Global Doctor Trading 2

Am I imagining, or did these journalists get the same brief? Nevertheless, a good piece from The Age.

Carol Nader and Adam Morton
July 14, 2007

IT MIGHT be the lure of opportunity, or the promise of a better life. The chance to flee from a bleak existence. Or it might just be the pursuit of adventure. In Dr Julie Miller's case, it was the love of a good man. The day after her wedding six years ago, Miller left New York and, following a spectacular African honeymoon, moved to Melbourne with her Australian husband. Soon after, the US-trained endocrine, general and trauma surgeon started work at the Royal Melbourne Hospital.

It should have been easy coming from an English-speaking country. But Miller found she had to learn a whole new language — medicine in the Australian tongue. An American clamp or hemostat became an Australian artery forceps. America's acetaminophen became Australia's paracetamol.

But among the growing army of overseas-trained doctors who ensure the Australian health system ticks over, Miller counts herself as lucky. She is married to another doctor who works at the same hospital, which helped make the transition relatively smooth. And English is her first language.

"American and Australian cultures are very different but they're not as different as other cultures," she says. "I really admire people who come here to try to get a better life for their families."

Miller's story shows that importing doctors can have a happy ending, but for many others — especially doctors from developing countries — it's a slog. The Federal Government says about a quarter of doctors in Australia are foreign trained. Health Minister Tony Abbott says overseas-trained doctors account for about 28 per cent of Medicare-billed services. Some have lived here for many years. Many work in suburban and regional practices, filling the jobs Australian-trained doctors do not want.

How did it come to this? The experts are in near universal agreement — shoddy workforce planning. According to a paper published this year in the Medical Journal of Australia, led by Catherine Joyce at Monash University, medical school intakes steadily rose during the 1970s, from 851 in 1970 to 1278 in 1980. By then, the medical workforce was believed to be in oversupply. By 1990, the numbers had slipped to 1030. There was little workforce planning by governments throughout the 1980s and 1990s until there was a realisation there was a problem. Since 2000, the Howard Government has started work on increasing the number of places again. But this has all happened late in the picture, and it will take years before these students start to work as qualified doctors.

It was always going to be a crisis, says Melbourne University's dean of medicine, Professor James Angus. "We're paying for about 20 or 25 years of static medical school production," he says.

The result some years later? Eighteen-year-olds desperate to get into medicine who can't, and state governments desperately recruiting doctors from overseas to fill the gaps.

Says Australian Health Policy Institute director Professor Stephen Leeder: "There's no doubt that we got it wrong in terms of protecting the number of doctors that we need, both now and for the future. I think everybody has got to take a share of that responsibility though. I don't think it's just government short-sightedness."

With fewer graduates coming through, the Government increased the number of doctors brought in on temporary visas. According to some researchers, monitoring of the standard of doctors coming in under the temporary skilled migration program is not as rigorous as it should be. Now the system is being patched up, but again, insiders say, it will be years before we see the results in the workforce.

Abbott says it is true that part of the problem is due to decisions made in the 1980s and early 1990s. "In those days the orthodox view was that supply created its own demand, and we needed to keep a tight cap on the number of health-care professionals. I think it was the view in those days that we were comparatively over-doctored and we didn't need as many doctors as we thought we had in those days. No one thinks that now."

In Victoria, there are 19,792 doctors registered with the Medical Practitioners Board of Victoria, of whom 5164 — about a quarter — learnt their profession abroad. Almost 1000 come from Britain, more than 800 from India and 500 were trained in New Zealand. At the other end of the scale, there is one doctor registered from each of Jordan, Tunisia and Malawi.

There is undoubtedly a great need for people such as Julie Miller, one of 29 American-trained doctors now registered in Victoria. Australia needs more doctors. And this need will be felt even more urgently as more and more older, fatter and sicker people need medical attention. But no one can nail precisely what the shortfall is. Estimates put the number somewhere in the thousands. The experts agree that Australia has no choice but to poach doctors from other countries.

While some people may view overseas-trained doctors with suspicion, there is no doubt that they are a pivotal part of the workforce. Few would say that Australia should shut its doors to them. But what is clear is that assessing the competency of international medical graduates is more fraught, particularly if they come from a vastly different health system.

There are multiple ways doctors can apply to be registered in Australia, an issue that the nation's governments are starting to address. In addition to clinical competence, there are language barriers, dealing with different cultures and ensuring foreign doctors have an understanding of the Australian health system. For the Australian Medical Council, the state medical boards and the specialist colleges that assess these doctors, it is a tricky job.

Tony Abbott says there is nothing wrong with overseas trained doctors working in Australia, as long as they are properly qualified. He says a degree of cross-cultural experience is healthy for the medical profession.

Much of the recruiting is from other wealthy countries such as Britain. But Australia has increasingly been drawing doctors from the developing world, hurting the health systems in those countries. It is a situation some say is outrageous.

"They shouldn't be coming from Third World countries who need basic medical services," says Doctors Reform Society president Dr Tim Woodruff. "It's an appalling situation for Australia to be having to bring in doctors from countries which desperately need them."

The optimum situation, says Woodruff, is to produce medical graduates in sufficient numbers so that we can actually help the developing world by exporting doctors instead.

Melbourne University's Professor Angus says Australia's problems mirror a worldwide health workforce crisis. "Every country, including a wealthy country like Australia, must play its part in training. It's an outrage that we pinch doctors from other sectors less wealthy than ours — absolutely an outrage," he says.

But Abbott says Australia does not actively seek out doctors from the Third World. "It would be a far worse thing for us to say to properly qualified doctors from Third World countries, 'Sorry mate, you can't come here,' " he says. "Shouldn't their doctors have the freedom, should they wish and should they be suitably qualified, to come to Australia?"

State Health Minister Bronwyn Pike recently went to Britain to try to recruit more doctors for Victoria. Pike led a chorus of people accusing the Federal Government of short-changing the state in terms of the number of university medicine places it funded.

Now that the Commonwealth has come to the party, the challenge will shift to the states providing more clinical places in hospitals to ensure that medical students get proper training. "The Howard Government has failed Australia and Victorians by not training enough doctors," Pike says.

But the Australian Health Policy Institute's Professor Leeder makes the point that the doctor shortage is relative. Adding to the desperate situation is an unwillingness by some doctors to work in remote areas.

"If you go to the more affluent suburbs in Sydney, there are so many GPs that you're tripping over them," he says. "Whereas in the outer suburbs in Sydney, or once you go to the rural or remote areas, there are too few … There's a shortage of doctors in some areas and goddamn too many in others."

Nowhere is the situation more urgent than in the bush. The more remote the area, the less desirable it is. Why would a doctor choose the harsher conditions of remote Australia over a plum gig in the city?

The rise in university places coincides with new medical schools opening at Wollongong and Western Sydney universities in NSW, Griffith and Bond in Queensland, Notre Dame in Western Australia and Deakin at Geelong. Melbourne and Monash — Victoria's other two medical schools — also won funding for 30 extra medical places each last year. Medical deans say new clinical schools have been created at suburban hospitals, and training in the regions is improving.

From next year, Deakin will enrol 120 Commonwealth-backed students in its new graduate medicine degree. Sixty full-fee payers from Australia and overseas will be added in 2009, bumping up the annual intake to 180. But it will be some time before people in the bush start to feel the benefits of this — the first Deakin graduates will be interns in 2012, and will then need further training. Many academics say there is a need to do something in the short to medium term as well. Which brings us back to recruiting overseas doctors.

Rural Doctors Association of Victoria president Dr Mike Moynihan, who is originally from Britain, estimates some 30 per cent of doctors working in country Victoria are now overseas trained.

Quite often, it's because they don't have any choice but to go to the country. Carrots and sticks are used to try to coax doctors to go to these areas. Doctors who come to Australia on temporary visas are given no option but to work in areas of need. There, in addition to trying to adjust to life in a new country, with a different culture and in some cases a different language, they also face social and geographical isolation.

Enticing locally trained doctors to want to work in those areas will also be harder. Melbourne University's medical school has lifted its intake so that it will soon produce about 330 graduates each year, a figure it expects to maintain as it moves from being mostly an undergraduate school to teaching only graduates under the US-style Melbourne Model. Under this new system, a growing number — the target is a third of Australians enrolled — will pay full fees of between $180,000 and $200,000 for the four-year course.

As James Angus acknowledges, would-be doctors paying this much are unlikely to be drawn to suburban or rural practice. Highly lucrative areas, such as plastic surgery, will become much more attractive to those wanting to erase debt in a hurry.

Says Angus: "I think it is a great pity that higher education has moved this way in this country, but if you want universities to survive we have absolutely no alternative."

He says the medical training level is now saturated — no more doctors can be trained until the full impact of the current changes can be assessed. "We should just draw breath for three or four years until the huge change that we have had flows through, and then we should revisit our capacity."

In the meantime, opinions are divided about whether overseas-trained doctor numbers will remain steady or continue to grow. What is clearer is the need to provide them with support.

Dr Joanna Flynn, president of the Medical Practitioners Board of Victoria and the Australian Medical Council, says some overseas-trained doctors get lots of support and do well. But some are vulnerable because they depend on the sponsorship of their employer. This is even more so for doctors who are here on temporary visas, who have no choice but to go to the more isolated rural areas.

"I think it's very important that people are mindful that overseas-trained doctors can be exploited. They're pretty powerless," she says. "They don't get access to Medicare, they don't get access to free health care, to free education for their kids.

Says Dr Neil Cunningham, an emergency consultant at St Vincent's Hospital who did his medical training in Britain and moved to Australia in 1999: "It's probably irresponsible to just bring people over and send them to a rural area without providing them with that support." Cunningham, who also trains medical students and junior doctors, moved to Australia as a qualified doctor because the specialist training for emergency medicine was superior in Australia. "The climate is much better and the more active lifestyle appealed to me as well," he says.

Cunningham easily slotted in to the Australian medical workforce, but says coming from an English-speaking country was on his side. He can see that it's not so easy for others.

"If we're going to bring people over and thrust them into an environment where they are expected to work in a second language and different culture, then we need to make as much effort as we can to support those people."

Carol Nader is health editor. Adam Morton is higher education reporter.
http://medicalboardvic.org.au/

Julie Miller is from one extreme end of the foreign doctor spectrum - the lucky end. She comes from a first world country. She has (effectively) no language barrier to overcome. Her specialist surgical qualifications have been automatically recognised. She has landed a plum job at a major teaching hospital. Not all foreign doctors are so lucky - but then not all foreign doctors are so desirable an asset to attract to Australia. Neil Cunningham is similarly blessed.

M&TS asked in a comment to the previous post:

Sheepish, do you think the medical students of this great efflux will receive a decent enough education to ensure they are as competent as you were at graduation?

I think that the infrastructure in place is probably good enough to maintain the competency of medical students at graduation - after all, interns are in reality only of limited competency, and there is a large postgraduate structure in place to supervise, maintain and compensate for intern competency. Truth be told, we don't expect all that much of a finishing medical student. Recent experience has shown that to perform at intern level, the rigour of academic knowledge that is necessary is not the same as what used to be required.

The issue will be what happens as these graduates progress through the advanced training system. The level of academic knowledge and sound judgement that is required at current standards is very high - and the gap between the standard of medical students at graduation and the standard of specialists at graduation is growing.

Global Doctor Trading

An excellent article from The Sydney Morning Herald.

A bright, shining dilemma
July 7, 2007
Australia has an acute shortage of doctors. Julie Robotham and Connie Levett reveal why we need to poach health professionals from around the world.

Dr Joga Chaganti is a man with options. The highly regarded Indian radiologist has just taken over as head of Sydney's St Vincent's Hospital MRI and cranial imaging department. He has studied in France, Germany, Britain and the United States and and worked for 20 years in the Indian public hospital system, most recently as the director of imaging for Bangalore's 1000-bed Manipal Hospital.

No health system needed him more than India's, but he chose Australia."I was doing very high-end work but my children wanted to achieve big things, and I didn't have the means to support them," Chaganti, 49, says. In India, the highest salary a specialist with his qualifications can earn is $38,000; in Australia it is three times that.

Even with the higher cost of living, the move will allow him to fund his children's education. His 20-year-old daughter, enrolled in a triple major in engineering at the Australian National University, hopes to study space engineering in the US. His 14-year-old is leaning towards studying human genetics.

"There is a parallel objective. I have always wanted to do cutting-edge research. It was always my desire," Chaganti says, showing off the hospital's new $4 million high-field strength MRI machine.

Chaganti's stellar career is the positive face of an unprecedented global migration of medics. It has long been standard practice for young doctors to do an international tour of duty. In a kind of rite of passage, they come home with new skills and connections, and the confidence to take their place as fully-fledged specialists.

But that is now being underpinned by a much larger migration of junior doctors, typically trained in poorer countries, who are recruited to the health systems of privileged nations which - somehow - have neglected to adequately develop their workforces.

The trend was thrust centre-stage this week with the detention of Dr Mohamed Haneef, a doctor at the Gold Coast Hospital, after the failed terrorist attacks in Britain. The Indian-trained 27-year-old had worked as a medic in Liverpool, in northern England, before arriving here last year to work under supervision on a temporary visa in Australia's busiest emergency department in its fastest growing city.

When an unlucky colleague of a similar career background as Haneef's was also hauled in for questioning, a picture emerged of itinerant communities of overseas-trained doctors, hopping between continents chasing emergency-department shifts like backpackers following the fruit-picking seasons.

On the Gold Coast - as in most other rural and regional areas of Australia - at least half the medical workforce was trained outside this country. Doctors work here under a motley collection of temporary and permanent visa rules, and expedient registration conditions, that could most kindly be described as inconsistent.

At least a quarter of the present Australian medical workforce was trained overseas, according to the Australian Medical Workforce Advisory Committee, while 2001 census data shows almost half of Australian citizens with medical qualifications were born overseas. The discrepancy is because of the high proportion of those who attended medical schools in other countries who have not been able to register as doctors here.

"We have just not been training enough doctors. These people have been the only option," says Professor Brendan Crotty, the head of Deakin University's new medical school, which plans to start training doctors next year.

The federal Health Department commissioned Crotty to report on how overseas doctors are trained and registered after the Queensland scandal involving a criminally incompetent Indian-trained surgeon, Dr Jayant Patel. Crotty found a minefield.

"It's been incredibly complicated and very hard for overseas-trained doctors themselves to follow," he says. State rules vary, and need to be pursued through "so many different agencies that are not very well co-ordinated [in addition to] vaguely-worded requirements for supervision". A plausible result of the rag-tag system is an unsuitable doctor who is inadequately supported in an unfamilar place. But if that scenario sounds far from the ideal, Crotty is also sympathetic towards the pressures put on them. "Employers in those locations are faced with a difficult choice," he says. "It's this particular person or no one."

Where a problem exists with an individual, Crotty says, it is almost never simple incompetence or malice, but more usually a cultural gulf too wide to bridge.

"Medical schools are trying to produce doctors fit for the purpose in the environment they're working in," he says. In developing countries that might mean concentrating "predominantly on infectious diseases, where there's limited diagnostic modalities or treatments". Such training simply might not shoehorn into general practice in outer-metropolitan Sydney.

Andrew Dix, the registrar and chief executive of the NSW Medical Board, says he has "no evidence that there is higher concern about the competence or conduct or performance" of overseas-trained doctors, compared with Australian graduates. In fact, he says, junior doctors who come to Australia to plug holes in regional hospital rosters may be less likely to attract complaints - because they are working in a structured environment with senior colleagues.

The board's brief, Dix says, is to ensure individual doctors are suitably qualified and experienced for a particular job. For temporary "area of need" positions this involves an interview and assessment process, after which 20 to 30 per cent of candidates are knocked back.

Those who succeed receive on-the-job supervision, including progress reports to the board at intervals set individually.

If a person does not make the grade, Dix says, that is the end of the matter. Despite the urgent need for medical staff, the standard should not shift. Nevertheless, he says, "we don't operate in a vacuum. We'd be stupid not to be aware [of the doctor shortage], and we'll look for different ways to make sure appropriate standards don't become ossified."

Of about 1500 overseas trained doctors working in NSW, about three or four have their registrations curtailed or withdrawn annually, Dix says, because their actual practice fall short of what the assessment suggests.

Proposed national standards for overseas trained doctors will involve - except for graduates from Britain, Ireland, New Zealand the United States or Canada, and those applying for specialist jobs - supervision based on individual assessment.

But NSW Health has so far resisted the streamlined assessments, out of concern they might add an extra hurdle for well-qualified would-be medicos.

That is no idle worry. The number of vacancies for rural GPs in NSW recently crashed through the 200 threshold, after hovering at about 120 for most of this decade. "In terms of the overall picture for rural GPs, we have a fairly pessimistic view for the next 10 years," says Mark Lynch, the general manager of Rural Doctors Network NSW, the agency that brokers medical appointments in the bush.

Baby-boomer GPs are reaching retirement age; younger doctors are less willing to adopt the long hours traditionally synonymous with country practice. "I think it's going to get worse before it gets better," says Lynch, who believes communities will need to adjust their expectations of doctors and employ nurses to cover more routine work. His organisation has focused on getting the pool of medically trained individuals already resident here into the state's workforce. But depending on where they trained and how long ago, it may still be unrealistic to give some doctors a leg-up into Australian practice.

How could a prosperous nation, socially conscious and a leader in medical research, have devised a skills shortage so severe it threatens to cripple the provision of health care in some regions? From the vantage point of 2007, it seems inconceivable that only a decade ago bureaucrats feared not a doctor shortage but the oversupply of medics. The wanton distribution of Medicare provider numbers, they thought, would lead to a blow-out in health care costs. Strict containment of student numbers was the solution.

Professor Allan Carmichael says nobody anticipated how changing career expectations among medics would combine with shifting population demographics and personal expectations to pull supply and demand in opposite directions.

"I don't think those factors had hit home," says Carmichael, the president of peak group Medical Deans Australia, which represents medical schools. "People are living longer and wanting access to [operations] in their 80s or 90s that even 15 years ago you'd have have thought twice about giving to people in their 70s."

Female graduates, who began pouring out of medical school in the 1980s, on average work shorter hours and spend fewer years in the workforce than men; but men, too, are less likely to accept the on-call lifestyle older doctors took for granted.

Rebuilding decimated student numbers is a hard slog, with a long lead-time. The trends to longer medical courses and sub-specialisation mean it can take 10 years before a young doctor is able to hang out an independent shingle.

Commonwealth bonded scholarships to tie graduates to rural communities were introduced from 2004. Medical schools may now offer full-fee places - at first capped at an extra 10 per cent on top of the public student allocation, then moved to 25 per cent, and from this year uncapped.

But those are tweaks compared with the expected effect of an explosion in the number of young medics set to graduate over the next decade. Enrolments in medical courses are tipped to surge from about 2100 this year to 3500 by 2010 - courtesy of new schools at the universities of Wollongong and Western Sydney, and several others around Australia, as well as rising intakes at established medical schools. That, though, is only the beginning of the story.

Students need lecture theatres, course materials and a teaching skeleton. New doctors still on training wheels also need the opportunity to rehearse their new-found skills under close and supportive supervision, until they have the confidence to practise independently.

Professor Allan Spigelman believes the transmission of those clinical skills is the biggest looming bottleneck in turning out the next generation of doctors.

In part, it is a matter of sheer volume.

Postgraduate training, traditionally, happens in the public hospital system, but it is here - where urgent cases frequently bump planned operations off surgical lists - that it may be hardest to ensure a trainee gets all the experience they need.

In the public system, Spigelman says, "there's very good emergency operating exposure for trainees … but you do need that mix [of routine operations] - hernias, gall bladders".

And medical practice has moved on. "The majority of elective surgery gets performed in private settings," says Spigelman, professor of surgery at the University of NSW and clinical associate dean at St Vincent's Hospital.

The private system - heavily underwritten by the Federal Government's private health insurance subsidies - will have to take on its share of the training burden, Spigelman says, and the Federal Government has recently begun to allow private hospitals to bid for registrar places.

But that raises a different conundrum: how to present the idea to a patient that a trainee will remove their cataract when they have paid good money to be able to choose an elite surgeon. "How are we going to ensure they cannot only watch, but do?" Spigelman asks.

Beyond the practicalities of shunting an expanding roll call of juniors through their paces, Spigelman believes cultural shifts within medicine may inhibit long-standing informal training practices.

The present generation of senior doctors undertook their medical degrees largely free of charge, on Commonwealth scholarships. "The majority see [training] as handing on the baton … that they have a moral and ethical obligation to train the next generation, in a pro bono fashion," he says.

But a new generation of full-fee paying medical students may carry heavy financial debts without a comparable debt of gratitude, breaking that unspoken social contract.

Joga Chaganti has had more cause than many to reflect on how to balance what medicine has given to him against what he can contribute through it. In Sydney, his research will focus on cellular changes in the optic nerve that might predict the course of multiple sclerosis and HIV-related dementia.

"To be what I am today, the huge experience I have behind me, the money that was spent on my education by my hospital, by society, that has been a loss [to India]," the Hindu doctor says. "If and when God permits, I want to set up at least two or three primary health care centres for people in need in my country, even if I don't go back."

However, as he points out, the brain drain works two ways. His home town of Bangalore, an information technology centre, draws foreign specialists from around the world.

For now, Chaganti has applied for permanent residency, and his wife, also a radiologist, is applying for the right to practise here. "I can't look at the far distant future," he says. "We would like to stay here until my children settle down."

There has always been a mismatch between medical student numbers and projected demand for doctors. This is due to many factors including:

• the long lag time between the intake of medical students and their permanent placement as a specialist or otherwise,
• doctors go through various stages in their careers, and that there is fluctuating demand for junior and senior doctors at the same time,
• the variety of specialty paths that doctors can follow, and the fact that not all specialties are equally in demand,
• the resources available for medical training are supervised and assisted at many levels, between universities, hospitals, medical colleges and societies, State and Federal Governments, not all of whom agree or even talk to each other,
• the rapidly increasing health expectations of the community and the medical community,
• the widespread lifestyle changes adopted by current-generation doctors (more part-time work, fewer solo practices),
• the temptation of quality, well-paid overseas postings.

All of the first-world countries use overseas doctors as a flexible employment pool - to fill in vacancies caused by a lack of effective workforce planning and fluctuating demand. I'm not saying that managing medical workforces are easy... after all, the way that we do it currently is more like one hand trying to control global warming while the other tries to stop it raining in Beijing. Hmm... maybe that didn't make sense.

Unfortunately for the developing nations that invest great amounts of money in training these doctors who get sucked into the brain-drain vortex, they lose money and staff at a steady rate, while we gain cheap labour, and a workforce that will just go elsewhere when either we or they are tired of the arrangement.

Doctors and Terrorists

The Glasgow car-ramming incident and the attempted car bombings in London have featured heavily in the news recently, even more so because the alleged perpetrators have been identified as doctors, and further links to doctors and health professionals in the UK and Australia are being pursued.

These were deplorable acts, and serve no positive purpose.

I am not really interested in commenting on these events, because I think that it says little about the medical profession.

I am, however compelled to comment on this opinion article by Dr Tanveer Ahmed: The Rough Road from Carer to Killer

I'm sure that Tanveer is a smart guy. He certainly does his share for the AMA and Doctors in Training. I lost his point a little though. Is he saying that there is a concrete link between doctors and terrorists or not? Does being a doctor make you more likely to be a terrorist?

A few examples of radicalised doctors mean nothing to me. Every few months I get a newsletter from the Medical Board describing cases of doctors who have made various ethical errors. Does that mean that being a doctor makes you unethical?

I suspect that he has no intention of implying that doctors are more likely to become radicalised, or that radicals are more likely to be Islamic - but that is how his article comes across. I think his purpose was merely to point out the ironic juxtaposition of a healer being a killer, but that message is lost in the rest of the text. In reality, I think all that he does is reinforce a social stereotype that you might see in a bad Hollywood movie.

As far as I am concerned, doctors are just people. And sometimes people do bad things. There you go.

Mind the Gap: Part 6 - Public Hospitals

This is Part 6 of a series outlining the Australian Health Insurance industry from the perspective of a health provider.

6. Public Hospitals

Public Hospitals have nothing to do with Medicare. They get their money from State and Territory Governments, charities, donations, and anywhere else they can make money (for example, raffles and lotteries). They then spend that money on treating as many patients as possible.

Most Australian State and Territory Governments decide how much to pay a hospital based on factors like how many patients go through the emergency department each day, how many patients live in the area of that hospital, what kind of diseases the hospital treats in a particular year and also how many and what type of operations are performed at that hospital. This is called a "Case-Mix" system. As a response, hospitals like treating conditions that make them money (such as gastroscopies, colonoscopies, haemorrhoidectomies, orthopaedic surgery, coronary angiograms or heart bypasses) and not so much treating those that lose money (cancers, difficult infections, major operations where patients are in hospital for a long time). That doesn't mean that they don't treat them, just that the accountants get unhappy.

In order to keep hospitals on their toes, the Governments also penalise hospitals by taking money away if they do anything that makes the Government look bad, such as having long waiting lists, people waiting in the emergency department for more than 4 or 12 hours, or going on ambulance bypass because they are full. These fines are in the order of about $10,000-$100,000 for each occasion or unmet target. Therefore hospitals will do almost anything to meet these targets and avoid being hit with penalties, even if it means not paying staff or cutting back on "financially viable treatments". In many cases, hospital budgets are "make or break" depending on the extent of these penalties, and usually there is a mad rush to meet targets in the few weeks leading up to the end of a financial reporting period.

Doctors are paid a fixed salary by the hospital for all of their work (including ward rounds and operations), and usually there are arrangements to pay for overtime or extra work that is not rostered or expected beforehand. As in all industries, the more work the hospital can squeeze out of its staff without paying them, the better their bottom line.

As a secondary concern, public teaching hospitals are also responsible for the teaching and training of medical students and postgraduate doctors. Where hospitals have strong undergraduate teaching alignments with universities, there may be arrangements for universities to pay the hospital directly (in particular, teaching costs associated with clinical tutoring of full-fee paying medical students from private universities), or indirectly (e.g. funding part of the salary of clinical staff for their academic duties, contributing to infrastructure costs and building works, etc.). Besides community kudos, there is little or no money in this, and no effective outcome measures exist or are employed to measure performance in this area. It is therefore often ignored and the quality of teaching declines year by year.

Major public hospitals also receive some extra money for research through public and private sector research grants. This, rather than undergraduate or junior doctor teaching, is probably responsible for the alignment of hospitals to university departments.

Just like private hospitals, public hospitals are more than happy to treat privately insured patients, as they then get reimbursed from the Private Health Insurer for some of their costs and therefore more money can go to treating uninsured patients.

While privately insured patients do not get any special treatment in a public hospital, they may feel good because they are effectively making a donation to the public hospital. They also benefit from the fact that major public hospitals are usually better equipped and have more round-the-clock medical staff than private hospitals, and are therefore better at managing very complex or critical patients than small private hospitals. An added benefit is that due to the profit incentive, many public hospitals will pay for any excess payments incurred by the patient on their policy, which means that subsequent admissions to a private hospital later in that year will be excess-free.

With the Federal Government's Lifetime Health Insurance drive in 2000, many patients took out very basic health cover, essentially private insurance when treated in a public hospital only - effectively a Clayton's Private Health Insurance policy: a policy which is good for everyone except the patient. Thankfully these policies are becoming less common as they are gradually withdrawn from the market by Health Insurance Companies.

Sydney Hospital from Wikipedia

• Public hospitals chase private patients
  
• Performance bonuses for veterans hospitals
  
• Abbott proposes private management of public hospitals

More on this series next week.

Where is everyone?

All of a sudden everyone has gone private... It started with BB when she was outed, as was Dr Flea, but now Dr Dork and Tea at Ten have gone subscription only.

Perhaps it is in bad taste, but medical bloggers seem to be dropping like... Fleas.

Obviously there are times and authors who overstep their boundaries, but I think it is sad that they cause other bloggers to become so afraid of the consequences of what they say that they have to restrict readership. Perhaps we should just learn to think twice about what we write. Surely it is common sense to publish your opinions only if and when you are prepared to stand by them, outed or anonymous?

If nothing else, I think that this will only limit the range of discussion and variety of opinion, and encourages inbred opinions and closed minds.

Of course we like comments from people who agree with us, but part of the whole point of blogging is to broadcast to, and then in turn listen to those who don't agree with us.

Call me stubborn, but I won't succumb to this trend. At least not easily. Let's see how long I last.