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MARCH/APRIL 2011

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Conversation Killer Do doctors make bad conversationalists?

Altruism in Medicine

Is it declining? Part Two: The Reason Why

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Highlights

08 12 18 26

Are Doctors Dull at the Dinner Table? Conversational habits of medicos

Altruism in Medicine ...Is it Declining? Part 2: The reasons why

Research Fraud in Anaesthetic Journals

Why you can't always believe what you read

Closed-Loop Anaesthesia

How close are we to delivering anaesthetist-free anaesthesia?

Departments 08 Features 30 Business & Finance 48 Risk Management 52 Careers 54 Alpha: Technology & Reviews 64 Lifestyle 66 Travel

contents 12

FEATURES

Are Doctors Dull at the Dinner Table?

Altruism in Medicine...Is it Declining?

Research Fraud in Anaesthetic Journals

Conversational habits of medicos

Part 2: The reasons why

Why you can't always believe what you read

Closed-Loop Anaesthesia

How close are we to delivering anaesthetist-free anaesthesia?

BUSINESS & FINANCE

Supercharge Your Estate

How planning can help to ensure equitable, efficient and tax-effective distribution of benefits

Investing in Health

Which new technologies or health sectors should you invest in?

Preventing Pain at the Time of Claim

Navigating your way through a life insurance claim

End of Financial Year Tax-Planning Checklist

Top 5 tax-saving tips for anaesthetists

MARCH/APRIL 2011

RISK MANAGEMENT

Downloading Indecent Images Queensland health care professionals deregistered and forced to use a chaperone

Failure to Use a Nasogastric Tube for Patient with Acute Abdomen

Anaesthetist negligent for esophagealoesophageal intubation causing aspiration

48 50

CAREERS

No Work Life Balance?

Are you sabotaging your own career?

ALPHA

Electronic Anaesthetic Records

Anaesthetic Information Management Systems Not if, but when?

The Top 5 Digital SLRs

54 58

LIFESTYLE

Floods Stink

A limited vintage for 2011

TRAVEL

Life on the Edge

The Zambezi River & the mighty Victoria Falls

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editorâ&#x20AC;&#x2122;s note was one that generated a huge reaction. We have received numerous e-mails and letters, thanking us for exposing the topic of bullying in medicine. I have been inundated with calls from victims who have since shared their experiences with me and who are now hoping more will be done to help vulnerable students, registrars and doctors in all positions. What has been most enlightening is the prompt this has given some of you to contribute on further topics linked to this issue. Many of you have also highlighted various concepts/challenges that we were unable to cover.

elcome the March/April Edition of Anaesthetic Life.

The response from the January/ February edition really got our mailbox overflowing, and your feedback forms about articles even from previous editions are still coming through in the hundreds. Your letters and e-mails have been encouraging and a delight to read. I am blown away with your support for the publication as well as your openness in sharing your vision for our future. I would, however, like to apologise for the slight delay you had in receiving the January/February edition, caused by the terrible chaos as a result of the Queensland floods. Here at Medical Life we would like to extend our support to all of you with practices and homes that were affected. The January/February edition was about starting the New Year and unveiling some issues that are often brushed under the carpet, yet affect many of you directly or indirectly. And it seems that they these topics have struck a chord. The article on bullying

If you would like to have your say and add your comments about any of our articles and engage in rich discussions with fellow readers, I would suggest you visit our website at www. anaesthetic-life.com.au which is updated regularly with all the articles featured in all our published editions. As you will have noticed, we have been advertising our Part3Course Event, which is the perfect conference for those of you eager to learn more on running your practice efficiently. Even if you have been running your medical business for some time and just feel you would like to polish up your existing skills, I would encourage you to attend to hear about the business and financial secrets of running a successful practice. The first conference is to be held on 16 April 2011 at the RACV Club in Melbourne. For further information, please register online at www.part3course.com. Regards,

Selina Vasdev Editor

The information contained in this magazine, while believed to be correct, is not guaranteed. Medical Life magazine and its directors, employees and consultants do not accept any liability for any error, omission or misrepresentation in relation to the Information. Nor does it accept any loss, damage, cost or expense incurred by any person whatsoever arising out of or referable to the Information displayed within the magazine. The Editor has the right to omit or edit contributions for style, space or legal concerns. Any view expressed in Medical Life magazines are not necessarily the view of the Medical Life Publishing. No part of this magazine can be reproduced or copied without the express prior consent of the publisher.

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MARCH/APRIL 2011

Selina Vasdev

Editor selina@medical-life.com.au

Ravi Agarwal

Business Editor Production ravi@medical-life.com.au Contributing Sources

Dr. Sud Agarwal Dr. Tanveer Ahmed Dr. Tony Blinde Dr. Richard Cavell Dr. James Nguyen The Anaesthetic Life magazine is published bi-monthly by Medical Life Publishing Pty Ltd. Anaesthetic Life & Medical Life Publishing are proud to be independent of any academic institution or professional association. Suggestions, content ideas or complete articles written by readers are welcome and will be reviewed by the Editorial Committee. Please direct all inquiries and submissions to: Medical Life Publishing PO Box 2471, Mount Waverley VIC 3149 Phone: +61 (03) 9001 6373 Fax: +61 (03) 8677 9554 Email: mail@medical-life.com.au

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LETTERS TO THE EDITOR

n order to share some of the comments that I receive, I have decided to introduce a new section—Letters to the Editor. This idea has also been supported by many of you who felt there was not enough encouragement for you to submit your thoughts to me publicly. So I take this opportunity to ask you all to take a few moments to send in your comments about Anaesthetic Life that you would be happy for me to publish in our next edition. I would like to hear more about your thoughts on our content and I am also open to your criticism about how we handled subjects and where improvements can be made. Please send your comments to editor@medical-life.com.au marked letters to the editor.

I would like to congratulate you and your team on your publication which is a refreshing and interesting read. I also commend you on your article, ‘Crossing the Boundary’. I was impressed with how you handled the subject and the level at which you discussed the behaviours associated with such an act. This is a difficult subject to approach and you have done a fantastic job— probably the best that I have read so far. Please continue the good work.

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So why trust a Anaesthetist, non-specialist with heal thyself

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Narcissism Amongst Doctors

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Depression,drug abuse and suicide amongst doctors

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TO GAP OR NOT TO GAP

- Dr M.K., WA

Out-of-pocket Costs and the Anaesthetist

BULLYING IN MEDICINE

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Growing Your Medical Practice

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JANUARY/FEBRUARY 2011

Is racial discrimination towards international doctors entrenched in Australia?

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July/August 2010

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Altruism in Medicine... Is it declining?

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Dear Editor, Hi Selina I enjoyed Karen Tonks’ article on bullying, having experienced this in my training. When I read the final fantasised reply by the bullied junior, I initially wished I’d known this information when I was bullied as a junior doctor. However, my next response was to realise that this reply would only happen in my dreams. Because, this sort of empowered reply would have been a declaration of war, only to be risked by someone prepared to lose their career. Bullying occurs within cultures which permit it. Onlookers have seen it before and possibly experienced it themselves, so they have already made a decision not to intervene on behalf of the victim. In order to win the battle, the junior doctor would have to obtain witnesses, most of whom would value their own careers, mortgages and providing for their families over truth, justice and altruism. The junior would also have to find allies in the senior ranks who often don’t care what the HR Department thinks. Then there would be the hospital administrators who are often in conflict with senior clinicians anyway, so the fate of one junior doctor may be swamped by other political battles. And asking other victims to speak up may be an isolating experience as frightened juniors didn’t want to know, or have their own plans for surviving and getting out. Certainly, communication workshops, education and powerful allies will help, but cultural change will not occur easily. In my opinion, the most relevant factor has been that of medical schools enrolling graduates, adults who have come to medicine with an identity of their own and are not as easily intimidated as school leavers.

A note of appreciation for Dr Nguyen on his recent article, ‘To Gap or Not to Gap’ (January/February Edition). I am in complete agreement about the health funds incorrectly branding their policies and presenting their features to misinform patients into thinking they are less likely to receive an out-of-pocket expense. This leaves us in a tricky situation, where we have to engage in awkward conversations with patients and manage their wrongly formed expectations. An interesting read with a legitimate analogy of why some doctors do charge gaps. That is not to say it doesn’t aggravate those doctors who don’t. Thanks. - Dr P.B.T., VIC

Please send your comments to editor@medical-life.com.au marked letters to the editor.

Anyway, thanks for raising this issue. - Dr (withheld by request)

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DULL ARE DOCTORS AT THE DINNER TABLE?

conversational habits of medicos

et’s take a moment to reflect upon the sacrifices of our partners, especially those that are not doctors. Not because of the many nights they have spent alone while we roamed sterile hallways manning overtime shifts. Nor is it because of the sudden intrusions of phones ringing in the middle of the night, piercing their REM sleep. Neither is it the countless functions, school plays or family dinners that our partners have been forced to attend alone, informing the other guests that we are too busy working. While such proclamations may be greeted with un-

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derstanding nods and tones reflecting their respect towards the serious work being undertaken, our partners remain Friday night widows and widowers. For all the things our partners have to deal with, perhaps the greatest sacrifice, which is largely unheralded, is the many hours they spend listening to us bang on about our work, detailing specific patients and their treatments and discussing our colleagues. I have attended countless dinner parties that have rapidly descended into mini medical conferences and have watched my partner’s at-

tention slowly drift away, with her backdrop being something like: ‘I’ve got a guy with myeloma that we’re giving the latest chemo to and he hasn’t responded at all.’ ‘I can’t believe this cirrhosis patient of mine who crapped all over the floor this week.’ ‘Hey, who’s that psychosis patient of yours that wanted to kill the medical superintendent?’ While I love intense banter about the latest infectious disease protocol at the hospital as much as all of you, I suspect many of our partners aren’t quite as thrilled. Few professional groups are as prone

F E AT U R E S to talking shop as medicos. There is no doubt all professional groups are likely to talk about their work when they gather, whether it is planned or otherwise. But in my experience, no other group does so with the intensity and frequency that doctors do. The most common complaints I hear from partners of doctors, including my own, is that doctors seem to forget that there is a world of work beyond their own. Furthermore, there can be an element of medical exceptionalism where we view other people’s jobs as fundamentally less stressful and less demanding when discussing it at social events. Another is our propensity for gallows humour. Talking about death, very ill patients and their ailments in a humorous light can appear insensitive. Most of us would agree that it is probably a healthy defence mechanism in the face of tragedy, loss and hopelessness, but it can appear shocking to the uninitiated. So why are doctors at the top of pyramid when it comes to talking shop?

Doctors often use small gatherings, with or without their partners, as support groups. I found this to be the case particularly as a junior doctor where the stresses were great and often undertaken in isolation. I remember as an intern resorting to drinking a glass of scotch a day when I arrived home from work. I had barely touched the stuff beforehand. So whenever the opportunity to unload with similarly placed colleagues arrived, especially if encouraged by alcohol, the impulse was to talk shop as a kind of therapy. I remember that this was also the time my partner felt my colleagues were least sympathetic to the stresses experienced in other occupations. Our educations are increasingly narrow, especially at a postgraduate level. This is perhaps the most worrying reason that doctors’ conversation can be limited.

from other fields of knowledge, the result is a narrowing of intellectual and occupational experience, limiting the broad experience that can be one of the hallmarks of engaging conversationalists. It is not cause for clamour and its urgent need for reform is unlikely to receive more funding in the latest health budget, but the conversational habits of doctors may be a problem for everybody else who loves, lives with or hangs around doctors. Next time you feel an urge to inform the table of the latest developments in your haemodialysis ward or why angiograms aren’t what they used to be, spare a thought for your company. Change the subject.

Our daily grind is often material ripe for prime time dramas, as well as lending itself to good old plain gossip

I think there are several reasons for this phenomenon. One is the obvious fact that there is a great deal of human drama in our everyday work. After all, it usually comes down to life and death. Even when it isn’t, it still involves people at their most vulnerable periods, times when they are emotionally stripped bare in the face of serious illness. Our daily grind is often material ripe for prime time dramas, as well as lending itself to good old plain gossip. As someone who works in mental health, I sometimes observe my colleagues and wonder if the attraction of the job was to have permission to madly engage in gossip about the private lives of strangers, anything from their sex lives to their drug habits, and get to call it work? This human drama makes good material for dinner party conversations and often pricks the ears of those not from a medical background. The same can’t be said when the ins and outs of a stunning merger are laid bare or when the details of a transformative administrative meeting are explained to tipsy, hungry guests.

Modern medical education is intensely detailed but increasingly specific to subgroups of specialisations. This, in part, reflects the broader economy where super specialisation is the trend in big urban centres. Why shouldn’t it also happen in medicine? As a result, something with which we can all probably relate to, many of my friends are now specialists in arenas like foot injuries alone or epileptologists or the intensive care of respiratory diseases. When such a trend is combined with long hours and isolation

Dr Tanveer Ahmed Consultant Psychiatrist, Sydney Images Page 8, "The blah blah man" by everywhereisimagined http:// www.flickr.com/photos/everywhereisimagined/4806038198/. Page 9, "hi i am not interested in what you are saying ok" by nozomiiqel http://www.flickr.com/photos/ nozomiiqel/4121753039/. Images licenced under a Creative Commons Attribution 2.0 Generic Licence http://creativecommons.org/licences/by/2.0

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F E AT U R E S

‘Altruism: unselfish concern for the welfare of others.’ ‘Selfish: chiefly concerned with one’s own interest, advantage, to the exclusion of the interests of others.’1

The Decline of Altruism in Medicine.

s noted previously, this is a problem within our profession, as some of us become increasingly disenchanted with our professional and personal lives. To recap, this can be explained (perhaps) by a number of things, particularly by the sheer pressure of population density. The Dunbar number (200), representing the maximum number of people we can meaningfully know, is a reflection of this and probably reflects our cortical wiring. Medical professionals are, of course, equally vulnerable to the consequences of this situation: seeking solitude amongst the crowd, due to the sheer pressure of the crowd.

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Altruism

ininMedicine... Medicine...IsIsititdeclining? declining? PART PART2:2:THE THEREASONS REASONSWHY WHY

F E AT U R E S

One of the changes that crept up on us whilst we were busy looking after our patients was to the way hospitals are managed. But are there other more pervasive and well entrenched causes of the decline that we should be aware of? I would like to suggest that there are a number of easily identifiable causes that fall under two broad headings. The reader who has reached this far will undoubtedly be able to think of others, but these are probably the most significant. The two broad categories are adulation of administration and the denigration of doctors. Both are a result of the medical profession taking their collective eyes off the ball and dropping it on their feet.

Adulation of Administration There was a time when hospitals were run by a small number of informed and dedicated people who were drawn from the senior medical and nursing staff, and other experienced hospital employees. In this situation, there was a clear chain of command and responsibility was in the hands of the decision makers. One of the changes that crept up on us whilst we were busy looking after our patients was to the way hospitals are managed. Quite noticeably, nowadays,

medical facilities are run primarily as businesses, by armies of people with layers of managers and assistants, most of whom have no hands-on experience with patient care. Or if they did have hands-on experience in the past, they got out of these roles as quickly as possible. There is no clear chain of command and, worryingly, responsibility lies with anybody BUT the decision makers. ‘Key Performance Indicators’ are no longer based on patient satisfaction but on ‘bums in beds’. This is problematic thinking. The deeply entrenched idea that a health care facility can be run like a pea processing plant is clearly indicative of the problems that are inherent in applying woolly theories of ‘economic rationalism’ to health care. Why is this sadly so? It takes a little thought to grasp the obvious, but people are not quite the same as peas—they are not standardised. They vary in their needs and their responses. To pretend otherwise and then express surprise is to miss the point entirely. (For details and a critique of one of the early armchair theorists responsible in large part for the present situation, see Dr. Michael Wynne’s excellent articles on Samuel’s presentation to the World Bank back in 2000.2) Administration has become a means to an end. That end appears to have more to do with furthering administrators’ careers and rewards than improvements in patient care. This is the exact opposite of how medicine arose, and awareness of this fact can be quite crushing to the embryonic altruist. It could also be the beginning of the curse of US style managed care here in Australia.3 4 We cannot allow such a situation (where grotesque sums are paid to already rich management figures whilst patients are denied the health care they need) to develop in Australia. Adulation of Administration leads to a number of related problems: Diversion of Money from Medical Care One does not have to be an economic genius to realise that if there is a finite pot of money available and if increasing amounts of this are diverted towards the

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F E AT U R E S important financial needs of burgeoning numbers of administrative bodies, then less goes towards patient care. The extreme consequences of this can be seen today in the UK. Latest raw figures indicate that the NHS now has 24,000 more ‘admin’ staff than hospital beds. The effects on staff morale can well be imagined. Monetisation of Medicine Nobody would suggest that we work for nothing. However, the early arrangements whereby a specialist accepted an honorary or low-paid public hospital post, with the attendant commitments to teaching and administration in recognition of the opportunity to earn significant rewards from private cases is long gone.

In its place, we have been forced into a system where everything has a price and nothing has value unless it adds to the bottom line and thereby improves ‘value’ for management and (where they exist) shareholders. Within the private system, the presence of such shareholders is a further burden. Clearly, money diverted to them is not available for patient care and ‘adding shareholder value’ would appear to be an unspoken ‘mission statement’. Money Mismanagement As individuals, we would not be able to run our practices and homes according to the standard ‘hospital’ model. The practice of compartmentalising available

finances and forcing departments and staff to ‘compete’ against each other for available funds is of no benefit whatsoever and causes wasted time, money and frustration. Can you imagine if your partner had to (explicitly) compete with your children for available funds? Hospitals should return to overall budgets with centralised control and impose tracking of materials and supplies to be overseen by the minimum number of capable people. Money should not be spent at financial year’s end to ensure next year’s allocation, but sensibly saved and used when necessary. Wasting money recklessly in this way is usually only done by bureaucracies funded by taxpayers, but this also seems to be the practice of various layers of administration in private hospitals, when the controlling boards lose sight of what is going on in their far flung medical empires. At the end of the day, patient care suffers and medical and nursing-staff become despondent. Divide and Conquer First espoused by Sun Tzu5 about 2500 years ago, this tactic is as effective now as it was then. Medical professionals are seriously divided, and this situation is encouraged and exploited by some administrators, both medical and none medical ... which we will discuss more of later. Denigration of Doctors

Hospitals should return to overall budgets with centralised control and impose tracking of materials and supplies to be overseen by the minimum number of capable people.

Once, a doctor’s word was akin to a message from the gods, but not anymore. This is not a bad thing. The rise of relatively freely available information on the internet, broadcast media and in magazines has helped to educate the public to a degree (but not enough to constrain various life threatening habits!!) so that they can ask intelligent questions of the medical professionals they attend. This is a good thing as long as people do not go away with the idea that what the doctor does is easy and without risk and should be priced accordingly. This way of thinking is a bit like somebody believing flying is easy because they

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F E AT U R E S only crashed in their flight simulator program twice. Unfortunately, this is not uncommon and it is not just members of the public who demonstrate such misplaced confidence. See later.

good managers?’ and ‘Why are they not content with being good nurses?’ are topics for another day.

Denigration of Doctors occurs due to a number of factors and factions:

Medical litigation is another cause for concern and loss of enthusiasm. We are victims of our own successes in that patients do not understand that life is a terminal condition and biological systems are inherently fallible (their bodies and the results of what we do for them). Consequently, there is an entire industry devoted to extracting recompense (and a percentage for a win) for often inevitable

Doctors without Degrees Pseudo-health interests which attract the gullible through the reliable efficacy of the placebo effect and by charging large fees for supportive chats and mysterious potions further undermine the standing

Interested Lawyers

failed to check his references or look at his resume and pick up easily noticeable and investigated clues. One of the consequences of this particular catastrophic maladministration is to reinforce the process whereby ALL medical practitioners are now treated as potential Patels and, in the event of any criticism or complaint, however vexatious or malicious, are subjected to harrowing ‘investigations’ by largely untrained but interested investigators. During this considered process, which usually proceeds at glacial pace, the practitioner is often unable to practice, earn money and support their family.

We are victims of our own successes in that patients do not understand that life is a terminal condition and biological systems are inherently fallible. of conventional medicine, which is somewhat harder pressed due to higher patient numbers and lower fees. There is an increasing push amongst nursing hierarchies to supplant the role of the doctor, prescribing (so far) a limited range of ‘safe’ medication without reference to the physician and positioning the nurse as a patient’s advocate, protecting them from maligning medical machinations. This is because of an overconfidence born of ignorance on the part of these nurse administrators who do not realise that medicine only looks easy because application to training and years of practice make it look so. Yet they really do believe that doctors can be replaced by ‘up-skilled’ nurses6. It is with this misplaced confidence that they teach this attitude to all nursing students from day one. There are ways to manage this situation. Look out for another interesting read ‘Sexual Politics in Medicine’. The nurse as an administrator is not confined to interference with medical matters either. It is not uncommon to see nurses ‘managing’ radiology departments and even trying to tell physiotherapists how to do their job. The questions ‘Why do they think nurses are automatically

adverse outcomes. The risk of this can be minimised by careful attention to the details of doctor-patient interaction and information, but this is still a cause of much anxiety, almost as much as that caused by the next category. Interested Lay People A critique of the ethics and behaviour of medical boards could take up all the pages of this topic and more. Whilst there is clearly a need for some oversight, the present process is out of control and quite uncaring. Contrary to their cosy messages, they are not the doctor’s friend in any way, shape or form. They are seemingly above the law, do not observe ‘rules of evidence’ and are composed of ‘interested people’, most of whom are not doctors and have little or no empathy or understanding. It is of great concern that when genuinely dangerous doctors have ‘slipped through the net’, the net is actually held by these boards who have accredited and the administrators who have employed that person. This fact is almost always glossed over. In the case of Dr. Patel in Bundaberg, for instance, hospital administration

Many careers and lives have been blighted by cavalier and carefree attitudes, impenetrable logic and protracted pseudo-legal processes. It is not uncommon that whilst the board ‘investigates’ a practitioner, they can in their turn do immense damage not only to the practitioner but also their family. The boards, of course, are not answerable to the profession and clearly care little for this not uncommon, but predictable, consequence of their institutional hypocrisy.

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F E AT U R E S

Some doctors unwisely go too far too fast and end up with massive financial commitments, and the only way they are able to service them is to take what is thrown at them and keep quiet.

Merely reading about their activities is dispiriting and depressing and a major reason for spreading disillusionment. Medical practitioners are, in fact, the only group of professionals who are assumed, often on the basis of unsubstantiated complaints, to be guilty liars and prematurely punished, until they have been proven so.

This unprofessional and dishonest behaviour quite rightly puts the gossiper in a very serious position vis-a-vis charges of professional misconduct and personal defamation. It also plays into the hands of those who would demean and denigrate the medical profession for their own personal, political and/or other short-term interests.

Much board activity would be very difficult if not impossible were it not for the next category of colleagues.

Doctors and Money

Disinterested, Dysfunctional Doctors If all the above was not enough, we also have to deal with some of our own who, through a combination of personal interests and personal problems, can do a great deal to sabotage their colleagues. And then there are those of our colleagues who make a living from appearing in the guise of ‘expert witness’ even if they a) have ceased to practice or b) have an interesting history of their own. We all know of gossips and story tellers, who gain some vicarious thrill and imagined personal gain spreading often mean and utterly destructive untruths about others, often in the most important of circumstances. We all know of doctors who exploit their colleagues from positions of seniority in various ways. Some are just ignorant, incompetent (The Peter Principle) others are wilfully mean. Secret contracts, hospital or departmental, are a good example of this. Secrecy in this matter is unnecessary and can only lead to suspicion and antagonism between those who should be co-operative friends.

ANAESTHETICLife

This is another huge topic in itself. But very briefly, anybody after years of training and dedication to their profession can reasonably expect to be able to provide a safe comfortable life for themselves and their families. Some doctors unwisely go too far too fast and end up with massive financial commitments, and the only way they are able to service them is to take what is thrown at them and keep quiet. Administrators, medical and other, obviously know this, and a number of them are not averse to taking advantage of playing on this vulnerability. This may be seen as efficient management, beneficial to their organisation (and bonuses) in the short term, but in the long term it is extremely unlikely to be beneficial to anybody7. Some Possible Solutions. 1. Recognise the constraints suggested by the Dunbar Number and organise accordingly. 2. Become involved, play their game. (EBM could be your best friend.) 3. Call mendacious administrators to account. Shine a light on THEIR wrong doing. 4. Recognise your strengths and weaknesses. 5. Stand by your friends and colleagues. 6. Reduce your vulnerability.

7. Do what you know is right. 8. Remember General ‘Vinegar Joe’ Stilwell’s motto … 'Nil carborundum illegitimi'. In Conclusion Altruism has made us the dominant species on the planet but led to serious problems of population pressure. These problems have wide ranging effects on all of us and can be compounded in our professional lives in a number of ways. The result of this is general unhappiness and demoralisation. Whilst this may, in fact, be a ‘natural consequence’ of population pressure which leads to a useful decline in fertility8, as a thinking species, surely we can do better. Simplest idea: we can work to improve the lives of others and this will then improve ours. Dr Tony Blinde References 1 Collins Concise Dictionary 2 http://www.uow.edu.au/~bmartin/dissent/documents/health/ critic_samuel.html 3 http://www.adf.com.au/archive.php?doc_id=96 4 http://www.healthissuescentre.org.au/documents/ items/2008/05/206739-upload-00001.pdf 5 Sun Tzu The Art of War.. Various publishers 6 The Peter Principle 7 Aesop’s Fables “The goose that lay the golden eggs.” On Papyrus. 8 http://www.un.org/esa/population/publications/ worldfertilityreport2007/wfr2007-text.pdf Images Page 12 & 13, "High priced medication" by Brooks Elliott http:// www.flickr.com/photos/8011986@N02/2689975613/ Page 14, "Hospital lobby escalator" by Stephen Cummings http:// www.flickr.com/photos/spcummings/2355907682/ Images licenced under a Creative Commons Attribution 2.0 Generic Licence http://creativecommons.org/licences/by/2.0

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RESEARCH

FRAUD IN INANAESTHETIC MEDICAL

JOURNALS Why you canâ&#x20AC;&#x2122;t always believe what you read

Of all the heinous crimes committed by doctors, nothing seems to provoke the wrath of our medical colleagues more than research fraud. Even though we frown with contempt at doctors who mistreat their patients, defraud Medicare, form relationships with their patients or self-prescribe narcotics, we are particularly repulsed by those doctors who cheat the wider medical community with falsified research findings.

18 22

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aybe it is the thought of ‘our own kind’ cheating us or the fact that that this is an abuse of privilege by an anaesthetist ‘just like us’ to further his own agenda (usually status, money or both).

In the anaesthetic world, the single biggest medical fraudster in history is Professor Scott S Reuben of the Baystate Medical Center, Massachusetts, USA1. Prof Reuben was a pioneering researcher who serially published in the field of pain medicine and had been heralded as one of the strongest proponents of ‘Multimodal Analgesia’. In 2009, the research journal, Scientific American dubbed Reuben, the Bernie Madoff of Medicine2. (Bernie Madoff was the disgraced former chairman of the NASDAQ stock exchange who was found guilty of the biggest corporate deception in history defrauding over $65 billion from investors.) Many anaesthetists in Australia still incorporate aspects of Reuben’s ‘scientific findings’ in their anaesthetic practice, especially pertaining to their management of intraoperative and post-operative analgesia. To date, Reuben has admitted that 21 journal articles were based on trials that never occurred. Most of these were published in Anaesthesia and Analgesia3. He further admitted that the raw data was mostly fabricated, even going as far as inventing patients. In addition, many of the co-workers who he

had allegedly published alongside were either unwilling participants or had their names forged on documents without their knowledge. Aspects of modern anaesthetic practice that were influenced heavily by Reuben’s findings that are now being questioned by the wider anaesthetic community are the analgesic properties of: •

Celebrex, Lyrica and Bextra (these are all drugs manufactured by Pfizer) 4,5,6,7

• •

Vioxx (manufactured by Merck) 8,4 Effexor (manufactured by Wyeth) 9

Reuben had received numerous research grants from Pfizer and, indeed, much of his fraudulent research which has now been retracted had been based on the analgesic properties of celecoxib (Celebrex) and pregabalin (Lyrica). It has been estimated that several billions of dollars worth of drug sales have been attributed to Reuben’s fraudulent findings. Ten of the 21 retracted papers had been published in Anaesthesia and Analgesia, a highly-regarded, peer-reviewed international anaesthetic journal. Even the

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F E AT U R E S due diligence process of an experienced editorial panel had been circumvented by the depth of Reuben’s deceptions. On 20 February 2009, Professor Steven Shafer wrote to the readership of his journal listing all 21 journals which were based on fabricated data. On 24 June 2010, Reuben was sentenced in Federal Court to six months in jail (after pleading guilty to one count of health care fraud on 21 February 2010) to be followed by three years of supervised release1. He has been on ‘indefinite medical leave’ from the Baystate Medical Center, his medical board registration with the Massachusetts Medical Board is ‘voluntary agreement not to practice’ and he no longer holds an appointment as a professor at Tufts University's medical school. 1 The second most significant research fraud of recent times is a 1998 paper published in The Lancet which reported a potential causal relationship between the MMR vaccine and autism.10 Dr Andrew Wakefield, an English general surgeon, published this ground-breaking paper in the Lancet describing this correlation. Following his radical statements, the MMR triple vaccine was withdrawn in many jurisdictions globally11 and many parents chose to opt out of immunising their children in fear of precipitating autism. Further research in Japan12 and elsewhere failed to corroborate Dr Wakefield’s findings, but he maintained his stance and continued to write about the potential link between MMR and autism. In February 2004, Wakefield was accused of a conflict of interest: The Sunday Times, a reputable British newspaper, reported that some of the parents of the children in the Lancet study were recruited via a UK lawyer preparing a lawsuit against the manufacturers of the MMR vaccine13. Following an investigation of The Sunday Times allegations by the UK General Medical Council, Wakefield was charged with serious professional misconduct, including dishonesty14. In December 2006, The Sunday Times further reported that the lawyers responsible for the MMR lawsuit had paid Wakefield personally more than £400,000, which he had not previously disclosed15. The Lancet responded to the public furore by publishing a statement

20 22

ANAESTHETICLife

There are no scientific police and most journals do not routinely check the raw data for signs of data manipulation. In essence, it is easy to cheat and even easier to get away with it. describing Wakefield’s research as ‘fatally flawed’ and then 10 of his 12 co-authors retracted their research findings en masse16: We wish to make it clear that in this paper no causal link was established between (the) vaccine and autism, as the data were insufficient. However, the possibility of such a link was raised, and consequent events have had major implications for public health. In view of this, we consider now is the appropriate time that we should together formally retract the interpretation placed upon these findings in the paper, according to precedent. Between July 2007 and May 2010, a UK General Medical Council tribunal ‘fitness to practice’ hearing found Wakefield guilty of professional misconduct and struck him off the Medical Board register17. A British investigative reporter for Channel 4 also uncovered that Wakefield had applied for a patent for

a single jab measles vaccine and was planning to create ‘autism diagnosis kits’ which he was planning to commercialise for personal financial gain18. The diagnostic kits were to be used for testing for bowel bacteria called autistic enterocolitis. Leaked forecast financials for this venture allege that the predicted revenue to be generated from sales of this diagnostic kit was to the order of $43 million.18 As a consequence of Wakefield’s fabricated research, immunisation rates in children plummeted from 92% to 73% nationally.19 This also led to a resurgence in the incidence of measles. In 2008, the number of measles cases being reported was the highest since 1997 and 90% of these were in unvaccinated children. Paul Hébert, editor-in-chief of the Canadian Medical Association Journal (CMAJ) has stated that: There has been a huge impact from the Wakefield fiasco. This spawned a whole anti-vaccine movement. Great

F E AT U R E S  Laziness – Even on the rare occasions when scientists do falsify data, they almost never do so with the active intent to introduce false information into the body of scientific knowledge. Rather, they intend to introduce a fact that they believe is true, without going to the trouble and difficulty of actually performing the experiments required.  Ease of Fabrication – With degrees of error and random spread of natural results, falsified data is relatively easy to inset without detection. There are no scientific police and most journals do not routinely check the raw data for signs of data manipulation. In essence, it is easy to cheat and even easier to get away with it. Professor Lord Ara Darzi, Former NHS Tsar and Health Minister of the UK, devotes an entire chapter to research fraud in his book entitled Key Topics in Surgical Research and Methodology 22. He subdivides research fraud in to the following categories:

Britain has seen measles outbreaks. It probably resulted in a lot of deaths. 20 There have also been calls for Wakefield to face criminal charges in the same manner that Dr Scott S Reuben did for his research fraud. So what makes a seemingly, highly motivated academic doctor who has chosen to devote his time to further science decide to fabricate his results and commit research fraud? David Goodstein21, a renowned academic at the California Institute of Technology has cited three reasons for researchers to commit scientific misconduct:  Career Pressure – Some scientific positions and academic chairs depend on the ability to receive ongoing support and funding. Where the loss of a job, academic title or status is at stake, some humans will be motivated to fabricate results.

 Fabrication – falsifying data or omission of significant negative findings. For example, Dr Scott S Reuben with his multiple publications demonstrating the supposed analgesic benefits of multimodal analgesia with COX-2 NSAIDs and Pregabalin instead of opiates.  Redundant Publications – duplicate publication of the same conclusion obtained with the same methodology in different journals. The best example of recent times is the near identical papers published by a team led by the highly respected Dr Andrew Ochroch from the University of Pennsylvania. Their article in the May 2010 issue of A&A23 on ventilation of patients recovering from bariatric surgery plagiarised an April 2009 paper in Anesthesiology24 — written by the same group. Ochroch et al issued a retraction of their A&A paper: ‘We sincerely apologize for the inappropriate and unacceptable intellectual overlap and selfplagiarism of our paper’. 25

 Plagiarism – Substantial unreferenced, textual copying of another’s work. Even though most scientific journals claim that it is near impossible to prevent a motivated author from breaching scientific integrity in his handling of research data, it is substantially easier with newer electronic technologies and with an increase in e-publishing of most published scientific material. Plagiarism can be prevented with ‘Copyscape’26 software which reguarly scans the whole World Wide Web for near-identical content and notifies the author of any such breach of copyright. Redundant publishing is being reduced now with registration of all clinical trials and the mandatory declaration of authors submitting original work about whether they have submitted elsewhere. Fabrication of data is perhaps the most difficult to detect, as this can be very carefully manipulated by the astute researcher. However, through a combination of careful statistical methodologies, it is possible to estimate the likelihood that the research data has been falsely obtained. Marris27 describes how the fabricating researcher will tend to create data which does not lie on the extremes of in terms of values within a set but which instead approximate the mean. Also the human mind exhibits ‘digit preference’ which reduces the normal variability which would be seen in authentic data. Evans et al have also devised a correlation matrix which can show anomalous relationships helping identify which data sets are too weak or too strong to be genuine data. In the wake of new technologies and increased rapidity with which research findings are disseminated, there is perhaps a greater responsibility on scientific journals to screen their content for signs of scientific misconduct. The potential for harm/death to patients because of treatment suggested by fraudulent research data has been labelled as murder. Perhaps the scientific journals should shoulder the responsibility of reviewing all raw data sets submitted by would-be authors to assess the likelihood of fraud and determine authenticity? What has emerged in the aftermath of

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21 23

F E AT U R E S

Fabrication of data is perhaps the most difficult to detect, as this can be very carefully manipulated by the astute researcher. the Reuben and Wakefield scandals is that the vast number of research fraud still goes undetected. All the fraudsters who are apprehended are usually caught through coincidental situations or where one of their co-researchers decides to act as a whistleblower. There is no rigorous system in space to eliminate the nonauthentic data. This lends the question as to what percentage of scientific data that we read is actually true and what has been concocted by doctors on the payroll of drug companies?

Dr James Nguyen

References: 17. 1. 2. 3. 4. 5. 6.

10. 11.

12.

13. 14.

15. 16.

http://en.wikipedia.org/wiki/Scott_Reuben Borrell B. A Medical Madoff: Anesthesiologist Faked Data in 21 Studies. Scientific American, March 10, 2009, Issue 54 “Retraction Notice", Steven L. Shafer, Anesthesia and Analgesia, 20 February 2009 Reuben SS, Connelly NR. Postoperative analgesic effects of celecoxib or rofecoxib after spinal fusion surgery. Anesth Analg. 2000;91:1221-5 Reuben SS, Ekman EF. The effect of cyclooxygenase-2 inhibition on analgesia and spinal fusion. J Bone Joint Surg Am. 2005;87:536-42 Reuben SS, Buvanendran A, Kroin JS, Raghunathan K. The analgesic efficacy of celecoxib, pregabalin, and their combination for spinal fusion surgery. Anesth Analg. 2006;103:12717 Reuben SS, Buvenandran A, Kroin JS, Raghunathan K. Analgesic efficacy of celecoxib, pregabalin, and their combination for spinal fusion surgery. Anesthesiology 2006;105: A1194. Reuben SS, Fingeroth R, Krushell R, Maciolek H: Evaluation of the safety and efficacy of the perioperative administration of rofecoxib for total knee arthroplasty. J Arthroplasty. 2002; 17: 26-31. Reuben SS, Makari-Judson G, Lurie SD: Evaluation of efficacy of the perioperative administration of venlafaxine XR in the prevention of postmastectomy pain syndrome. J Pain Symptom Manage. 2004; 27: 133-9. Wakefield A et al: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. The Lancet, 1998; 351, 9103. Smith MJ, Ellenberg SS, Bell LM, Rubin DM (April 2008). "Media coverage of the measlesmumps-rubella vaccine and autism controversy and its relationship to MMR immunization rates in the United States". Pediatrics 121 (4): e836–43. Honda H, Shimizu Y, Rutter M (2005). "No effect of MMR withdrawal on the incidence of autism: a total population study". J Child Psychol Psychiatry 46 (6): 572–9. doi:10.1111/ j.1469-7610.2005.01425.x. PMID 15877763. Deer, Brian. "Taxpayer cash for MMR action is stopped after £15m that stoked fear was spent". briandeer.com. http://briandeer.com/mmr/lancet-lsc.htm. Retrieved 2007-08-10. General Medical Council press office (2007-10-08). "Dr Andrew Wakefield, Professor John Walker-Smith, Professor Simon Murch: Fitness to Practise Hearings". Press release. Archived from the original on 2007-10-27. http://web.archive.org/web/20071027142725/ http://www.gmcpressoffice.org.uk/apps/news/events/detail.php?key=1970. Deer, Brian. "Revealed: undisclosed payments to Andrew Wakefield at the heart of vaccine alarm". briandeer.com. http://briandeer.com/wakefield/legal-aid.htm. Retrieved 2007-08-10. Murch SH, Anthony A, Casson DH, et al. (2004). "Retraction of an interpretation". Lancet

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18.

19.

20.

21. 22. 23.

24.

25.

26. 27.

363 (9411): 750. Meikle, James and Sarah Boseley (2010-05-24). "MMR row doctor Andrew Wakefield struck off register". The Guardian (London). http://www.guardian.co.uk/society/2010/ may/24/mmr-doctor-andrew-wakefield-struck-off. Russell, Peter (2011-01-11). "MMR Doctor 'Planned to Make Millions,' Journal Claims". WebMD Health News. http://www.webmd.com/brain/autism/news/20110111/mmr-doctorplanned-make-millions-journal-claims. Retrieved 2011-01-12. Will autism fraud report be a vaccine booster?” Associated Press. 2011-01-07. http://www. google.com/hostednews/ap/article/ALeqM5ikh0N7yFEnFGWrqH8eczGq8NGKqg?docId=b1 3613eaa5bc4836bbc8276bd4e9a654. Retrieved 2011-01-08. Ross, Oakland (2011-01-07). "Andrew Wakefield's fraudulent vaccine research". The Star. http://www.thestar.com/news/insight/article/918362--andrew-wakefield-s-fraudulentresearch. Retrieved 2011-01-08. Goodstein, David (January-February 2002). "Scientific misconduct". Academe Thanos Athanasiou, Ara Darzi. Key Topics in Surgical Research and Methodology. Chapter 23, Pages 283-290. Springer Publishing. Neligan PJ, Malhotra G, Fraser M, Williams N, Greenblatt EP, Cereda M, Ochroch EA. Noninvasive ventilation immediately after extubation improves lung function in morbidly obese patients with obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesth Analg. 2010 May 1; 110(5):1360-5. Neligan PJ, Malhotra G, Fraser M, Williams N, Greenblatt EP, Cereda M, Ochroch EA. Continuous positive airway pressure via the Boussignac system immediately after extubation improves lung function in morbidly obese patients with obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesthesiology. 2009 Apr; 110 (4):878-84. Retraction Letter for Neligan P, Malhotra G, Fraser MW, Williams N, Greenblatt EP, Cereda M, Ochroch EA. Noninvasive Ventilation Immediately After Extubation Improves Lung Function in Morbidly Obese Patients with Obstructive Sleep Apnea Undergoing Laparoscopic Bariatric Surgery. Anesthesia & Analgesia 2010;110:1360–5 http://www.copyscape.ccom Odling-Smee L, Giles J, Fuyuno I, Cyranoski D, Marris E. Where are they now? Nature. 2007 Jan 18; 445(7125):244-5.

Images Page 20 & 21, "Just_In_Jail" by Mark Strozier http://www.flickr.com/photos/r80o/1583486/ Page 22, "Project 365 #30: 300109 Never Say Die" by comedy_nose http://www.flickr.com/photos/ comedynose/3239472516/ Images licensed under a Creative Commons Attribution 2.0 Generic Licence http:// creativecommons.org/licences/by/2.0

F E AT U R E S

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F E AT U R E S

Closed-Loop

Anaesthesia

How close are we to delivering anaesthetist-free anaesthesia? 26

ANAESTHETICLife

F E AT U R E S

urrently, nearly all of us practise ‘open-loop’ anaesthesia where we, as anaesthetists, have to make a decision to maintain or change a desired target drug dose or concentration, or a desired clinical effect (e.g. the depth of the anaesthesia or analgesia). There is now emerging technology enabling the practice of ‘closed-loop’ anaesthesia, which is where automated controllers are designed to maintain a targeted effect by adapting the administered amount of drug without human interference. In closedloop control, the anaesthetist only enters the desired variable to be maintained (e.g. the target BIS score, target blood pressure or target level of muscle relaxation) and the machine does the rest.

...automated controllers are designed to maintain a targeted effect by adapting the administered amount of drug without human interference.

The minimum requirements to perform closed loop anaesthesia are: 1) A patient 2) A controlled variable that measures the relevant drug effect; e.g. BIS, haemodynamics 3) A set point for this variable, which is the chosen target value specified by the user 4) An actuator which could be an infusion pump or vaporiser driving the administration of drug 5) A controller to control the actuator, which comprises an algorithm to translate a measured value of the controlled variable to a particular action for the actuator to steer the controlled variable closer to the target value. In anaesthetics, the three key variables where most of the Closed-Loop System (CLS) research has occurred have been

in the monitoring of depth of anaesthesia, analgesia and haemodynamics. The world’s first totally automated anaesthesia system was recently unveiled by Dr Thomas Hemmerling and his coresearchers at McGill University Health Centre in Canada. They created an Integrated Monitor of Anaesthesia which simultaneously processed: • •

•

Hypnosis by measuring the EEG score Pain by measuring the ‘Analgoscore’ (a calculated score using MAP and heart rate changes from baseline) Muscle relaxation via phonomyography.

Similarly, there a variety of automated anaesthesia systems in development which utilise predesignated targets for physiological variables and modify the dose of anaesthetic agents given until the physiological variables meet the targets. This is the most basic form of CLS, as it relies on fixed targets, and patients not fitting into the parameters for the measured variables create confusion. The next level of sophistication above this is a CLS with adaptive control. In the basic CLS controller, the controller algorithms remained constant throughout the procedure. However, there are situations where the algorithms of the control gain should be dependent on the state

ANAESTHETICLife

F E AT U R E S

Actuator

Patient

Closed-Loop System (CLS) Controller sends signal to translate the measured value into an action for the actuator

Measurement of a Key Variable

Comparison to a Desired Set Point for that Variable of the patient. For example, paediatric patients may experience significant increases in heart rate with intubation, stimulation and extubation. The adaptive controller should recognise this and alter its algorithmic calculations to modify the controller response. The measured outputs of the patient are compared to the predicted response of the patient and the controller algorithms for the patientâ&#x20AC;&#x2122;s behaviour are updated continuously during the operation. Scientific inventions made in the laboratory frequently take years before they become commercialised and are available for everyday use. However,

ANAESTHETICLife

this might not be the case with CLS in anaesthesia. SedasysÂŽ (Ethicon Endo Surgery, Inc., Cincinnati, OH, USA) is a new proprietary system developed for automated sedation with Propofol that is used in conjunction with comprehensive patient monitoring. Described as computer-assisted personalised sedation (CAPS), the apparatus monitors the patientâ&#x20AC;&#x2122;s ECG, oxygen saturation, expired CO2, and patient responsiveness to auditory commands. Depending on the values and various mathematical algorithms, the system administers Propofol sedation. Operation of the sedation protocol is contingent on patient

Scientific inventions made in the laboratory frequently take years before they become commercialised and are available for everyday use.

F E AT U R E S responsiveness and the absence of apnoea or desaturation. Sedasys® is a hybrid system—more complex than an open-loop system, such as Diprifusor®, yet not a true closed-loop anaesthesia system which titrates drug against an effect measure to achieve a hypnotic endpoint. Instead, Sedasys® delivers a fixed sedation protocol and will reduce the rate of administered Propofol to protect patient safety.

To date, approval has been granted by the respective licensing authorities in the USA, Canada and Europe, paving the way for sedation to be administered by nonanaesthetists.

To date, approval has been granted by the respective licensing authorities in the USA, Canada and Europe, paving the way for sedation to be administered by nonanaesthetists. Another example of CLS available today is the Drager Zeus Infinity Empowered anaesthetic machine which is a device that controls the delivery of volatile anaesthesia and carrier gar and oxygen to ensure reaching a target FiO2, a target ET concentration for the volatile and also ensures that the lowest gas flows are used to reduce operating costs. The device also compensates for potential leakages automatically. The haemodynamic monitoring, which can be integrated as an option, feeds back to the volatile delivery system to influence the amount of volatile delivered. In addition, the machine automatically selects the most appropriate form of ventilation for the patient and adjusts as necessary, if the patient becomes apnoeic, hypopneic or fights the ventilator. Finally, the machine has four syringe pumps (Fresenius Module DPS), which can be programmed via the control panel, and an integrated medication database, which includes pre-configured default values and dosing limits for numerous pharmaceuticals, ensuring optimal intravenous anaesthesia based on both mathematically calculated presets and also haemodynamic responses.

Could this machine be the future of modern anaesthesia? Does this machine relinquish the necessity for highly trained anaesthetists? The Drager Zeus machine is already available as a fully-functional anaesthetic delivery machine. The only thing limiting its widespread uptake is the prohibitive price. Having said that, the same was said about sevoflurane, remifentanil and portable ultrasound machines, so let’s wait and see.

 Dr Sud Agarwal Consultant Anaesthetist, Melbourne

ANAESTHETICLife

How planning can help to ensure equitable, efficient and tax-effective distribution of benefits

Supercharge your ESTATE O ver their professional careers, anaesthetists will generate significant wealth. But if they have sought good professional financial advice, chances are they will finish their lives owning nothing!

For tax efficiency and due to the relatively high risk nature of their profession, it's not wise for medical professionals to accumulate assets in their own names. Therefore it's common that over lifeâ&#x20AC;&#x2122;s journey assets are accumulated in their spouseâ&#x20AC;&#x2122;s name, a family discretionary trust, their own self-managed superannuation fund and sometimes a company. Structuring your affairs through the use of such entities enables medical professionals to exercise control over assets without directly owning them and therefore provides a level of protection against litigation. Tax minimisation and asset protection through the use of such structures is a sound strategy to shore up your financial future in retirement. But what happens when you finally leave this planet?

ANAESTHETICLife

Assets owned in trusts, superannuation funds, companies and in joint names are not estate assets and cannot be passed on to chosen beneficiaries in your will. Only assets a person actually owns can be passed on in a will. Another key issue for medical professionals is the inadvertent inheritance of assets in their own names as a result of their parentâ&#x20AC;&#x2122;s death or in the situation where their spouse predeceases them. Having structured your own affairs appropriately, the last thing you want is to inherit substantial assets and the family home in your own name. This presents a number of challenges for medical professionals. Properly managed estate planning ensures that the right assets are transferred to the intended people at the appropriate time.

BUSINESS & FINANCE It involves complete consideration of a person’s assets and liabilities—whether technically owned by that person or otherwise—to ensure that the transfer and control of assets are managed to maximise the benefit to the deceased’s estate and beneficiaries. Unique control and tax issues must be addressed when passing control and assets from trusts, companies and super funds. However, superannuation often ends up becoming the entity in which medical practitioners accumulate the majority of their wealth, so we will focus on this entity. Here are some key tips and strategies to help protect your family’s wealth into the future. Superannuation, Often Your Largest Asset Given the considerable tax concessions associated with investing in superannuation, it has become for many their primary, if not only, retirement savings vehicle. This has the advantage of minimising tax during the member’s retirement, but may present considerable difficulties for estate planning purposes. Estate planning for those without a spouse or minor children, or for those who wish to leave benefits to other nondependent beneficiaries (as defined by the taxation legislation), presents a number of issues for a superannuation member trying to ensure an equitable, efficient and tax-effective distribution of their benefits. Assets in an SMSF, such as cash, direct shares, managed funds or property, cannot be left in a will. When a person dies, their interest in the superannuation fund will be paid out as a superannuation death benefit. Within an SMSF, it is the surviving trustee(s) who ordinarily makes the death benefit payment decisions. While a member can often make a direction to the surviving trustees regarding the payment of their death benefit, they cannot leave assets directly in a fund to the people they want to benefit. Generally, the payment of death benefits is governed by: • any binding or non-binding death benefit nominations the member made • the fund's trust deed

• superannuation law which sets out to whom death benefits may be paid • tax law—which determines how those benefits will be taxed. Where they have the discretion to do so, trustees will pay the benefit to those they deem to be the most appropriate person or persons in accordance with the rules of the superannuation legislation. For instance, benefits might be paid directly to your dependants, to your estate or to a mixture of both. Depending on your circumstances, special consideration needs to be given to what sort of superannuation death benefit nomination you might make. Should you make the nomination binding or nonbinding? Should the nomination direct your benefits to your estate or directly to your dependant/s? Where certainty of distribution is paramount, such as ensuring children from a previous marriage are looked after, then binding death benefit nominations are preferable. However, you will never be able to fully predict changes in laws, circumstances of beneficiaries and assets at the time of death. So as a general rule, using non-binding nominations that are directed to the deceased member’s

children under 18, and children up to age 25 who are financially dependent. Non-tax dependants can pay up to 16.5% on death benefit lump sums and up to 46.5% on life insurance proceeds paid out through superannuation. To paint a clear picture of how tax can bite if you do not have a well thought through estate plan, let's look at the case of Dr Jones. Dr Jones has $1.5m of taxable benefits in his SMSF. He also has a $1m life policy held inside his fund. Dr Jones’s wife had previously passed away, so on his death the $2.5m of benefits are paid out to his two sons, who are 17 and 22 years old. The tax consequences for his two sons on receiving the lump sum death benefits were very different. The 17-year-old met the definition of a tax dependant, so he received his inheritance tax free. However, the 22 year old was not so fortunate. Being fully employed, he did not qualify as a tax dependant so he incurred the following tax on the lump sum death benefit paid to him: • On the 750k of taxable benefits he was subject to tax at 16.5% and paid

Properly managed estate planning ensures that the right assets are transferred to the intended people at the appropriate time. estate and provide the most flexibility to be able to manage the estate in the most effective way is preferable. Tax on Super Lump Sum Death Benefits As they say 'there is nothing more certain than death and taxes'. If you do not structure your estate plan carefully and comprehensively, a death benefit payout to your loved ones can be significantly reduced due to the potential tax consequences. Generally, benefits paid to tax dependants, as defined by tax legislation, will be received tax free. Tax dependants will include your spouse,

$123,750 tax • On the $500k of insurance proceeds, because these have come from an untaxed source, he was subject to tax on this money at 31.5%, a total of $157,500. All up the older son’s inheritance was reduced by $281,250—all of which went to the tax man. Saving Death Benefits Tax Some tips in managing your affairs to negate the impact of any tax on superannuation benefits are: • operate through an SMSF where as

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BUSINESS & FINANCE

trustee you can hold tighter control • nominate a reversionary pension beneficiary on pension accounts to maintain capital inside super where possible • don’t over insure in super • maximise non-concessional contributions • implement withdrawal and recontribution strategies to increase your tax free component • don’t be too prescriptive, rather build in strategies for flexibility • include provisions for equalisation of benefits in your will. Some of the options that Dr Jones could have made available to his executors through a properly thought through estate plan to reduce this tax impost are: 1. Employing a withdrawal and nonconcessional re-contribution strategy in the fund whilst he was still alive to increase the proportion of the tax free component in the fund. Once over 60, by using his 3 year $450k non-concessional cap twice he would have converted $900k of his taxable component to tax free. The tax-free component of a super fund member account comes out to dependants and non-dependants tax free. 2. Restructuring the ownership of his life insurance policy from his super fund to his own name. This may be problematic depending on Dr Jones's health conditions at the time. 3. Use a non-binding death benefit nomination to direct his superannuation money to his estate. The distribution of his super would then be governed by his will and his executor would then have

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greater flexibility in allocating his assets across both sons in the most tax-effective manner. This would enable other estate assets with no tax consequences (e.g. the family home or cash) to be allocated to the older son with more of the superannuation assets being allocated to the younger son. To ensure all beneficiaries are dealt with equitably, it is vital that equalisation clauses be built into the will. Avoid Being a Beneficiary of Your Parent’s Estate It’s also important that you work with your parents to ensure their own wills do not leave their assets to you as a medical professional in your own name. It is vital that they build in the option for you to take your inheritance in the form of a testamentary trust. Within a testamentary trust, a trust created by will, you can continue to control those inherited assets so that they are not exposed to risks such as litigation or threats from divorce. You will also be able to distribute taxable income earned on investments held in a testamentary trust to your children at adult tax rates. This means your children can be earning up to $16k per annum each tax free–a significant tax advantage for your family that will see your parents' gift to you stretch further. A Comprehensive Estate Plan A will should be used in combination with ownership structures as they provide direction to the parties or beneficiaries involved. I favour having

a will that attempts to take control of all those other structures, including your superannuation assets, so the will becomes a very creative and powerful document which acts as the conductor of the orchestra of wealth that the client may have. But that’s not just done by wishful thinking; you’ve got to sit down and go through it thoroughly, systemically and comprehensively. It requires a good understanding of all the tax and other laws, and certainly requires someone with a creative mind. This is not something that can be done in a hurry so, generally, it costs money to do this properly, but it’s usually money well spent. Roger Wilson is a Partner – Wealth Management at Lachlan Partners. Lachlan Partners is a private client advisory firm with offices in Melbourne, Sydney and Brisbane. www.lachlanpartners.com.au or telephone (03) 9605 9200. Disclaimer: This advice may not be suitable to you because it contains general advice that has not been tailored to your personal circumstances. Please seek personal financial and tax advice prior to acting on this information. Before acquiring a financial product a person should obtain a Product Disclosure Statement (PDS) relating to that product and consider the contents of the PDS before making a decision about whether to acquire the product. The material contained in this document is based on information received in good faith from sources within the market, and on our understanding of legislation and Government press releases at the date of publication, which are believed to be reliable and accurate. Opinions constitute our judgement at the time of issue and are subject to change. Neither, the Licensee or any of the National Australia group of companies, nor their employees or directors give any warranty of accuracy, nor accept any responsibility for errors or omissions in this document. David Davidson Financial Services Pty. Ltd. trading as Priority Life is an Authorised Representative(s) of Apogee Financial Planning Limited ABN 28 056 426 932, an Australian Financial Services Licensee, Registered office at 105 –153 Miller St North Sydney NSW 2060 and a member of the National Australia group of companies.

Protect your investments in 2011 and get a FREE consultation to make sure you are on track! 2011 is shaping up to be a challenging year for investors - getting the right advice will make all the difference. Lachlan Partners is bringing together some of Australia’s foremost experts at their key seminars to be held in March 2011 across the Eastern Seaboard. Our eminent speaking panel includes Chris Caton Chief Economist BT Financial Group ‘Global Economic and Market Outlook’

Brisbane

John Marasco Paul Saliba Managing Director Investment Services Chief Investment Officer Colliers International Lachlan Partners ‘Investing in Commercial ‘Dynamic Approach to and Residential Properties Asset Allocation - Applying what is happening the new Zone System’ Australia and Globally’ Seminars are being held in the following locations Sydney Melbourne

Tuesday March 8th 2011 2 - 4pm The Novotel Brisbane 200 Creek Street, Brisbane QLD

Wednesday March 16th 2011 7.30 - 9.30am The Portside Centre, Level 5, Symantec House, 207 Kent Street, Sydney NSW

Thursday March 31st 2011 4.30 - 6.30pm Level 1, Crown Towers, 8 Whiteman Street, Southbank VIC (Free Parking Available)

Lachlan Partners is a Private Client Advisory Firm focused on client needs and financial goals with offices in Melbourne, Sydney and Brisbane. REGISTER NOW AS SEATS ARE LIMITED To attend, obtain a Seminar DVD, receive a 3 month complimentary subscription to Investing Times or a free consultation email your details to update@lachlanpartners.com.au Investing Times, Australia’s foremost independent newsletter providing financial and investment wealth creation strategies since 1971. www.lachlanpartners.com.au Telephone 1800 643 631 (Freecall)

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BUSINESS & FINANCE

INVESTING IN HEALTH Which new technologies or health sectors should you invest in?

e’re an ageing population, and more importantly we are demanding better and more effective health care. As a result, industries related to medical technologies and health services are increasingly in demand. Which of these medical technologies and health service providers have you have you heard of and which should you invest in? Established companies Investing in these larger listed companies will offer you a nice slice of the healthcare pie. Let’s see what these well-established healthcare companies are doing. Medical Technologies CSL CSL’s business is in health care; it is involved in producing life-saving products derived from human plasma, pharmaceuticals and diagnostics essential to community health, and animal health vaccines and diagnostics to protect livestock and companion animals. An ageing population means a greater demand for blood plasma products. CSL has significant scale which enables it to lower its costs considerably. It also has pricing power, given that it controls supply. Recently, the strength of the Australian dollar has negatively impacted earnings; however, we expect exchange rate volatility to settle down over time which will allow CSL to deliver improved earnings. The other risk to CSL remains regulatory changes from governments which may prevent them from charging their current prices.

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CSL’s Environment rating from EcoInvestor has recently been increased from 4 to 5 stars. The company has also published its first Corporate Responsibility report detailing significant improvement in its environmental performance, particularly in its energy and water use. Total Shareholder Return (average annual rate): 1 year 10.2%, 10 year 13.6% Sonic Healthcare Sonic Healthcare Limited (SHL) is an international medical diagnostics company, providing pathology and radiology services in Australia, the UK, US, New Zealand, Germany and Hong Kong. SHL´s competitive advantage is aligning the interest of its pathologists and radiologists to grow revenues through profit share agreements. Strong cash flow generation means the balance sheet remains healthy and healthcare expenditure is set to increase faster than inflation as the population ages and the demand for services increase. Combining this with acquisitions will lead to increased earnings growth over the next five years. Sonic has recently announced the acquisition of Cen-

tral Coast Pathology Consultants (CCPC) located in California, USA. Given that the acquisitions of their centres in the US and Europe are sunk costs, these operations should soon start to deliver earnings growth. While domestically, Sonic’s operations have consistent cash flow and good scale which makes it difficult for competitors to enter the market. The main risk to continued growth is a policy shift by government that would reduce diagnostic expenditure. Total Shareholder Return (average annual rate): 1 year -9.3%, 10 year 7.4% Natural Medicine Blackmores Blackmores (BKL) manufactures and markets vitamin, mineral and herbal supplements and natural beauty products throughout Australia and South East Asia. Health awareness and educa-

BUSINESS & FINANCE

tion is also offered. Blackmores provides customers with access to a team of health experts to give advice on natural healthcare, research findings, issues, news and information on products. Healthy living is part of their corporate culture. Staff are served healthy meals at the staff canteen, and have access to a fitness program at the local health centre. Looking after the environment is also important. In 1995, the company’s warehouse and distribution centre won the Environment Achievement Award for Industry in the Warringah area, for initiatives to reduce waste, water, and energy consumption. The management of Blackmores has an excellent track record. The brand remains well-trusted and this means that replicating their success is difficult. Additionally, demand is increasing for complementary medicines, as they are accepted as more mainstream. Blackmores continues to look to expand to

Asia, however, at this time, it is focused domestically. Total Shareholder Return (average annual rate): 1 year 46.80%, 10 year 23.00% Health and Medical Services Primary HealthCare Primary Health Care Ltd (PRY) Limited provides a range of services and facilities to those medical professionals that run their own practices at its medical centres, licensed day surgeries, specialist and dental clinics. The group’s earnings proportionally by area are as follows: Pathology 40%, Medical Centres 40%, Radiology 15% and Health Technology 5%. The group has recently established new centres in Victoria and the Australian Capital Territory. With these new additions the group now has a total of 31 large scale medical centres. Additionally, the group also owns and operates

SDS Pathology located at North Ryde, Sydney. The laboratory services Primary Health Care’s Medical Centre’s and other practitioners and health care providers. The medical centres are a lucrative part of the business with EBITDA margins running at 55%. These high margins deliver a great return. However, there is a risk that they may be reduced if the government looks at cutting costs and rolling out public healthcare centres to alleviate the pressure on hospitals. Total Shareholder Return (average annual rate): 1 year -13.1%, 10 year 3.0% Medical Property In addition to the above sectors, you can look at investing in hospitals and medical centres. Australian Unity Healthcare Property Trust

ANAESTHETICLife

BUSINESS & FINANCE However, they do have an opportunity for growth as government is committed to spending on IT infrastructure for the healthcare sector. As the business risk remains high, this stock would only be suitable for investors with a high risk appetite. Total Shareholder Return (average annual rate): 1 year -87.2%, 10 year -12.8% Medical Technologies Here are a few medical technology companies involved in a range of medical treatments: • • The Australian Unity Healthcare Property Trust owns the physical infrastructure supporting the healthcare system, including the land, bricks and mortar of hospitals, medical clinics, nursing homes, day surgeries, consulting rooms, rehabilitation units, radiology and pathology centres. The properties are geographically diverse and include regional areas, such as the Ipswich Medical Centre and Day Surgery, and Illawarra Private Hospital. Some of the major tenants include Ramsay Health, Sonic Health, Vision Group, Calvary Health, and Healthscope. The wholesale fund has returned 7.65% over the past 12 months, and 11.27% pa over the past 5 years (for the period ended 31 January 2011). Ramsay Healthcare Ramsay Healthcare Ltd (RHC) has a mixture of acute surgical, regional and psychiatric hospitals which are located throughout Australia. They have grown to a global group with operations in the UK, France and Indonesia. Certain hospitals hold a competitive advantage over other participants, because Ramsay hospitals have a superior location, reputation and scale. There is also scope for further growth as they take their business model overseas for further expansion. It is also important to note, however, that as a private hospital operator, Ramsay is reliant on the health of the private insurance industry. Any regulatory change or economic weakness could result in a contraction of spending which could deprive the private industry of funds.

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Total Shareholder Return (average annual rate): 1 year 43.6%, 10 year 26.0% New companies If your risk appetite is large and you are keen to support the new players in the market, then you might like to consider the following companies which are making medical advances. Medical IT iSOFT Group iSOFT Group Ltd (ISF) provides healthcare information systems and e-health services to public and private hospitals as well as community and primary care organisations. Installations are in hospitals and clinics in the UK, Europe, Australia, New Zealand, Asia and the Middle East. The technology and communication solutions are designed to connect providers, payers, patients and communities. The software works across hospitals, clinics, aged care and primary care, as well as, claims and payment processes. They also offer financial software (accounting and purchasing), and bespoke solutions. It currently has a weak balance sheet, as they are at the early rollout stage.

• • • • •

Alchemia Ltd (ACL) – develops anti-coagulant and cancer drugs Avita Medical Ltd (AVH) – regenerative and respiratory medicine Circadian Ltd (CIR) – cancer therapies Phosphagenics Ltd (POH) – bloodstream delivery systems Resonance Health Ltd (RHT) – magnetic resonance imaging ResMed Inc (RMD) – sleep and breathing disorders Tissue Therapies Ltd (TIS) – wound healing

Returns Investing in the healthcare sector has been financial rewarding. The S&P / ASX 200 Health Care Accumulation Index has risen 12.09% over the past year (to 31 January 2011). While the 5-year return is an outstanding 10.03%. If you’d like more information about the above investments, feel free to contact our office. Karen Mcleod is an Authorised Representative (No. 242000) of Ethical Investment Advisers (AFSL 276544). References: Returns information sourced from Morningstar, www.morningstar. com.au

Disclaimer: This advice may not be suitable to you because it contains general advice that has not been tailored to your personal circumstances. Please seek personal financial and tax advice prior to acting on this information. Before acquiring a financial product a person should obtain a Product Disclosure Statement (PDS) relating to that product and consider the contents of the PDS before making a decision about whether to acquire the product. The material contained in this document is based on information received in good faith from sources within the market, and on our understanding of legislation and Government press releases at the date of publication, which are believed to be reliable and accurate. Opinions constitute our judgement at the time of issue and are subject to change. Neither, the Licensee or any of the National Australia group of companies, nor their employees or directors give any warranty of accuracy, nor accept any responsibility for errors or omissions in this document. David DavidsoAn Financial Services Pty. Ltd. trading as Priority Life is an Authorised Representative(s) of Apogee Financial Planning Limited ABN 28 056 426 932, an Australian Financial Services Licensee, Registered office at 105 –153 Miller St North Sydney NSW 2060 and a member of the National Australia group of companies.

contributing

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Feel you have something you would like to share with all other Anaesthetists?

We are currently looking for articles and submissions for ANAESTHETICLife . Please email: editor@medical-life.com.au

Pain of Claim

Preventing at the Time

NAVIGATING YOUR WAY THROUGH A LIFE INSURANCE CLAIM

42 38

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BUSINESS & FINANCE

nsurance is one of life’s necessary evils. We all pay our premiums with the expectation that if we become victim to accident, ill health or other misfortunes, we can make a claim with relative ease. Even though Australia’s insurers enjoy a reputation for fairness and reliability, insurance claims are invariably a formal and complicated process requiring much paperwork, verification and negotiation. Policy wordings vary greatly and cheapest can often mean that ‘fine print’ will work to your disadvantage (although this is not always the case). This article focuses on some of the more common and preventable claims issues within the area of personal risk insurances, namely Life, TPD, Critical Illness, Income Protection, Business Expense and Needlestick covers. 1. Meeting the Definition of Disability

2. Events covered under Critical Illness

Medical specialists have a very unique skill set which is naturally dependent on their physical function. For this reason, the definition of disability is perhaps the most important term in a Disability Insurance policy such as Income Protection or Total & Permanent Disability (TPD). Better definitions will not only be occupation specific, they will also contain criteria that are both reasonable and realistic. To illustrate, an anaesthetist with a broken leg may still be able to see patients both pre- and post-op. A serious problem can therefore arise when a policy requires the individual to be unable to perform ‘any occupation’ before paying out a disability claim. Similarly, a policy that requires the inability to perform ‘all of the duties of one’s occupation’ is much more difficult to satisfy than say, ‘one of the important duties of one’s own occupation’. The most progressive of definitions for selfemployed specialists will actually allow the claimant to work up to 10 hours per week without any reduction in their claimable benefits.

Critical Illness cover (also called Trauma) provides a lump sum benefit on diagnosis of defined events, irrespective on one’s ability to work. This makes both the breadth of the illnesses covers as well as the quality of their definitions of paramount importance. Today’s insurers compete by adding claimable events. Recent additions include diabetes, rheumatoid arthritis and severe burns. It is not uncommon for older policies to be missing what are now fairly standard events such as benign brain tumours, blindness, cardiomyopathy and kidney failure. The introduction of partial payments for early stage cancers and partial blindness and deafness make such upgrades even more important. Surprisingly, these conditions can generally be added without the need to pay any more for your Trauma cover (however, you may need to have your application accepted as part of the insurer’s underwriting process). Be sure to upgrade your policy ahead of such an event or before other changes to your health make the upgrade unviable.

The most progressive of definitions for self-employed specialists will actually allow the claimant to work up to 10 hours per week without any reduction in their claimable benefits. ANAESTHETICLife

BUSINESS & FINANCE

3. Disclosure Matters Before you enter into a life insurance contract, you have a legal duty to disclose to the insurer every matter you know is relevant to the insurer’s decision. Your failure in meeting this duty when taking out the policy is the main ‘get out’ clause an insurer will consider when called upon to pay a claim. Conversely, thorough and thoughtful disclosures at the time of application will typically lead to a smooth claims process. There is often a tendency for applicants to assume that one’s medical issues are not worth noting, as they are not all that serious or are now long since passed. It is, however, prudent to err on the side of caution here. It is also important to note that your Duty of Disclosure continues until you are informed that your application is accepted. For this reason, it is important to have your applications progress through the underwriting process as effectively and efficiently as possible. A lack of specialist advice and assistance in this area can mean serious problems during a future claim. 4. Fast-Tracking the Claims Process Disability and Critical Illness claims will always require reports from the treating doctor/s. Alert them to this requirement and be sure to obtain the required forms as soon as possible, so that you are appropriately prepared during your next visit. It is also important to establish your first medical consult for the illness or injury that is the basis of your claim and most insurers start to count down the ‘waiting period’ from that first visit. Consequently, seeking medical advice sooner will only help you get paid faster. During most claims, insurers will conduct due diligence around your medical history to confirm that you had not failed to disclose any facts of material importance. The primary method of this

There is often a tendency for applicants to assume that one’s medical issues are not worth noting, as they are not all that serious or are now long since passed. is for the insurer to obtain your Medicare history information after receiving your authorisation. It is common for Medicare to take up to 6 weeks turnaround in providing this information, so it is crucial to get this form signed and sent to your insurers as soon as the claim is lodged. 5. Knowing When a Claim Can Be Made Which would you expect is more common: the policy holder puts in a claim when they have now valid claim or the policy holder who fails to put in a claim when they are actually entitled to a payout? In our experience, it is the later. This is partly due to the comprehensive nature of many policies today. Two recent examples from our practice include a lawyer paid out several hundred thousand dollars following a Clark Level 3 melanoma and an accountant who was paid a similar amount for having had heart valve surgery 2 years prior. Both clients had no idea that they could make a full claim under their trauma policies until it was explained to them as part of their insurance review process. Since the problem is about failing to understand a policy’s provisions rather than a lack of medical understanding, it is common for medical professionals to fail to realise a claim can be made. One of our surgical clients recently required several days of hospitalisation for having his gall stones removed. Even though the ‘waiting period’ on his income protection was the standard 30 days, he was able to make a claim on account of

being confined to bed and under medical supervision. Another medical specialist client reported a clavicle fracture from a recent skiing trip. He had concluded that no claim could be made, as he was back at work prior to the end of his waiting period. Again, his policy allowed for such a claim under the ‘Specified Injuries’ feature of his professional-grade policy. It is fair to say that some claims are too small to bother with. Nevertheless, it is worth knowing your potential claim— something your adviser should be able to explain to you with minimal effort on your part. 6. Claims Assistance Navigating your way through a claim can be an arduous process during a time that is invariably stressful and emotional. Even insurers with an excellent claims service require claimants to call 1300 numbers, fill in a barrage of forms and then take weeks to process basic tasks. It is therefore important that you and your loved ones have someone reliable and competent to assist with the process. As issues arise, it can be invaluable to have someone in your corner to negotiate a successful outcome on your behalf. Just as insurance needs to be in place prior to a claimable event, appointing the right people to help you and your family must be done prior to your time of need.  Aaron Zelman is a partner of specialist risk advisory firm, Priority Life. He can be contacted at aaron@prioritylife.com.au, 1300 12 24 36 or after hours at 0412 366643.

Disclaimer: This advice may not be suitable to you because it contains general advice that has not been tailored to your personal circumstances. Please seek personal financial and tax advice prior to acting on this information. Before acquiring a financial product a person should obtain a Product Disclosure Statement (PDS) relating to that product and consider the contents of the PDS before making a decision about whether to acquire the product. The material contained in this document is based on information received in good faith from sources within the market, and on our understanding of legislation and Government press releases at the date of publication, which are believed to be reliable and accurate. Opinions constitute our judgement at the time of issue and are subject to change. Neither, the Licensee or any of the National Australia group of companies, nor their employees or directors give any warranty of accuracy, nor accept any responsibility for errors or omissions in this document. David Davidson Financial Services Pty. Ltd. trading as Priority Life is an Authorised Representative of Apogee Financial Planning Limited ABN 28 056 426 932, an Australian Financial Services Licensee, Registered office at 105 –153 Miller St North Sydney NSW 2060 and a member of the National Australia group of companies.

ANAESTHETICLife

End of year

tax-planning checklist

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BUSINESS & FINANCE

Top 5 tax-saving tips for anaesthetists

sing the following checklist, most anaesthetists should be able to reduce their taxable income by a substantial amount. We highly recommend systematically working your way down this list with your accountant or financial advisor and seeing which of the following five categories can benefit you:

Summary 1. Defer Income 2. Prepay Tax-deductible Expenses (adhering to 12 month rule) a. Medical indemnity fees b. ANZCA College, ASA fees, AMA fees c. Prepay all travel expenses and registration fees for next yearâ&#x20AC;&#x2122;s anaesthetic conferences d. Billing agency fees e. Purchase any educational expenses (e.g. medical books) f. Purchase any work-related equipment (< $1,000) including laptops, software, mobile phones, PDAs g. Prepay interest on business related loans (e.g. car loans, equipment finance, rooms fit-out finance) h. Prepay anaesthetic group fees for the whole financial year ahead 3. Scrap obsolete equipment to bring forward the unused depreciation valueâ&#x20AC;&#x201D;for anaesthetists this could be their old ultrasound machine. 4. Superannuation Contributions a. Up to $25,000 concessional (under 50 years of age) b. Up to $50,000 concessional (over 50 years of age) c. Non-concessional contribution of up to $450,000 in any three-year period 5. Prepay interest on investment loans used to purchase investment property or shares.

ANAESTHETICLife

BUSINESS & FINANCE Anaesthetists are a relatively homogenous bunch when it comes to income and expenses. The expenses are relatively fixed for the majority and usually consist of the following categories. (The example given is for an anaesthetist who typically works 35 hours private practice with a 10 hours/week public VMO commitment):

Work-Related Deduction Medical Indemnity

15,000

Anaesthetic Group Fees/ Billing Agent Fees

25,000

Conferences/ CME (books, travel, conference registration, hotels, courses)

15,000

Work-Related Travel (car, petrol, insurance, maintenance, loans)

15,000

Income Protection Insurance Premiums

10,000

Mobile Phone Costs

2,000

Home Office Costs (stationery, lighting, heating

4,000

Professional Subscriptions and Memberships (ANZCA, ASA, AMA)

5,000

Total

Anaesthetists are a relatively homogenous bunch when it comes to income and expenses.

ANAESTHETICLife

Typical Value (annualised) $

$91,000

The categories are more or less standard working hard is limited because for every for most anaesthetists, and the range in dollar you earn, almost a half (46.5%) costs for each of the categories are not goes towards tax. Thevaried. categories are less standard that Based onmore theseortypical figures,for most anaesthetists and the range in costs for each of the categories are not that varied. Based on these typical figures,isthere One (short-term) solution to simply there reaches a point in the financial year reaches a point in the financial year at which you have earned enough money tobills payuntil not submit any more patient atfor which you professional have earned expenses. enough money all these the following financial year. However, this to pay for all these professional expenses. usually means you have merely deferred Then later in the year, there reaches a your tax liability until the next financial point where you have earned enough year so is not really a well thought out to cover all the expenses and $180,000 strategy. above this to reach the top end of the 37% In reality, the only way to circumvent tax bracket. All taxable income (after this issue is to build your wealth (the expenses) above $180,000 will be taxed asset value of the possessions you own) at the highest rate of 45% (plus 1.5% in a low-tax environment. So how do you Medicare levy). achieve this? Here is a quick and simple The dilemma that now arises is that after summary: this point, the incentive to continue

BUSINESS & FINANCE If a typical good investment generating a 10% growth per annum is owned by an investor with a marginal tax rate of 46.5%, and all the return from the investment is taxable, then the after tax rate of return will be 5.35% of the original investment. (Calculated as 10% x (100-46.5) = 5.35%) If we assume inflation is approximately 3%, the real post-tax return (i.e. after inflation) will be 2.35%. That reward is not enough for most of us to consider taking any investments. Why would you want to take any form of risk when a ‘good’ return will only return a meagre 2.34% after tax and inflation? Maybe it’s better to simply take some time off work, work fewer hours or just go on holiday. So how do you avoid your investment returns being destroyed by tax and inflation? You cannot do much about inflation, although staying in growth assets and avoiding non-growth assets is one way to overcome inflation. (Growth assets are items such as shares and property which provide investment returns usually in excess of inflation. Non-growth assets are items such as fixed-securities or cash deposits whose returns are eroded by inflation). What you can do is reduce the tax applied to your investment returns by following these three simple rules: •

Choose investments where the return is either tax-free or concessionally taxed.

•

Choose tax efficient legal structures, or combinations of legal structures, i.e. legal structures that are taxed at a rate less than the top marginal individual tax rates, i.e., use companies, trusts and SMSFs (selfmanaged super funds) to hold your

investments. •

Choose concessional (i.e. deductible) super contributions and non-concessional (i.e. nondeductible)

Here are the typical investment strategies we would offer anaesthetists to accumulate wealth through tax-savvy investment plans: Superannuation Fund

Make sure you buy a home, structure your debt so you can pay off your home as early as possible, and then reap the rewards of any rise in value of this asset being CGT free.

Building up wealth and assets in your SMSF is a great opportunity for nearly all anaesthetists. This money is concessionally taxed when it enters the super fund, capital gains are taxed at a modest rate of 10% and income generated from it is taxed at 15%. Superannuation, especially an SMSF, because of the additional freedom to choose your asset classes is an excellent way to accumulate wealth in a low-tax environment. Principal Place of Residence The appreciation in value of your personal home is 100% Capital Gains Tax free. Pay off your mortgage and any rise in value over the years is yours to keep untouched by the tax-man. Make sure you buy a home, structure your debt so you can pay off your home as early as possible, and then reap the rewards of any rise in value of this asset being CGT free. Negatively Geared Investment Properties Buying investment property can be a highly tax-effective means of reducing your taxable income and building up your asset base. Prepaying interest on the loans and also having an organised depreciation schedule for the investment properties allow you to maximise your taxdeductions in the immediate years. The growth in value of the properties remain untaxed until you choose to sell them (which will often be after retirement)

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BUSINESS & FINANCE

Similar to buying negatively geared property, you can buy shares in your own name or an investment entity .

or in financial year when you have lower earnings (e.g. a sabbatical year) or even in a financial year when you may incur a business loss (e.g. a share market crash). Even then, when you do dispose of the properties, they will be entitled to a 50% exemption on any CGT (if they have been held by you for over 12 months) making this a brilliant way to reduce your taxable income in the short-term and accumulate wealth over the long-term.

many of my clients). The option is there to use margin lending to gear your share portfolio. The interest for these loans for the year ahead can be prepaid making this an excellent way of bringing forward tax deductions.

Geared Share Investments

In summary, as an anaesthetist, you will have excellent access to reliable income earning capacity and a relatively low costof-sales (i.e. the fixed costs of running your anaesthetic practice will be very low compared to other medical specialties).

Similar to buying negatively geared property, you can buy shares in your own name or an investment entity (I frequently set up an investment trust entity for

The problem with working harder to generate a higher income is that this now increases your tax burden and becomes a case of diminishing returns.

Your success in building up wealth during your working lifetime depends not on how hard you work, not even on how lucrative your private practice is, but it depends on how much you save, invest and shield from tax.

ď&#x192;¨James Clyne, CA MEDIQ Medical Financial Services advises medical practices and individuals on structures, accounting, taxation and finance. Visit www.MEDIQfinancial.com.au to learn more tax and finance strategies for anaesthetists.

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RISK MANAGEMENT

You wouldn’t trust a non-specialist to anaesthetise you or your family? So why trust a non-specialist with your finances?

Specialist Medical Accountants and Financial Planners for Doctors You will never need to explain ‘salary packaging’, ‘Medicare Safety Net’ or 'out-of-pocket' fees to us because we speak the same language as you. We think we know just about every tax deduction and financial planning secret for doctors and their medical practices because that’s what we have chosen to specialise in.

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SMSF

RISK MANAGEMENT

Downloading Indecent images

Queensland health care professionals deregistered and forced to use a chaperone Dr CB was a general practitioner. Mr TG was a medical radiation technologist. Mr BG was a pharmacist. All three were from Queensland.

r CB, the GP downloaded child pornography to his home computer. He downloaded between 20 and 100 images, on a single day. Unfortunately for him, his downloads were monitored by the Australian Federal Police, who passed on information to the Queensland Police.

Mr TG, the radiation technologist paid a monthly fee to access an Internet site that contained images of child pornography. He had a password to access the site, and visited it regularly from home, but never from work. His fiancĂŠ knew that he had been accessing the images for some time. The police discovered his use of the site and questioned him about it. He admitted that he might have accessed 'possibly up to 20 images.' The police examined his computer and

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RISK MANAGEMENT

The Tribunal desires to uphold professional standards and maintain public confidence in each of the health professions. found 2,634 images of child pornography. Many of them were images of naked children who were posing in a sexual manner. Others were images of sexual intercourse between children and adults. Mr BG, the pharmacist, downloaded 3,290 images while at home. He too did not access any of these images at work. Several of the images depicted what a judge called 'sadistic sexualised violence.' Mr BG saved the images in a folder called Glock (a brand of firearm) and hid his activities from his wife. Dr CB, the GP, pleaded guilty to accessing child exploitation images and was given a suspended sentence in November 2010. Mr TG, the medical radiation technologist, pleaded guilty to possession of child exploitation images and was also given a suspended sentence. Mr BG, the pharmacist, pleaded guilty to accessing and possessing child pornography and child abuse material, and was given a suspended sentence with a $100 bond. The Queensland Civil and Administrative Tribunal then had to consider what to do about their registrations in their respective areas. Dr CB accessed all of the images in his case in a single day. The Tribunal indicated that he was driven by depression and relationship issues, and that he did not gain sexual gratification from the images he had downloaded. The Tribunal decided that because Mr TG was paying a monthly fee, and had a password to enter, the child pornography website in his case, his interest in the images was not passing or incidental. The fact that he did not access the images from work counts in his favour somewhat but that did not prevent him from being deregistered as a health professional. The Tribunal said 'it reflects upon his character that he knowingly participated in criminal conduct. This brings into question whether he possesses the qualities expected of a member of the profession.'

concern over his 'professionalism', given his knowing engagement in criminal conduct. The Tribunal said that the crimes were 'not victimless'. Disciplinary proceedings are not intended to be punitive. However, the proceedings are designed to protect the public, so deterrence is one of the matters considered by the Tribunal in deciding whether to deregister a professional, and if so, for how long. The Tribunal desires to uphold professional standards and maintain public confidence in each of the health professions. The Medical Board of Queensland said that the board was obligated to take the least 'onerous' action to protect the well-being of “vulnerable persons”, being patients under the age of 18. Dr CB was suspended from admitting patients to the local hospital. Although he was not deregistered, he is required to have a chaperone whenever he is with a person under 18 years old, for three years during his sentence. The Tribunal decided that Mr BG presented less risk to patients because he had not come into physical contact with a child, and pharmacists do not generally have one-on-one consultations with their customers. The Tribunal chose to deregister Mr BG for two years, starting March 2010. In contrast, the practice of medical radiation does involve unsupervised contact with patients, including children. Patients, including adolescents, are alone with the technologist. The lights are dimmed and the patients are in a state of undress. The technologist must touch the patient to position them correctly. The Tribunal decided that this made the radiation technologist’s case far more serious. The radiation technologist was therefore deregistered for three and a half years. The Tribunal observed that protection of the public is a primary concern in its decisions. These cases also demonstrate that actions taken by a health care professional in their private life, apparently unconnected with their work, can count against them professionally. Dr Richard Cavell

In the case of Mr BG, the Tribunal said that the offences were not concerned with his practice of pharmacy. However, there was a

ANAESTHETICLife

Anaesthetist negligent for esophageal intubation causing aspiration

Failure to Use a Nasogastric Tube for Patient with Acute Abdomen 50

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CAREERS RISK MANAGEMENT

Soon it became clear that Dr NJ had intubated the patient’s oesophagus.

Ms SW was a 27-year-old women undergoing IVF treatment. She had recently had an embryo implanted and, hopefully, was in the early stages of pregnancy. One afternoon she experienced abdominal pain, vomiting and diarrhoea.

he visited the Emergency Department of her local hospital, where she was diagnosed as having a small bowel obstruction. A surgeon decided to perform a laparotomy that evening.

The anaesthetist, Dr NJ, elected to perform a rapid sequence induction. He did not pass a nasogastric tube. He told his anaesthetic technician to apply pressure to the patient’s cricoid cartilage, and then intubated the patient. He remarked that the patient was difficult to intubate, with a Mallampati score of 2 or 3. The patient then aspirated her stomach contents into her right lung. The patient’s oxygen saturation levels fell to 50 percent and she turned blue. Soon it became clear that Dr NJ had intubated the patient’s oesophagus. The patient was ventilated with a bag and mask, and re-intubated properly. A decision was made to continue with the operation. The rest of the procedure went uneventfully. It was found that she had a closed loop small bowel obstruction, due to volvulus. After the procedure, a chest X-ray showed that she had a pneumothorax and pneumonitis. The patient sued Dr NJ, claiming that he had been negligent in three areas: Firstly, in failing to adequately pre-oxygenate her, allowing her oxygen levels to fall too low; secondly, in having intubated her oesophagus; and thirdly, in failing to pass a nasogastric tube. The judge heard evidence that before a rapid sequence induction, a patient should be given at least three minutes of full oxygenation. This should give enough time for an anaesthetist to intubate and, if an oesophageal intubation results, re-intubate the patient, without any additional need for oxygenation. Dr NJ and his technician both testified that they gave adequate pre-oxygenation. The judge heard from the patient’s lawyer,

though, that given that the patient’s oxygen levels fell so low, it was evidence that the patient had not been pre-oxygenated. The judge dismissed this ground against the anaesthetist. He was willing to accept the anaesthetist’s evidence that the patient had been properly oxygenated. Even if the patient had not been properly oxygenated, she had not suffered any damage from it. The judge was unwilling to find the anaesthetist negligent for having intubated the patient’s oesophagus the first time. Two experts both told the judge ‘this could happen to anyone’. However, the judge said that it is important to quickly recognise that an oesophageal intubation has occurred. The judge did explore evidence that questioned how an oesophageal intubation could take place while a technician applies proper cricoid cartilage pressure. However, the judge found the anaesthetist not to be negligent for the oesophageal intubation. On the last complaint, that the anaesthetist should have passed a nasogastric tube, the judge heard evidence that: Once a person is anaesthetised, the person's normal defences against regurgitation of stomach contents are ineffective. Accordingly, where a person is lying down there is a real risk of stomach contents flowing via the oesophagus and into the pharynx and then into the trachea to the lungs. One expert told the judge that it was ‘almost obligatory’ to pass a nasogastric tube in the context of an acute abdomen. This is because of the greater risk of regurgitation and aspiration. The judge said that the anaesthetist does not have a unilateral obligation to prevent harm occurring to the patient. However, the law would hold the anaesthetist to the same standard of care expected of the ordinary skilled anaesthetist. The judge found that the failure to decompress the stomach by use of a nasogastric tube amounted to negligence. The cricoid pressure technique is designed to prevent aspiration. Although it is unlikely that the technique would fail, the possibility of failure is not ‘far-fetched or fanciful’. Passing a nasogastric tube was likely to be effective and not pose any undue risk. Ms SW suffered harm as a result of Dr NJ’s failure to pass the nasogastric tube, and therefore she won the case. Dr Richard Cavell

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C A R ECE ARCAREERS RSE E R S

NO WORK

LIFE BALANCE?

Are you sabotaging your own career?

t’s the dreaded high achiever syndrome! Your career is on track—perhaps you’re further ahead than you thought you might be by now—life is fast, you have good cash flow, the luxury car is parked in the garage of your well respected home and you may also have a family. BUT you are feeling frazzled with no space to reap the rewards or to bask in your successes. In fact, you don’t even appreciate the nice car anymore; it has just become another of your many possessions. You are the superhero but it has come at a cost—at the cost of your WORK-LIFE BALANCE. You have a lack of balance and control and your values are a little out of whack. You’re on the treadmill of achievement, and you can’t find the stop button? As a doctor you are many things. You are a medical expert, a specialist, forever

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a student of medical advancement and scientific breakthroughs, a teacher, and a striving business owner. You work late, often through the night. You’re on call or have to work early. You have the lives of others in your hands but you can’t be stressed—you need to be calm, pleasant, personable and patient.

In many cases you are also a businessperson, a marketer and let’s not forget a model citizen within your community. On top of all this, alongside your role amongst your family and friends, you need to be YOU. How can any one person be all of these things? Looking at your situation it is easy to see how YOU are the first thing to lose out because you need to be so many other things first. The diagnosis: self-sabotage. Most doctors are in need of a ‘pause’ in the day, week or month, some freedom and more career satisfaction. If not, it will come at a cost of your health, relationships, career and wealth creation.

CAREERS

So how can one stop the self-sabotage and control the treadmill of medical life?

1 2

Take a good snap shot of now. What is good in my life and what is not so good? Start with a sheet of paper and some headings: Career, Education, My Health, My Finances, My Home, My Family, Fun. Under each, write a list of what your current situation is. Extremely successful and confident doctors, who are in control, do this every 6 months. Now determine the desired state that will give you what you need in your career/practice and as a person. When doctors can be specific about what they need to make their life easier, the education and up-skilling needed and their overall running of their career and practice is clear, they can then identify what changes or outsourcing needs to be done. I would bet most doctors hardly ever stop to evaluate their situation, let alone make a habit of doing so every six months—yet this is how you gain balance and better control over your busy and important role in life. Most importantly, write down your desired state! You need to clearly understand what it is you want in order to go after it and get it!

Gain clarity on what can change. Don’t think that your changes need to be big. Clearly list what you want and from that what you need to do in order to get it. Get a trainer, see a financial planner, hire a bookkeeper, a nanny, a cleaner, a gardener. Know how you want to spend your spare time and do what it takes to keep that spare time your own—it is an investment in your success. Remember, a fit doctor is a great doctor! Now it’s time to sit down, and get a vision going—a 3, 5 and 10 year plan. Write next to this where you want to be with your career, practice, health, finance and relationships. Get some real clarity on your own health, your own fun, what you want to be doing with your time, what you want to be doing with your family,friends,travel, etc. Understand what it is that you are you working so hard for and visualise it. Also consider what would happen if you couldn’t work - do you have an exit plan? Verbalise your plan with others so you become accountable—do what you say you are going to do!

Don’t just be a great doctor, be a great personal operator with balance—the rest will then follow!

Put some structure in place. Yes structure. The busiest doctors I know who commit to structure achieve work life balance. They TAKE CONTROL! They identify that to have inner confidence they have decided to take full responsibility for themselves. They are successful doctors because they have clarity and vision on who they want to be. They know what they want to do with their time and have created the space required to process and think their visions and plans through. They work their calendars and diaries to their own advantage. For example, a structure might be to have a regular trainer; a regular day off each month to review your life and how to tweak it; a monthly night out with the family, which can be booked around your schedule; or commitment to a hobby or a soft skills education. Any of these things can turn you from an achiever into a great role model and leader… A tip: Identify who is on your team. Do you have a mentor, a coach, a support crew? The best athletes and the best business people do, so you should too. Surround yourself with people who understand your vision and who can support you in owning and achieving it.

Acknowledge that balance is a choice. Doctors and those in the medical field can obtain balance. With a good vision for where they are going in life, along with a good structure to support it, the only thing left to challenge is yourself – can you do it? No matter how many patients or priorities you have, you only need a few anchors during the day to feel in control. You function more smoothly and make better decisions when you’re in control…so take control! Make it simple to begin with—slow down and choose to taste that glass of wine instead of drinking it like water or stop and enjoy the taste of your morning coffee instead of drinking it on the run. Commit to having fun at your family events rather than feeling exhausted. By understanding the four steps mentioned above, balance, or a feeling of balance, can be easily achieved. Life balance for doctors is about feeling successful and in control every day with a clear path into the future. By implementing some basic daily structure we are able to achieve this. These structures of health, fitness, personal growth and a sense of responsibility and control can give you that great feeling of energy and contentment which extends into all areas of your life including your career. Shannah Kennedy, Executive Life Strategist/ ICA Advanced Coach/ NLP Practitioner www.shannahkennedy.com

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ELectronic

Anaesthetic records

Anaesthetic Information Management Systems (AIMS) Not if, but when? It seems somewhat archaic in anaesthesia, how we manually write down what we have just done on a paper-based chart, which then gets filed away in some inaccessible location in the hidden vaults of a hospital. It would seem the true purpose of anaesthetic charts is somewhat lost due to the fact this data is: •

unreliable – it has had manual interference before being transcribed and also its transcription was retrospective not contemporaneous

•

subject to deterioration or loss – paper charts are susceptible to wear and tear

•

not available instantly when needed – paper-based records need filing which in many hospitals are both geographically remote (offsite medical records) and temporally distant (takes several hours/days for medical records to search and deliver them)

•

not able to be amalgamated, searched and audited – by not collecting our real-time data in a

standardised electronic format, we miss out on creating the ultimate tool for auditing drugs, techniques, equipment, anaesthetists, registrars, etc. In its most basic form, an AIMS is simply a collection of data about a patient and a set of logic rules which guide the anaesthetist on what to do when something is significantly wrong and when we have missed something critical. The technophobes who oppose electronic records will say, ‘We should be vigilant enough to be able to practise safely without reliance on computers.’ Although, they are correct, they could probably extrapolate the same argument to include haemodynamic monitoring, pulse oximetry, awareness monitoring, surgical checklists, as all of these are externally ‘introduced’. Like the electronic medical record, all of these act as guides that we use in conjunction with our specialist knowledge and experience to make a decision about a patient’s clinical management. In the original AIMS systems, patient data was manually entered, which naturally created the opportunity for human error. In the modern systems, most data is captured automatically. E.g. demographic data can be captured from linking in with patient management systems or

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scanning the barcode on Bradma labels. Physiological data is captured realtime from anaesthetic machines and the drugs, given intra-operatively and in PACU are recorded real-time via user interfaces. When the system is expanded to capture pre-admission clinic data, and also pain service data, the entirety of the anaesthetist’s record keeping is recorded in a single system. So why has there not been a big push for widespread AIMS installation, when the benefits are so significant? Automated anaesthetic record management systems have been around for over 20 years but they have only really been growing in clinical practice since 2007. What are the reasons for this inertia? A 2010 survey of European anaesthetic departments published in the European Journal of Anaesthesiology found that about 50% of respondents had already installed or were about to install an anaesthetic record keeping system. In the USA, a 2008 study demonstrated that around 44% of all academic departments had already installed or were committed to installing an electronic system. In Australia, all anaesthetic departments in Queensland were given a common anaesthetic record keeping system as part of the AARK project. However, the uptake throughout the rest of Australia has been

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sparse and has been significantly less than our international counterparts. The reasons given in the European and USA studies by non-adopters of electronic anaesthesia records were: •

cost

•

hassle

•

lack of support from IT departments

•

lack of perceived value.

Undoubtedly, the reasons given for the poor adoption in Australia (except Queensland) would be the same. So what are the benefits of using an electronic system? There are different levels of benefit depending on the ability of an anaesthetic department to deploy the system and make full use of it. Here is a summary of these levels of benefit: Administrative – enforces standardised data capture, record keeping, improved communication between different team members (preadmission clinic, pain service, perioperative care, etc) and facilitates retrieval of previous perioperative episode information. Operating Room Suite Management

– AIMS have the ability to integrate with current operating room management software —e.g. IPM to enable improved workflow management, tracking operational throughput, managing usage of controlled drugs, managing usage, supply and replacement of other drugs through automated procurement systems. Clinical Practice Tools – provision of radiology via PACS, frequently updated electronic pathology records, drug dosage guides, advice on drug-interactions/ allergies, provision of results from other perioperative tests—e.g. stress tests, lung function, etc. Clinical Decision Support – this takes the capture of perioperative information one step further and actually advises the anaesthetist on items such as: •

reminders to re-dose antibiotics

•

reminders to measure blood glucose in diabetics

•

calculation of PONV risk and need for prophylaxis

•

advice on the degree of invasive monitoring to use

•

evidence-based advice on which pre-operative investigations are needed based on a standardised

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pre-operative questionnaire that can be filled in by the patient themselves or a clinic nurse. E.g. if the patient is scheduled for major surgery and the patient self-reports an inability to climb a flight of stairs, then the software would stratify the patient as potentially requiring non-invasive cardiac stress testing. This decision-making system has the potential to reduce incorrect use of preoperative testing. •

real-time diagnosis of intraoperative clinical events. E.g. If the patient’s CO2 and temperature are rising after the patient had received volatile anaesthesia, then the system would advise the anaesthetist to consider the possibility of malignant hyperperexia. Similarly, a sudden collapse in blood pressure after giving an antibiotic would prompt the system to advise about the possibility of anaphylaxis.

Financial Management – data captured about the type of surgery, modifiers, the patient’s demographic data and duration of operation can be used to automate billing of Medicare and private health funds, eliminating the need to re-enter the clinical data on billing software.

Quality Assurance and Quality Improvement – this has to be one of the major reasons why medical administrators throughout Australia would welcome the AIMS. The ability to aggregate all perioperative data creates a powerful cloud of information which can be used to benchmark and assess medical providers, theatre personnel and whole departments. The data could be used to work out the mean time for a laparoscopic cholecystectomy, and any surgeon who consistently takes much more than this may be counselled regarding his practice. Similarly, anaesthetists who use excessively high flow anaesthesia in combination with Desflurane may be counselled on their inappropriate drug usage. The vast pools of data collected create a huge data-mining opportunity for research, improved patient management, workflow, patient safety, cost control, provider accreditation and much more.

organisations, will continue to drive adoption nationwide. Key challenges include a lack of interoperability, the lack of integration with current systems, usage of outdated technologies on many of the earlier AIMS systems and fear of the data misrepresenting peri-operative outcomes and being used by lawyers to affect medicolegal trials. In reality, the horse has already bolted, and it seems inevitable that paper-based anaesthetic charts will become ancient museum relics just like halothane and thiopentone within 5 years.

 Dr Sud Agarwal Consultant Anaesthetist, Melbourne

In summary, AIMS systems clearly bring a number of benefits to anaesthetists. These include the ability to provide clinical decision support, track and improve clinical performance, and potentially increase departmental revenue through the maximisation of revenue opportunities. Although AIMS are not universally present in operating theatres in Australia, increasing pressure to provide more indepth, case-based details, such to thirdparties or external quality improvement

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The

TOP

FIVE Digital SLRs

2010 was a peculiar year for the digital SLR.

or the entire first half of the year, virtually no new cameras were released. There was no news about upcoming cameras, and no indication about what the manufacturers were planning next.

And then - towards the very end of the year â&#x20AC;&#x201C; eight new cameras were released within the span of two months. Anyone considering the purchase of a new digital SLR was quite suddenly overwhelmed with options. The bad news is that you now have a lot of cameras to compare and contrast. The good news is that all of these new cameras leverage the latest technical innovations to help make your photos and videos look spectacular.

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anon long ago established itself as the dominant player in the digital SLR market.

They were one of the first to develop digital SLRs and were also the first to lower prices enough so that amateur and beginning photographers could buy them. Canon has four distinct lines of cameras: beginner, intermediate, advanced and professional. The 60D is one of their intermediate models. The 60D interests more advanced photographers for a variety of reasons. The first one is speed: a high-performance 9-point autofocus is paired with the ability to capture 5 consecutive photos per second. To further distinguish itself, the Canon 60D has a robust video mode. It captures Full High Definition 1080p video clips that can be played back on computer LCD screens and widescreen televisions.

The 60D interests more advanced photographers for a variety of reasons. The first one is speed: a highperformance 9-point autofocus is paired with the ability to capture 5 consecutive photos per second. The most notable aspect of the 60D is its LCD screen. This is the first time that Canon has applied a flexible LCD (one that flips out from the camera and rotates) to one of their DSLRs.

The flexible LCD is immensely useful when you capture video – it lets you see exactly what you’re capturing even when you’re not holding the camera right up in front of your face.

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he D7000 has two memory card slots instead of just one and you can customise how data is stored. For example, if you want to keep videos separate from photos, you can save still images to one card and videos to the other. The E-5 takes weather sealing to the next level: you can expose it to rain and dust without having to worry about damaging the camera. Like the Canon 60D, the 3 inch LCD on the E-5 flips out from the camera body and swivels 270 degrees for easy viewing from all angles. This flexible LCD can be used to capture High Definition 720p video – a first for an Olympus digital SLR camera. Those who want superior sound quality can connect a stereo microphone to a built-in port. To reduce image blur due to camera shake, the E-5 includes a built-in image

stabilisation system. This system works with any Olympus Zuiko Four Thirds® lens, and it’s a great tool for photographers who want to take pictures in dim light without flash. For creative types, the E-5 has a variety of art filters that can be applied to any image on the memory card. These filters allow you to manipulate the look of your images in camera, without having to spend extra time in front of your computer. Some of the 10 filters include Pop Art, Soft Focus, Grainy Film, Gentle Sepia and the latest addition: Dramatic Tone. Each year, digital SLRs get better at taking pictures in dim ambient light. They are able to do this because of a feature called ISO, which affects how quickly the sensor absorbs light. With very high ISO settings, you can take pictures in

The E-5 has a variety of art filters that can be applied to any image on the memory card allowing you to manipulate the look of your images in camera, without having to spend extra time in front of your computer. 60

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low light without needing a flash.

n older DSLRs, 6400 was considered a pretty high ISO. The Pentax K-5 trumps that with a maximum ISO of 51200 – the highest of any DSLR currently available. The high ISO setting would be impressive enough, but the K-5 has plenty of other features to keep photographers happy: a faster improved 11-point autofocus is paired with the ability to capture 7 photos per second. Video enthusiasts can capture Full High Definition 1080p movies and still photographers can snap blur-free shots thanks to the built-in image stabilisation.

Sony SLTA55

ven though the Sony SLT-A55 isn’t a “true” digital SLR, it still belongs in this lineup because of its unique innovation.

For landscape photographers, a built-in High Dynamic Range (HDR) mode helps to capture nature in all its glory, preserving details in every part of the image.

The K-5 is compatible with every Pentax lens ever made, great news for anyone with a collection of old Pentax film SLR lenses.

Many digital SLRs cannot leverage the power of their multi-point autofocus systems when you take video. This is due to a mirror inside the camera that reflects the image from the lens up to the viewfinder. In movie mode, the mirror must be locked up – this blocks the viewfinder and disables the autofocus system. DSLRs with mirrors rely on an alternate form of autofocus called contrast detection which is terribly slow.

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through the mirror to the camera’s sensor, you can continuously focus in movie mode with no loss of autofocus speed. A second benefit of this new system is that the camera is capable of capturing images at an astounding rate of 10 per second – a great tool for sports photographers who want to capture the peak of the action. The flexible 3 inch LCD works equally well for stills as for video, and a sweep panorama mode lets you capture majestic landscapes merely by pressing and holding the shutter button.

Sony has eliminated this problem by placing a semi-transparent mirror inside the SLT-A55. Since some light passes

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ne thing is for sure: the Nikon D7000 is built with durability in mind.

The camera borrows its body material – magnesium alloy – from Nikon’s line of professional cameras. Its shutter can capture images at a rate of 6 per second and is rated for 150,000 activations. The D7000 has a Full High Definition 1080p video mode, activated via the press of a single button on the camera’s back. This makes it easy to capture a video in the middle of a photo shoot. The 3 inch LCD screen is not flexible, but it does have a live view mode so you can preview the image you’re about to take. Unlike its predecessor the Nikon D90, the D7000 can autofocus during movie capture. It can also control multiple remote flash units, and with an added GPS accessory it keeps track of location information for every photo you take.

Chris Roberts, since 2005, has been providing photographers with straightforward plain-English information about digital SLR cameras, lenses and accessories through his web site, The Digital SLR Guide.

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Interested in advertising in this free publication sent to every Australian Anaesthetist? You no woul n d ana -spec n’t tr i e a you sthe list ust a r fa tise to mil y So y? ou o wh r non y tr u s you spec t a r fin ialis anc t wi es? th

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RY 2

LIFESTYLE

Floods stink A limited vintage for 2011

was a teenager when the 1974 floods wrought havoc in my hometown of Brisbane. I remember listening to the radio reports with fear, awe and guilty gratitude that my parents had the foresight to build our home far from angry waterways. When the rain finally stopped and the floodwaters began to subside, we emerged from our safe, dry haven and were shocked at what we saw. We wanted to help. We needed to help. It was the last week of the school holidays and tuck shop mums ferried carloads of teens to the muddied suburbs, where we queued for a tetanus jab, then headed for a house (any house) to start work. Our soft student hands blistered after about an hour of shovelling muck. By day three they were as tough as navvies. We worked incredibly hard, but not always effectively. Well, none of us had ever before cleaned a house which had been completely submerged by river water. Who knew you had to check the roof cavity for dead livestock before starting to mop the floors and walls? When the ceiling of the lounge room we had enthusiastically cleaned began to groan and buckle, we suspected we were in trouble. But, like typical teenagers, we ignored the warning

ANAESTHETICLife

Who knew you had to check the roof cavity for dead livestock before starting to mop the floors and walls?

LIFESTYLE

be serious impacts for grape growers up and down the Eastern seaboard. Obviously, complete immersion can be catastrophic for vines, and growers from South-East Queensland to South-West Victoria and even Tasmania have lost complete crops. And that’s not all. Areas which escaped the path of floodwaters can still be affected. Heavy rains and high humidity bring the ravages of powdery mildew and botrytis, which can seriously compromise fruit quality. It’s clear that we can expect a limited vintage in 2011. Australian wine producers are accustomed to doing it tough. The ubiquitous wine glut has been forcing prices ever downward. The big retail chains add to pricing pressures, and competition from imports (from New Zealand, for example) has never been stronger. For some, this may be the final straw.

Kaeserberg Vineyard in Queensland Photos by Jason Kaeser

signs. The bulging ceiling finally gave way with an ugly ripping sound, spewing onto the floor mud, water, and (to our enormous surprise) a dead cow. There’s something truly unforgettable about the sight of a bloated beast in the middle of the lounge room floor. I’m sure it’s no coincidence that the thing I remember most strongly about those humid, muddy days is the incredible stink. As it happens, I was back in Brisbane in January this year, just as the 2011 floodwaters began to recede. Glued to the radio, as I had been all those years earlier, I listened to the stories of the heartbroken, the frightened, and the stoic. Once again, from all over Brisbane and well beyond, friends, neighbours and absolute strangers came together for the cleanup. Carloads, truckloads, and busloads of wonderful

people put in days and weeks of sweaty, stinky, and sometimes dangerous, work to help out. Why? Because they could. Then, just as they were shovelling the last of the putrid silt from bedrooms and lounges, along came Yasi to terrorise the Queenslanders of the north. Thankfully, early warnings, and sound infrastructure kept casualties amazingly low. But the damage has been well and truly done. Through all this, hard working people across rural Australia quietly and warily prepared for their own wall of water to descend. Forewarned may well be forearmed, but it certainly isn’t fun. I am filled with admiration and compassion for them all.

Many of us, particularly city-dwellers, will be only indirectly affected: no rivers will flow through our bedrooms; our livelihoods may not be lost. Our pain will be mostly supermarket-based, as prices soar to match demand. But it’s time to show where our loyalties lie, and support our brave and tenacious Australian growers: Send those flawless lemons back to California! Bring me the Aussie citrus! So what if they’re a bit spotty? (Who eats lemon skin anyway?) And drink up! Those of you in the medical fraternity are well-apprised of the health benefits – and it’s time to spread the joy! Take yourself to your local bottle shop (an independent, if you can find one!), or pick up the phone and call the friendly wine advisor at your wine club, and make a purchase of quality Australian wine. Then sit down with a kindred spirit and enjoy a delicious, heart-friendly, antioxidant laden glass of rural recovery. That warm glow you feel may not be alcohol related at all. Gillian Hyde, ten years ago, made a mid-life career change from show business to the wine industry, and today holds the position of Head of Membership at The Wine Society. www.winesociety.com.au

As with all primary producers, there will

ANAESTHETICLife

Life on the Edge ANAESTHETICLife

TRAVEL

A hotel on the edge of the Zambezi River is near neighbour to the mighty Victoria Falls. Hilary Doling follows in the footsteps of Livingstone—but in a lot more luxury. "Is that a croc or a rock?" asks my companion as our water taxi buzzes like a tsetse fly across the surface of the Zambezi River in Zambia. Over the other side of the boat a hippo rises like doe from the depths, just its nostrils and eyes showing, and surveys us with disinterest. This has to be the world's best hotel arrival. Ahead of us, the spray from mighty Victoria Falls rises hundreds of metres into the air and, as the water gathers speed toward the edge of the falls, I am more than a little relieved when our tiny boat swings towards the landing stage of The Royal Livingstone Hotel. We've been tipped straight from the plane into the heart of Africa, to the place where Livingstone first set eyes on the falls and named them after his queen. The locals of the time called the rushing water 'The Smoke That Roars' (Mosi-oa-Tunya) and fewer are closer to the Big Smoke than The Royal Livingstone. Any closer and we’d be plunging over. Liveried staff are waiting at the private dock with African-sunset coloured cocktails and cold towels. Soaked by spray, my sun hat appears to be wilting in the heat and I’m not far behind it, so the cold towel is more than welcome . Although it was only built in 2001, The Royal Livingstone has channelled its namesake in a big way. It oozes colonial charm from the wind-up gramophone on its terrace to the triple gin and tonics served in the bar. (I like this place already). Oh, and did I mention the

Opposite page: Aerial view of The Royal Livingstone and Victoria Falls. Left: Exterior view of The Royal Livingstone at night

ANAESTHETICLife

TRAVEL

Liveried staff are waiting at the private dock with African-sunset coloured cocktails and cold towels.

Cocktails on the Sundeck

cucumber sandwiches for afternoon tea. There is a languid charm about the place that instantly relaxes you. Perhaps it’s the easy charm of the Zambian staff, or Internet slower than snail-mail, which means crack-berry types are forced to wind down, or the sound of the Zambezi constantly flowing past the edge of the manicured lawns, which makes me so relaxed. Or perhaps it’s the size of those damned gins. Whatever the reason, by late afternoon I am so relaxed I’m virtually catatonic. It is all I can do to leaf indolently through the

ANAESTHETICLife

pages of my novel and gaze at the river and those smoking falls. At breakfast the next morning, zebras graze gently on the hotel grass as we drink our morning cup of tea and, when my guard is down, a monkey leaps onto the breakfast table and grabs a handful of sugar packets. I flap my white linen napkin but it is too little too late. Evading capture by the groundsman, he shoots off across the lawn and sits triumphantly in the nearest tree, pouring the packets down his throat as fast as he can—now that’s one speedy monkey that really

didn’t need a sugar high. Later, I see him running round and round the edge of the swimming pool with the guard in hot, but ineffective pursuit. Rooms at Royal Livingstone are in ostrich-egg cream-coloured buildings which fan out on either side of the main lobby. The decor is suitably ‘Out of Africa’ with wooden bed-heads, animal prints on the wall, black and white tiled bathroom floors and marble-edged baths. The rooms are set for a ‘refresh’, as they call them in the trade, and the new rooms will have shades of mint green and white

TRAVEL

The Courtyard

The Royal Livingstone has channelled its namesake in a big way. It oozes colonial charm from the wind up gramophone on its terrace to the triple gin and tonics served in the bar. nets draped romantically over the beds. Balconies will be enclosed so that guests can sit out on warm nights and not be bothered by mosquitoes or anything else beginning with “M”(Take that, monkey). One afternoon we fly over the falls and see just how close our hotel is to the edge, closer than the orange ring of its

sister property Zambezi Sun and closer than Elephant Hills and the historic but faded Victoria Falls Hotel over the border in Zimbabwe. From here it looks as if the hotels are facing each other across a tiny crack in a pond not a yawning canyon cut by the relentless river. Another day we take a boat trip out to

Livingstone Island and I stand in the very spot where Livingston first saw the falls and called them ‘The most wonderful sight I have witnessed in Africa'. I am inclined to agree. This is my fourth visit to Mosi- oa- Tunya and I’ve seen her in many moods. I wouldn’t be standing here in the rainy season because the island would be virtually submerged. After

ANAESTHETICLife

TRAVEL

Royal Livingstone Entrance

ANAESTHETICLife

TRAVEL TRAVEL

The Sundeck

At breakfast the next morning zebra graze gently on the hotel grass as we drink our morning cup of tea the rainfalls, thunder strikes so loudly you almost need earplugs and the spray rises so high into the sky you think it will soak the planes. This time, however, it is dry season and the falls are in a quieter mood. It means that those braver than I can clamber out and swim in the Devilâ&#x20AC;&#x2122;s Pool on the very, very edge. Back at the hotel, white canopied massage tents have been set up at the very edge of the river, their muslin curtains blowing gently in the breeze.

Strong hands knead away the knots, while I listen to the sound of the river and the strange bassoon cry of the hippos. When I come out of my massage the sun is a blood orange in the sky. It looks as if its juice is leaking into the river, a shiny red trail that glimmers across the water as the sun setsâ&#x20AC;&#x201D;the end of another perfect day in Africa.

ANAESTHETICLife

TRAVEL

NIAGARA FALLS, Canada/USA Obviously the most famous falls in the US and possibly the most visited in the world . This powerful waterfall ranks as the largest one by volume of water with an impressive average of 2.8 million litres a second pouring over. Don’t expect to have these falls to yourself, as Niagara is tourism central. It is worth queuing to ride the boats which take you to the bottom of the falls, packed full of tourists in multi-coloured plastic raincoats. Stay at: Sheraton on the Falls, www.sheratononthefalls.com

VICTORIA FALLS (MOSI-OA-TUNYA), Zambia/ Zimbabwe The largest singular waterfall in the world, spanning a width of 1.7 km, a height of 108 m, and an average flow of 1 million litres per second. It’s no wonder this ‘smoke that roars ‘ is a UNESCO World Heritage site. At the end of the rainy season when the falls are at their fullest, you really will find the end of the rainbow here, as completely circular rainbows dance all around you. Stay at: The Royal Livingstone, www.suninternational.com

World's Great

Waterfalls IGUAZU FALLS, Argentina/Brazil It takes a long time to walk around these stretched out falls which are actually 275 individual cascades combined. However, a series of catwalks makes exploring easy. Little yellow butterflies dot the route and rainforest curls down to the catwalks. Its brink spans a distance of 2 km and its average flow is 1.3 million litres a second. Stay at: Hotel das Cataratas, www.hoteldascataratas. com

ANGEL FALLS, Venezuela These are the falls where they shot The Mission (remember the priest plummeting over the falls?) Now that is some way to fall! Widely credited with being the world’s tallest falls, the water drops a staggering 979m from a mysterious tabletop mountain in the heart of the Venezuelan rainforest. The biggest mystery of all is its source. There is no river, just the moisture from the cloud forest on the plateau. Stay at: Waku Lodge, www.wakulodge.com

ANAESTHETICLife

Hilary Doling is Editor in Chief of www.Luxurytravelbible.com, the world’s ultimate on-line destination guide. For further hotel information contact www.suninternational. com. South African Airways flies to Zambia from Australia, for flight details contact www.flysaa.com.

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