basically made me feel as though I was making a mistake I would suffer for later."
  
  Nick said he was pressured to buy a month's supply of nasal spray and a gel for about $350. The spray had limited effect and the gel did not work on him. When he asked for a refund, the company refused, arguing there were no guarantees the products work for everyone.
  
  Months later, Nick's relationship with his partner became exclusive. He says his erection problems vanished, without the assistance of medication.
  
  * Name has been changed to protect identity

  
  
  
• From Siberian gulag to 'this beautiful country' - The Sydney Morning Herald
  (Click to Expand)
  
  
  

  From Siberian gulag to 'this beautiful country'
  Rachel Browne and Kelly Burke
  The Sydney Morning Herald, February 1, 2009
  
  

  Rags to riches .. Jack Vaisman. Photo: Jacky Ghossein from SMH

  
  
  JACK/Jacov/Jakov/Javov Vaisman/Vaysman/Waterman was born in Moscow/Ovruch/Odessa/Kiev/Ukraine/place unknown on August 23 and 28, in 1945 and 1946, according to the personal details provided by the company director and shareholder to the Australian Securities and Investments Commission.
  
  But life has long been complex for the self-proclaimed former Soviet political prisoner, whose path to Australian citizenship was smoothed by a former prime minister.
  
  Trouble started for the young doctor, who had graduated from the Donetsk State Medical University in 1968, when he applied for an exit visa in the mid-1970s. He says his application to leave the Soviet Union resulted in his expulsion from the university, where he says he was associate professor of gynaecology.
  
  In 1980, as he was preparing to conduct an operation, the KGB came calling.
  
  Vaisman says he spent the next six years as a prisoner in Siberia, first logging forests then building a power station.
  
  "In winter it's minus 62 … the birds drop dead mid-flight," he recalls. "The prisoners were loaded on to the truck and every half-hour we were told to get off and run behind the truck, otherwise we would be frozen before we came to the job. Every morning you wake up in the barracks and somebody is dead. "Nobody knows why, nobody cares. It took me almost 1½ years until they realised I was a doctor."
  
  On one occasion Vaisman was told by the prison's chief commander that if he did not cure him of gonorrhoea in three days he would be executed.
  
  "I treated him in two days … I saved my own life."
  
  Throughout the 1980s, Vaisman's parents-in-law, who had emigrated to Australia, had been lobbying Bob Hawke.
  
  Vaisman's name was on a list Hawke took to Moscow in 1987, the former prime minister has confirmed to The Sun-Herald, and petitioned for his release.
  
  In 1987, while still on parole, Vaisman was told he and his wife, daughter and mother were free to leave the country if he left his papers behind. Vaisman arrived in Adelaide with two suitcases and $200. Six years later, using $9000 he had saved from his jobs in a service station and a mattress factory, Vaisman opened his first clinic.
  
  "I don't believe in God, but every morning I pray," says Vaisman. "I am in this beautiful country of opportunity. I came without language, without money, without anything, but I had an aim and I am here … I tell my grandchildren, some time you will remember that your grandfather brought you to this beautiful country. He risked his life, he risked his career, everything, to bring you to the best country in the world."