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."

I am a Bully (Yes, you read that correctly)

Not long after I gained my RACS Fellowship and became a fully-fledged consultant surgeon, I found myself operating at 3am on a bleeding patient. This young girl’s life was literally slipping through my fingers. I had tried everything: pressure on the bleeding veins, applying clamps and pushing with swabs on sticks, suturing the holes that were getting progressively bigger and bigger, pledgeted sutures, packing the abdomen, clamping the aorta to stem the venous haemorrhage.

Everything I did seemed to make things worse, and I felt this rising tide of frustration beginning to well up inside me. Even worse everything seemed to be happening in slow motion. The retractors I needed weren’t available. The scrub nurse couldn’t find the instruments I asked for. The needle holders didn’t grip. The scissors didn’t cut. The lights weren’t right. The psMonitor was going flat.

I had never experienced this as a trainee. There was always a senior surgeon to turn to, who had the responsibility. Up until then I had not truly faced the prospect that a patient would imminently die because I wasn't up the the task - and then my assistant stuck the back of my hand with a needle.

“What the F!@)(k did you just do?” I exclaimed. The moment after I had said it I had realised what had happened. I had just abused my hard working registrar, who was just as tired as I was, even more nervous than I was, and completely undeserving of my foul-mouthed critique of his left-handedness. The look on his eyes told it all. His face went pale, and he looked like he was about to pass out. But it was too late. I had become a bully.

Anyone who has read my blog before will know how much I love to boast about myself (completely justified, of course). I am, after all, the perfect model of the considerate, caring surgeon. I spend an inordinately long time with my patients in clinic, and they all love me even though they have to wait two hours beyond their appointment slot.  I put up with the incompetence of the constantly rotating stream of junior nurses all the time because I love to teach, and it takes an extraordinary level of medical student ignorance to irk me.

But it has taken a long time for me to become this tolerant. I have had to hone this skill over many years, gradually learning how to refrain from my natural instinct to yell, throw sharp objects, scrunch my face and stamp my feet. This has turned me into the wonderful teacher, leader and all-round nice-guy that I am today (except for Othman who thinks I am a "nasty consultant").

Occasionally, however, something makes me snap. I liken it to a generalised epileptiform seizure. If I am tired, stressed, ill, overworked, underpaid, and forced to work in an underfunded, under-resourced healthcare system, or god forbid going through a divorce, then my likelihood of losing my cool increases. I can keep it in check, but given the right stimuli my inner bully emerges and a torrent of abuse will inflict itself upon whomever is the nearest appropriate target. Sometimes the odd phenytoin-laced movie voucher from hospital administration for unpaid overtime will stabilise my condition but otherwise I am like a coiled viper ready to strike at the next inappropriately metaphorical simile.

Last night, however, I watched the Four Corners episode on Bullying in Surgery and realised that I am not alone. Indeed, there are many latent bullies out there just like me. We are a horde of ugly monsters hiding in a world of reasonableness, tranquility and sincerity, like those damn vampires in Twilight. We do not belong here. We cannot change or adapt to this modern world. We must either destroy humanity and reclaim our place at the Iron Throne of Westeros or fade away gently into the night due to our irrelevance.

Indeed, I expressed this to Mrs Sheepish and she suggested that perhaps I should retire and then we could go all Greece-like and default on the massive debt I used to finance my medical education, specialist training and private practice. It took me a while to realise that she was joking and then she very sensibly pointed out that everybody has the capacity to be a bully in the wrong circumstances and that does not mean that I am a “bad person” who is beyond redemption.

Therefore tomorrow I will ring my ex-registrar who is now a respected and successful neurosurgeon working at an ivory tower and I will apologise for almost destroying his career. And I'll have a quiet laugh at him because he still holds the forceps funny.

PS For those of you with no sense of humour then you have my pity.

That Which Does Not Kill Us Makes Us Stronger

“The report of my death was an exaggeration” - Mark Twain, New York Journal, 2 June 1897. 

Firstly an apology to my long time readers – there has been some upheaval in the ranks of the Paper household and so other issues have taken priority over blogging and social commentary. Therefore this blog may have appeared to be dead or semi-comatose, but instead it has just been in hibernation. It comes back to life for worthy issues, and there have been at least three very worthy issues that deserve some attention. The first is something that should hit close to home for every doctor and health professional, being that of personal security.

Like many other surgeons around the country I was shocked at the senseless, violent attack on a fellow surgeon in Melbourne last week. I do not purport to know the details of what happened, but from newspaper reports and the surgical rumour mill, it appears to have been a targeted attack by a somewhat unhinged patient or relative. It was vicious and unrelenting and the victim has been lucky to survive, probably saved by the fact that it happened at the start of a weekday in a fully staffed major hospital.

I have chosen not to link to news reports of this attack as I suspect this colleague would prefer that his online profile and the rest of his life is not defined by this event any more than necessary.

Security in hospitals has been a hot topic. It has been championed by the AMA particularly in the Emergency Department setting.  Ambulance officers, ED and Psychiatry nurses often bear the brunt of violent behaviour from patients, along with staff in aged care facilities caring for confused and demented patients, as well as the perfectly intact but lecherous ones. GPs take personal security so seriously (especially after the tragic death of GP Dr Khulod Maarouf-Hassan in Melbourne some years ago - link included since I see little harm in doing so) that they now design consulting rooms around quick escapes and duress alarms. The last case I recall of an Australian surgeon being violently attacked was that of Victor Chang who was killed by some thugs with a rather daft plan to make money. There may well have been others that I am not aware of.

Some suggest that the problem of frequent violent assaults on health care staff is due to soaring nationwide crime and the standard knee-jerk response to these assaults is to beef up security, such as arming security guards with guns, putting up plexiglass screens, handing out duress alarms to all staff, and even setting up metal detectors at hospital entrances akin to some US schools after the Columbine Massacre. Obviously this risks escalation of violence and creation of a divide between staff and patient.

Others say that it represents inadequate mental health funding, or the natural outcome of community-based mental health care.

If you ask me, this represents a slow and gradual shift in the degree of respect that the community holds for health care workers in general. The nurse, the paramedic and the doctor are no longer perceived as someone who has dedicated their lives to the wellbeing of patients and the community in general. They become a valid target of outrage and violence.

Modern medical TV dramas (see ER, Chicago Hope, Grey's Anatomy) portray us as “real people” who have “real problems”. We are invincible and then we are fallible. We make a few mistakes and then we clock off and go home without a care for the bloke in Bed 22 with the fractured NOF and urinary retention that the overnight cover will sort out (unless it suits the dramatic love-interest plot twist for us to hang around in the on-call lounge).

Industrial bargaining portrays us as replaceable commodities, or heartless negotiators risking our patient’s lives for a 4% pay rise. (See Link 1, Link 2) Admittedly, certain health unions will play the same card back at the Government of the day seeking a similar productivity gain (how on earth do you measure productivity on a ward?).

Health care is no longer seen to be full of altruistic souls in a profession that holds a high moral ground. It is no longer a desirable profession to work in. It pays poorly compared to many careers in commerce or IT. It involves menial and what some might consider degrading tasks on a daily basis that cannot be delegated to some unpaid intern (much as we might try). On an hourly basis my plumber makes more than me and we both have to wade around in wee and poo. Who would want to be a doctor, and why do they deserve our respect?

The reason, I think, should be simple. When you are at your lowest, when your body is flaccid and your soul is shaken, when every skerrick of hope seems to be gone, we are the people to will tend to you, look out for you, and make decisions in your best interest until you recover and can make them for yourself. We have to act for your benefit above any personal benefit to us. And if you don’t respect us, it makes it mighty hard for us to respect you.

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.

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 

Botox? Bollocks!

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

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

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

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

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

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

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

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

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

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

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

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


Links:

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

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