ANAESTHETICLife NOVEMBER/DECEMBER 2010
health...wealth...lifestyle...
Anaesthetist, heal thyself Depression,drug abuse and suicide amongst doctors
Financial Planning for
iPhones in Anaesthesia
The Best iPhone Apps for Anaesthetists
Anaesthetists
$12.95
Crossing the Boundary An insight into why some doctors form sexual relationships with patients
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ANAESTHETICLife
health...wealth...lifestyle...
Highlights
16 18 22 58
Departments
Medicare Audits
07 Features
The Anaesthetist’s Guide to Understanding the PSR
30 Medical Legends
Anaesthetist, heal thyself Depression, drug abuse and suicide amongst doctors
32 Business & Finance 49 Risk Management
Crossing the Boundary
55 Careers
An insight into why some doctors form sexual relationships with patients
58 Alpha: Technology & Reviews
iPhones in Anaesthesia
62 Boutique
The Best iPhone Apps for Anaesthetists
64 Travel 69 Lifestyle
26
contents FEATURES
07
40
Creating Oversupply The impact of the so-called ‘Medical Tsunami’?
12
Green Doctors
16
Medicare Audits and the Anaesthetist The Anaesthetist’s Guide to Understanding the PSR
18
Anaesthetist, heal thyself Depression, drug abuse and suicide amongst doctors
22
Crossing the Boundary An insight into why some doctors form sexual relationships with patients
26
Specialists Without Borders
MEDICAL LEGENDS
30
Robert Reynolds Macintosh
BUSINESS & FINANCE
32
Express Your Individuality in the World of Investment Choice “What should I do with my money?”
36
Financial Planning for Anaesthetists
40
Green Property Learning from the professionals
69 64
07 43
Income Protection Insurance
46
Taking on Risk for your Children Inter vivos estate planning
RISK MANAGEMENT
49
The Legal Risks of Quality Assurance Keeping quality assurance reports away from plaintiff lawyers
51
National Registration Difficulties
52
Tax Avoidance Anaesthetist ordered to pay $50,000 in back taxes
CAREERS
55
Dare to Dream How to set meaningful goals and achieve them
ALPHA
58
iPhones in Anaesthesia The Best iPhone Apps for Anaesthetists
BOUTIQUE
62
Boutique
TRAVEL
64
Five Star Gazing
LIFESTYLE
69
Tropical Discovery: the Wines of Bali
71
Soft-roof Drop-top with Panache Mercedes E-class cabriolet oozes quality, style and comfort
ANAESTHETICLife health...wealth...lifestyle...
editor’s note
W
ELCOME to the Summer Edition of Anaesthetic Life. This issue presents some fascinating feature articles, some ground breaking business and finance content, as well as some light hearted lifestyle pieces that you can enjoy over the holiday period. In this edition we touch on some sensitive topics which we hope you will appreciate. We uncover some of the psychosocial problems associated with our professional choices by looking at the disturbing topics of depression, drug abuse & suicide. From our interviews with Mr Jeff Kennett, chairman of beyondblue and Dr Mukesh Haikerwal, former President of the AMA and current chairman of the Doctors’ Mental Health Program Advisory Committee we talk about some of the challenges we face that can lead to poor mental health and self destruction. We have also covered a topic on the fine line between doctors and their patients and talked about the complications associated with crossing this relationship boundary. Our business section would like to welcome Mediq – a Medical Financial Services company who present the finance section cover story and share with us some financial planning strategies. Since the last edition, we have been overwhelmed with your feedback and are delighted to continue receiving submissions from our readers. I would encourage you to submit any editorials you feel would be of interest to your peers, both personally and professionally. Please submit feedback, compliments, complaints and letters to the editor at: editorial@medical-life. com.au Seasons greetings.
NOVEMBER/DECEMBER 2010
Selina Vasdev
Editor selina@medical-life.com.au
Ravi Agarwal
Business Editor Marketing ravi@medical-life.com.au Contributing Sources
Dr. Richard Cavell Dr. John Williamson Dr. Paul Anderson Dr. Eugenie Kayak Dr. Peter Matthews Dr. Sud Agarwal The Anaesthetic Life magazine is published bi-monthly by Medical Life Publishing Pty Ltd. Anaesthetic Life & Medical Life Publishing is 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:
Selina Vasdev Editor
Medical Life Publishing PO Box 2471 Mount Waverley VIC 3149
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.
Phone: +61 (03) 9001 6373 Fax: +61 (03) 8677 9554 Email: mail@medical-life.com.au
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 magazines or espresso media. No part of this magazine can be reproduced or copied without the express prior consent of the publisher.
FEATURES
Creating
Oversupply
by Selina Vasdev
The impact of the so-called ‘Medical Tsunami’? When speaking to medical students these days, their biggest concern is no longer passing exams, chatting up partners or even where to go for their next holiday. The biggest fear looming over their minds, is now the reality that they may not get an internship position in Australia upon graduation. Gone are the days when you could complete your medical degree as an Australian medical student and be guaranteed internship and resident/registrar jobs to follow.
B
ETWEEN 2007 and 2012 the number of new doctors being generated by medical schools will rise by 86 per cent - from 1586 to 2945 per year. The harsh reality is that ten new medical schools have
opened up since 2000 and many of the older medical schools have increased their intakes. Spurred by the prospects of increased funding, more money from overseas students and scoring significant vote-winning ANAESTHETICLife
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FEATURES points with the public, there has been an unprecedented growth in medical training places. Sadly, it appears that no-one has done their sums when it comes to a single cold truth: There is a massive disparity between medical student places and intern positions. To date, the number of intern positions has managed to keep up with the number of medical graduates, but the sustainability of this over the next 5 years is looking highly unlikely. A 50% increase in intern numbers will be required to keep pace with the new numbers of domestic student graduates. There are numerous initiatives being explored by a variety of stakeholders (e.g. Postgraduate Medical Councils, AMA subcommittees, Governmental bodies, Department of Health and Ageing) looking at ways and places to create new internship jobs to meet the demands. Professor James Angus of the Medical Deans of Australia and New Zealand has predicted a potential 20% shortfall of intern placements
“Gone are the days when you could complete your medical degree as an Australian medical student and be guaranteed internship and resident/registrar jobs to follow.�
The latest Medical Training Review Panel published by the Department of Health and Ageing in April 2010, demonstrates the ballooning number of medical graduates. UNIVERSITY Adelaide ANU Bond Deakin Flinders Griffith James Cook Melbourne PG Melbourne UG Monash PG Monash UG Newcastle/UNE Notre Dame Sydney Notre Dame WA UNSW Queensland Sydney Tasmania UWA PG UWA UG UWS Wollongong Total
2009
2010
2011
2012
2013
2014
85 72 55 0 74 117 82 68 132 0 159 85 0 80 169 272 206 75 15 168 0 0
97 85 73 0 106 149 100 69 143 0 182 104 0 90 162 328 228 88 33 159 0 68
98 78 84 112 114 142 88 88 148 52 221 80 107 106 200 300 222 81 60 126 90 70
125 86 80 132 125 156 96 72 150 67 228 166 113 109 206 306 251 109 58 105 98 74
145 85 93 128 120 150 162 79 172 65 247 172 112 104 209 305 228 99 64 115 118 73
155 95 80 128 132 150 162 280 0 65 240 169 112 104 210 305 228 100 65 145 110 73
1,914
2,264
2,667
2,912
3,045
3,108
* (this table does not include international students, only domestic students enrolled at Australian universities). Source: 2010 MTRP report from the Medical Deans of Australia and New Zealand (MDANZ)
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even with all the suggested measures being implemented. All the State Governments have guaranteed intern positions for all Commonwealth Supported Place and domestic full-fee paying medical students. Therefore, it appears that International students, Interstate applicants, New Zealand and AMC graduates will be the ones who will likely be affected by the shortfall. In addition, there will likely be a lack of accredited training positions in specialist training and general practice training programs to absorb all the new graduates who have completed internships. Currently, the total number of first year accredited trainee positions across all the specialties roughly matches the number of doctors completing intern positions. Rising graduate and intern numbers could lead to the following additional problems: 1. Inadequate numbers of supervisors for interns and other junior postgraduate trainees. In most settings, trainee supervision is largely driven by the enthusiasm and goodwill of senior clinicians. This is seldom remunerated directly (although some employment contracts stipulate teaching and supervisory duties) and often incurs a substantial opportunity cost for consultants. With the estimated growth in trainee numbers, this pro-bono system is unlikely to be sufficient. There is a real risk of supervisor disengagement and burnout, which could ultimately influence clinical outcomes. 2. Bottlenecks in accessing Training Positions. Increasing numbers of graduates will lead to an increase in demand for training positions, especially in the more popular specialties. This phenomenon occurred very recently in the UK where some popular specialties had doctors completing up to five unaccredited years and securing a whole array of postgraduate qualifications to try to be shortlisted.
FEATURES
“ There is a real risk of supervisor disengagement and burnout, which could ultimately influence clinical outcomes.”
3. A lack of Consultant positions after completion of specialist training. This happened in the UK where fully qualified obstetricians were working as registrars for many years after completion of all requirements for admission to fellowship. The expansion in trainee numbers has been huge for certain specialties as demonstrated by the table. There has been an overall 51% increase in trainee numbers over the last 5 years, a significant proportion of this being in Psychiatry, Surgery, ICU and Emergency Medicine. The question that arises is, will there be the consultant posts available to accommodate this vast jump in trainees? Predicting future workforce numbers has always been difficult to estimate and previously, the healthcare system has always erred on the side of
Growth in Advanced Training Positions across all medical specialties between 2005 and 2009
Medical specialty
2005
2006
2007
2008
2009
Adult medicine Anaesthesia Pain medicine Dermatology Emergency medicine General practice Intensive care Medical administration Obstetrics and gyneacology Educational and environmental Ophthalmology Paediatrics Pathology Pathology and RACP (jointly) Psychiatry Public health medicine Radiation oncology Radiology
672 477 N/A 60 458 1,905 187 81 299 72 53 234 282 N/A 87 71 77 263
690 477 36 64 489 2,003 180 84 325 74 50 284 194 107 178 80 57 288
9948 416 49 31 462 2,003 285 86 338 59 47 286 176 95 177 75 96 299
1,043 463 45 33 480 2,162 326 80 109 61 70 395 211 124 278 75 104 314
1,157 485 53 39 811 2,309 375 92 131 55 77 453 224 137 322 61 101 328
% Increase 72.62 1.7 N/A -35 77.1 21.2 100.5 13.6 -56.2 -23.6 45.3 93.6 -20.6 N/A 270.1 -14.1 31.2 24.7
Source: Medical Training Review Panel 13th annual report – with figures quoted as being from GPET and the specialist Colleges
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FEATURES
“...some popular specialties had doctors completing up to five unaccredited years and securing a whole array of postgraduate qualifications to try to be shortlisted.”
References: 1. GJ Fox and SJ Arnold. The rising tide of medical graduates: how will postgraduate training be affected? MJA 2008; 189 (9): 515-518 2. Medical Training Review Panel. Department of Health and Ageing, July 2010 3. www.mmc.nhs.uk Images: Page 7, “School of Medicine” by rhennau http:// www.flickr.com/photos/rhennau/2932237513/ Page 9, “Sydney University - Medical School” by State Records NSW http://www.flickr.com/photos/state -records-nsw/4057365850/ Page 10, “Medical School Mural 1” by Sam Blackman http://www.flickr.com/photos/samblackman/141643386/. Images licensed under Creative Commons Attribution 2.0 Generic license, http://creativecommons.org/licenses/by/2.0
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a mild shortage of doctors knowing that any shortfall could be easily accommodated with international medical graduates. However, erring on the side of having too many doctors at an undifferentiated junior doctor level or a specialist level could have devastating consequences on the profession. We only have to follow the example of countries around the world with surpluses of doctors. The situation occurring in Australia at the moment mirrors what happened in the UK over the last 4 years very closely. The debacle occurred between 2006 until now in the UK due to a combination of events. Firstly, there was political impetus to build new medical schools and expand the older ones. In addition, there was a significant growth in overseas trained doctors (mainly from European Union Countries) entering under new EU regulations. Finally, there was a knee-jerk response to increased numbers of junior trainees by creating a ‘fast-track’ system to specialist training where a medical graduate becomes a specialist within 7 years of graduation. This project came
under the auspices of the Modernising Medical Careers group of the NHS with disastrous consequences. Those graduates unable to secure training posts in the MMC-managed selection process were now unable to take up positions and were forced to wait until the following year to apply again. Medical graduates had to face the prospect of being unemployed and finding work outside of the medical profession. In 2007, there were approximately 10,000 unemployed doctors. Many emigrated overseas, principally to Australia and New Zealand. Some left to find jobs outside of the medical profession. Others registered for the dole. The NHS to this day has not lived down the shame of mishandling medical postgraduate training and the damage that it did to the goodwill of doctors of all specialties. Whether there will be an Australian version of this situation, in the near future, is hard to say. What appears definite is that medical workforce demographics are changing, and the ‘Medical Tsunami’ at junior doctor level is almost unavoidable.
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FEATURES
GreenDoctors As doctors we have a duty to, firstly do no harm and secondly to provide leadership in advocating action to protect health and humanity. Yet for many of us our workplaces significantly contribute to an adverse ecological footprint.
E
VIDENCE strongly suggests that human activity is significantly contributing to an alarming rate of climate change, which is predicted to present increasing challenges to the maintenance of human health and the effective delivery of local and global healthcare. Within Australia, it is likely that there will be more extreme heatwaves, fires and floods as well as changes in the distribution of certain vector-borne diseases such as dengue fever and Ross River viruses. These changes will lead to further demands on our increasingly strained health and emergency services. Globally as the Lancet publishes ‘climate change is the biggest global health threat of the 21st century’1.
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We are a profession that prides ourselves on evidence-based practices yet we remain relatively quiet as scientific evidence continues to accumulate on the need to reduce carbon emissions to prevent an impending devastating situation for humanity. All whilst plausible answers and solutions are published daily. Even if the evidence for anthropogenic involvement is not absolutely 100% we should be reminded of the precautionary principle, written by Bradford Hill in 1965 ‘… all scientific work is incomplete…and is liable to be upset or modified by advancing knowledge. This does not confer upon us a freedom to ignore the knowledge that we already have, or to postpone that action that it appears to
FEATURES demand at a given time’2. The healthcare sector’s contribution to greenhouse gas emissions, landfill and environmental degradation is not insignificant. Although there is no equivalent Australian data we know the United Kingdom’s National Health System (NHS) produces 3.2% of that country’s total carbon footprint3. Hospitals are high energy and water consuming, waste producing organisations. Embracing sustainable practices can lead to significant environmental advantages as well as having the potential to deliver financial gains. A recent joint publication by the World Health Organization and Health Care Without Harm ‘Healthy Hospitals, Healthy Planet, Healthy People’ describes numerous cost saving examples associated with environmentally sustainable hospital modifications4. As practising doctors we can instigate actions within our everyday practice that have the potential to lead to significant reductions in carbon emissions. Audits investigating the sources of CO2 emissions generated by the NHS have shown that addressing the procurement practices of medical equipment and drugs as well as those of goods and services (procurement accounting for a staggering 60% of total NHS CO2 emissions) is just as, if not more important, than decreasing the emissions accrued from powering healthcare buildings (22%) or through staff and patient travel (18%)5. Within hospitals, operating suites are a significant contributor to energy resource consumption and waste production, generating approximately 20% of hospital waste6. Anaesthetists and surgeons are a constant presence in operating suites and are well placed to improve the environmental effect of their workplaces. By following the waste hierarchy ethos of ‘Reduce, Reuse, Recycle’ in our everyday practice and even taking further steps to ‘Rethink and Research’ our daily environmental impact, we can make a difference and hopefully encourage thoe around us as well.
REDUCE
RECYCLE
Address adverse environmental impacts, waste and costs by using less of everything (power, equipment, products, medications etc.) Reduce landfill and clinical waste streams by ensuring correct waste segregation and the implementation of recycling options. Clinical waste generally has a higher fossil fuel carbon content compared with general waste, requires either high temperature incineration or chemical treatment before deposition into landfill, and is usually 10 fold the expense of general waste to dispose of.
Promote recycling options at work. Co-mingled (collecting paper, cardboard, glass, plastic and metal in the one receptacle) recycling programs exist for local government curb-side collections. It is incongruous that co-mingled recycling does not occur within the controlled setting of all our hospitals. Almost 60% of anaesthetic general waste is potentially recyclable12. Manufacturing recycled plastics uses approximately 25% of the energy compared to equivalent plastic products produced from raw products. Hospitals are beginning to recycle non-contaminated plastic products. Not all plastics within hospitals can be recycled together with up to 30% of medical plastics comprising PVC (polyvinyl chlorine). PVC requires separation from other plastics and undergoes a different recycling process. However preliminary PVC recycling programs converting hospital waste into PVC pipes have been set up. Minimising the volume of batteries, electronic items and medical equipment that ends up in landfill is also important. Food waste has been diverted from landfill to compost deposits or warm farms in several
REUSE Assess the validity of reusing medical equipment where appropriate. The replacement of reusable medical items with disposable (single-use) items is ubiquitous, often due to perceived lower costs and infection risks. Yet little evidence supports this practice, in fact evidence exists to the contrary. Life cycle analysis studies that have been done on anaesthetic trays and laparoscopic surgical equipment have shown environmental and financial advantages of reusable items compared with disposable ones9-11.
“Climate change... is predicted to present increasing challenges to the maintenance of human health and the effective delivery of local and global healthcare.” ANAESTHETICLife
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FEATURES hospitals. Deposition into landfill comes at both an environmental and financial cost. Recycling can lead to significant advantages in both these areas. Water is increasingly scarce in many parts of Australia. Reverseosmosis renal dialysis units ‘reject’ or discard water (30-50% of the original mains water used) that is formed by pre-dialysis water filtration before exposure to blood products. This ‘reject’ water falls within potable limits in most parts of Australia and has been used in hospital gardens and toilets13.
RETHINK Analyse the latest evidence and clinical recommendations to ensure appropriate use, prescription and administration habits are preventing unnecessary consumption, waste and cost. Production of most medical drugs can have significant adverse
environmental impacts with 99% of the raw materials used in their manufacturing ending up as landfill3. Each patient in French and German hospitals accounts for 1.9 kg and 0.4 kg of waste per day respectively, whereas a patient in a UK hospital accounts for 5.5 kg, with Australian estimates reflecting UK amounts14. Attention to the procurement policies and processes by which medical drugs, equipment and paper (accounting for 22%, 9% and 5% respectively of total NHS CO2 emissions5)are sourced could result in significant environmental, financial and ethical benefits.
RESEARCH Further research surrounding the entire life cycle analyses of the equipment, products and medications used in our health care system is needed enabling practitioners to
“The GreenClinic Guide outlines ten points to assist doctors and practice managers to make simple changes to help save energy and water, reduce waste and promote sustainable practices.”
References: Costello A, Abbas M, Allen A et al. Managing the health effects of climate change. Lancet 2009; 373: 1693-1733. 2 Hill AB. The environment and disease: association or causation? Proc R Soc Med 1965; 58: 295-300. 3 Cole A. Saving the Planet as Well As Lives. BMJ. 2009;338:742-744. 4 Healthy Hospitals, Healthy Planet, Healthy People. World Health Organization and health Care Without Harm. www.noharm.org/lib/downloads/energy/Healthy_Hosp_Planet_Peop.pdf (accessed August 2010). 5 Saving Carbon, Improving Health: NHS Carbon Reduction Strategy for England. www.sdu.nhs.uk/ page.php?page_id=94 (accessed August 2010). 6 Lee BK, Ellenbecker MJ, Moure-Eraso R. Analyses of the recycling potential of medical plastic wastes. Waste Management 2002; 22: 461-470. 7 McGain F. Why anaesthetists should no longer use nitrous oxide. Anaesth Intens Care 2007; 35:8089. 8 McGain F, McAlister S, McGavin A, Story D. The financial and environmental costs of reusable and 1
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make truly informed decisions about environmental and financial impacts.
GREEN PRACTICES / CONSULTING ROOMS Medical professionals who own or manage clinics can make further changes. The Australian Conservation Fund in collaboration with Doctors for the Environment Australia have developed ‘The GreenClinic Guide’15. The guide outlines ten points to assist doctors and practice managers to make simple changes to help save energy and water, reduce waste and promote sustainable practices. The suggestions range from purchasing renewable energy for clinics to procuring products with reduce environmental impacts. Several Australian medical practitioners have also developed the GreenPractice initiative, which aims to inspire both doctors and patients to live and work in a sustainable manner. Health care professionals as community leaders, educators, providers and contributors to environmental degradation and greenhouse gas emissions need to look towards embracing environmentally sustainable practices within their homes, their workplaces, and the wider community16.
Dr Eugenie Kayak MBBS, FANZCA, MSc Member of the National Management Committee of Doctors for the Environment Australia (DEA) www.dea.org.au
single-use plastic anaesthetic drug trays. Anaes Intens Care 2010; 38:538-544. 9 Adler S, Scherrer M, Ruckauer KD, Daschner FD. Comparison of economic and environmental impacts between disposable and reusable instruments used for laparoscopic cholecystectomy. Surg Endosc 2005; 19: 268-272. 10 Schaer GN, Ossi RK, Haller U. Single-use versus reusable laparoscopic surgical instruments: A comparative cost analysis. Am J Obs Gyn 1995; 173 (6): 1812-1815. 11 McGain F, Hendel S, Story D. An audit of recyclable waste from anaesthetic practice. Anaes Intens Care 2009; 820-823. 12 Agar JWM. Reusing renal Diálisis Wastewater: The Elephant in the Room. Am J Kidney Dis 2008; 52 (1):10-12. 13 Tudor TL, Marsh CK, Butler S et al. Realising resource efficiency in the management of healthcare waste from the Cornwall National Health Service (NHS) in the UK. Waste Manag 2008; 28: 1209-1218 14 www.acfonline.org.au/greenclinic (accessed August 2010) 15 www.greenpractice.org.au (accessed August 2010)
contributing
WANTED riters
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
FEATURES
Medicare Audits and the Anaesthetist
The Anaesthetist’s Guide to Understanding the PSR A Professional Services Review (PSR) involves an assessment of Medicare claims to determine whether there has been “inappropriate practice” by a medical practitioner.
A
Professional Services Review (PSR) involves an assessment of Medicare claims to determine whether there has been “inappropriate practice” by a medical practitioner. A PSR investigation can be triggered by a number of items which are flagged as being outside the normal range of behaviour for a particular specialty group. That is to say, your billing patterns are always compared to your peers. If your billing methodology is two standard deviations away from the mean for your craft group, you could trigger a Red Flag. Typical Red Flags for
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Anaesthetists would include: Upcoding of preoperative consults – it would be normal practice for anaesthetists’ preoperative consultations to be of varying lengths. Anaesthetists whose consults were heavily coded to be of longer durations, would potentially open them up to triggering an audit due to their billing behaviour being vastly different to that of their peers. Improper use of modifiers – modifier billing practice would vary between anaesthetists depending mainly on their individual casemix. However, a significantly higher number of ‘emergency’ or higher ASA scoring than your peers would be immediately
FEATURES comparable and could similarly trigger an audit. Billing for services when the anaesthetist is not present – billing for services performed by others who are unable to access Medicare. e.g. trainees. In addition to the above, behaviour which could also be referable to the PSR would be where allegations have been made, or anonymous sources have reported that one of the following activities is occurring: • Billing for goods and services not rendered • Billing for phantom patients • Upcoding or billing for more time than the duration of the actual service • Paying kickbacks in exchange for referrals (income splitting) • Billing for medically unnecessary interventions • Misrepresenting the quality of care provided • Double billing After receiving a warning either from claims data or from an anonymous report, the PSR would normally review a random sample of the anaesthetist’s records. Following examination of the medical records, a report to the anaesthetist and consideration of any submission received from the practitioner, the Director of the PSR must select one of the following three outcomes: • Decide to take no further action (all charges are dropped) • Enter into a confidential agreement with the anaesthetist including an acknowledgement of inappropriate practice and sometimes an agreement to repay certain Medicare benefits and / or a partial or complete disqualification from claiming benefits for a certain period. Other outcomes may include a requirement for counselling, disqualification from Medicare for up to 3 years, referral to the relevant Medical Board and / or publishing details of the investigative findings. • Establish and make a referral to a peer review Committee. Where the Director considers the conduct of the person under review needs further investigation, a Committee is established. The Committee comprises members drawn from the panel appointed by the Minister for Health and Ageing. The Committee may conduct a hearing where the person under review can provide both oral and written evidence in support of their case. After considering all the evidence and taking into account any submissions received, the Committee produces a draft report containing findings on the conduct of the person under review. Where the findings are that the person under review has not practiced inappropriately, the matter concludes. Where the findings are of inappropriate practice, the person under review is given time to make submissions on the draft report. After considering those further submissions a final report of any inappropriate practice is then forwarded to the Determining
Authority. At any stage in the process the person under review may seek judicial review in the Federal Court. The PSR has produced an annual report on its activities since 2007 and over this time, PSR investigations have increased over seven-fold. The majority of investigations involve GPs, but there is a growing proportion of specialist referrals. Key ways to minimise the risk of Medicare concerns leading to a PSR referral include: • Ensuring you have a clear clinical justification for management decisions, including referrals and prescriptions, which accords with generally accepted peer professional practice.
“At any stage in the process the person under review may seek judicial review in the Federal Court.” • Ensuring your notes are legible and contain sufficient detail of history taken, examination / testing / investigation results, diagnosis and management plan – a common test is whether the notes contain sufficient information to allow another practitioner to take over the patient’s care. • When claims are made for less common Medicare items, i.e. longer consultations, there is sufficient reason and notes to justify later why the claim was appropriate. • Ensuring complete compliance with all Medicare requirements for certain items, i.e. liaising with other care providers and completing certain forms / plans. If you are contacted by Medicare or the PSR about your practice, we recommend you notify one of the solicitors in the Medico-legal Department of your Medical Defence Organisation immediately for advice before responding.
Charles Gordon is a Medical Indemnity Specialist Insurance Adviser and is also the director of Medselect, Australia’s leading medical defence advisory service.
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features
Anaesthetist, heal thyself Depression, drug abuse and suicide amongst doctors We are known for being healers and carers of our patients. But the dark side of our profession is relatively understated. Although our position ensures that we take good care of those we treat, we massively neglect the issues causing hurt in our own lives.
D
“Female doctors have a suicide rate more than twice as high as lay females.�
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epression is a relatively undiscussed problem, yet common among medical students and doctors, and can occur at any stage of our careers. Australian doctors have a suicide rate that is higher than that of the general population, and female doctors have a suicide rate more than twice as high as lay females1. We have to admit, we are notoriously bad at seeking help or treatment for our personal illnesses, a stereotype which is not only based on anecdotal evidence but confirmed by research. A study into preventative health behaviour among General Practitioners in Victoria found that 57% of GPs did not have their own GP, while 12% of them
nominated themselves as their own GP and 30% assigned a professional partner2. More interestingly, recent research carried out by the national depression initiative beyondblue found that many doctors and medical students who suffered depression and anxiety ignored their condition1. So why is it that doctors who suffer from mental illnesses are so reluctant to seek help? Studies have found that doctors are more concerned with the aftermath of admitting such vulnerabilities3. Of course, as a doctor you have a duty to maintain a happy persona and healthy outlook. It is usually this fear of appearing vulnerable and the reluctance to seek advice that can lead to devastating outcomes. The unsettling truth is that doctors have the highest rate of suicide of any profession4. This year, beyondblue reported that male doctors are 26% more likely to commit suicide than other males, and female doctors are 146% more likely to commit suicide than other females1. It is believed that General Practitioners who suffer from depression are concerned about the potential implications for their practice and that admitting the need
FEATURES for help could trigger uproar amongst the medical community, perhaps even causing a stir with the medical board. Doctors of all specialties are understandably worried about the implications for career development5 and the risk of backlash. There is real concern about; stigma6, confidentiality and embarrassment1. It is the fear that disclosing a mental illness will stifle our careers and that our colleagues will question our professional integrity1. So instead... many doctors choose to suffer in silence. But when this isolation and pain becomes unbearable, who better to be able to prescribe the drugs needed to end such misery? Which is why we are more likely to take addictive prescription drugs than the general population. With the most commonly abused prescription drugs being, benzodiazepines and opioids1. Self prescription is popular7, even though it is frowned upon and illegal in some places. Not only do we know how the drugs will react with our bodies but we know exactly what amount to use to cause the body to shut down and bring the heart to a grinding halt! Dr Mukesh Haikerwal, former President of the AMA and current chairman of the Doctors’ Mental Health Program Advisory Committee, was beaten and robbed in September 2008. He underwent a craniotomy during which part of his brain was removed, and was in hospital for two months. He claims that whilst recovering from an illness “which included psychological problems...I made a point of seeking help. I see it as a professional responsibility to make sure that I am well and fit for work before I went back to work.” Dr Haikerwal says, “Nobody would think twice about taking insulin if they needed it when they had diabetes, or a puffer if they had asthma. And it’s much the same for mental illness including depression and anxiety.” From an outsider’s perspective, a doctor’s life seems rich and rewarding and of course for most of us, it is. But Mr Jeff Kennett, chairman
of beyondblue, has an alternative opinion. He says, “With due respect to the profession, who’d want to be a doctor? ...You’re seeing sick people, you don’t have a break, you’ve got to somehow present yourself in a way that looks enthusiastic and fresh the whole time, and you’re dealing with people who are depressed, with other forms of injury, snotty noses. It’s a hell of a bloody lifestyle. Endless. And the demand never ceases.” With this in mind, we can confirm that there are numerous factors that can contribute to the downward spiral of a doctor’s health and well being. The stresses of a medical career are widely acknowledged. We are continually exposed to pain, disease, death and suffering; a morbid routine for anyone to get used to. Our working environment is intense to say the least8 and yet it is stretched, not only by having to remain alert under such pressures, but having to do so whilst upholding high professional responsibility. Some of us more than others fear the risk of complaints and legal action based on the decisions we make and the actions we take whilst helping our patients and it
is this fear of scrutiny that causes doctors to keep their problems hidden. Some causes of our ill-health may actually be attributed to our own personalities including the tendency for perfectionism. Some of us suffer from incredible inflexibility and a gross over-commitment to work, which inevitably causes conflicting demands on our time. Self- criticism and an inability to relax are also quite common and perhaps are linked to the early stages of one’s medical career which during the studying phase and training years re-affirmed such qualities and associated them with the success of becoming a doctor. Long working hours is perhaps the most complained about factor9, clearly detrimental to the health of any individual let alone a doctor responsible for the care of others. It seems that doctors who are geographically isolated or feel marginalised may also experience particular stress which can develop into something far more problematic. Being single9 or even spending considerable lengths of time working exclusively in private practise or as a locum may also be detrimental.
“It is usually this fear of appearing vulnerable and the reluctance to seek advice that can lead to devastating outcomes.” ANAESTHETICLife
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FEATURES Inevitably this isolation, with a lack of peer support can be a major source of job dissatisfaction. Although most doctors adopt effective strategies and copying mechanisms, others find it hard to juggle the responsibilities and expectations put on them. Personality traits such as conscientiousness, commitment and obsessionality are also to blame for high levels of stress and burnout10. But what if this is the personality profile of the kind of people who become doctors in the first place? There are several interventions that are believed to reduce the risk of mental illness and in turn suicide. Doctors are less likely to become depressed if they sleep more, have greater job satisfaction, have a higher income and have less stress at work. beyondblue also advocates a number
of interventions as effective in the treatment of depression including; cognitive-behavioural therapy, interpersonal therapy and medication. The feelings associated with depression, coupled with drug taking behaviour have resulted in numerous documented suicide cases amongst medical professionals. Suicide of a doctor is shocking to society. The damage that is left behind, among family and friends, and the workplace, is enormous. During an interview Psychiatrist Professor David Clarke said, “Suicide is an uncommon event, but it’s so tragic and has such ramifications that it’s a marker for something. The suicide rate in doctors is a little bit higher than the general population, but the good news of course is the suicide rate in Australia has been dropping for the last ten years, and
“It is usually this fear of appearing vulnerable and the reluctance to seek advice that can lead to devastating outcomes.” References 1 beyondblue. The Mental Health of Doctors: A Systematic Literature Review, a meta‐analysis of mental illness in doctors and medical students. 2010 2 McCall L, Maher T, Piterman L. Preventive health behaviour among general practitioners in Victoria. Aust Fam Physician 1999; 28: 854‐857 3 Anonymous. View from the bottom. Psychiatric Bulletin 1990;14 452-4. 4 Rosenberg HM, Burnett C, Maurer J, et al: Mortality by occupation, industry, and cause of death: 12 reporting states, 1984. Monthly Vital Statistics Report, Centers for Disease Control and Prevention 1993; 42:1‐64 5 North CS, Ryall JM: Psychiatric illness in female physicians:are high rates of depression an occupational hazard? Postgrad Med 1997;101:233–236,239–240,242. 6 http://www.abc.net.au/pm/content/2010/s2986807.htm 7 Selly P. Self-prescribing by doctors. HealthTrends. 1988;20:128-129. 8 Arnetz BB. Psychosocial challenges facing physicians of today. Soc Sci Med 2001;52(2):203‐13 9 Sullivan P, Buske L. Results from CMA’s huge 1998 physician survey point to a dispirited profession. CMAJ 1998;159(5):525‐8
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we should feel very good about that.” The most common method of suicide among doctors is the use of drugs and poisons. Anaesthetists and Emergency Doctors are especially likely to kill themselves, implying that drug abuse is related to medical speciality, usually emphasised by the availability of drugs11. Doctors are by no means immune to psychosocial problems and the associated traps of depression, drug abuse and suicide. Yet self-care and well being are not exactly subjects covered as part of professional training, nor are they topics that receive immediate attention in professional practice. More importantly, medical training seems to put a premium on physical stamina and emotional resilience12 making it almost impossible for us to fight back. With huge stresses based around our personal and professional lives, doctors can develop serious issues that often go undetected and untreated. It is therefore crucial for interventions to be made readily available for doctors to allow them to seek help and treatment without fear of repercussions. According to Mr Kennett, beyondblue aims to increase awareness of the symptoms of mood disorders, identify risk factors, reduce barriers to seeking help, and promote existing services with “The objective to ensure that we have a healthy medical profession.” Doctors in trouble should be able to seek help without stigmatisation and with confidence that our profession will support their rehabilitation13.
Dr. Richard Cavell & Selina Vasdev
Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. 2003;289 (23): 3161–3166 11 McManus IC, Keeling A, Paice E. Stress, burnout and doctors’ attitudes to work are determined by personality and learning style: a twelve year longitudinal study of UK medical graduates. BMC Med 2004;2:29 12 http://scienceweek.com/2005/sw050826‐4.htm 13 http://www.nytimes.com/2003/07/08/health/doctors‐toughest‐diagnosis‐own‐mentalhealth. html?pagewanted=1 10
Images: Page 15, “Conditional Suicide - How Long?” by Kazi Tahsin Agaz (Apurbo) www.flickr.com/photos/elomelosnapshots/512396611/ Page 16, “Despair” by fakelvis www.flickr.com/photos/lloydm/2305701220/. Images licensed under Creative Commons Attribution 2.0 Generic license
‘Depression is
‘Depression is
more than thanstress. stress. more doesn’tgo goaway.’ away.’ ItIt doesn’t
You can’t leave depression at home. It goes to work with you. You can’t think straight. You don’t tell anyone because you fear what others will think – but hiding it is exhausting. Find out more about how to deal with depression and where to get help. For more information visit our website or contact the beyondblue info line.
1300 22 4636 infoline@beyondblue.org.au ANAESTHETICLife
Crossing theBoundary An insight into why some doctors form sexual relationships with patients
Hardly a month goes by without news of a doctor somewhere in Australia confessing to partaking in a sexual relationship with a current or former patient. The purpose of this article is not to discuss the ethics and wrongs of this, as these are widely documented elsewhere.
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his article has been written to give doctors an insight and understanding of how a lapse in personal behaviour can escalate to serious criminal actions. Firstly, it is important to realise that this problem is not unique to doctors; teachers, nurses and priests have had similar complaints to their registration boards. It is hard to estimate the prevalence of inappropriate doctorpatient relationships, because the vast majority go unreported1 as many patients are often reluctant to complain, because of feelings of guilt and shame, fear they will not be believed, and bizarrely continuing concern for their doctor2. Surveys from overseas indicate that about 3-10% of doctors have formed sexual relationships with a patient3-5. Local experience is limited to an anonymous postal survey of psychiatrists which found that almost 8% of psychiatrists reported some form of erotic contact with a patient during or after termination of treatment6. Another local survey, this time with General Practitioners as the studied population, reported 6% of GP’s had dated a patient and 4% had engaged in sexual contact with a patient 7. The underlying principle upon which this prohibition of sexual intimacy with a patient is based on is the fiduciary duty arising from this relationship. If a lawyer is going to handle a doctor/patient sexual misconduct case, he must have a solid understanding of the fiduciary relationship that exists between the patient and the patient’s doctor. The nature of the relationship is significant not only to elements of negligence or other causes of action, but also underpins the injuries and damages those patients and their families suffer8. A fiduciary relationship is defined as a relationship where a person (patient) justifiably relies upon another person (doctor) to protect their personal interests and/or act in their best interests. The doctor/patient
relationship is a clear example of a fiduciary relationship. Often, service professionals are legally construed to be fiduciaries for those people that seek and obtain their professional’s services9. Within the doctor/patient relationship is the element of power. The doctor has the knowledge, the training, the education, and the ability to treat the patient. This knowledge and training, places the doctor in a position of power. The patient, not having this knowledge, justifiably relies upon the doctor to act in the patients’ best interests. Vulnerability in the patient is also present in the doctor/patient relationship. This vulnerability arises from the fact that most patients seek medical service because of physical or mental problems or conditions. The patient then is expected within this fiduciary relationship to disclose confidential and sometimes embarrassing information, thereby further increasing the patient’s vulnerability10. One key concept in ascertaining how premeditated the boundary violations are is the concept of grooming. Grooming is the term used to describe the escalation and the positioning of a patient by the doctor, making the patient more vulnerable to being used by the doctor for his own needs, instead of dealing with the patient’s needs. One scenario of grooming a patient is where the doctor begins by complementing the patient on her looks, beauty, dress, etc. Later the doctor begins to touch the patient’s hand as the doctor delivers his advice and treatment. Even later, the doctor starts hugging the patient during or at the end of a visit. At the same time or shortly following this physical contact the doctor will often engage in sexual innuendo or some form of sexual talk. The doctor will often begin disclosing his own personal information (making the patient an equal, and no longer just a patient); this information can often include disclosure of lack of satisfaction and pleasure with his sex-life and with
“Surveys from overseas indicate that about 3-10% of doctors have formed sexual relationships with a patient.” his sexual partner. This step-by-step grooming of a patient usually suggests the behaviour is more calculated, sinister and more premeditated. Earlier, we established that this problem is not confined to a miniscule minority. Now let us explore what leads to doctors to transgress professional boundaries and partake in this reprehensible behaviour. When we analyse the profiles of the doctors concerned, they tend to fit two major groups: A small number of the perpetrators are predatory serial offenders who sexually exploit multiple patients for their own sexual gratification11. The second group consists of doctors who committed a single offence where the usual reason given is usually the culmination of a series of boundary crossings (non exploitative departures from usual practice). The distinction between boundary crossings and boundary violations is important. Crossings are departures from usual practice that are not exploitative, and can sometimes be helpful to the patient (e.g. embracing a patient), while boundary violations (e.g. kissing a patient) are crossings that are harmful to the patient. The failure to recognise ANAESTHETICLife
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FEATURES when this behaviour is escalating and the loss of insight into when the succession of boundary crossings has culminated into a violation are the key steps leading to the transgression12. Risk factors for doctor/patient relationships which cross the boundary: Doctors who practice an informal style of medicine where they use first names to refer to each other. The overly patient-centric consulting style is divorced from the historical paternalistic doctor patient relationship. e.g. Treating patients without clear management goals, therapy exceeding a normal length of time, therapy outside of your normal areas of competence, special fee arrangements, personal telephone calls between sessions, treating the patient as a friend, adoption of unwise techniques such as routine hugs, excessive touching, out-ofcontext socializing with patients and excessive self disclosures. These actions can be misinterpreted by patients and may make it more difficult for doctors to simultaneously maintain clear professional and personal boundaries13. 1. Patients who have previously been victims of sexual abuse are prone to recreating patterns where they expose themselves to sexual abuse. The so-called “sitting duck” syndrome. A survey of 40 Australian women who had experienced sexual abuse from a healthcare provider found that twothirds had a history of childhood abuse14. • Emotional stress, mental illness or substance abuse in the doctor • Disclosure of personal information or stressful circumstances in the doctor’s life (role reversal and abandonment of the traditional doctor/patient relationship) 2. Patients with dependent and borderline personality disorders are also risk factors. They have considerable difficulty with interpersonal relationships and maintaining consistent and
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appropriate boundaries15. 3. Specialties where repeated and long term contact is maintained. Also specialties where patients make disclosures about their emotional wellbeing have a higher propensity to lead to boundary crossing. Specialties identified as being of higher risk are Psychiatry, General Practice and Gynaecology16. What happens when the transgressors are caught? Well until recently, medical boards were different State based entities with different regulations, and so the punishments served were of a particularly diverse nature. In general, most doctors were deregistered for 6 months to 2 years for professional misconduct, received some form of psychotherapy/ counselling and some were forced to have chaperones if their crimes were thought to be more opportunistic or predatory. One can only assume that a high percentage of these cases would be pursued in the civil courts for medical negligence including the tort of outrage, the intentional torts of assault and battery, and one might also include an allegation of
lack of informed consent. If a breach of fiduciary duty (duties) is proven, the patient/victim is entitled to all physical and psychological damages that are directly and proximately caused by the doctor’s breach. Currently, there is no official program to rehabilitate offenders back into the medical workforce as the consequence. A treatment program for Australian clergy who have breached sexual boundaries has been in existence for several years now. The program uses a multidisciplinary team approach and includes individual and group therapy, from both psychodynamic and cognitive perspectives. Clergy who have responded well to treatment can then negotiate a graded return to restricted ministry. 17 A similar program may well be beneficial to doctors who have violated patient boundaries and have expressed remorse. The whole area of sexual boundary violations by doctors with their patients is a cloudy area with many medical authorities very unwilling to commit any formal policies on how to prevent this happening. The
“Grooming is the term used to describe the escalation and the positioning of a patient by the doctor, making the patient more vulnerable to being used by the doctor for his own needs.”
best advisory position statement guiding doctors on managing boundary violations in clinical practice has been issued by the Royal College of Psychiatrists (UK) which offers the following sound advice:18 • Physical touch beyond normal social exchange should be used with caution. A ‘no touch’ policy is unworkable and may be anti‑therapeutic, but the inherent power imbalance between professionals and patients means that touch of any kind may be misinterpreted.
• Inappropriate self‑disclosure (the commonest form of boundary violation) or disclosure of confidential personal material without consent should be avoided. • Treatment or therapy should generally not take place in a practitioner’s home. If the practitioner is in private practice and works from home, the work should take place in a designated area, kept apart from the practitioner’s ordinary domiciliary arrangements. • Treatment or therapy should not generally take place outside the workplace (e.g. in restaurants or places
References 1 Quadrio C. Sexual abuse in therapy: gender issues. Aust N Z J Psychiatry 1996; 30: 124-131. 2 Galletly CA. Psychiatrist-patient sexual relationships — the ethical dilemmas. Aust N Z J Psychiatry 1993; 27: 133-139. 3 Kardener SH. Sex and the physician-patient relationship. Am J Psychiatry 1974; 131: 1134-1136 4 Gartrell N, Herman J, Olarte S, et al. Psychiatrist-patient sexual contact: results of a national survey. I: Prevalence. Am J Psychiatry 1986; 143: 1126-1131. 5 Wilbers D, Veenstra G, van de Wiel HB, Weijmar Schultz WC. Sexual contact in the doctor-patient relationship in The Netherlands. BMJ 1992; 304: 1531-1534. 6 Leggett A. A survey of Australian psychiatrists’ attitudes and practices regarding physical contact with patients. Aust N Z J Psychiatry 1994; 28: 488-497. 7 Coverdale JH, Thomson, AN and White GE. Social and sexual contact between general practitioners and patients in New Zealand: attitudes and prevalence. Br J Gen Pract. 1995 May; 45(394): 245–247. 8 http://en.wikipedia.org/wiki/Fiduciary 9 http://definitions.uslegal.com/b/breach-of-fiduciary-duty 10 Robert A. Zielke, et. al. Secrets In the Exam Room: Sexual Misconduct by Doctors. 11 Crow SM, Hartman SJ, Nolan TE, Zembo M. A prescription for the rogue doctor: part I — begin with diagnosis. Clin Orthop 2003; 411: 334-339 12 Gutheil TG, Gabbard GO. The concept of boundaries in clinical practice; theoretical and risk management dimensions. Am J Psychiatry 1993; 150: 188-196. 13 Nadelson C, Notman M. Boundaries in the doctor-patient relationship. Theor Med Bioeth 2002; 23: 191-201.
FEATURES of entertainment). • Treatment, therapy or clinical assessment in the patient’s home is justified only on clinical grounds, and clinicians should be prepared to justify how and why such work has taken place. • Treatment or therapy outside inpatient settings should generally take place within working hours of the service (which may vary). If such work is to take place at unusual hours, this should be agreed with a mentor, supervisor or senior colleague and the reasons recorded. • Doctors should avoid being in dual roles with patients, for example doctors should avoid treating family members, friends, family of friends, colleagues or family of colleagues. This is particularly true in cases where the patient is a doctor. • Other role conflicts include issues relating to money and dual relationships. • Doctors should not appear as expert or professional witnesses in cases where they know the patient in a clinical relationship. They may act as professional witnesses but will be bound by their duty of confidentiality in the ordinary way.
Selina Vasdev
Kluft RP. Treating the patient who has been sexually exploited by a previous therapist. Psychiatr Clin North Am 1989; 12: 483-500. 15 Cherrie A Galletly. Crossing professional boundaries in medicine: the slippery slope to patient sexual exploitation. MJA 2004; 181 (7): 380-383 16 Randy A. Sansone, MD, and Lori A. Sansone, MD. Crossing the Line: Sexual Boundary Violations by Physicians. Psychiatry (Edgemont) 2009;6(6):45–48 17 Canaris C. The ‘out of house’ solution to boundary violations. Aust Psychiatry 2003; 11: 406-409. 18 Royal College of Psychiatrists. Vulnerable patients, safe doctors; College Report CR146, London UK 2007; pp 1-30. 19 Epstein RS, Simon RI. The Exploitation Index: an early warning indicator of boundary violations in psychotherapy. Bull Menninger Clin 1990; 54: 450-65. 20 Vamos M. The concept of appropriate professional boundaries in psychiatric practice: a pilot training course. Aust NZ J Psych 2001; 35: 613-18. 14
Images: Page 18, “Crossing the Line” by CarbonNYC www.flickr.com/photos/carbonnyc/35399751/ Page 20/21, “Crossed fingers 1” by Katie Tegtmeyer www. flickr.com/photos/katietegtmeyer/124315323/ Images licensed under Creative Commons Attribution 2.0 Generic license, http://creativecommons.org/licenses/by/2.0
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Image above: "MEDCAP - Natural Fire 10 - Palabek Kal Health Clinic - US Army Africa - AFRICOM - 091018-F-8314S-108" by US Army Africa www.flickr.com/photos/usarmyafrica/4036889678/ Images licensed under Creative Commons Attribution 2.0 Generic license, http://creativecommons.org/licenses/by/2.0
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imagine that most people at some stage in their life have had someone persist and influence a decision that turns out to be not only positive but life shaping. Russell Lee is one of those people. He has been responsible for coordinating operation “open heart” which takes both cardiac surgical and intensive care teams into developing countries to operate on paediatric cases deemed beyond the capabilities of the medical teams in that developing country. It is through his persistence that I lead a medical team into Rwanda and down onto the Congolese border as part of a worldwide response to the 10 year anniversary of the genocide, which has also caused me to adjust my medical/ surgical focus. That didn’t happen overnight and there were several specific things that his persistence needed to overcome. A successful private practice, which doesn’t easily release its primary practitioner, was one. Then there was the wilful replacement of personal goals to go where the need is greatest, something that is also often difficult to fit in with being a single parent. The third aspect, and not the least
important in changing lanes in your fifties, centred around a return to Africa, which would mean for me confronting the ghosts of having been involved in a terrorist attack. While a young consultant surgeon in South Africa, I had been quietly attending a church when it was attacked by five terrorists. They entered the church with AK-47s shooting and throwing grenades into the congregation. This killed 11 and seriously injured 50 of us. One of the bullets grazed my temple, another passed subcutaneously through my left flank, the grenade which exploded in the aisle near to me caused a comminuted 14 part fracture of my left radius and ulna. The only thing really left intact was the neurovascular bundle. I was fortunate that a great friend of mine, spent five hours putting together my forearm so that I could operate again. Getting out of Africa at that point was a primary aim. Going back, was not as you might imagine even a consideration. It was 10 years almost since that incident and I had often reflected on that part of my training which was in Africa and the great need that there is
FEATURES there for doctors/nurses. But the desire to go back and contribute had been held in check by the past trauma which had provided a convenient excuse to deny the challenge. Australia has a fantastic health system, founded on an equally impressive medical education structure. The thought remained that with motivation there is a lot we can contribute from that to developing countries. In addition, the fact that a little also goes such a long way continued to provoke one’s thinking and question whether one could overcome ghosts of the past. I think that you go into surgery partly enjoying the challenge of dealing with difficult situations. There was definitely a part of me that was challenged to go back and also be part of a global response which had been so lacking at the time of the genocide. But there was also the challenge to deny those ghosts any further licence. Part of me needed to know that I could do that. Gisenyi is a small town right on the Rwandan Congolese border. It has a 300 bed hospital which has not been repaired since the genocide. It was, and is in a serious state of disrepair. It serves a catchment area of over a million people on both sides of the border. It is seriously understaffed both with doctors and nurses. The team of 13 from Australia/New Zealand/ England/America and South Africa that I led was mostly nurses, although we had a physiotherapist, pharmacist and hospital administrator. Having worked in Africa previously I had some insight into what to expect. To say that the rest of the team were shell-shocked on the first day would be an understatement. However, the camaraderie and the desire to make a difference made that one of the most memorable two weeks for all the team and myself. And out of that experience came the realisation that more should and could be done. Although it would be fair to say no one was quite certain how. What then was needed was a calculated assessment of where there
was maximum benefit. The following year a small group went back to the same hospital for two weeks. While working in the hospital a truck lost its brakes coming down the hill and went through the hospital fence overturning and trapping eight people underneath it, including five children who all died. Coming out of the theatre all that we could do was to organise the townspeople to get the truck off the dead and place them in the morgue. Given the injuries that they sustained the facilities would not have been adequate to have treated them had they survived. We quickly realised that ours was far from an ideal contribution in addition to which,
surgical education. It was proposed therefore that a seminar/conference be arranged to be held in Kigali to cover at a postgraduate level, medical and surgical emergencies. After discussions with the Dean at Flinders University in South Australia a memorandum of understanding was struck and the task of finding a group of specialists in medicine/anaesthetics/surgery to teach began. My initial feeling was that with a group of seven specialists we could successfully stage a twoday seminar. When we began our search through various contacts, we secured a Professor of Medicine from Arizona, a Canadian Anaesthetist, an
“Then there was the wilful replacement of personal goals to go where the need is greatest, something that is also often difficult to fit in with being a single parent.� there were no theatre lights, hygiene was nonexistent, the steriliser was broken and the power frequently went out. Everyone you had to treat as being HIV positive. One also had the feeling that any changes that were initiated in terms of surgical technique needed ongoing supervision to become accepted practice. We needed to find a more effective way of helping. From this humble beginning Specialists without Borders grew. Initially we had no idea whether there would be any like-minded people who were at that point in their lives where they wanted to and could give up some of their time to help those who are less fortunate. After discussions with the Dean of the medical school in Rwanda, it was decided that one of the areas where there was most need was postgraduate medical and
Italian Immunologist, a Tasmanian Dentist, and seven surgical specialists from Australasia covering ENT/ Orthopaedics / Neurosurgery and General Surgery. We also had five nurses who were going to conduct a separate nursing seminar. In the end we were oversubscribed and had to say no to seven of our colleagues/ specialists. The response of so many who wanted to help was in itself an endorsement of what we were trying to achieve. Trying to coordinate a conference from so far away has its challenges. Asking 13 of your more esteemed colleagues to attend and lecture when you have no idea of what the turnout is going to be like or the conference facilities is daunting to say the least. But it was clear that they had great faith in the concept ANAESTHETICLife
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FEATURES and were prepared to pay their own travel and accommodation. This provided great encouragement in spite of the organisational difficulties. The conference was attended by 100 African doctors, and the nurse’s conference by 90 nurses. Our evaluation carried out at the end of the seminar indicated an overwhelmingly positive response. The doctors and nurses/specialists who participated also felt that they were meeting a significant need in terms of education and that this was a concept which should be developed and sustained into the future. The team that had formed by that stage was then invited down to the medical school at Butare. This is about a 3 ½ hour trip from the capital Kigali. Both doctors and nurses
“Then there was the wilful replacement of personal goals to go where the need is greatest, something that is also often difficult to fit in with being a single parent.”
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then involved themselves with Ward rounds and teaching over two days before returning to Kigali. The experience of sharing with a group of consultants, who are all likeminded in wanting to improve medical education by giving of their time and effort should not be undervalued and is perhaps best summarized by Kate Drummond an Australasian neurosurgeon who participated in the last seminar in Kigali."What a joy it was to interact with colleagues who work in such a different place but with whom we had so much in common in terms of clinical, personal and training challenges. We could all have so much to offer each other in the future.” The success of the seminar has led to a request to return and with the development of the organisation Specialists without Borders and a request for further medical/ surgical education seminars in Cambodia/Honduras/ Mongolia and the Pacific. SWB as the organisation is now known has evolved to have a National Australasian executive and the growing international database of specialists and all aspects of medicine and surgery as well in nursing and Allied health. SWB is a not-for-profit organisation registered with the Australian Securities Commission with a request lodged for Australian Aid status. An educational baseline has been now developed, from which the current consultants are able to input the level of medical education required in the future and contribute to an evolving curriculum. Professional and personal relationships have developed which will allow the ongoing exchange of medical information, and the exchange of African/Asian/Pacific doctors in specialty training. It is hopeful therefore that the current format will be able to be developed into an even more effective model in the future given the significant input of both consultants/specialists and the
feedback from participating doctors. Having input from those specialists who have participated has been invaluable in developing Specialists without Borders. I think it would be fair to say that all are keen on seeing a return on their investment of time and money. There is a need to see that what is being done has an impact, and what is being offered is of the highest standard. The appointment of an educator from Flinders University to oversee the quality of teaching has been one of the innovations. Ongoing assessment of knowledge at the completion of seminars to test the development of those doctors attending is another. The establishment of relationships with colleagues in developing countries has opened up the opportunity for assisted exchange of young doctors. The request for our faculty to provide personnel to assist in examination and assessment of medical students in developing countries has also been a commendation of the level of teaching provided. Perhaps the most surprising aspect of this to me, was the number of people who are prepared to offer something back and who are prepared to endure the personal and financial challenges to do that. What was also surprising was not only that there was a growing number who on learning about what we do want to join us, but that one hundred percent of the original team want to go back and contribute more. But then again I suppose it should not be too surprising. For many this is the motivation in doing medicine and we as an organisation are merely facilitating an effective way of dealing with the original desire to help people.
Dr Paul Anderson is a director/ founder of Specialists without Borders and is a consultant upper gastrointestinal surgeon in Adelaide. MBChB, FRACS, FRCS (Edin), PhD, MA www.specialistswithoutborders.org
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10
MEDICAL LEGENDS
Robert Reynolds
Macintosh The father of modern Anaesthesia
R
“Macintosh was one of the first to engage in audits of patients who die while under anaesthesia, spearheading modern quality assurance techniques.”
obert Reynolds Macintosh was born in Timaru, New Zealand, in 1897. He attended Waitaki Boys’ High School, and excelled not only in academia but also athletics. He spent part of his childhood in Argentina, where he learned to speak Spanish. He emigrated to England in 1995, when he was 18, in the midst of World War I.Upon his arrival he joined the British Army and was assigned to the Royal Scots Fusiliers, an infantry regiment. While there he served alongside a frustrated young man called Winston Churchill, who was posted to the regiment in 1915 as a Lieutenant-Colonel before embarking on a post-war political career. The regiment was posted on the front line of the Western Front, and there was a real risk of being killed for both of them. Robert Macintosh then trained as a pilot with the Royal Flying Corps. He was shot down during a 1917 flight, and became a prisoner of war. Although he managed to escape from prison several times, he was recaptured each time.
After World War I, Robert Macintosh graduated from Guys Hospital Medical School and trained to be a surgeon. His surgical training included a stint in Uruguay, where he was able to put his Spanish to good use. While training as a surgeon, he made a living performing anaesthesia on dental patients, which is where he developed an interest in anaesthesia as a specialty distinct from surgery. He became a fellow of the Edinburgh Royal College of Surgeons and practiced surgery, but he also set up the “Mayfair Gas Company”, a business that would\ now be called a private anaesthetic group. A few years later, Macintosh happened to anaesthetise one William Morris, founder of the Morris Motor Company. Morris Motor Company was very successful during this period, and produced many iconic cars including the Morris Minor and the MG. William Morris was created Baronet, then Baron, then Viscount, and ended up as Lord Nuffield, Lord Knight Grand Cross of the Order of the British Empire. Sir William Morris (Lord Nuffield) was impressed by Macintosh’s
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approach to “simple and safe” anaesthesia. Macintosh had used intravenous barbiturates for Morris’ anaesthetic, far more enjoyable than the substances commonly used for anaesthesia in those days. Following their encounter, Morris and Macintosh became friends and played golf together. When the University of Oxford desired to create three chairs, in medicine, surgery and obstetrics/ gynaecology, in 1936, they approached Sir William. Sir William agreed to donate £2 million to the University of Oxford in 1936 (worth about $170 million today) for the creation of the chairs, on the condition that a fourth chair in anaesthesia was created, and filled by Robert Reynolds Macintosh. The University could not turn the offer down, and Macintosh became Oxford University’s first Professor of Anaesthetics – in fact, the first Professor of Anaesthetics outside North America. Macintosh designed the Macintoshblade (curved-blade) laryngoscope in 1943. For proper usage, his blade is placed in the vallecula, anterior to the epiglottis. The straight blades used
prior to 1943 were placed posterior to the epiglottis. In 1949, Macintosh wrote in the British Medical Journal: During the past two years I have been experimenting with large-bore oral endotracheal tubes of different shapes. One of the difficulties in passing tubes beyond a certain size is that the body of the tube obscures the view of the cords through which the tip must be directed. He then desfcribes a technique of using a urinary catheter as an endotracheal tube introducer, which led to the invention of dedicated endotracheal tube introducers. Macintosh also designed a endobronchial tube that was named after him. During World War II, Robert Reynolds Macintosh performed several experiments on survivability, for the military’s benefit. One series of experiments on life jackets involved anaesthetising a Mr Pask and immersing him in a tank of water. He also conducted research into human respiration in the artificial atmospheres of submarines, and tried to design a submarine escape
mechanism. He researched into oxygen delivery during high-altitude parachute jumps. He designed the Oxford vaporiser, which delivers ether at the concentration selected by the operator, and which saw use in the battlefield theatres of World War II and later in the Falkland Islands. Macintosh was one of the first to engage in audits of patients who die while under anaesthesia, spearheading modern quality assurance techniques. He first proposed such audits in 1944, with the Association of Anaesthetists voting unanimously to “take no action” on the proposal. However, by 1949 the Association had changed their mind, and anaesthetists are now rightly regarded as being among the leaders in patient audit and quality assurance. In 1955, he was knighted for his contribution to anaesthesia, and travelled the world teaching “safe and simple” anaesthesia to other doctors, including those from developing countries. Sir Robert Reynolds Macintosh died in 1986, aged 91, at Oxford. By Dr P Matthews
lds Macintosh ANAESTHETICLife
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BUSINESS & FINANCE
Express your individuality in the world of investment choice “What should I do with my money?” Most financial advisers, when asked this question by a client, adopt the traditional approach of investment in managed funds, typically accessed through what is termed a master trust or wrap platform.
T
his recognises that the financial adviser, in implementing wealth creation structures and strategies for you, requires the services of a professional investment manager (accessed through a managed fund) in the day-to-day management of your money. Managed funds involve the pooling of assets for a large number of investors into a single fund that is then invested on their behalf, with returns allocated based on the number of units held. Such an approach undoubtedly is of advantage for smaller investors
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given the benefit of professional management and access to investment opportunities they would otherwise miss. “But I don’t think managed funds are for me?” The managed fund approach has its shortcomings, the most common of which are tax and transparency related. If an investor buys units in a managed fund just before the fund sells a stock which, for example, has doubled in value, the new investor is hit with a capital gains tax liability immediately. And, in
BUSINESS & FINANCE the ongoing management of the fund, the investment manager at no time makes decisions having regard to each investor’s tax position. It is often said tax is an investor’s greatest expense. Yet you are paying a fee to the fund without this being considered. As a consequence, larger investors take a different approach, that is, to invest directly. This is typically done either: • on a do-it-yourself (DIY) basis (e.g. buying and selling shares over the internet), • through a stockbroker (what is termed an advisory relationship – the stockbroker will make a recommendation to you and you agree or not to go-ahead with that decision); or • via a financial adviser (again on an advisory basis with the financial adviser, acting as an intermediary and/ or sounding board, usually transacting on your behalf through an on-line broker or stockbroker). Whilst this comes with the benefits of direct ownership i.e. clear entitlement to franking credits attaching to shares, flexibility of making buy and sell decisions according to your tax position etc., it does not come with the benefits of professional investment management afforded by managed funds. These encompass skills in constructing portfolios, day-to-day active management of portfolios, the applied research in terms of stock selection and access to macro-economic data which can play a part in decisionmaking. These direct approaches are the domain of DIYers who are willing to take an active interest in their investment affairs and accept overall responsibility for performance of their portfolio, as at no stage do any of the other parties take on this responsibility. “I like the direct investment approach but am a doctor, not an
investment manager – and just don’t have the time or experience “ If having a professional investment manager to take responsibility for the management and performance of your very own portfolio has appeal, don’t despair. There is another option -a Managed Account. A Managed Account, initially developed in the US, is an account whose key feature is that the underlying assets are held personally by the investor. It does not involve pooling of assets or you being a unit holder. You have your own portfolio, with holdings in your own name. Managed accounts come in various forms, the two most common of which are a Separately Managed Account (SMA) and an Individually Managed Account (IMA). The essential difference between the two is the legislative framework which governs the operation of each. A SMA is accessible much like a traditional managed fund through a Product Disclosure Statement (PDS). A SMA is thus a “ununitised managed fund”, whereby you have a portfolio of directly held investments managed by a professional investment manager who uses a model portfolio approach, implementing the same investment decisions across all accounts generally without taking into account your personal circumstances. A SMA is viewed as an alternative to the traditional managed fund. It is typically seen as being at the lower end of the value scale given it is a managed fund replacement. “OK, I am interested but I want something with a fuller service offering allowing for my own circumstances now and in the future” This is where an IMA fits in. An IMA is a portfolio management service for high worth clients, whereby the professional investment manager implements decisions across your portfolio, based on the mandate you have agreed with them and with full consideration of your personal circumstances. Some of these relate not only to your tax position but also to
“Such an approach undoubtedly is of advantage for smaller investors given the benefit of professional management and access to investment opportunities they would otherwise miss.”
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“An IMA is not for everyone. It suits an investor who has or is coming into some wealth but does not have the time, inclination or experience to run their money – yet wants a couple of professionals to run it, as they would like it run.”
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your investment preferences (e.g. as a doctor, you may not want to invest in a tobacco company from an ethical perspective). With an IMA provider, you will also not only have access to an investment management capability customized to your unique situation but also to a financial advisory offering. This means any financial advice around structuring and strategies is closely aligned with the mandate attached to managing your money. It all happens under the one roof. These roles are separate with SMAs, as exemplified by the fact that financial planners use SMAs in place of traditional managed funds i.e. as a product replacement, not a change in service offering. The overall relationship with an IMA provider is more akin to a “family office” style arrangement, where any issue attaching to the client’s financial affairs can be coordinated at this level, given the knowledge of the client. An IMA is not for everyone. It suits an investor who has or is coming into some wealth but does not have the time, inclination or experience to run
their money – yet wants a couple of professionals to run it, as they would like it run. Essentially it is a Do It For Me offering as opposed to Do It Yourself. “I like the sound of this IMA . But what are the negatives? ” Hard to find once you accept the fact that entrusting an IMA provider to manage your money is not dissimilar to giving over your money to a managed fund-just that with an IMA provider you can actually see what you own ! One of the disadvantages floated within the industry is that, for the IMA provider, the individualised nature of the service can mean IMAs are labour-intensive. It is said IMA providers don’t possess the economies of scale in transacting on your behalf that more mass market SMAs and managed funds have. Whilst perhaps justifiable in certain circumstances in the past, technology has served to level the playing field in recent times – as is the case with technology in general. And will only continue to reduce the cost of delivering this offering as the popularity of IMAs grows. • So, if you tick yes to the following: • an individually tailored portfolio; • the benefits of direct share ownership; • attention to and consideration of your tax position; • a transparent fee structure; • all paperwork attended to by someone else; • easy accessible on-line reporting; • access to your own portfolio manager as well as financial adviser under the one roof; and • no tax impact if you wish to change service providers, given stocks are in your name an IMA is hard to beat.
Geoff Greetham, BEc , CFP, CPA Geoff is a co-Executive Director of Accordius, a privately-owned personal funds management business, based in Melbourne.
Nurturing your medical
wealth How personal are your investments? Are your investments tailored to your needs? Do you always know what you are invested in? Are your investments structured to allow for effective tax management? Are you aware of all the fees being charged against all your investments? Is the person making investment decisions on your behalf a full time fund manager or just a relationship manager? Do they do their own research or just follow the recommendations of others? AT ACCORDIUS we know that you have worked hard to create your wealth. We work one-to-one with our clients providing them with Individually Managed Accounts that are tailored to maximise returns. We have the flexibility to either work with your own financial advisor or, if required, provide high quality, unaligned advice. We believe in complete investment transparency. You can see every transaction made on your behalf.
Dr Paul Kasian
Fiona Hinrichsen
Hamish Moore
Geoff Greetham
If answering yes to the above questions is important to you then you should
CALL us at 03 8623 3368, EMAIL us at pkasian@accordius.com.au or ggreetham@accordius.com.au or VISIT www.accordius.com.au.
BUSINESS & FINANCE
Financial Planning for Anaesthetists You’ve probably achieved a measure of financial success in your medical career. Your lifestyle is comfortable and you earn enough money to satisfy your every day needs. But what I am about to discuss is a way to leverage your medical career to achieve true financial liberty –the choice of an early retirement, the ability to live and give to your family and community well beyond the years of your career and practice - this is an achievable and realistic option.
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I
t’s too easy to become complacent in the presumption that you have “arrived” (financially) now that you an anaesthetist. You and I both know that your 6 years at Medical School and then another 7 or 8 years of training and specialist exams to become a consultant, have prepared you to fulfil your potential professionally. It is the same with your finances. The planning and foundation that you lay today will provide the platform to leverage your true financial potential and become financially independent. As the proverb says, “the best time to plant a tree is twenty years ago. The next best time is now.” The same applies to financial planning. Even though every anaesthetist’s situation is unique, there are some sound financial strategies which apply to the majority of anaesthetists.
• Claim every single deduction that is legitimately claimable including cars, home office expenses, phones, IT expenses, medical indemnity and income protection insurance as appropriate.
• Structure non-deductible vs. deductible debt. This involves minimising and eliminating non-deductible debt (bad debt) connected to home purchases and renovations, through the careful management and re-cycling of work and investment cash flow. It also involves structuring your deductible debt (e.g. car loans or leases and capital equipment such as ultrasound machines) so it is connected to your work/ investments and deductible at the highest possible marginal rate.
• Defer tax as far as possible and use
the improved cash flow for investment strategies and non-deductible debtelimination.
“It’s too easy to become complacent in the presumption that you have “arrived” (financially) now that you an anaesthetist.” Applying them to your life will ensure that you are in the best position for the future and that you are protected in the present. Here are the most important financial rules for Anaesthetists:
• Choose the correct legal structure for your practice. This will usually
be a trust based structure for most specialist anaesthetists with the maximum amount of income distributed to lower tax rate beneficiaries and will usually include an investment company.
• Invest in your home as a tax-free investment and additional properties from which you can benefit from negative gearing.
• Pay the maximum amount of Superannuation annually (up to the
Government allowed limit) and use gearing through non-recourse loans as needed to grow your superannuation in a stable, accelerated fashion.
• Use gearing in investments and SMSF to
maximise the returns on your investments and to optimise tax deductions to reduce taxable income.
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“The corporate structure of your practice is the financial foundation that will govern how much wealth you are able to generate and retain from your business.”
Choose the correct legal structure for your practice. Choosing the correct structure for your medical practice is vital from day one. The two main reasons are asset protection and tax efficiency. The corporate structure of your practice is the financial foundation that will govern how much wealth you are able to generate and retain from your business. It is extremely important to “begin with the end in mind”. We find it gut-wrenching to see medical specialists who take huge taxhits after all those years of gruelling study and hard work, simply because they did not take the time upfront to ensure their corporate structure suited their business operation and growth plans. In general, the options will involve some combination of trusts and companies but the exact tree and arrangement of these should be determined by a good accountant prior to even starting your business. If you are already operating under one structure and find out that this is not the best structure for you, rolling over to another business structure may have Capital Gains Tax implications. Issues to consider when choosing the legal structure for your practice include: • whether your assets will be protected from patient litigation risks? • costs of setting up and running the
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structure; • ability to share income with family members and related trusts and companies; • administrative simplicity; • payroll tax and other employment on-costs; • regulatory requirements; • ability to change the ownership structure easily and cheaply; • administrative simplicity, particularly GST compliance; • the ability to pay fully deductible superannuation contributions for the practitioner and related persons. You should source an accountant with experience in structuring or-restructuring medical practices.
(including overseas travel, accommodation, meals) • Professional Associations/ ASA/ AMA/ ANZCA fees • Medical Indemnity • Income Protection Insurance • Financial Advisory Fees
Claim every single deduction that is legitimately claimable
The difference between deductible and non-deductible debt lies in the after-tax cost. Non-deductible debt and interest costs are repaid with after-tax income, while deductible debt reduces assessable income and provides a tax benefit. Debt generally becomes deductible when the purpose of the funds is to produce assessable income.
Many anaesthetists (and their advisors) don’t pursue every legitimate tax-deduction in fear of upsetting the tax-office or because they are unsure what is permissible. You should be guided by Tax Rulings which are the financial equivalent of ‘Evidence-Based Practice’ and where precedents can be used to clarify exactly what has been permitted. Deductions which are commonly the source of confusion but are frequently applicable to anaesthetists include: • Deductions related to investment property co-owned with your super fund • Car-Related Deductions • Home Office Expenses • Continuing Education Expenses
The long and short of it is most Anaesthetists will need some expert clarification on what is claimable. There is some science to it and your tax advisor should be able to offer Tax advice to simplify grey areas of tax law.
Non-deductible vs. deductible Debt
All Anaesthetists’ should aim to reduce or even eliminate all nondeductible debt (any borrowings on personal-use items e.g. homes, boats, lifestyle items etc) and to re-structure debt so it is connected to your work or investments and deductible at the highest possible marginal rate. This will usually tie in with how you restructure your whole clinical practice and alter your borrowing from external entities (such as banks)
BUSINESS & FINANCE and also borrowing within entities you own (Division 7a loans). For most anaesthetists who do at least some private work, an optimised structure will usually involve a trust based structure with an investment vehicle as one of the beneficiaries. In addition, a self-managed superannuation fund (for yourself your spouse and up to two additional family members) will commonly be linked to your structures.
Invest in your home as a tax-free investment Yes, your home is a lifestyle asset. Rarely will it be used to provide a passive investment income stream for you now or in retirement. And, as you know, while it may grow in value, so it seems is every other house around you! Your home however is still a key part of your wealth accumulation strategy. Structured correctly to ensure asset protection, your home can provide a funding base for long-term investments that provide a virtuous cash cycle – lower tax paid and investment income provide extra cash flow to reduce nondeductible debt, which is then replaced (re-cycled) with deductible investment debt to fund new investments, further lowering tax and increasing investment income to again pay down more private debt. Further, your home is a Capital Gains Tax free investment. It may be used to provide a rental income stream (with associated tax deductions) for extended trips away, and can be downsized in retirement all without capital gains tax consequences.
Use gearing in investments and Self Managed Super Funds (SMSF) A Self Managed Super Fund is one of the most effective tax-shelters for the accumulation of wealth and the provision of passive income streams in retirement.
A number of strategies are now possible to co-own assets with your super fund, to borrow within your super fund and leverage your investments in shares and property (commercial or residential), to lend money to your super fund from related entities or businesses, to transfer assets to your super fund via in-specie contributions or via your super fund acquiring assets in co-invested unit trusts. All of these strategies can be used to lower the total cost of your investments, to increase the flow of non-contribution style funds to your SMSF where you have used up your contributions capacity, and beyond age 60 to generate a tax-free income stream while protecting your wealth in a capital-gains-tax-free environment.
Don’t let time pass you by...
“Yes, your home is a lifestyle asset. Rarely will it be used to provide a passive investment income stream for you now or in retirement. And, as you know, while it may grow in value, so it seems is every other house around you!”
Most Anaesthetists who come to us have rarely laid the basic foundation for optimising the generation and preservation of wealth. Most fail to integrate one or more of these strategies into their core wealth plan. What is described above is really only the tip of the iceberg with regards to financial planning for anaesthetists and I encourage you to begin the planning process in the early stages of your career. As the “sage from Omaha” (Warren Buffett) said “Someone is sitting in the shade today, because someone planted a tree a long time ago.”
Simon Lucas CA, AFP is a Medical Wealth Strategist at MEDIQ Medical Financial Services and advises medical practices and individuals on structures, accounting, taxation & finance. Visit www.MEDIQfinancial.com. au to learn more tax and finance strategies for Anaesthetists and access three additional financial mistakes made by Anaesthetists at www.MEDIQ fin an ci al .com .au / anaesthetist
Disclaimer: The above article has been written as general in nature and does not replace individual financial advice. You should not assume that any or all of it applies to your individual circumstances. We highly recommend every anaesthetist to seek specialist financial advice to create a plan based on their individual situation.
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Green
PROPERTY:
Learning from the professionals
Property is all about location, location, location right? Not necessarily say professional property managers, who are now ‘greening’ their buildings to improve returns.
P
roperty managers at the big end of town have realised that by offering ‘greener’ buildings they can improve the wellbeing of tenants and also receive a better financial return.
What’s driving greener buildings? Improved Tenant Wellbeing ‘Greener buildings both attract prospective tenants and help retain existing tenants, driving building values’ says Ernst & Young partner Richard Bowman.i By offering comfort factors such as increased natural light and fresh air, the property owners can improve the wellbeing of the tenants. Happy tenants means fewer complaints and less attrition. It also means that property owners can attract better quality tenants and charge them a premium. All of which favourably impacts the bottom line. The tenants will also experience a boost in staff productivity and a reduction in absenteeism, as occupant health and comfort improves. ‘What’s clear in our portfolio is the greener the building, the stickier the tenants,’ concludes Tony Cope, head of office at GPT.ii Rising Energy and Water Costs Rising electricity costs and increasing water bills are more and
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more commonplace. Indeed further energy price increases are inevitable. By improving the sustainability features of your property you can reduce your operational and maintenance costs immediately. Ignoring these rising costs simply means that the ‘cost’ of not going green will continue to grow. Staying Profitable The property market is rapidly changing. By acting proactively and enhancing the sustainable features of your property, you can help ensure its financial viability into the future. ‘Sustainable refurbishment produces a return of better than 10% on investment’ according to research by Langdon Davis, Global Construction Consultants.iii A studyiv, on sustainable refurbishment titled Existing Buildings Survival Strategies: Making It Happen, gives property owners a guide to assessing building assets, setting appropriate targets and identifying key upgrade initiatives to make sure they are making sound investment decisions. The study shows that sustainable refurbishment of commercial property will increase the property’s value and cash flow. Additionally, the study concludes that refurbishment will soon be essential to maintaining occupancy rates and
avoiding obsolescence. Government Legislation Commercial buildings, mainly old buildings, account for ten per cent of Australia’s total annual greenhouse gas emissions. From later this year, mandatory disclosure of energy ratings and performance may be required for commercial offices > 2000m2, sold or leased. Mandatory disclosure will be required if the Building Energy Efficiency Disclosure Bill is passed. ‘Mandatory disclosure is likely to lead to a period of investment arbitrage where informed market participants take advantage of their superior knowledge to create a competitive position for themselves,’ says Adam Murchie director of Melbourne-based property investment group Forza Capital, and vice president of the Australian Direct Property Investment Association.v Tenants Go Green Tenants are increasingly demanding buildings that are energy efficient. Large (mainly listed) companies and Government tenants are seeking to ‘reduce their greenhouse footprint’ and also their energy costs. Savvy businesses also realise that happy staff are more productive.
BUSINESS & FINANCE ‘Keeping in mind that the greatest Leading Australian Building Owners cost to business is that of salaries, any improvement in productivity, through occupant comfort, lighting, Top-5 Listed Property Companies temperature and increased natural Rank Company ventilation, etc will have a major impact on the bottom line,’ Davis 1 GPT Langdon, Global Construction 2 Stockland vi Consultants. 3 Commonwealth Property Office Fund 4 Colonial First State Retail Property Trust What can you do? 5 Valad Property Group Obtain a Green Star certification If you would like to register your building for Green Star certification, the Green Building Council of Australia (GBCA) recommends that you appoint a Green Star Accredited Professional (GSAP). The GBCA recommends that you ask your consultant: • Are you a registered Green Star Accredited Professional, assessor, or independent chair? • How many Green Star projects have you worked on? • Have you undertaken any Green Star courses? • Is your company a member of the GBCA? Review your Listed Property Stocks If you have an investment in listed property securities you would be wise to review your holdings. Assuming mandatory disclosure becomes legislated some property trusts will be well ahead of the pack, and others lagging. Mandatory disclosure is likely to lead to a period of investment arbitrage where informed market participants take advantage of their superior
Management & Policy 83 83 91 87 74
Implementation & Measurement 89 80 66 63 53
Total 86 81 76 72 61
MAASTRICHT UNIVERSITY, ‘Environmental Performance: A Global Perspective on Commercial Real Estate’
Top-5 Private Property Funds Rank 1 2 3 4 5
Company
Fund Name
GPT Funds Management GPT Wholesale Office Fund Investa Investa Commercial GPT Funds Management GPT (W) Shopping Centre Fund QIC Retail QIC Westfield Westfield PLN
Management & Policy 87 91 87 70 39
Implementation & Measurement 87 80 54 17 37
Total 86 84 67 38 38
MAASTRICHT UNIVERSITY, ‘Environmental Performance: A Global Perspective on Commercial Real Estate’
knowledge to create a competitive position for themselves,’ Adam Murchie director of Melbourne-based property investment group Forza Capital, and vice president of the Australian Direct Property Investment Association.viii A studyix in January 2010 by Masstricht University’s European Centre for Corporate Engagement has rated the Australian property fund managers and companies in its Environmental Real Estate Index. Make Green Property Work for You Like most things in life, change is inevitable. The same can be said of the
property sector. It is changing rapidly. Those companies and individuals who act proactively to adapt their share holdings and buildings to the changing tastes of tenants, rising energy costs and impending legislation will be ahead of the pack, and financially rewarded.
Karen
McLeod is an Authorised Representative (No. 242000) of Ethical Investment Advisers (AFSL 276544). We provide investment advice for ethicallyminded and socially-conscious investors who are seeking competitive returns.
References i WAGG, Oliver. ‘Doing the REIT thing.’ Ethical Investor, June/July 2010, issue 92, page 12. ii WAGG, Oliver. ‘Doing the REIT thing.’ Ethical Investor, June/July 2010, issue 92, page 13. iii DAVIS LANDON. ‘The Road to Green Property, Version 2.0’ 2010, page 54. http://www.gbca.org.au/resources/gbca‐publications/the‐road‐to‐green‐property‐version‐2‐0‐‐davis‐langdon/2817.htm iv The study was a collaborative effort between Davis Langdon, Arup and Colliers International for the Property Council of Australia. v MURCHIE, Adam. ‘Mandatory energy efficiency disclosure offers investment opportunities’, Ethical Investor, June/July 2010, issue 92, page 31. vi DAVIS LANDON. ‘The Road to Green Property, Version 2.0’ 2010, page 34. http://www.gbca.org.au/resources/gbca‐publications/the‐road‐to‐green‐property‐version‐2‐0‐‐davis‐langdon/2817.htm vii DAVIS LANDON. ‘The Road to Green Property, Version 2.0’ 2010, page 15. http://www.gbca.org.au/resources/gbca‐publications/the‐road‐to‐green‐property‐version‐2‐0‐‐davis‐langdon/2817.htm viii MURCHIE, Adam. ‘Mandatory energy efficiency disclosure offers investment opportunities’, Ethical Investor, June/July 2010, issue 92, page 31. ix MAASTRICHT UNIVERSITY, ‘Environmental Performance: A Global Perspective on Commercial Real Estate’ 2010: pages 25 and 30. http://www.uss.co.uk/Documents/Environmental%20Performance%20 A%20Global%20Persepective%20on%20Commericial%20Real%20Estate%20Report.pdf Ethical Investment Advisers (AFSL 276544) has been certified by RIAA according to the strict disclosure practices required under the Responsible Investment Certification Program. See www. responsibleinvestment.org for details.The contents of this article are intended as general advice only. No specific person’s circumstances, financial situation or objectives have been taken into consideration. You
shouldout not more act on the provided without seeking personal advice from an appropriately qualified financial planner. Information included from third parties has been reproduced with their permission. To find goinformation to http://www. While the source has been verified as reliable, the actual content has not been checked for accuracy. Consequently Ethical Investment Advisers does not warrant the accuracy of the information nor accept yourbuilding.org/ or http://www.gbca.org.au/. liability for any errors in the data.
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Income Protection Insurance Learn how to save 10s of $1,000s and even over $100,000 in income protection insurance payments with strategies to keep you covered your whole working life and keep your money in your pocket.
Y
OUR income is worth protecting and in your profession seeing illness and injury first hand the importance of income protection is highlighted every day. As a medical professional, it’s incredibly important to obtain the best income protection policy for you. A good policy covers you for blood borne diseases, allows you to keep an eye on your business for up to 10 hours each week without penalty and covers you for total or partial disability. Let’s look at how you can save on your income protection policy without compromising on benefits and features by firstly concentrating on payment structure and then on a two policy tailored strategy.
Payment Structure – Cost Reduction Strategy Stepped premiums are great in the short term, though will end up costing you a lot more in the longer term than level premiums.
Stepped Premiums
Sometimes you are only told about stepped premiums as these are the cheaper option, at least initially. However, over time as you receive your renewal notice in the mail, you start notice that the policy premium increases more than CPI. This is an age based increase and is only a few percent in your thirties, a little more in your early forties. In your late forties and beyond, the cost of your insurance
will become so high that you may be forced to either reduce your benefit or cancel the cover all together. This potentially leaves you without the required cover at a time when you need it most.
Level Premiums
Level premiums are designed to remove the age based increases and therefore do not have the dramatic increases in cost over time. Level Premiums usually cost 50% more than stepped premiums however as you will see, Level premiums give you the certainty of knowing what you will pay for your insurance up to age 65 or 70.
CASE STUDY Dr Joseph Smith is 40 years old and is married with 2 children aged 4 and 2. His family has one income. He plans to send his children to private school and possibly to assist them through university. He is a physician and works as a sole trader and his business shows a profit after uninsurable expenses of approximately $250,000 per annum. Joseph wishes to insure his income.
OPTION A – ONE POLICY As an industry standard, Joseph can only insure 75% of his income which is $18,750 per month. He has been quoted for a policy that after waiting 30 days, pays a benefit until ANAESTHETICLife
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BUSINESS & FINANCE age 70 with CPI on claim. Policy 1 - $18,750 per month, 30 day waiting period, benefit period until age 70, CPI on claim. The stepped premium cost of this policy is around $4,900pa. Please refer to the red line on the chart to note the increase to income protection insurance premiums over time. As you can see by the time Joseph is 50 his policy will cost him around $11,100pa
differing waiting and benefit periods can reduce cost and allow you to meet your insurance needs. Let’s explain these terms before we proceed with the example. The waiting period is the time that needs to pass after the commencement of your accident or illness before you start to receive a benefit from the insurance company. This can range from 2 weeks to 2 years. This may reflect the period of time that you can manage because of leave, annual leave, savings etc. that you have without needing an income protection benefit stream. The longer the waiting period, generally the less expensive the insurance premium will be. The benefit period is the period you will continue to receive an income protection benefit in the event that Joseph was then provided a quote for level premiums for the same policy for $7700. The level premium you are unable to work due structure works out to be HALF the cost of the stepped premium structure if the policy is held for the and at 54, it will cost $14,800pa. to illness or accident. This can be for duration. In fact using the graph as an example, although a stepped premium is cheaper initially, its evident These costs concerned Joseph as at a set period (i.e. 2 or 5 years) or until that in your late 40’s you could be paying the same amount for your insurance premiums than you would for the level premium policy. If you hold your income protection policy into your 50’s, the cost of a stepped 54, his children will be aged 18 and a set age (i.e. to age 55, 60, 65 or 70). premium policy grows above and beyond the level premium. 16 and will still be fully dependent on The choice of which benefit period is SAVINGS TIP him. He is concerned he may be forced suitable to you reflects your income to cancel the cover due to cost. protection goals and objectives. The If when asked “how long you see yourself needing income protection?” and the answer is 10 years or more, then you should consider a level premium structure for your policy as it will more than Joseph was then provided a quote longer the benefit period, generally likely be cheaper in the long term. for level premiums for the same the more expensive the premiums will policy for $7700. The level premium be. Waiting Period and Benefit Period – Cost Reduction Strategy structure works out to be HALF the A TWO POLICY option that has differing waiting and benefit periods can reduce cost and allow you to meet your insurance needs. Let’s explain these terms before we proceed with the example. cost of the stepped premium structure OPTION B - TWO POLICIES TAILORED if the policy is held for the duration. TO YOUR NEEDS The waiting period is the time that needs to pass after the commencement of your accident or illness before you start to receive a benefit from the insurance company. This can range from 2 weeks to 2 years. This may In fact using the graph as an example, reflect the period of time that you can manage because of leave, annual leave, savings etc. that you have without needing an income protection benefit stream. The longer the waiting period, generally the less although a stepped premium is Joseph thinks that he can survive expensive the insurance premium will be. cheaper initially, it’s evident that in on savings and his LOC and $10,000 The benefit period is the period you will continue to receive an income protection benefit in the event that your late 40’s you could be paying per month in the short term. He you are unable to work due to illness or accident. This can be for a set period (i.e. 2 or 5 years) or until a set age (i.e. to age 55, 60, 65 or 70). The choice of which benefit period is suitable to you reflects your income the same amount for your insurance wishes to consider a waiting period premiums than you would for the of 30 days for $10,000 per month and level premium policy. If you hold your a staggered 90 days for the balance income protection policy into your of $8,750. That way, if he has a long 50’s, the cost of a stepped premium term disability, he will receive the full policy grows above and beyond the benefit after 90 days as the policies level premium. run in tandem. Considering he plans to send his children to private school Waiting Period and Benefit Period and possibly to assist them through – Cost Reduction Strategy university Joseph needs the full cover until this time. After the age of 60 he A TWO POLICY option that has and his wife may be empty nesters
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and he believes they need only $10,000 per month until age 70. Let’s see how this two policy option can save you. Policy 1 - $10,000 per month, 30 day waiting period, pays this benefit until age 70. Policy 2 - $8,750 per month, 90 day waiting period, pays this benefit until age 60. Both with CPI on claim. The stepped premium price for both of these in total is $4,165 pa and increases each year. Alternatively, the level premium here is $6,335pa. As you can see in the tables comparing Option A and B, Joseph has a cheaper option that covers his needs using this two policy strategy combined with level premiums. By tailoring your income protection policies to your needs and considering level premiums, you can afford to be comprehensively covered over your working life and save over half the possible premium cost based on the standard stepped one policy option. Carolyn Wright, Partner, Insurance Advisor at Life Shield Pty Ltd. Carolyn has had experience across a broad range of financial services and now concentrates on advising professionals how to have a complete and cost effective insurance strategy that meets their needs now and over the longer term.
This material is not intended to constitute personal advice and must not be relied upon as such. This material is of a general nature only and has been prepared without taking into account your individual objectives, financial situation or needs. The example provided is an indication only and these are not personal quotations or firm market pricing. You should consider the appropriateness of this material having regard to your objectives; financial situation and needs, before making a decision based on this material, and consider obtaining independent advice from a licensed financial adviser. You should read the relevant Product Disclosure Statement before making a decision about whether to acquire a product. Life Shield Pty Ltd ATF Life Shield Trust is a Corporate Authorised Representative of Millennium3 Pty Ltd FS ABN 61 094 529 987 (AFSL No. 244252)
Anaesthetists visit
Health Professionals go to Anaesthetists visit www.lifeshield.com.au www.lifeshield.com.au
Health Professionals go to www.lifeshield.com.au or call 1300 44 77 10 www.lifeshield.com.au or call 1300
44 77 10
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Unbiased and Professional Insurance Solutions. Unbiased and Professional Insurance Solutions.
Who’s got you covered? Life Shield enables the increasing amount of time poor Australians efficient access to unbiased, professional insurance advice. You spend your life helping people who are sick or injured. So you know life doesn’t always go to plan. But what if you were the one who needed support? Not just physically and emotionally, but financially?
If you couldn’t work due to illness or injury... »» How would you replace your lost income? »» How would you keep up with your debt repayments? »» How long would your savings last?
Life insurance strategies for you; your family and your wallet.
We work Australia wide with access to all of Australia’s major insurance companies. Call us to see how our insurance specialists can ensure you have top insurance cover at the right price. Whether you are wanting your existing insurances reviewed or would like to investigate new Life Insurance, Total and Permanent Disability, Trauma and Income Protection policies, Life Shield can assist.
We understand Anaesthetists. We have the experience and knowledge required to provide an efficient and professional service.
CAREERS
Taking on risk for your
children
Inter vivos estate planning - The pros and cons of going guarantor and giving your adult children a ‘heads up’ in life.
W
e describe inter vivos estate planning as giving your family part of their inheritance while you’re alive to see them enjoy it. With the affordability of housing continuing to be out of reach, parents are increasingly offering financial assistance to children and their spouses, particularly to purchase residential property. Those of us who have children would all agree that helping them make the most of life’s opportunities is a great motivator to give, but sadly, many of us lack a body of objective experience against which to temper the nature and extent of our giving. People usually only have one case study to work from: their own experience. Occasionally, they will share the experience of other family members or close personal friends, but that too provides only a narrow view of the issues that need to be considered. The fine line that everyone seeks to identify is where constructive assistance ceases and where indulgence or waste begins. When it comes to providing financial assistance to our children we would recommend taking some of the emotion and personal bias out of the decision making process by seeking professional advice and employing an objective framework to find where that fine line is.
Some Ground Rules
There is no fashion in either inter vivos or testamentary estate planning solutions because the dynamics of each family are unique. There are, however, some ground rules that can help define how you should approach giving to your children.
Gifting or lending?
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There is a difference. Gifting places no responsibility on the donor and experience has shown us that frequently the donor’s expectations are not met. The X and Y generations have a reputation for being blasé, which often time leads their parents to believe they are being taken for granted. Experience in working with clients has shown us that gifting any more than modest amounts is counterproductive. In fact, we generally advise clients not to gift money to their adult children unless those children are parents themselves.
Children under 30? Only a lender be
It is strongly recommended that if your child is less than 30 years of age, you be a lender. The lending should be used not just to assist, but also to educate. The objective of the education is to leave adult children financially competent and with a healthy respect for their financial affairs. As a lender, you can choose to charge interest or not; to secure or not; or to demand repayment of capital or not. It is healthy to dis-intermediate within a family, in other words to cut out the bank wherever possible. If the parent has to borrow to provide the loan, they should not seek to profit by it, but only to be fully reimbursed for their expense. Parents can generally borrow at cheaper rates than adult children. For example, you can lend to adult children the funds to buy a car under the same terms and conditions as a bank loan, but take advantage of cheaper mortgage lending rates.
Protect your investments in 2011 CAREERS
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
John Marasco
Paul Saliba
Chief Economist BT Financial Group ‘Global Economic and Market Outlook’
CEO Colliers ‘Investing in Commercial and Residential Properties what is happening in Australia and Globally’
Chief Investment Officer Lachlan Partners ‘Dynamic Approach to Asset Allocation - Applying the new Zone System’
Seminars are being held in the following locations Brisbane
Tuesday March 8th 2011 2 - 4pm The Novotel Brisbane 200 Creek St, Brisbane QLD
Sydney
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Melbourne
Thursday March 31st 2011 4.30 - 6.30pm Level 1, Crown Towers, 8 Whiteman Steet, 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 To attend OR obtain a Seminar DVD and receive a 3 month complimentary subscription to Investing Times 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)
BUSINESS & FINANCE
Case Study : Failure to register a mortgage If the parents are not borrowing to provide the loan, then the charge should be the interest they were receiving plus 50% of the difference between that rate and the rate the adult child could secure using their own resources. Where there is substantial assistance being provided for housing and there is an external lender, we advise that where it is affordable for the parent, that the loan be conditional to the extent that interest foregone be applied as voluntary additional payments to accelerate repayment of the non-deductible bank debt.
Documentation? Always put it in writing
Whether you are considering lending or gifting to your children, it is vital that it be properly and formally documented. The primary reasons are control, risk management and asset protection. It would be negligent of both parent and child to assume that there will never be any conflict that may create discord. Additionally, the fluid nature of relationships today means that others may become unintended beneficiaries in the event of divorce or relationship breakdown. Control triggers should be clearly outlined in documentation. For example, if a child accepts assistance from a parent to purchase a real asset and decides six months later to dispose of the asset, it is important that the parent’s interest in the property to the extent of the loan be documented formally to guarantee return of that capital.
Should the loan be stamped or registered against the asset?
There is no prescriptive answer to this question and it depends entirely on the circumstances. Generally though, if the loan is being made to purchase a real asset, such as a property, it makes good sense for the lender to register a first mortgage over that asset. The case study below examines what can go wrong if a child defaults on the mortgage and parents have not registered their interest.
Divorce and relationship breakdown
The Family Court hears most property disputes involving de facto spouses. With binding financial agreements becoming a favoured tool of high-income earners to mitigate the costs associated with divorce and relationship breakdown, such agreements may now have greater implications for parents who provide financial assistance to children in de facto relationships. Having amounts lent to your children properly documented and secured will help protect this capital and ensure it remains within the family in cases of relationship breakdown.
A final word
If your financial position truly allows you to be unconstrained in your capacity to enhance the quality of your life, then it makes sense to extend that same privilege to other family members. But, for both the giver’s and receiver’s peace of mind, it’s important to apply commercial principles when setting the ground rules.
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Angus is 25 years old and single. He is in the process of starting an IT business so savings are scarce. However Angus, like many of his friends, has a dream of owning his own home and soon. He has found a property for sale at $450,000 and his parents, John and Christine have offered financial assistance to Angus to purchase the property. Given Angus’s current financial position, he gratefully accepts the offer. John and Christine are able to fully fund the purchase price on Angus’s behalf. Under the loan agreement, the newly purchased home is offered as security for repayment of the debt to John and Christine. John and Christine see this as a way of protecting their capital in the event Angus’s new business does not perform as well as expected. However, due to their unfailing confidence in his ability to succeed in business, John and Christine fail to register their security on title. Angus, not wanting to borrow further money from his parents, obtained a loan of $200,000 from the bank to help develop his business. He didn’t tell John and Christine because he wanted to prove to them he could manage on his own. The bank, with Angus’s consent, immediately registered an all monies mortgage over Angus’s home. John and Christine now find themselves in a dangerous predicament. Although they have security over Angus’s home, it is not registered. As a start-up business, statistics show that it is more likely to fail than succeed. If that happens, then the bank, having a registered mortgage, will be able to exercise its security over the home in priority to John and Christine, whose security is unregistered. Even if they register their security now, they will only have a second registered mortgage since priority is based on the date of registration, not on the date of the loan. If the home is sold to repay Angus’s loan, then the bank will be paid its $200,000 first and John and Christine will be second in line. Assuming the house is still worth $450,000, John and Christine will be able to recover $250,000 but in order to recover the balance of their loan ($200,000) they will rank equally with all of Angus’s other unsecured creditors e.g. employees, suppliers, etc. This could have been avoided if they registered a first mortgage over the property when they entered into the loan agreement with Angus principles when setting the ground rules. LACHLAN PARTNERS is a Private Advisory Firm focused on client needs and financial goals with offices in Melbourne, Sydney and Brisbane www.lachlanpartners.com.au. The following can assist you with your Estate Planning needs; Roger Wilson (Partner); Eric Maillard (Partner)
RISK MANAGEMENT
The
LEGAL RISKS of Quality Assurance
Keeping quality assurance reports away from plaintiff lawyers A quality assurance report helps a doctor and his or her employer to identify problems that have lead to adverse patient outcomes. Yet, these quality assurance reports may harm the doctor by casting him or her in a negative light, or appearing to admit wrongdoing. A wellwritten quality assurance report may do the hard work in finding out where the problem lay, and save the patient’s lawyer from having to do it.
“A patient may obtain a quality assurance report using various legal methods document discovery, subpoenas, the Freedom of Information Acts (and the private patient equivalents in the ACT, New South Wales and Victoria), as well as the emerging doctrine of open disclosure.”
A
patient may obtain a quality assurance report using various legal methods - document discovery, subpoenas, the Freedom of Information Acts (and the private patient equivalents in the ACT, New South Wales and Victoria), as well as the emerging doctrine of open disclosure. A staff member may legally release an otherwise confidential quality assurance report under one of several laws designed to allow disclosure in certain circumstances (for example, whistle blowing, child abuse, and occupational health and safety). A staff member may also accidentally or not-so-accidentally allow the report to fall into the patient’s hands, if that staff member is sympathetic towards the patient or unsympathetic towards the doctor. To some extent, doctors may have to learn to simply accept the legal risk that goes with writing quality assurance reports. A doctor’s commitment to truth, and to his or her patients’ welfare, mean that it
may well be the right thing to create quality assurance reports even in the knowledge that they may be used against the doctor in litigation. It is not necessarily the case that a damning quality assurance report will turn the tide against the doctor in a trial court. A patient who has a winning case with a critical quality assurance report in hand is likely to have a winning case even without it. The damage is not done when documenting an adverse outcome, but rather when the adverse outcome occurred. A good quality assurance system may increase the risk of some litigation, but it may also in fact protect the doctor against other legal risks, such that the overall effect is to decrease the doctor’s overall exposure to litigation. The most robust legal method that is available to doctors to keep quality assurance reports secret is called legal professional privilege. If a doctor is engaged in litigation or reasonably anticipates litigation, he or she should ANAESTHETICLife
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RISK MANAGEMENT conduct a full analysis of the patient’s care for the dominant purpose of advising the doctor’s solicitors. (That is to say, the insurer’s solicitors). This will probably protect the report from the legal methods of obtaining reports mentioned above, and will give the doctor the best chance of finding out the true story behind an incident. Legal professional privilege, as it applies to doctors, is the principle that confidential communications between a lawyer and a doctor need not be given in evidence or otherwise
“The most robust legal method that is available to doctors to keep quality assurance reports secret is called legal professional privilege.”
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disclosed by the doctor, and without the doctor’s consent, must not be given in evidence or otherwise disclosed by the lawyer, if those communications were made either to enable the doctor to receive legal advice or were made with reference to litigation that is in progress or anticipated by the doctor. Legal professional privilege is properly regarded not as a privilege given to lawyers, but as one that is given to doctors who are their clients. The privilege allows doctors to speak freely with their lawyers. The obvious nuisance of legal professional privilege is that it may result in crucial information being withheld from a judge, and there is a possibility that a judge will reach an incorrect verdict as a result. It has been suggested that, therefore, legal professional privilege protects those who are guilty. This is true. However, legal professional privilege can also protect a doctor who is innocent but who is immersed in suspicion, and needs to confide in a legal expert who can help him or her out of it. The conflict between the desire to find the truth and the desire to protect a client’s right to communicate with his or her lawyer is less pronounced in civil litigation than it is in criminal cases, but still, the conflict is there. In 1846, a British judge proclaimed: Truth, like all other good things, may be loved unwisely – may be pursued too keenly – may cost too much. And surely the meanness and mischief of prying into a man’s confidential consultations with his legal adviser, the general evil of infusing reserve and dissimulation, uneasiness and suspicion and fear, into those communications which must take place, and which, useless in a condition of perfect security, must take place uselessly or worse, are too great a price to pay for truth. This is still the attitude of the law today. It therefore seems plain that in Australian law, if a legally privileged quality assurance
investigation manages to uncover the truth of a bad outcome for a patient, which is otherwise unknown and undocumented, then that truth may be withheld from a patient or relative, or their lawyers. This holds true even if, for example, it results in the hospital being able to withhold crucial information from a court and thereby successfully defend itself against a lawsuit. A hospital or doctor who seeks to claim legal professional privilege needs to show that the document or communication was made for the dominant purpose of obtaining or giving legal advice. Even if the documents could be used or are later used for other purposes such as managing the hospital, the privilege remains. A quality assurance report that is made for a superior in the everyday course of hospital or clinic administration cannot be privileged. It is not enough that the report might turn out to be useful if the institution is sued; the possibility of litigation must be in the mind of the person who creates the report. If a patient somehow does obtain reports that are legally privileged, and tries to use the reports as evidence in litigation, the doctor has an obligation to claim the privilege in court, at the time that the evidence is produced. If a privileged document is placed into evidence and the doctor does not object, then the privilege may be lost. If a doctor voluntarily communicates the results of a quality assurance study to a patient, any legal professional privilege that might otherwise attach to it is lost. A hospital or clinic needs to have adequate systems in place to prevent quality assurance reports from being communicated to patients without proper consideration of the consequences. For a more detailed analysis, see Richard Cavell, “The legal risks of quality assurance in Australian public hospitals” (2007) 15 Journal of Law and Medicine 219.
National registration difficulties
Since 1st July 2010 in most States and Territories of Australia the registration of health professionals became centralised, and is now administered by the Australian Health Professional Regulation Agency (AHPRA).
T
his will have advantages, particularly for those doctors who practise interstate. There is also a unified national code of conduct outlining the expectations for Good Medical Practice (http://www.medicalboard.gov. au/en/Codes-and-Guidelines.aspx). This is comprehensive and replaces a range of guidance previously available on the web-sites of the various state boards. When information is transferred from a series of databases to a single large computerised system, the possibility of errors may arise, and medical practitioners may wish to verify their details on the web-site for accuracy (http://www.ahpra.gov.au/). With national registration has come the requirement for mandatory reporting, which is a new feature (apart from in New South Wales where is was introduced earlier) and requires registered practitioners to inform AHPRA if they form a reasonable belief that another registered health practitioner has behaved in a way that constitutes notifiable conduct; or that a student has an impairment that, in the course of the student undertaking clinical training, may place the public at substantial risk of harm.1 Notfiable conduct means the practitioner has: (a) practised the practitioner's profession while intoxicated by alcohol or drugs; or (b) engaged in sexual misconduct in connection with the practice of the practitioner's profession; or (c) placed the public at risk of substantial harm in the practitioner's practice of the profession because the practitioner has an impairment; or (d) placed the public at risk of harm because the practitioner has practised the profession in a way that constitutes a significant departure from accepted professional standards.2 While the first three may be straightforward, careful judgement may be required to determine whether a practice may represent a significant departure from the required standard. Although registered practitioners are mandatorily required to make a report, there is nothing to prevent anyone who has a concern about a health practitioner contacting the National Agency.3
Those who make a notification about a practitioner are protected from liability for giving the information, provided this has been done in good faith.4 It is therefore important that if doctors are considering making a notification about another health practitioner they should ensure that the facts are correct and where possible they should verify the issues first-hand, rather than relying on reports from others. If the health practitioner about whom there are concerns is employed, for example by a hospital, then the employer is mandatorily required to make a notification. This in many situations may be more appropriate than an individual doctor contacting the National Agency (and once the individual is aware that another party has made the notification, his or her obligation to notify ceases).5 While the issue of mandatory notification is relatively new here, a failure to notify appropriately may amount to professional misconduct. In 1994 the General Medical Council in the UK found a consultant guilty of serious professional misconduct for failing to investigate complaints that a locum was endangering patients.6 Recent research in the United States showed that while the majority of over 1800 doctors surveyed agreed with the professional commitment (that is where there was no mandatory obligation involved) to report all instances of impaired or incompetent colleagues in their medical practice to a relevant authority, many were reluctant to take steps to advise the relevant authority.7 While it is likely to take some time to assess the effectiveness of the new arrangements, it is clear that the health profession’s responsibility to take action over a colleague who may be putting patients at risk of harm is an issue to be taken seriously.
Dr John Williamson References 1 Health Practitioner Regulation National Law Act 2009 (QLD) Section 141 2 Ibid. Section 140 3 Ibid Sections 144-145 4 Ibid Section 237 5 Ibid Section 141 (4) (e) 6 Clare Dyer ‘Consultant found guilty of failing to act on colleague’ BMJ 1994;308:809 (26 March) 7 Catherine M. DesRoches, Sowmya R. Rao, John A. Fromson, et al ‘Physicians' Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues’ JAMA. 2010;304(2):187-193
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TAX
avoidance Anaesthetist ordered to pay $50,000 in back taxes
Ms AG was a 53 year old woman with a long history of bipolar disorder and a cardiac condition for which she was prescribed digoxin. She overdosed on alcohol, aspirin and codeine and was admitted to hospital with an altered conscious state, where she was noted to have acute-on-chronic renal failure. When her overdose had been managed, she was transferred to the psychiatric unit of a private hospital for treatment of severe depression.
“The company did not pay salary fortnightly or monthly, but rather, annually, in arrears.”
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Dr X, an anaesthetist from New Zealand, works full time in both public and private practice. She works in a public hospital as an employee of the local Health Board. She also works in private practice, at a private hospital and at a dental practice. Since 1987, along with her husband and three children, she has owned and operated a family trust that operates an anaesthetic group. The anaesthetist’s income from private practice was channelled through the trust, and she was employed by the trust. The anaesthetic group has also hired a locum to do some private anaesthetic work.
In 2002, she restructured her business affairs. She and her husband sold their two properties, which were the family home and a motel unit, to the family trust. The family trust also bought a nearby avocado orchard. Meanwhile, she set up a company, the name of which was the single letter “W”. W was owned by herself, her husband and her three children. Her private practice was restructured so that all of its patients became customers of W. W in turn employed her to provide anaesthetic services. Unusually, the company did not pay salary fortnightly or monthly, but rather, annually, in arrears. The company would wait for its annual
RISK MANAGEMENT profit results before determining Dr X’s salary. W operated Dr X’s private practice and also the avocado orchard. It paid the family trust significant sums for equipment rental, but did not have any assets of its own. W barely made a profit. Although it earned huge sums, in the order of more than $200 per anaesthetic patient, these losses were offset by losses in the avocado business. As a result, W paid hardly any corporate income tax. W also decided to pay Dr X very little salary. For 5 months of full time work as an anaesthetist, she received zero salary. For the next 12 months of full time work, she received less than $5000. The net effect was that Dr X paid very little personal income tax. So the net effect was that the income from Dr X’s anaesthetic
practice was diverted into the family trust, virtually untaxed. The Commissioner of Taxation claimed that the salary paid to Dr X was artificially low and commercially unrealistic, and decided to charge her personal income tax on her earnings as an anaesthetist. She received a bill for over $50,000, and responded by taking the matter to court. The judge agreed with the tax office, saying that the arrangement was an “artificial, contrived, and very uncommercial arrangement”. W’s practice of renting equipment from the family trust had the effect of funnelling money from the private practice into the family trust, without paying tax. Without the anaesthetist’s services, W would not have had any income. Meanwhile, the anaesthetist was
paid very little by W. The judge said that it was “commercially unrealistic” for an anaesthetist to work without remuneration, or for very little remuneration. He declared that the whole arrangement was “contrived” to avoid paying tax. However, the judge said that Dr X acted in good faith on the advice of her business advisers, and that although the net effect of the scheme was tax avoidance, she did not intend to act illegally. She was ordered to pay the back taxes bill of more than $50,000. Dr X’s name was suppressed. She was not found guilty of any crime, and she is free to continue practising as an anaesthetist.
Dr. Richard Cavell
“The income from Dr X’s anaesthetic practice was diverted into the family trust, virtually untaxed.”
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INTRODUCING THE NEW
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Dare toDream
How to set meaningful goals and to achieve them
This edition focuses on something that many doctors neglect. Because of the prescribed course that a medical career can take many doctors don’t set defined goals and often just go with the flow. While it can seem like the easiest option it leaves a lot to chance. This article shares a new way of setting meaningful goals that has the ability to put your goals on anabolic steroids.
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s humans we steer towards what we focus on. This is the reason that goal setting is so important. Goals send commands to our subconscious minds that cause us to move towards those goals. Studies have shown the subconscious mind to be at least 30,000 times more powerful than our conscious mind so
it’s important to get the subconscious mind moving in the direction we want. But while it’s incredibly powerful, the subconscious mind does not have the ability to choose or to make value judgements; it merely obeys your dominant thoughts - what you are focussing on most of the time. It’s therefore important that our
Image above: “dream on” by TheAlienness GiselaGiardino www.flickr.com/photos/ gi/2953550/. Images licensed under Creative Commons Attribution 2.0 Generic license, http://creativecommons.org/licenses/by/2.0
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CAREERS dominant thoughts are what we want in our lives, because regardless of whether you want it or not, if you’re focussing on it your subconscious will make sure you’re moving towards it. States/emotions like anxiety are in effect negative goal setting, because by worrying about what you don’t want you are actually setting this up as your dominant thought and your subconscious moves you towards it, even though you don’t want it. For example, if you’re worried about not having enough money and you’re focussing on your lack of money, chances are you’re going to end up in worse financial difficulties. Have you ever thought something like “don’t stub my toe, don’t stub my toe”, then you’ve done exactly that, stubbed your toe? That is exactly what negative goal setting is. The purpose of goals is not just to achieve that goal, the purpose of goals is to create dominant thoughts that moves you and your life in the direction you want. But I noticed that just setting goals wasn’t enough; I noticed there were a lot of people who had goals but who never seemed to achieve them, and I also noticed that this happened to me sometimes. So I searched for an answer as to why this was the case, and I think I’ve found it.
Activating the whole mind The old wives’ tale is that the left brain is based on logic, while the right brain is based on creativity. We have already established that our goals are there to move us, and for goals to be truly effective they need to register in both our left and right brains. Most people set goals by writing them down. This is great because the written word communicates with our logical left brain. But the problem with this is that our creative right brain is not activated by simply writing goals; the right brain speaks in images and emotions and therefore these need to
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be used to harness our full potential.
The benefits of positive thinking While some people think positive thinking is merely the ‘woo woo’ practice of naive simpletons who just want to feel good, science has demonstrated the undeniable benefits of it. Positive thinking causes the brain to release serotonin. Not only does serotonin cause you to feel happiness and a sense of wellbeing, but it has now been demonstrated to form a bridge to more effectively connect brain cells and to connect the left and right brains. On the other hand, negative thinking causes the release of cortisol which causes feelings of stress, sadness and depression. And if this isn’t enough, it has also now been demonstrated to reduce communication between brain cells and also the left and right brains. So, by combining positive thinking with a practice of goal setting that
I had the same thoughts and my search for an answer led me to a man called Brian Mayne. Brian teaches a process that is fun and easy to do and results in both your left and right brain being activated; it’s called Goal Mapping which can be summarised by the following process: 1. Dream – create a vision for your ultimate life and set goals 2. Order – determine your key goal that will make the other goals happen too 3. Draw – activate your right brain and your subconscious through images 4. Why – activate your subconscious through emotions – why is this goal so important to you? 5. When – set a deadline, a goal without a deadline is just a wish! 6. How – what are the actions you need to take? 7. Who – choose the people or organisations that can support you.
“The purpose of goals is not just to achieve that goal, the purpose of goals is to create dominant thoughts that moves you and your life in the direction you want.” activates both the left and right brains, we give ourselves the best chance at not only a happy life, but also a life where we achieve the things that are meaningful to us.
The answer… You might be thinking “this is all well and good, but what specifically can I do to set goals that activate my left and right brain so that I get them aligned and on target so that my life flows exactly where I want it to?”
“If you think you can do a thing or think you can't do a thing, you're right.” Henry Ford Dr Sam Hazeldine is the Director of Medrecruit who recently did a presentation of Goal Mapping and how to apply it to get results. http://goals.medrecruit.com
When It Comes To Working As A Specialist Anaesthesiologist, Your Needs Are Different From Junior Doctors At MedRecruit we understand that finding the right positions in a locum capacity and in a permanent capacity as a specialist have its own specific needs and requirements. Your needs are as unique as your speciality and your career and you don’t want to be lumped in with the junior doctors who have very different needs and requirements. As you decide to work with MedRecruit you will be matched with your own personal Solutions Specialist who specialises in working with anaesthesiologists to get you the perfect placement, a placement that meets all your unique needs. Your personal Solutions Specialist is trained to negotiate the very best deal possible for you so you can be secure and comfortable in the knowledge that you’re getting the best package, personalised for you. When you register with MedRecruit you will also
receive valuable and much sort after resources related to locuming to ensure you maximise the benefits to you. You will also receive membership only access to our specialist partners, such as Deloitte, who are industry leaders at working with doctors to ensure they get the most out of their careers. With offices in both Australia and New Zealand, and relationships with more hospitals across Australasia than any other agency in our field, you will gain access to the largest database of vacancies which will ensure you get the best solution tailored specifically to you; we have far too many vacancies in your speciality to list on this page! Due to our long standing and strong relationships with many hospitals you will have choices of positions that are not advertised anywhere else. When you register with MedRecruit you will immediately receive:
Passport to Lifestyle & Career
Webinar
eBook
•
This online webinar is potentially worth many thousands of dollars to you and you will receive access to it at no charge.
This eBook was created using 3 years of validated research and testing. It reveals: • The secrets to setting meaningful goals • The keys to achieving those goals • The 7 habits that highly successful doctors utilise to create their desired lifestyle in medicine, whatever that is for them
This is a much sought after eBook for doctors that you will get as soon as you register with MedRecruit. In this eBook you will find:
• • •
Video interviews with NZ Prime Minister John Key and top sportspeople about peak performance The 7 myths of locuming revealed Rewards for you! Videos of sucessful, real locum doctors sharing their feelings and experience using the renowned MedRecruit system
The 7 Secrets to Explode Your Income as a Locum
It reveals: • The 7 things that any senior doctor can apply immediately to maximise their income • The key ways to become tax efficient to keep even more of that increased income in your pocket!
What should you do now?
Creating a Lifestyle in Medicine – The 7 Habits of Highly Successful Doctors
Either register at www.medrecruit.com or call 1800 MEDRECRUIT (633 732) and you will receive these three resources absolutely free and we will schedule a call for you with the exact Solutions Specialist who can best serve you.
If you need to recruit a doctor for your practice then please register in the same way and we will find you the right doctor to meet your needs.
Welcome to a whole new way of locuming where you are the priority and you have your own personal specialist team to assist you to get you the best outcome.
ALPHA
iPhones in Anaesthesia The Best iPhone Apps for Anaesthetists
by Dr Sud Agarwal, Consultant Anaesthetist
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HE iPhone has become the latest commodified gadget sported by almost every member of the anaesthetic team from junior registrar to senior specialist. It is no wonder that this ubiqnity on total penetration has spawned a whole genre of iPhone apps targeting anaesthetists. No doubt, by the time this article goes to print, it will be out-ofdate as there will be newer, cooler, more sophisticated Apps with greater utility for the practicing anaesthetist. However, at the time of writing, I can reassuringly confirm that I have reviewed, graded and selected the best iPhone apps for the technologically savvy anaesthetist:
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ALPHA
Sonoaccess – Sonosite Pty Ltd - Free – **** Ultrasound Guided Regional Anaesthesia Guide and Image Collection AS an anaesthetist bursting with enthusiasm (and lacking in experience) on regional anaesthesia, I am zealously trying to climb the learning curve of ultrasound guided regional anaesthesia. Historically, I have always had to quickly glance through an atlas of sonoanatomy before performing a block that I was not completely comfortable with, especially if I have not performed the block for a period of time. The solution to this is an excellent collection of images available at the point of care through this App. Giving me the ability to refresh my visual memory immediately before I perform the block vastly increases my confidence (and usually success) in performing the block. Blocks available are the axillary, femoral, infraclavicular, interscalene, median, popliteal, sciatic and supraclavicular. The provision of updatable, clinically useful visual imagery at the point of care has the potential to significantly alter clinical practice. In anaesthesia, where large volumes of rapidly updating content is needed, this application will undoubtedly spawn a multitude of copycats.
“The provision of updatable, clinically useful visual imagery at the point-of-care has the potential to significantly alter clinical practice.”
American College of Cardiology Pocket guidelines - ACC – Free - *** EVEN though there are only a few ACC guidelines which are of particular interest to anaesthetists, the ability to quickly glance at these whilst on call is invaluable. The guidelines which I found myself accessing the most frequently were the “Perioperative Cardiovascular Evaluation for Non-cardiac Surgery” and “Management of Patients with Valvular Heart Disease” guidelines. I found this App particularly helpful during Pre-Anaesthetic Clinics. Another useful set of gadgets in this App is the “TTE/TOE Appropriateness Criteria Tool” and “SPECT Myocardial Perfusion Imaging Appropriateness Tool” which assists in deciding whether cardiac function investigations are indicated.
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MedCalc – Mathias Schopp - Free - **½ WHEN you go onto the iTunes website and search for a Medical Calculator iPhone App, there are at least 5 different options including Mediquations, MediMath, MedCalculator, CliniCalc, Medical Calulator. All of these cost somewhere between $1 and $15. However, if you browse that little bit harder, there is a free App that contains almost all the most useful anaesthetic formulas and calculations and is totally free - MedCalc. If one browses under the “Anesthesiology” section, there are over 50 calculators especially for anaesthetists of which the ones with the highest utility would be: 1. 2. 3. 4. 5. 6. 7.
Allowable Blood Loss BMI CO Drug Infusion calculator Opioids Equivalence Paediatric Resuscitation Doses Paediatric Endotracheal Tube Sizing
Even though this has clearly been written by a non-anaesthetist and has tried to provide a whole range of calculators for a plethora of medical specialties, I can’t find too many faults with it. The App runs smoothly, is easy to navigate and provides the calculations that a clinical anaesthetist needs every day.
Anaesthetics Logbook Apps: 1. iGaslog – iMobileMedic - $36.99 - **½ 2. Vaper – Vaper Pty Ltd $26.99 - *** THESE two iPhone Apps that enable anaesthetists to collect details of all the operations, including operation type, surgeon, airways device used, choice of anaesthetic, blocks used, complications and time taken. They are excellent Apps for trainees who need to substantiate what they have to meet then module accreditation requirements for ANZCA. Both use smooth, easy to use interfaces to collect data and rarely crash. Both also allow exporting of all data to Excel format for printing or emailing to third parties. If I was to say which out of the two was better, I would say it was close but Vaper narrowly beats iGaslog.
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“If you browse that little bit harder, there is a free App that contains almost all the most useful anaesthetic formulas and calculations.” MBS and RVG database billing software Apps: 1. iMBS – CE Soft - $4.99 - ***½ 2. iRVG – CE So ft - Free (to ASA members) - ***½ 3. Pocket MBS - Vaper Pty Ltd - $4.99 - ***½ 4. Pocket RVG – Vaper Pty Ltd - $4.99 - ***½ 5. MBS Search – Umbrella Networks Pty Ltd – Free - ***½ THE burden of having to look up RVG or MBS numbers in a cumbersome book seemed so old-fashioned in this technologically-enabled era. With the advent and ubiquitous dissemination of the iPhone, the opportunity to convert the arduous task of thumbing through pages of a big book to simply selecting options from a dropdown menu on the iPhone screen is a godsend. I can only sympathise with the anaesthetists of yesteryear who trawled around private hospital to private hospital with the MBS guide in their briefcase. Admittedly, the big MBS book provided the intricate details of remuneration for private anaesthetists, but its usability and portability did leave a lot to be desired. The Apps provided by Umbrella Networks, Vaper Pty Ltd and CE Soft appear to be very similar and all provide the same data. They all have fast loading, slick menus with ease of navigation. There is little to separate the different Apps other than perhaps cost and support. Notably, the free Apps don’t seem to offer any support.
ALPHA
Oxford Handbook of Anaesthesia – MedHand International - $74.99 - **** THIS time-honoured icon of anaesthesia is a handbook which every single one of us became closely acquainted with whilst studying for our Part 2 exams. To facilitate portability and accessibility during clinical practice, it is now available as an iPhone App. But does it work? Absolutely. This e-book usurps the original paper version as we are given free updates, fast-loading colour diagrams and most importantly portability. The price has been set as the same as the book at $74.99 which some may argue is a little steep considering there is no incremental cost involved in selling each e-book. I have personally found the main use as being a source of questions (and answers) when giving vivas to the trainees at my hospital. Although, I must confess to having recently used it to refresh my memory on the intricacies of an eye block.
almost
In a nutshell, would I buy it?..... I already have.
AnestAssist PK/PD - Palma Healthcare
“This e-book usurps the original paper version as we are given free updates, fast-loading colour diagrams and most importantly portability.”
Systems, LLC - $23.99 **½ This neat little App allows the anaesthetist to model multicompartmental pharmokinetics for a plethora of commonly used anaesthetic drugs including Propofol, Remifentanil, Midazolam, Morphine, muscle relaxants and many more. It also allows the user to estimate uptake and Fa/Fi curves for most of the common volatiles and nitrous. Apart from drawing pretty diagrams, what is the actual utility of such a gizmo? Well, my uses for it include calculating remifentanil or propofol doses in some hospitals which don’t have TCI pumps especially when it is late at night and I don’t want to rely on my mental arithmetic. It also forms a great tool for teaching pharmacokinetics to first part candidates.
DrugDoses – Oliver Karam - $23.99 - ***½ The Frank Shann paediatric drug doses goes digital. This iPhone app has re-created the eternally useful Frank Shann drug dosing book and converted to an iPhone App. Oliver Karam is a Paediatric Intensive Care Specialist in Geneva, Switzerland and has probably bought himself the opportunity to retire early. This App is almost a mandatory download for anaesthetists whose practice incorporates any paediatric anaesthesia at all. ANAESTHETIC ANAESTHETIC Life Life
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BOUTIQUE
Clear Skies Ahead Does your practice need a little more light or perhaps you have a wall at home in need of a new aspect? Sky Factory Luminous SkyCeilings are virtual skylights offering photographic illusions of real sky with amazing results. www.theskyfactory.com
Designer Sounds Stand In Case Treat your iPad to its very own leather case that protects it securely and becomes a stand for easily delivered presentations or movie watching. Truss Case for iPad RRP $69.95. www.targus.com.au
Red Letter Days Stand out in your street and ensure the postman never misses a delivery with this eye catching Project Letter Box RRP $570. www.robertplumb.com.au
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This feature piece docking station comes with a fully active 5-speaker system and is guaranteed to fill any room with deep, clear, quality sound. Edifier Breathe RRP $499 www.edifier-international.com
Pool Toy Cool Down Celebrate summer in style with the 1 litre fridge carafe $102 and stylish covers $30. www.top3.com.au
Your Serve Delight at the table with the appetizer 4x4 serving set comprises of4 sets of ‘spoon and fork’ in a stunning presentation gift box, 8 piece set RRP $110. www.top3.com.au
Set your Zodiac pool cleaning robot to work and enjoy a long summer of a spotless pool. Set the Polaris 9300 Sport to work and in an average of 90 minutes, your pool will be sparkling again. RRP $2,000 www.zodiac.com.au
It’s Time Arrive on time with the Rolex white gold Daytona available at LK Jewellery RRP $40,860 www.lkjewellery.com
Turn Styles Show off your cooking style with the Boomerang Wok. It lets your food come back with a simple flick of the wrist – the no effort push action simply turns and then returns your food to the same place it started. RRP$174.95 www.milkandsugar.com.au
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ďƒš
Igloo Village, Finnish Lapland, Scandinavia
Igloo Village, Finnish Lapland, Scandinavia Lapland is the magnificent country of fells, reindeer and Northern Lights. From December until April, in close proximity to Hotel Kakslauttanen is the famous Igloo Village. The Igloo Village boasts 20 amazing Snow Igloos as lodgings, an Ice Gallery, a bar made of ice and the world's largest snow restaurant. The star attractions in the village are the five Glass Igloos, which provide a unique opportunity to sleep under the Lapp sky admiring the northern lights in a warmer environment. They tell us that the experience is also unforgettable when there is a snowstorm! For those brave enough, you can take a morning dip in a nearby ice hole, but we think we’ll stick to the sauna. www.kakslauttanen.fi
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TRAVEL
Five Star GAZING If camping out isn’t your idea of a holiday, Sarah Harvey has discovered some spots that might change your mind. No need for the sleeping bag at these five star camping destinations, all you need is an adventurous spirit and a desire for the unique. ANAESTHETICLife
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TRAVEL
Nxabega Okavango Safari Camp, Botswana, Africa
Nxabega Okavango Safari Camp, Botswana, Africa Africa’s Nxabega Okavango Safari Camp is located on the edge of the Okavango Delta on more than 17,000 acres bordering the Moremi Game Reserve in Botswana. Meaning ‘Place of the Giraffe’, Nxabega is ideally positioned to explore the magnificence of the Okavango. Twice a day, you can jump in an open 4WD safari vehicle or take a powerboat excursion and experience the majesty of the wildlife up close. Nxabega is an intimate camp for a maximum of 18 guests. This means you have the opportunity to meet fellow travellers but the site is private enough for you to feel as
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if you are the only campers on the Delta. Luxury camping is in one of the nine classic safari tents on raised wooden platforms. Each tent has a private game-viewing deck and ensuite bathroom. The heart of Nxabega consists of sophisticated living and dining areas made from local timber and thatch overlooking the flood plain. You can indulge in bush picnics in surprise settings, breakfast in bed, lamplit cocktails on a river island, or a walking safari with delectable picnic. www.ccafrica.com
TRAVEL
ďƒš
Tented Camp, Golden Triangle, Thailand
Tented Camp, Golden Triangle, Thailand Located near Chang Rai your experience at the Four Seasons Tented Camp in Thailand begins on your trip to the campsite as it is accessible only by riverboat. Every detail in the 15 luxury tents has been attended to, right down to the hand hammered oversized copper bathtub. Each tent has two massage beds on its private sundeck, a reminder that you are well and truly in the midst of Thai luxury. Spend your days learning to care for the elephants, in cooking classes, taking riverbank picnics or simply enjoying the spa treatments on offer. The finest details are attended to
Dinner is an elegant affair with white linen and beautifully simple porcelain and glassware. extending to mealtimes as well. During breakfast and lunch, tables are decorated with local hill tribe artifacts, with indigenous stoneware and silver cutlery used for serving. Dinner is an elegant affair with white linen and beautifully simple porcelain and glassware. www.fourseasons.com/ goldentriangle ANAESTHETICLife
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TRAVEL
Spend your days in spa treatments, or for the more adventurous, perhaps an elephant trek.
The Oberoi Vanyavilas, Rajasthan, India
The Oberoi Vanyavilas, Rajasthan, India The Oberoi Vanyavilas is India’s first luxury jungle resort. It offers a unique opportunity to experience the natural peace and beauty of the jungle in private and luxurious accommodation that needs to be experienced to be believed. Like the hunting parties of old, guests at the resort stay in tents. However, these tents are nothing like any you have seen before, offering the utmost luxury. With only 25 in total, each air-conditioned with marble bathroom, freestanding bathtub, private walled garden and sun deck offering total privacy. Tents are scattered within the 20acre jungle estate, allowing you to marvel at the stunning scenery including the Ranthambhore Tiger Reserve next door. Spend your days in spa treatments, or for the more adventurous, perhaps an elephant trek. The Vanyavilas make a perfect base to recharge before exploring the palaces of Rajasthan. www.slh.com/vanyavilas
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Voyages Longitude 131°
WHY NOT TRY … Masai experience Two nine-suite tented camps in the Masai Mara Plains immerse you in nature, but without sacrificing luxury – butler included. Bateleur Camp at Kichwa Tembo offers an abundance of game throughout the year, but from June to October the area witnesses an awe-inspiring sight – the great migration. www.slh.com/bateleur
Star gazing at the Rock Situated overlooking the World Heritage–listed wilderness of Uluru-Kata Tjuta National Park, Longitude 131° offers complete five-star luxury and private views of the sun rising and setting over Uluru. Enjoy dining out under the spectacular desert night sky. www.longitude131.com.au L
the wines of Bali In my previous career as an actor (yes, it’s a loose definition), holidays didn’t feature much. Jobbing actors tend to lurch from one scantily paid contract to another. The period in between shows, once charmingly referred to as “resting”, is now better known as telemarketing. Holidays are thin on the ground. Of course there is a multitude of wonderful things about being a jobbing actor, but none of them is holidays.
T
his year marks my tenth anniversary as an ex–thespian, and it still gives me a thrill to be able to take a holiday from time to time. Nothing quite as luxurious as one every year, but just every so often... We all need holidays. But of course, it’s all relative. I was reading recently about a 3–day arts and music festival. It’s a camping event – or glamping they call it now since they’ve installed a hairdressing tent. In the article a sweet young twenty–something was quoted as saying “This is my first holiday since November, so I’m really going to go all out”. Poor kid – all those months without a holiday. My heart just bled. I’ve just had my first holiday since November too. 2007. Our destination was Bali. (Hardly an exotic destination I know, but we’ve been regulars for years, and
we really didn’t have the energy to break in a new country: sightseeing... photo opportunities... scary toileting arrangements...) We’ve been to Bali so many times now, that a beautiful decaying temple is just another temple. The gorgeous terraced rice fields truly are gorgeous, and very ricey, but we don’t need to go for a day trip and take snaps. What we desperately needed was a fly and flop, and that’s precisely what we had. After a reassuringly uneventful six–hour flight, and a steamy one hour queue at immigration with genial fellow travellers, we drove just far enough to take us beyond the reach of the tourist traps. And there, in the undeveloped west of the island, we hunkered down. Of course, we could have simply gone to the Gold Coast but the exchange rates were prohibitive.
“This year marks my tenth anniversary as an ex–thespian, and it still gives me a thrill to be able to take a holiday from time to time.”
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LIFESTYLE Our room had no television, no phone, no radio. Just an enormous and stupidly comfortable bed with a vast, billowing mosquito net and a huge picture window opening onto to the tropical garden, and beach beyond. It wasn’t possible to abandon all decision making responsibility: the first decision of the day centred on shorts or sarongs. Then there were decisions involving papaya, pineapple pancakes and Nasi Goreng. But with those breakfast obstacles cleared, we would waddle to the pool area. As midday approached, the choices become more complex: massage or walk or beer?
our modest resort featured Jacob’s Creek Chardonnay at a shade under AUD$100 per bottle. Meaning absolutely no disrespect to the good people at Jacob’s Creek – or their very fine wines – the words over my dead body sprang from my lips faster than you can say Bintang. The only remotely affordable alternative is the range of locally made Balinese wines, and I confess to having approached them with extreme caution. This isn’t just wine–wanker prejudice. It’s fair to wonder how a fruit which can thrive on near vertical slopes in chilly Europe handles life
“The wines of Bali are clean, simple styles which are climatically, culturally, and gastronomically apt.” It was my avowed intention to banish all thoughts of work for fourteen days. And I almost did. But working in the wine industry does have its drawbacks. To approach lunch without a beer was unthinkable; and a gin and tonic at sunset was mandatory. But at dinner time, my thoughts would fly to a zesty off–dry Riesling or a lightly chilled Pinot Noir... maybe a Verdelho or a Grenache – yum. Then the beaming young Balinese waiter would present the wine list and my heart would sink. While it offers tropical delights in abundance, it would be fair to say that Bali is not a wine–lover’s paradise. The extraordinarily high price of imported wine is an effective disincentive. The restaurant at
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in the tropics. Grapes are prone to a range of fungal infections. How do the Balinese winemakers manage the vicissitudes of producing wine in humid, tropical conditions? The answer is with ingenuity, creativity, and skill. The 100% Balinese–owned family winery has 14.5 hectares under vine in the north–east of the island, and a state of the art winery in the south. They produce a range of fruit– driven, light to medium bodied wines that reflect the tropical climate, and complement the spicy flavours of the local cuisine. It’s an impressive undertaking, particularly when you consider the unique challenges of producing wines barely 8 degrees from the Equator.
Vines are trained onto very high trellises, supported by small trees. The height maximises exposure to cooling breezes and discourages pests. The shade from the trees protects the berries from the sun, and affords a degree of comfort for the vine workers. It’s an ingenious solution, although seeing grapes being picked from overhead takes some getting used to! The lush climate results in year– round fruit. While the vines we know in Australia have a dormant cycle, Bali’s vines are evergreen, producing grapes which can be harvested continually throughout the year – turning our traditional notion of “vintage” on its head. In the 14 years that they have been making their popular Rosé, over 200 vintages have been produced! Are the wines any good? Of course they are, and that’s not just Holiday Taste talking! (Holiday Taste is that oxymoronic phenomenon, which leads us to make surprising choices that we would certainly repudiate back home. It can, for instance, lead grown women who should know better, to allow themselves to be photographed performing the traditional dance of the indigenes. But that’s another story.) The wines of Bali are clean, simple styles which are climatically, culturally, and gastronomically apt. And, while a gin and tonic will always be my first choice for watching a tropical sunset, you could do a lot worse than a lightly chilled glass of Aga Red with your Sate Ayam.
Gillian Hyde After a 35 year career as a “Jobbing Actor”, Gillian transferred her attention to the wine industry. Today she holds the position of Head of Membership at The Wine Society (www.winesociety.com.au) – which she juggles with the increasing demands on her as a wine writer.
LIFESTYLE
p o t p o r d f o o r t f e o h S c a n a with p ss
la c E s e d e c Mer ty, i l a u q s e z o cabriolet eoand comfort. styl
Mercedes-Benz E250 CGI Avantgarde cabriolet in metallic palladium silver paint,with AMG Sports Package, Entertainment Package and Dynamic Handling option. Real world drive-away price: $135, 500.
S
leek and elegant. This car is beautiful. It’s the MercedesBenz E250 CGI cabriolet. It has an imposing, angular front end, a swept-back windscreen, two doors and four seats. Its external appearance is stylish, strong and elegant. Feedback from casual observers on the exterior is uniformly positive. Inside, the car radiates quality and style. It’s automatic-electroniceverything. When you get in and out of the back seat, the front seats scoot forward and back automatically. Buttons on the steering wheel can control your mobile phone and most of the car’s other functions. The sound system is superb, and when cranked loud is good enough to wake up the carpark of my local hospital. When parked, you can watch television on the centre display. The satellite navigation system knows every hospital in Australia, including private hospitals
and day care centres. It is bright and clear, even in direct sunlight. But this car is all about the roof. When the weather allows it, you can direct the soft black fabric roof to fold itself into the boot in a matter of seconds, leaving you exposed to the sun and the stares of admiring pedestrians. The system is quick and neat, and invokes an elaborate choreograph of machinery and material. It is entirely automatic. When the roof deploys itself, it snicks itself into position neatly. With the roof on, it’s remarkably quiet inside. The roof mechanism consumes a considerable amount of boot space. You could stow several surgical kits and a doctor’s bag in the boot comfortably, but don’t expect to cram several large suitcases in if you want to put the roof down. The red-brown leather seats are perfect for boy racers. The front
“The satellite navigation system knows every hospital in Australia.” seats are slightly uncomfortable for lipophilic passengers, but the shape is modifiable by controlling the inflation of several air bladders. The rear seats look cramped. They are of the “plus two”-style – this is not a car intended to routinely carry four adults – but they are surprisingly comfortable for those of modest stature. While sitting in the rear, my fivefeet-ten-inch frame missed the roof comfortably, but my engineer friend who is six feet tall complained that his head scraped the roof while he sat in the back. High-BMI doctors will definitely prefer the front seats. I had a chance to compare the vehicle with an E-class saloon, and the cabriolet sure feels cramped by comparison. For example, a $1 coin left behind by a previous passenger of the cabriolet had ANAESTHETICLife
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LIFESTYLE fallen between the passenger seat and the centre console and could only be retrieved using surgical tools. The air conditioner is impressively cool, and the heater equally impressive in its warmth. Each gets to the target temperature rapidly after being switched on. The efficient seat warmers kept my gluteal region nice and warm. Mercedes offers the Airscarf system, which blows warm air posterior to your neck independent of what the air conditioner is doing. The badge at the front of the car is of the inlaid type, rather than the trophy type that invites jealous hooligans to rip it off. Much attention has been paid to lighting in this car. The headlights and indicators are bright enough to make the car stand out at night among ordinary vehicles. When reversing, visibility is poor even with the roof down. The car comes with reversing proximity sensors and a reversing camera is an option. The rear headrests may be lowered if no one is in the back seats. The car has a few quirks. The
steering wheel tends to block the driver’s view of the instrument cluster when placed in its most natural position, but it can be moved. The gearstick must be moved “around corners” rather than in a straight line. There’s a quaint foot-operated parking brake with a manual release. The chassis is solidly built, and the doors close with a satisfying clunk. There is an overriding feeling of safety. Front seat passenger leg room is extraordinary given the car’s modest length. Now to the engine. It’s a 4 cylinder 1.8 litre job that revs to 5500 rpm. It is so quiet that several times I attempted to start the engine, having failed to realise that it was already running. Under hard acceleration you get a faint side-to-side shake, but otherwise it exudes refinement. For performance enthusiasts the 1.8 litre will definitely feel anaemic. It is mated to a 5-speed “flappy paddle” semi-automatic gearbox. Merely $3000 more will upgrade you to a 2.2 litre diesel with way more torque and 25%
more fuel efficiency than the petrol 1.8, so this upgrade is an absolute nobrainer if you don’t mind filling your car with diesel. Higher-displacement petrol engines are available, at additional cost of course - a 3.5L 6-cylinder and a 5.5L 8-cylinder. They come with a seven-speed auto. Final opinion: Exciting, luxurious and comfortable. I’d buy one. I would prefer the 3.5L 6-cylinder version, with the Entertainment package (better sound system, keyless entry and TV tuner) and Dynamic Handling option (steering wheel mounted shift paddles and electronic damping system). It comes with reversing camera, 7-speed gearbox, and metallic paint as standard. Real world drive-away price: $168,010.
Dr Anton Babinski. Dr Babinski is a medical practitioner who has worked in motoring journalism as a hobby for 13 years. Mercedes-Benz loaned us the vehicle for 4 days. Our reviewers have no other relationship with Mercedes-Benz.
Second opinion
On an aesthetic level, I love the red leather. It’s muted and elegant. The driver’s seat is very comfortable and well supported. This felt like I was driving around in a brochure. Everyone looked at me and said, “Who’s that rich, classy lady?” The roof is quick enough to go up or down while stopped at a traffic light. When I put my foot down, the engine hesitated. You need more power. I loved the fact that the car offered me my seatbelt. I quite liked the voice of the satnav. When I had the radio on, I liked the feeling of an old-fashioned wireless, but the tuner changes were too slow. The coffee cup holders are deep, so your drink won’t topple over. The steering wheel obscured the indicator lights. There’s not enough room in the boot with the top down. I would prefer two seats and a bigger boot. The heating was very efficient. It kept me warm when it was pretty icy outside. If you were a guy, you’d say it was a chick’s car. I saw it in the Sex and the City movie. Chicks with a disposable income would buy this car. Final verdict: Yes, I’d buy one, if I could get a good deal. I would get it in black. By CC, collaborative legal practitioner
Third opinion
Above Photograph by S. Kayman
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With the roof up, it’s quite dark. The saloon has a sunroof that lets more light in. The cabriolet’s perfect for a summer drive. I’d stick with the sedan, though. This car’s not as practical. Also, it’s not high-powered enough for me. Final verdict: It’s a reasonably-featured, well-priced coupe, but I want the torque and the horsepower to fully enjoy the experience. I’d get the V8. By Gregorius, Mercedes owner and IT consultant
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