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.

Reform for Reform's Sake?

It has been a big week in healthcare news. One cannot have missed all the talk about Kevin Rudd's bold new plan, to take health care where health care has never been before (except in Victoria). Much of these reforms derive from the previously published NHHRC report which I will not expand upon. I will, however, give some of my mind on efficiency in the medical sector.

Nicola Roxon loves banging on about efficiency, and funding the "efficient costs" of health care. Here she is on ABC's Lateline on the 27th of July last year:

NICOLA ROXON: Yes. Yeah, that's right. They - of the funding, what they recommend - and remember we're talking about their proposals to us - is 40 per cent of efficient funding, which is actually an interesting concept, which is the states should fund the extra 60 per cent and any inefficiencies that are in their system. And they even say if you even went up to 100 per cent in the future, you should only pay 100 per cent of an efficient system, which would sort of have a penalty there for -

TONY JONES: Just to clear up what that means. Effectively, that means that, centrally, you would set the actual cost that should be charged for individual operations. A hip replacement, for example, should cost X and that would be the efficient cost.

NICOLA ROXON: That's right. Yep. That's right.

TONY JONES: Inefficient costs would be anything above X, is that right?

NICOLA ROXON: That's right. And so you would have a activity-based and efficiency-based payment. So if hospitals were - in particular states were not good at particular procedures, they would bear the extra cost, or if you're in a booming state where you've got a higher population putting more demand on your hospital services, you get paid more because you're undertaking more activity. That's the key tool that they are recommending we use for funding, which is a big change from where
we are in block funding the states for their whole activities.

Nicola Roxon - ABC Lateline - July 27 2009

There is plenty in the media about the pros and cons of a central pricing authority, and either additional or streamlined bureaucracy (depending on your point of view), but I am more interested in the "efficiency" concept. Now, efficiency in health care can be measured in very different ways, but generally they do not directly relate to improved health care, quality of life, or prolonged life expectancy. Efficiency does not automatically lead to improved population health.

The usual argument is that if you treat more patients with the same amount of money, then you are benefiting more people and therefore improving the health of your population. That is great if you have lots of waste and slack in your system but that is a very managerial and administrative view of the world. There is, of course, a great deal of waste and slack in our health system nationwide partly because health events are by their nature episodic and unpredictable (just look at the recent swine flu pandemic) and health infrastructure is not something that can be ramped up and down as necessary.

An analogous situation would be that your would not want all fire stations to be working at full capacity all the time, because when a particularly nasty factory blaze occurred there would be nobody to fight it. There is therefore an inherent downside at encouraging hospitals to work at > 90% bed capacity.

Unfortunately the usual measure of efficiency is throughput, which features very highly in health-administration KPIs (also known as "Key Performance Indicators"). For example, a standard means of measuring emergency department efficiency is how many patients are treated in a day, or a month or a year. Similarly we often ask how many patients are seen in a clinic, how many patients are admitted or discharged from hospital, how many operations performed in a month, patients taken off a waiting list, etc.

Obviously these are very simplistic views of the world and so token attempts are made to complicate things by "weighting", or "prioritising", or adding "descriptors" - all managerial jargon-speak for abstracting these figures from real life. The reason these KPIs predominate are:

1. They are readily reproducible (there is a defined common method for calculating these KPIs)
2. They are readily manipulated (there is no point monitoring a KPI unless you can improve it... ostensibly by improving performance, but in reality by a short term funding boost, or changing the way it is calculated)
3. They are readily manipulated in the short term (there is no point monitoring a KPI that takes 20 or 30 years to improve upon)

But back to the point I wanted to make. Kevin Rudd's whole health reform is said to be about eliminating State and Federal buckpassing, or the "blame game" as he likes to put it. This is mere political smoke and mirrors for what is the real purpose of these reforms. I am not saying that this is not worthwhile or important reform - but it should be seen for what it is.

The Blame Game
It has always been human nature to seek to blame someone else for your troubles. Currently our public hospital system is composed of infrastructure funding which comes from Federal and State Governments, recurrent operational funding which comes from State Governments (except when Federal Goverments seek short term headlines by giving away more money), and an Aged-Care system which comes from Federal Government funding.

All of these systems are interdependent, and the only thing that is really being changed is that the Federal Government is proposing to pay for recurrent operational funding through these new reforms. This pays for wages and consumables but who will pay for rebuilding a hospital or adding ICU beds? Who will decide whether a new hospital should be built or relocated against parochial or local interests? It is only natural that every resident wants to have every subspecialty service at their local and nearest hospital, even when this is a recipe for substandard care or unsustainable funding, and rural hospitals need to focus on core services and expanded primary care roles (PDF). Who will make the hard decision to remove maternity, or paediatric, or oncology services from some hospitals and centralise them at another? I'm no expert, but I don't see the Federal Government Reformists putting their hands out - and so the blame game continues.

Furthermore, Victorian Hospitals regularly find ways to manipulate the case-mix funding system to try to squeeze extra money out of the State Government. This is not unethical or immoral - it is just a fact of how the system is designed that a hospital cannot remain viable other than to make the most of the system under which it operates, and if that means improving your funding by meeting the targets in a innovative manner, then that is what the system encourages. Just like Darwinian evolution. Only now, hospitals (and State Governments) will be working hard to find ways to maximise the Federal Government's "Efficient Costs" payments. Get ready for some creative accounting, Kevin!

The Real Reform
The underlying purpose of this reform is no secret - it is merely obscured and obfuscated by the "Blame Game" argument. Kevin Rudd himself has said in his Australia Day Speech:

Treasury analysis which will be contained in the Government's upcoming Australia 2050 report points to the fact that over the next 40 years real health spending on those aged 65 and older is expected to increase around seven-fold. Real health spending on those aged 85 and over is expected to increase 12 fold.

This is a product of the increasing age of Australians overall and secondly the fact that within innovations in pharmaceuticals and medical technologies and the rest the cost of treating each individual aged Australian will rise as well. That is our first problem.

The second problem is, of course, the proportion of Australians in the workforce generating the tax revenue to support those services will become less.

So what does Australia, in response to this 2050 report that we will release soon, do about the challenges for the future when it comes to this ageing of our population.

One further thought we should bear in mind is the impact on our budgets.

Forty years ago, Australian Government spending on health equated to 1.2 per cent of Gross Domestic Product.

In 2010, Australian Government health spending equates to 4 per cent of GDP, and the Intergenerational Report projects that it will rise to 7.1 per cent in 2050.

In dollar terms, that's an increase of over $200 billion by 2050 - and equates to an increase in average Australian Government health spending per person in real terms from $2,290 today to $7,210 in 2050.

These are figures we should all reflect on.

Rising health and hospitals spending is already having an impact on state budgets.

States and territories have experienced growth in health spending of around 11 per cent per year over the past five years.

This contrasts with growth in state revenues of around 3 to 4 per cent a year.

Rapidly rising health costs create a real risk, absent major policy change, as state governments will be overwhelmed by their rising health spending obligations.

If current spending and revenue trends continue, Treasury projects that the total health spending of all states will exceed 100 per cent of their tax revenues, excluding the GST, by around 2045-46 - and possibly earlier in some states.

The NSW treasury has estimated that spending on health will almost double as a share of the NSW total Budget - from 30 per cent today to around 55 per cent in 2032-33.

These are challenging statistics, but it is important the nation becomes familiar with them, because we must do something about them.

Without reform - States ability to provide the services they currently provide will be significantly strained.

That is why 2010 must be and will be a year of major health reform.

Prime Minister Address to Australia Day reception, Sydney - 24 January 2010

The one success of Stephen Duckett's Victorian Case-Mix Funding model is that it has reduced the episodic cost of treating patients in public hospitals. Basically the way it works is that for patients being admitted to hospital with a specific condition (or similar groups of conditions, or similar operations) they receive a set payment which is predetermined. In order to allow for variations in the cost of treating those conditions throughout the state or between hospitals, or the State Government's desire for each hospital to provide various types of services, a complex series of calculations are applied to the actual amount that a hospital can receive. Effectively, hospitals are given a target of patients to treat or procedures to perform. If a hospital goes over that target either on a patient-by-patient basis or over a financial quarter then there is no further funding - they lose money.

In order to determine the appropriate payment, an audit is performed to estimate the costs involved with treating a standard patient in each hospital. This is compared to hospitals statewide and a statistical target is generated. Year upon year these figures are revised with more data, and hospitals try to make a little extra profit by beating their previous year's performance, until you get a "steady state efficient price" which is the price at which a hospital (the cheapest hospital) can treat a patient, most likely by cutting corners and taking risks - i.e. the price at which it starts to become unsafe to treat that patient.

As I intimated earlier - this is all about meeting budgetary targets, not about providing quality care. Doctors and nurses at the coalface are generally divorced from the cost of treating patients. Generally we like it that way as I don't feel guilty doing an ERCP on an 89 year old woman who will die in the next six months of a cholangiocarcinoma even if I save her life today. From a budgetary perspective the hospital would much prefer that I operated on a 20 year old man with early appendicitis than put the ERCP stent in, because it costs less to treat the appendix than the stent, but I have the luxury of not giving a shit, and therefore I am responsible for blowing out the health budget, as Kevin Rudd says.

There are perverse outcomes to this system (or "innovative solutions" depending which side of the fence you sit on). For example, the fewer days a patient is in hospital the more money a hospital gets for a certain condition. If you have shaved all the waste out of your hospital and are operating on maximum efficiency, the only way to get more money is to kick a patient out before they are ready. In order to combat this less money is paid if a patient "bounces", or is re-admitted for the same condition within 30 days. Therefore nobody comes in with the same condition within 30 days. They always have something unrelated to their last admission.

Furthermore, the more complications a patient experiences the more money a hospital gets. I remember my first day in a Victorian hospital included an orientation to "DRGs" or Diagnosis-related groups and "coding". I never realised that if a patient has an episode of dysuria and an equivocal dipstick they can be coded as having a postoperative UTI and therefore the casemix payment jumps 50%. Similarly, everyone has hyperkalaemia or hypernatraemia at some stage, or pulmonary atelectasis, or a wound infection (even if no antibiotics are required), or acute urinary retention (averted at the last minute by the threat of an urinary catheter).

And as Stephen Duckett also pointed out:

Mr Rudd's promise to provide 60 per cent of hospital funding also risked generating a rise in unnecessary hospital procedures.

The fixed cost of running a public hospital accounted for about 50 per cent, with the other half generated by surgery and treatment costs for individuals. "That will be an incentive to increase activity," he said.

The Age - March 5, 2010

Lastly, there is another downside to Case-Mix funding. In order for it to work, the funding body must define what procedures and conditions it will fund. If a patient suffers from something unusual that falls between the "coding cracks" or undergoes a procedure that is not listed in the manual, then they are unfunded, and the hospital must pay for that treatment out of general revenue at a complete loss. This discourages hospitals from treating patients with unclear illnesses (House would never survive in a Case-Mix funded hospital if it weren't for the fact that he does so many unnecessary procedures), and also discourages them from performing or rolling out new procedures or techniques which may have clear clinical benefits but are not in the list of funded procedures, unless a way can be found to "fudge the figures".

Ultimately, the real reason for this reform is to roll out the cost-capping measures of the Case-Mix funding system nationally. It provides a means to control and limit recurrent expenditure on health care in public hospitals over the long term. All the other claimed "advantages" are merely spin. This is the only valuable, long term and lasting outcome of these reforms. No doubt they are necessary, but it is disingenuous to hide this from the Australian public by overpromoting the other aspects of this reform.

The Underlying Problem
I have long held the opinion that the cause of ballooning costs of health care in this country is not the ageing population, or the costs of new drugs or devices (though these things do obviously contribute). It is that as a society we are completely incapable of drawing a line and saying that "This is as healthy as you need to be. If you want more, then you pay for it." Both the UK NHS and New Zealand health systems have had to overtly ration health care. South Australia has basically banned varicose veins surgery from public hospitals. Currently we prioritise but we don't limit what we offer in public hostels.

I do not speak from the moral high ground. I am no more likely to deny a patient varicose veins surgery or repair of a small hernia as a renal physician deny someone dialysis or a panelbeater recommend doing nothing to an insured smash-up. Generally as doctors we can tell when a treatment is futile, or unnecessary but ultimately we are people, and just like our patients - if a treatment is funded, the risk is low, and it works, then why not use it?

There is a precedent here which flies against the argument of those that say the Federal Government does not have the experience to roll out these reforms, and that precedent is Medicare. Medicare is effectively a case-mix system delivered on an outpatient basis. If you see a doctor, and you have a certain type of treatment (which correlates roughly to a certain condition) then the doctor receives a benchmark payment (75% of the Scheduled Fee). If the doctor's operating costs (+ profit) are greater than the reimbursement fee, then they charge you for the difference (the "Gap" fee). If the condition or treatment is not in the schedule, then the Federal Government does not pay and you get lumped with the whole cost.

Similar to the proposed efficient cost system, the Schedule fee is regularly revised (or some would say regularly ignored) to reflect the costs of providing each treatment. Sometimes the fee goes up, sometimes the fee goes down. Usually it goes down relative to CPI, and has (over the last 25 years) been a very effective way for successive Federal Governments to cap outpatient and primary care funding costs. Notice how the NHHRC said very little about primary care funding reform? It is because this reform is already in place, and the only thing that needs to happen is to turn the screws a little tighter as was recently attempted to cataract surgery.

I would predict that the nature of the Federal Government hospital reform funding rollout (Gee that is a mouthful) will closely reflect the way that private hospital cover is funded. Let us assume that the Medicare Schedule Fee for a Laparoscopic Cholecystectomy is the "efficient cost" of providing that service. The Federal Government currently agrees to pay doctors 80% of the "efficient cost" of that service. The remaining 20% comes from the patient's private health insurer. Any additional fees charged by the surgeon is paid for by the patient.

Similarly, private hospitals receive a payment for that patient's stay in hospital based on the patient's condition and their procedure, which is partly funded by state and federal governments but also by private health insurers. If those payments don't meet the hospitals costs then the patient is charged a further gap fee. All that Kevin Rudd and Nicola Roxon need to do is take that same system, insert "State Government" instead of "Private Health Insurer", apply it to public hospitals and voila - you have Public Hospital Medicare, with the added benefit that you can limit or reduce the "efficient cost" reimbursement as much as and whenever you like. If you don't want to pay for a procedure such as lap banding then you just refuse to add it to the list of funded procedures, and then it becomes the Local Board and the State Government's responsibility whether they want to pay for these unfunded procedures that the public is clamouring for access to… and the Blame Game continues.

We talk about a safety net but we are not brave enough to discuss how high or low the safety net should be positioned, or who we are really trying to catch. It is political suicide to say that some people need to suffer or die for the benefit of the rest of the community, even if that suffering is minor, or the death is inevitable. This reform is not about the "Blame Game", or restoring control to local or regional communities, or even improving the quality of our hospital system or population health.

It is about controlling the costs of health care in the long term, and it will work… for a little while, at least. But as I have pointed out before to my colleagues, Medicare (and these new Efficient Costs reforms) are basically the Australian version of public Managed Care, and I hope that we do not end up at the end of a Get Smart episode with Max lamenting: "If only Managed Care and Kevin Rudd's health reform had been used for good, not evil."

Links:

• Rudd to tour hospitals on reform opinions - ABC Lateline July 27, 2009. Watch: Win Lo | Win Hi
• Health reform proposal receives mixed reactions - ABC Lateline July 27, 2009. Watch: Win Lo | Win Hi
• Roxon discusses health reform proposal - Lateline July 27, 2009. Watch: Win Lo | Win Hi
• Taxpayers may have to dig deep for reform - ABC Lateline July 28, 2009. Watch: Win Lo | Win Hi
• Dutton discusses health reform plans - ABC Lateline July 28, 2009. Watch: Win Lo | Win Hi
• Much more than bravery required - The Australian July 28, 2009
• Healing a sick system - The Australian July 28, 2009
• Ageing population to add to pressure - The Australian July 28, 2009
• Federal government gets casemix wrong - The Australian September 19, 2009
• Rudd's magic cure: more process - The Australian March 04, 2010
• Hands off our hospitals, Victoria tells Rudd - The Age March 4, 2010
• Health deal a bitter pill for Victoria - The Age March 5, 2010
• Hospitals reform: Rudd says states running 'scare campaign' - Daily Telegraph March 04, 2010
• Top bureaucrat casts doubt on hospital overhaul - The Age March 5, 2010
• Fears for primary healthcare - The Age March 5, 2010
• Health FAQs for the confused - The Australian March 05, 2010
• Rudd's cosmetic surgery - The Australian March 06, 2010
• New hospital roof a huge waste of money, say doctors - SMH March 6, 2010
• Voters know I'm right' - SMH March 6, 2010
• Health reform plan has rationalist fingerprints - SMH March 8, 2010
• Voters warm to Rudd's health plan - SMH March 8, 2010
• Health reform causes local concern - Singleton Argus March 09, 2010
• Show us the money, Victoria tells Rudd - The Age March 9, 2010
• To improve rural health, we need to move beyond the hospital focus - Crikey.com.au March 9, 2010
• Issues and challenges facing rural hospitals - David Wilkinson, Australian Health Review 2002, 95-105,25(5)
• Managed care: Implications of managed care for health systems, clinicians, and patients - Fairfield et al., BMJ 1997;314:1895 (28 June)
• Casemix: moving forward Special Supplement - MJA 1998
• Casemix: moving forward. The surgeon and casemix - John A L Hart and David Wallace, MJA 1998; 169: S51-S52
• About Casemix - Victorian Department of Health Website

What Waiting List? A followup.

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

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

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

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

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

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

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

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

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

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

Meeting Fatigue

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

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

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

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

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

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

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

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

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

Waiting Lists? What Waiting Lists?

Waiting in Line at the Eiffel Tower - gadl @ Flickr

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

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

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

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

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

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

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

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


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


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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

Storm Clouds Gather

Mrs Hodge walks in with her wheelie frame. She is not happy. Neither is her daughter.

"I'm sorry about the wait," I say as I usher them into the cramped, drab Outpatients cubicle. "As you can see, we have been very busy and are a bit behind".

"So you should be," she snaps. "I've been out there for an hour and a half. This is pathetic. You better fix me or I'm walking out of here now."

I already get the feeling that this will be a difficult consultation, as both women scowl at me.

"So could you tell me what the problem is, Mrs Hodge?"

"You tell me, you're the doctor!"

I scan the GP letter again.

Dear Dr Sheepish:

Thankyou for reviewing this 68 year old woman. Please assess, investigate and manage as appropriate.

Kind regards,

Dr GP.

Oh dear. I could think of quite a few reasons why the GP had no referring details - but the real reason was becoming quite obvious.

"Unfortunately the GP has not given me much information. I'm relying on you to give me some idea. What have you noticed that has been wrong recently?"

"I have stomach problems."

"What kind of stomach problems?" I enquire - now we are getting somewhere.

"It hurts sometimes. Some times I feel sick."

"How long has this been going on for?"

"A while."

Silence.

"Well, are we talking a few days, a few months, years?"

"Years."

"5, 10, 20? All your life?"

"At least 5 years." The scowl has not moved since the consultation started. I know things are going badly when I degenerate into closed questioning within the first 30 seconds.

"So less than 10?"

"That's what I said. At least 5." The patient is getting agitated. "Aren't you listening? I said 5 years. What kind of doctor are you?"

"OK, where do you feel this discomfort? Does it happen at any specific time? After meals? Does it last long? What do you do to make it better? Is it worse when you lie down? Do you ever vomit or feel like vomiting?" There is no way that open questioning will do any good here.

"Sometimes in my chest, sometimes in my tummy. Sometimes it happens with food. Sometimes I just get it. It goes away after a while. Usually I feel sick but I don't vomit."

The consultation is stalling, so I move the patient into the examination bay, and find some mild right upper quadrant tenderness, and some epigastric tenderness. My money is on gallstones, but there is also a small umbilical hernia.

"So when you get this discomfort, is it mainly in your chest or in your tummy? Can you point to where it is? Have you ever had pain in your shoulder?"

"Haven't we been here before?" Her daughter interjects, as the patient starts waving her hand around her torso. "What kind of question is that? Don't you listen? Why are you asking about her chest and shoulder? She said it was her stomach." I start wishing I hadn't invited her in.

"Firstly, I need to ask these questions because it could be a number of problems. Clearly your situation is not straightforward, and I'm trying to establish what the main issue is. What bothers you most: stomach pain, or nausea?"

It's the patient's turn to chime in. "I told you it was my stomach. What's wrong with you? I came here because of my stomach - 6 years of medicine and you think you're all high and mighty. Why ask me what the problem is? I don't have a medical degree. It's people like you that really disgust me." She all but spits on the floor.

"I'm here to try to work out what is going on. Obviously you don't approve of what I am doing, and we aren't making a great deal of progress with your symptoms." It has already taken 20 minutes of tense negotiation to get the information that I have. Like drawing blood from a stone. "I have other patients waiting, but at the moment I'm prepared to offer you an ultrasound and some antacid tablets to start with, and an ECG. I can see you in 2 weeks with the results or, if you don't wish to see me, you can make an appointment to see one of the other surgeons at the hospital."

"Hang on a minute." Storm clouds start gathering as I hear thunder in the background. "I didn't say anything about not wanting to see you. You're just trying to get rid of me. Go on, close my file, you sick bastard."

"Mrs Hodge, it's clear that this consultation is not working for either of us. I am still prepared to organise your tests and send a letter to your GP, but clearly you are too agitated to continue. If you wish to come back we can discuss the results in two weeks."

"You can take your tests and shove it up your arse. I'm leaving. Where do you get off treating me like a dog?" She and her daughter storm out of the cubicle. I can hear them loudly complaining outside as I pick up the telephone and let the Patient Liaison Officer know that she will be meeting some very upset people soon.

A Traumatic Experience

For those who are unaware, there is a surgeon in Melbourne who has been the subject of a number of accusations leading to his suspension, amongst them that he is difficult to work with (or for), that he performs unnecessary operative procedures on serious trauma patients, and that he has been engaging in improper billing practices. These allegations are currently being hotly debated in the press and also the subject of a Supreme Court action.

I do not pass judgement about his character, surgical decision-making, or skill.

These two articles, however, have caught my attention:

TAC probes its links to hospitals - The Age
(Click to Expand)

TAC probes its links to hospitals
Richard Baker and Nick McKenzie
The Age, February 9, 2008

THE Transport Accident Commission is reviewing its relationship with Victoria's public hospitals, amid growing controversy over suspect billing practices by senior doctors.

In a move that could have funding implications for major hospitals reliant on TAC money, a spokeswoman for TAC Minister Tim Holding yesterday revealed the commission had initiated a review of services it is billed for by public hospitals in December last year.

The TAC, which pays multimillion-dollar amounts each year for treatment and income support for Victorian road accident victims, is also investigating the billing practices of surgeons as part of the review.

The commission is funded by a compulsory third-party insurance premium that is part of annual motor vehicle registration fees in Victoria.

The State Government's confirmation of the TAC review came after The Age yesterday revealed a secret TAC 2007 audit of The Alfred hospital was unable to verify if surgeons who had billed it for patient consults had actually seen the patients.

The draft audit found that irregular note-keeping in patient files made it impossible to correlate surgeons' billing records with the information in patient files.

It also questioned why the TAC was paying millions to public hospitals for services already funded by taxpayers.

The TAC began its review of its relationship with public hospitals after its board and senior executives were briefed on the draft findings of an Alfred hospital-commissioned medical panel investigating serious allegations against one of Victoria's most high-profile surgeons, The Alfred's suspended trauma director, Thomas Kossmann.

Mr Holding's spokeswoman said the TAC's hospital review would incorporate the medical panel's findings, which are expected to be made public once it delivers its final report to The Alfred's chief executive, Jennifer Williams, this month.

The medical panel's draft report made adverse findings against Professor Kossmann in the areas of clinical practice, TAC billing, supervision of staff and participation in peer review.

The TAC contacted Victoria Police after being briefed on the draft report and Professor Kossmann was stood down from The Alfred by Ms Williams because of the report's serious findings. He was also one of two doctors named in last year's secret TAC audit of The Alfred.

But the German-born surgeon has strenuously rejected the allegations and challenged many of the medical panel's findings against him in its draft report. He has also taken legal action to overturn his suspension in November by Bayside Health.

Opposition Leader Ted Baillieu yesterday said the TAC had to reassure Victorians that their funds were not being misused and called for greater disclosure.

Mr Baillieu said Mr Holding and Health Minister Daniel Andrews also must disclose how much TAC money has been paid to Professor Kossmann "in these questionable deals".

Surgeons' billing questioned by secret TAC audit - The Age
(Click to Expand)

Surgeons' billing questioned by secret TAC audit
Richard Baker and Nick McKenzie
The Age, February 8, 2008

A SECRET Transport Accident Commission audit of The Alfred hospital reveals surgeons may have billed the TAC for treating patients they had not actually seen.

The 2007 TAC draft audit also asks why the commission is pumping millions of dollars it receives from Victorian drivers into hospital services that are already taxpayer-funded.

The release of the audit under the Freedom of Information Act comes amid continuing controversy over the suspension of The Alfred's trauma director, Thomas Kossmann, who is being investigated by a medical panel over allegations that he performed unnecessary surgery on patients and wrongly billed the TAC. He has rejected the allegations.

The identities of two doctors named in the audit were removed from the documents, but The Age has confirmed Professor Kossmann is one of the doctors named. It has been reported that The Alfred received a percentage, possibly as much as 50%, from each of his TAC billings.

Written by the deputy of the TAC's clinical panel, David Bolzonello, the audit found irregular note-keeping in patient files at The Alfred made it impossible to correlate doctors' billing records with patient data.

The February 2007 audit, done without the knowledge of The Alfred, was unable to ascertain if senior doctors who had billed for treating patients had actually seen them or whether more junior doctors — who cannot charge the TAC — had done the work. It concluded: "It is unclear from the notes if this reflected actual review by these people themselves (who submitted bills) or the unit staff such as registrars as I could not see regular entries in the files to correlate the billing."

The TAC pays for the treatment of road accident victims in Victoria through compulsory third-party insurance premiums on motor vehicle registrations.

Several doctors at The Alfred have accused some senior colleagues of billing the TAC for work they have not done.

The disclosure of the audit has renewed pressure on the Brumby Government to review the relationship between the TAC, doctors and public hospitals, with Opposition Leader Ted Baillieu yesterday saying it enhanced his call for a judicial inquiry into the controversy at The Alfred. "There are numerous doctors and public officials involved in this matter and it is imperative that their roles and actions are clarified as soon as possible," he said.

Other issues raised by Dr Bolzonello's audit included:

• A review of the State Government policy governing financial transactions between public hospitals and the TAC. "… The Alfred and its equipment are owned already by the people of Victoria. The resident staff is also paid by public funding. The TAC is then billed at private rates for radiology, pathology and bed fees. There is some argument for review of this."
  
• A lack of clinical notes to summarise the "management and decision making" of The Alfred's emergency department.
  
• Queries over whether the use of scans and hospital equipment — for which the TAC could be billed — was excessive.

The TAC took no further action after receiving Dr Bolzonello's audit, which examined 50 patient files and concluded the medical management to be reasonable. His audit did not review individual billings.

A TAC spokesman said the rules governing billing "rely to some degree on the honesty of the individual or organisation submitting the account". Procedures were in place for fraud to be investigated, he said.

A spokeswoman for The Alfred said the hospital had not received any billing complaints from the TAC. "There is a funding system set up by the Department of Human Services and the TAC. We follow the rules and we are no different to other hospitals working in that system."

Professor Kossmann, who is awaiting the final report of a medical panel commissioned by The Alfred to investigate serious allegations against him, said the TAC audit contained nothing to undermine his reputation.

The German-born surgeon was suspended by The Alfred in November due to adverse findings in the panel's draft report. He has challenged his suspension by Bayside Health in the Supreme Court.

Professor Kossmann said he would be happy to work under a more efficient TAC billing system if one could be established. "I'm a surgeon not a policy maker. These issues are for the (TAC) minister and the TAC board."

The final report into the allegations against Professor Kossmann is expected to be released this month.

For those not familiar with the TAC (or Victorian Transport Accident Commission) its role is to act as a defacto private health insurer for those people sustaining personal injuries as a result of traffic accidents in Victoria, Australia - similar to the Motor Accidents Authority of NSW. It is funded by way of compulsory insurance premiums paid by all motor vehicle registrants in that state (currently around $300-$400 a year for a standard passenger vehicle).

From its website:

The TAC is a Victorian Government-owned organisation set up in 1986.

Its role is to pay for treatment and benefits for people injured in transport accidents. It is also involved in promoting road safety in Victoria and in improving Victoria's trauma system.

Funding used by the TAC to perform these functions comes from payments made by Victorian motorists when they register their vehicles each year with VicRoads.

The TAC is a "no-fault" scheme. This means that medical benefits will be paid to an injured person - regardless of who caused the accident.

Legislation guides the TAC in the types of benefits it can pay and any conditions that apply. This legislation is called the Transport Accident Act 1986.

To ensure it remains a long-term compensation scheme, the TAC uses its funds fairly and responsibly. This ensures the TAC is able to meet the needs of seriously injured people who need lifetime care.

The TAC is fairly flexible on what it pays out - it was established to cover all the long-term out-of-pocket and accessory costs of a serious traffic injury, such as those incurred by someone with a major spinal or head injury. Often these are costs which are not well funded through Medicare, or are often not covered under Private Health Insurance. It is analogous in function to the various WorkCover or WorkSafe schemes - and as such can be the subject of similar client (patient or claimant) abuse.

The way that it operates is very similar to that of a Private Health Insurer with fantastic "extras" cover - physiotherapy, long-term rehabilitation, dental care, transport costs, specialised equipment, carer's costs etc. In-hospital costs are paid for treatment in public and private hospitals. For public hospitals, these rates are agreed upon between the TAC and the Victorian Department of Human Services. Generally the TAC has to give written or telephone approval for anything outside of an emergency situation.

Obviously, public hospitals love TAC patients the same way that they love privately insured patients - it is money in the bank for them.

The TAC also has set fees for surgery and consultations which it will pay to doctors who engage in private practice, or have the right of private practice in a public hospital (i.e. Consultant Staff Specialists or VMOs). Where these fees are not paid directly to the doctor it is common that they are paid into a Private Practice Fund, "Dillon Fund", or some other trust fund often administered by the hospital.

The concerns raised in these two articles relate to firstly, whether Professor Kossman or his colleagues were entitled to TAC payments for services rendered by them or on their behalf, and secondly whether the TAC should be paying for services for which patients would be entitled to care in the public hospital system already.

These strike to the heart of several deeper issues:

1. Does the TAC require specialists to render services directly to the patient, or is it acceptable to (directly or indirectly) supervise or delegate this treatment to a junior or assistant?

There does not seem to be any specific rule about this, and it is common for orthopaedic registrars to perform procedures on TAC patients with the bill still going to the TAC. This is in contradiction to the general practice whereby privately insured patients should be directly operated upon by their chosen specialist - as this is a condition of Medicare funding their portion of the patient's medical fee.

Does the TAC draw upon Medicare to pay the bulk of these fees in the same way as a private health insurer? If not, then what rules exist to say that the operating surgeon or consulting physician must be the one who personally rendered the service?

Clearly The Alfred Hospital has been claiming TAC fees on behalf of Professor Kossman and his colleagues. Presumably these fees were paid into a pooled private practice fund of some sort. Was some arrangement as part of his employment contract reached whereby Professor Kossman received a greater proportion of these payments than other doctors? Does The Alfred have the right to use TAC or private insurance payments to "sweeten the deal"? Did Professor Kossman raise the profile of some questionable practices as a result of his high operative load?

As for the issue of demonstrating that consultations occurred - this relates to the perennial issue of medical record-keeping. Nobody I know is a perfect record keeper. I most certainly am not. I try to make a short entry every time I see someone in private, but I am not infallible. Generally I rely on my junior staff to do that in public - and I would not be surprised if they were to omit the fact of my attendance in the interests of brevity. It is not the least surprising that some consultations were undocumented.

2. Should the TAC pay for the costs incurred by a public hospital for covered patients?

If the TAC did not exist (such as in Queensland) the Victorian State Government would still have to pay for the care of these patients in the public hospital system, but there is no doubt that their out-of-hospital care would be cost-shifted to the Federal Government and also be of significantly poorer quality. It would, however, be cheaper.

However, part of the reason for the TAC's payment scheme is to allow patients to exit the public hospital system and be treated in private hospitals. This benefits the public hospital system by reducing demand on resources, and also encourages the development of efficient specialist treatment centres for people with severe traffic-related injuries. A number of private rehabilitation centres specialise in TAC-related work. The Austin Hospital's Spinal Injury Unit is constantly filled with TAC-funded patients. And Melbourne's Alfred Hospital is presumably an excellent first-line major trauma centre, and therefore handles large numbers of TAC-insured patients.

No doubt having specialised centres giving excellent care may drive down the short-term costs (by way of volume and system efficiency savings) and long-term costs (by way of giving the best clinical and functional result, thereby leading to fewer ongoing care costs) for these groups of patients, but it also means that these centres will strive to provide the best care available to them by engaging to treatments and investigations which are costly in the short term and potentially less rewarding in the long term... effectively having a decreasing "bang for the buck" to put it crudely.

Perhaps these are issues which raise more questions than answers, but I believe that they deserve more attention than what is portrayed in the news and general media.

Background News Articles from The Age:

• Top surgeon stood down after inquiry
  
• Hospital divided over surgeon
  
• The charismatic surgeon and the mutiny
  
• Experts to probe complaints against trauma surgeon

Walking backwards, slowly.

I have been following, on and off, a thread on Paging Dr about how to "Survive First Year". After three pages of posts it is a bit muddled about the first year of what, but all the talk about work-life balance has raised the hairs on the back of my neck.

Now don't get me wrong, I am not against doctors having a social life and being able to wind down away from work. Heaven forbid, my family would be very unhappy if I completely ignored them to work all day and all night.

But this concept that doctors (and medical students) are entitled to a fun and enjoyable experience during their work or study irks me. Medical school is meant to get you trained up as a decent doctor... but it just so happens that all the students want it to be fun and enjoyable. Being a doctor is about treating patients as best as you can, and drawing appropriate reward (personal satisfaction is a form of reward) from doing so.

There are many previous generations of doctors who chose to let (or failed to stop) work taking over their lives. 50 years ago it was normal to eat, breathe and sleep medicine all day every day while you were a RMO or Registrar. Even as a GP in a solo practice it was normal. And your patients appreciated it. Doctoring was not a job, it was a lifestyle.

These days, nobody (in any profession) wants to make any personal sacrifices for the sake of work. We all want to clock off at the end of our shift, turn off our pagers and forget about work. And by that I don't mean just doctors, but everyone in the wider community. No longer is the community expectation "8 hours work, 8 hours rest, 8 hours sleep" (care of the trade union movement) but so is the 2 week overseas holiday, investment property, beach-house, private school education, 4WD, and token sustainable garden. Are we becoming a society of spoilt brats?

I increasingly see it in the surgical trainees (and I must confess that I am and was no exception). They don't want to move out of town for rural rotations, let alone interstate or overseas, for fear of disrupting their personal or family arrangements (neither did I, at that stage). They want to claim every single dollar of their award entitlements (as do I), though obviously this eats into the budget for treating patients. There is a cost and a benefit to each of these decisions - though self-interest increasingly outweighs that of community-interest.

But back to the point - if you want to give up your social life you will make significant professional and educational advances. If you want to prioritise your social life you will suffer some impediment to your career or study (in comparison to those geeks who don't sleep and talk med all day long). You may well live longer as well. BUT IT IS YOUR CHOICE.

Some people like to blame "the system" for making medicine stressful and demanding. Blame it all you like. "The System" is the way it is, and if you want to go into medical politics and change it for everyone else, it will have community-wide ramifications (not necessarily all for the better). A plethora of large and small organisations from the AMA to the DRS push their views on how to improve the health system and also working conditions for doctors.

Sometimes I don't know whether reform of the medical profession or medical employment is for the better or worse. I find it a rather ego-centric view that we have to demarcate roles, engage professional industrial representatives, or wage public campaigns in order to maintain wages and conditions for doctors.

It feels like we are stooping to a lower level, and that it demeans us as a profession that we have to engage in underhand tactics, or play hardball in order to maintain conditions. Every "victory" over some measly little payment or benefit seems to degrade my professional self-respect even more. Perhaps it says more about our government, our industrial landscape, or our lawyers. Most of all, it sickens me that the time spent on this detracts from what I want to do - treat my patients well.

I'd like to see someone stand up and say "Good Job, Doctors. Here's a pat on the back, a few days off, and a pay rise because you deserve it." But I know I'm just dreaming.