AnaestheticLifeJulyAugust

JULY/AUGUST 2010

ANAESTHETICLife

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Another Fine Mess?

Is racial discrimination towards international doctors entrenched in Australia?

Narcissism Amongst Doctors

Why it can help create some great doctors whilst break others

Growing Your Medical Practice

From Solo To SymphonyThe art of taking on associates for profit

Medical Interviews Demystified Unlock the secret of winning at medical job interviews

own your practice property rather than rent it, why wouldn’t you?

Purchasing your own practice property has the potential to be a profitable long-term business strategy. As a specialist financier, Investec Experien gives doctors access to mortgage finance of up to 100% of the purchase price of their owner occupied practice premises. With repayments designed to suit your cash flow, there may be minimal difference between renting and buying.

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Contact your local banker, call 1300 131 141 or visit www.investec.com.au/professionalfinance.

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HIGHLIGHTS

19 22 25 53

Narcissism Amongst Doctors Why it can help create some great doctors whilst break others

Another Fine Mess?

Is racial discrimination towards international doctors entrenched in Australia?

Growing Your Medical Practice From Solo To Symphony; the art of taking on associates for profit

Medical Interviews Demystified

Unlock the secret of winning at medical job interviews

DEPARTMENTS 07 Features 25 Finance 42 Risk Management 53 Careers 58 Medical Legends 60 Alpha: Technology & Reviews 62 Travel 64 Lifestyle

contents features 07

Doctor Rating Websites

10

Behind the Mask

12

The Bad Apples Amongst Us

19

Narcissism Amongst Doctors

Why it can help create some great doctors whilst break others

22

Another Fine Mess?

Friend or Foe? Public Perception of Anaesthetists?

Doctors who become Serial Killers

Dual-doctor Marriages

Do doctor/doctor relationships work better than doctor/non- doctor relationships?

Is racial discrimination towards international doctors entrenched in Australia?

Story on Page 16

finance 25

From Solo to Symphony; the art of taking on associates for profit

29

Investing In A Risk-Averse World

32

Estate Planning

35

Smart Money Goes Green

Take Care of Your Financial Needs Throughout Life’s Stages As your life changes, so do your financial planning needs.

Story on Page 39

Growing Your Medical Practice

We debunk some myths and offer tips on investing for success in a risk-averse world What happens if you die without a Will?

Can investments be ethical?

careers 53

Medical Interviews Demystified Unlock the secret of winning at medical job interviews

medical legends I’m Sorry

58

Story on Page 49

alpha

Apologising without admitting liability

risk management 42

Why Are You Afraid of NFR Orders?

45

Opioids in Head Injury Patients

60

August Bier (1961-1949) “Father of Spinal Anaesthesia”

iPad Review: A Medical Perspective

Not For Resuscitation (NFR) orders are rapidly becoming standard medical practice but some doctors are reluctant to issue them.

Anaesthetic Case Report

travel lifestyle 64

Interview With James Grierson

68

No Wine Thanks- I’m Vegetarian

Sri Lanka Ignites All The Senses

Islands have a way of captivating you and the teardrop-shaped island of Sri Lanka captivates around every corner.

Story on Page 62

We head over to Kuala Lumpur, Malaysia to talk food and travel.

Is it just me, or does Masterchef have an awful lot to answer for?

70 First Ferrari 458 lands Down Under

Ferrari’s fastest ever road car has landed in Australia

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editor’s note

W

ELCOME to the Winter Edition of Anaesthetic Life, the second anaesthetic magazine from the Medical Life team.

Our first edition certainly created a storm in the medical world and we have since received an overwhelming amount of positive feedback, greatly supporting our publication.

It seems our readers especially appreciated some of our feature articles and were particularly responsive to the business/finance sections. So, we hope to sustain this level of interest by continuing to provide you with information that isn’t always easy to come by, bringing to your attention topical issues and interesting insights.

This edition touches on some subject matters which might otherwise go undisclosed, such as racial discrimination towards international doctors. We have also revealed some further secrets into the world of marketing giving you some practical tips on how to grow your practice.

To enhance our appeal we have also created a careers section, which will tackle topics which receive minimal coverage in other medical publications. This edition addresses the mystery behind the medical interview process.

Numerous readers have also encouraged us to declare the publishers name and individual authors of the articles. So this feedback has been taken on board and incorporated into this current edition.

Finally, we applaud the ASA and ANZCA for mass-mailing all anaesthetists warning them to be wary of disclosing personal details. Medical Life Publishing encourages any support of the National Privacy Principle and assures readers that we are fully compliant. Once more, we can reassure our readers that their contact details will never be passed on to third parties without their prior consent.

Again, we encourage feedback, compliments, complaints and letters to the editor to be sent to us at: editorial@medical-life.com.au.

Selina Vasdev

Editor selina@medical-life.com.au

Ravi Agarwal

Business Editor Marketing ravi@medical-life.com.au

Tristan Bowers

Graphics & Design tristan@medical-life.com.au Contributing Sources

Dr. Richard Cavell Dr. John Williamson Dr. L. Chung Dr. B. Marne Karen tonks 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 completed articles written by readers are welcome and will be reviewed by the Editorial Committee.

Please direct all inquiries and submissions to:

Enjoy!

Selina Vasdev Editor

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Medical Life Publishing PO Box 2471 Mount Waverley VIC 3149 Phone: +61 (03) 9001 6373 Fax: +61 (03) 9923 6662 Email: mail@medical-life.com.au

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Doctor Rating Websites Friend or Foe? Your medical practice is both built and broken through word of mouth.

Building a good reputation is an important skill to learn for any doctor.

However, recent surveys show that doctors cannot rely solely upon themselves to create and maintain their status. More and more patients want control regarding their care, and this includes seeking out further information about their doctors online. The Internet has empowered patients to rate their doctors using a growing number of websites, ultimately giving them the ability to directly affect their doctor’s reputation.

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HE GENERAL ATTITUDE OF doctors towards these websites has been mostly cold or negative1. After all, a single adverse post by a displeased patient in an internet forum might ruin an otherwise solid reputation and thriving practice. Unfortunately, there are few legal actions a doctor can take to work against this online activity and prevent people posting opinions of them.

A notable doctor-rating website is ratemds.com. This website allows Australians to rate the professionalism of their doctor as well as the quality of treatments he/she delivers. These patients are given free reign, instantly, to criticize their doctor’s advice, judgement, competence, bedside manner, and even how well they get

along with their patients, often using strong and/or offensive language2.

Try to click onto one of these websites and you will be quite surprised at what you find. Patients are indeed candid and bold about their opinions of their doctors. But having said that; there is a peculiar observation: most patients post positive comments about their doctors.

RateMDs cofounder, John Swapceinski says that on their website, 75% of posters actually want the world to know how good their doctors are. They go to great lengths to describe their doctors: “The most wonderful doctor”, “never felt rushed”, “answered all my questions”, “a gem”. And these are just some of the positive posts3.

Sometimes it makes you wonder if there is something fishy about the

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feature whole rating thing. Is it possible doctors themselves post these good ratings to boost their own reputation? 1 Unlikely, but still, it makes you wonder.

Anonymity does work both ways. This instantly, flags up a major flaw, creating doubt about the actual validity of the anonymous postings. RateMDs is arguably the leading website in terms of traffic, with more than 400 new ratings daily, rating more than 120,000 doctors3.

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urrently in the United States, there are more than 40 web sites allowing patients to rate their doctors based on their personal experiences, both, good and bad, including; RateMDs.com, DrScore.com and Angie’s List. Up to three-quarters of the ratings are mostly positive, achieving grades of “A” on Angie’s List, glowing testimonies on DrScore.com or bright smiley faces on RateMDs.com2. But the bad ratings can be downright nasty.

Doctors are routinely branded as rude, incompetent - or worse…

Expectedly, some doctors get quite resentful and angry at the anonymous postings on these websites. Dr. Chris Davis, president of The Australian Medical Association Queensland, warned such sites could be a derisive tool for disgruntled patients. “It certainly has the potential to be abused4”.

Some doctors get quite resentful and angry at the anonymous postings on these websites.

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commentator who takes their time to post is either the satisfied patient or the disgruntled one. The patient who has an unremarkable experience doesn’t seem to care much about posting any comment at all. Socioeconomics may explain this phenomenon, as disadvantaged patients may lack access, education or technical know-how to make use of health resources.

Dr. Jeffrey Segal, is a neurosurgeon and founder of Medical Justice Service Inc. a business based in America that charges doctors to fight defamation cases. Segal explains that whilst with some sites, like Angie’s List, you know who’s posting, the majority don’t identify or verify commenters. This highlights the fact that “You don’t know whether it’s a patient, an ex-employee, an ex-spouse or even a competitor”2.

This method of evaluating doctor performance has its drawbacks.

But evaluating the quality of care as experienced by patients is increasingly given more attention today. Instead of trying to discourage people from offering their opinions, it would also be advantageous for doctors to use the sites to learn what their patients think. “Patients SHOULD rate doctors”, says an orthopaedic surgeon, “but the rating should include both subjective and objective information and [sites should] prevent anonymous slanderous information from being included”6.

A few doctors have made moves to protect their reputation, requiring patients to sign contracts - critics call them “gag orders” - prohibiting patients to post on public forums5. Ratings can go to both extremes.

For example, a New York plastic surgeon is either “very skilled and aesthetically gifted” or “very bad”2. It seems the

Word of mouth was the conventional way of being referred to a doctor by friends and relatives. But, if a specialist is required, patients may be referred through other means. Doctors with established practices have built successful relationships over time through; medical school and their training years; by working in the same

feature region or hosptial and by attending networking events. However, nowadays the importance of geo-location in developing your practice is complemented or even supplanted by online resources such as public forums and social networking.

But a new study advises doctors to retain their composure regarding this issue and not overreact. The study, published in the Journal of General Internal Medicine, found that ‘the websites haven’t caught on in any big way with consumers.

Additionally, many of the reviews posted online are positive5’.

So how can you turn these rating sites to your advantage?

Establish an Online Presence The key point here is to create an online presence early on before the need becomes obvious. This, for example, can be done by creating your own profile on the doctor rating sites. Allowing you to add information about your practice online, instantly attracting patients and if written well helps in generating a good first impression.

Creating and maintaining an online presence: 1) Allows you to appeal to patients and thereby permits you to engage with patients outside of the practice.

2) Gives you the opportunity to introduce your services and makes an identity for your practice.

3) Provides patients a venue to share their positive experience about your practice.

This is particularly useful for potential patients who are comparing online reviews of doctors and practices.

Encourage positive posts Connect with your patients and ask them to post positive comments. Do away with so-called ‘gag orders’.

Requesting patients to talk about

their positive reviews online will prove beneficial to you and your practice in the long run.

Nancy R. Terry, an anaesthetist, recommends that doctors have their patients fill out comment cards or survey forms in the office that can later be posted on doctor-ratings websites6.

You most probably have happy patients who are more than willing to post positive comments online regarding you and your practice. Just imagine if a good number of them actually do. Their positive posts would actually fill your opinions page, and drown out the few negative comments. An emergency medicine doctor says, “Dilute the negative comments by encouraging your satisfied patients to post their comments”.6 So, go ahead and ask them.

Conclusion Online doctor ratings websites work as a powerful platform informing patients of their choice of doctors and their practices and helping them form decisions over health related issues. In which case, doctors ought to be encouraged to work with, rather than against this new revolution.

One doctor sees the notable increase of online patient comments as a wake-up call. “If I were still practicing, I would welcome my patients to comment. As I see it, one of two things would happen: [the postings] would become a source of referrals, or I would learn something and my skills would improve. Either way I would be better off!” 6 Judging by the number of Australian doctors already rated on RateMDs.com, it looks like the online doctor-rating trend is here to stay.

Doctor-rating websites do break new ground for patients to share information about medical care they receive. They also provide huge opportunities for us as medical professionals to understand how we can minimise our shortcomings and take pride in what we are commended on.

RAVI AGARWAL is a marketing specialist at the Marketing Doctors. Australia’s first full service marketing agency serving the medical profession. www.MarketingDoctors.com.au

As rating sites grow, doctors voice concerns, Ginger Rough - 2009 http://azcentral.com/arizonarepublic/new/articles/2009/07/04/200 90704MDrating0704.html 2 Docs seek to stifle patients’ rants on Web sites But ‘medical gag order’ contracts may backfire with bad publicity, JoNel Aleccia – 2010 www.msnbc.msn.com/id/34794632/ns/health-health_care 3 Rating Doctors: A Rank Practice? Michelle Andrews - 2008 http://health.usnews.com/health-news/blogs/on-health-andmoney/2008/2/1/ratinf-doctors-a-rank-practice.htm 4 How to rate your doctor, Robyn Wuth – 2009 http://www. goldcoast.com.au/article/2009/05/24/81761_ gold-coast-news.html 5 Physicianhysis rating websites mainly sing doctor’s praises, study finds, Shari Roan – 2010 http://latimesblogs.latimes.com/booster_shots/2010/05/physicianrating-websites-mainly-sing-doctors-praises-study-finds.html 6 Physician-Ratings Websites Get Zero Stars From Doctors, Nancy R. Terry - 2009 www.medscape.com/viewarticle/701720 1

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Behind the Mask:

The Public Perception of Anaesthetists?

We all frequently encounter patients who ask us, “When will the doctor come and see me?� and this always grates a little bit. However, it is easy to rationalise this as just being the words of another ignorant patient.

I

T MAY COME AS SOME SURPRISE that Braun et al1 discovered in a survey of a Melbourne preadmission clinic that 90% of patients recognised that anaesthetists were indeed medically qualified. A similar result to a survey about pathologists2, where 87% of patients correctly identified that pathologists were actually

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medically qualified doctors. What is slightly disconcerting about Pathologists, is that the remaining 13% of patients thought that pathologists were laboratory technicians, policemen or undertakers.

It is widely recognised that one of the most stressful aspects and most unappealing aspects of the profession

feature of anaesthesia is being made to feel that you are playing second fiddle to your surgical counterpart3. Many of our non-anaesthetist medical colleagues and some nurses too share the view that anaesthetists are there to ‘assist’ surgeons. In fact, it is not uncommon for some anaesthetists themselves, when asked who they work with, to state that “I work for Mr …” rather than “I work with Mr ….” If anaesthetists begin to denigrate their own status by insinuating they work for surgeons, it is difficult to elevate our status as highly skilled professionals rather than surgical assistants.

Interestingly, studies from India5, Singapore6, the UK and Australia all demonstrate very similar results regarding patient’s perceptions of anaesthetists. While the majority recognise that Anaesthetists are medical qualified, there is a significant proportion of patients that believe anaesthetists do not stay in the operating theatre with the patient for the duration of the surgery.

The UK Royal College of Anaesthetists ran a high-profile campaign to educate both patients and also other healthcare personnel about the extended and diverse roles of the anaesthetist in 2001.

Large adverts and billboards were used to promote ‘Behind the Mask’, utilising the services of a nationwide PR agency and celebrating ‘the important role that anaesthetists played in today’s healthcare.’ These are the words which were used on billboards in visible public locations as part of a public eduation campaign: Who run intensive care units?

Anaesthetists.

Who run pain clinics? Anaesthetists.

Who manage safe pain relief during labour and birth? Anaesthetists.

Who are amongst the first doctors at the

scene of a crash? Anaesthetists.

Who has revolutionised day surgery?

Anaesthetists.

Who can be found in 90% of hospital departments? Anaesthetists.

Anaesthetists are highly trained doctors with a wealth of skills, but is the public perception that of a group of anonymous technicians who only put people to sleep? Now here’s a chance to look behind the mask. Is there a role for a similar education program in Australia?

Please email your opinions and comments to editor@Medical-Life.com. au

It is widely recognised that one of the most stressful aspects and most unappealing aspects of the profession of anaesthesia is being made to feel that you are playing second fiddle to your surgical counterpart SELINA VASDEV

Braun AR, Leslie K, Morgan C, Bugler S. Patients’ knowledge of the qualifications and roles of anaesthetists. Anaesth Intensive Care. 2007 Aug;35(4):570-4 2 Start RD, Saul CA, Cotton DWK. Public Perception of Histopathology. Clin Pathol 1995;48:398-401 3 Larsson J, Holmström I, Rosenqvist U. Enjoying work or burdened by it? How anaesthetists experience and handle difficulties at work: a qualitative study BJA 2007 99(4):493-499 4 Jathar D, Shinde VS, Patel RD A STUDY OF PATIENTS’ PERCEPTION ABOUT 5 KNOWLEDGE OF ANAESTHESIA & ANAESTHESIOLOGIST Indian J. Anaesth.

2002; 46 (1) : 26-30 6 Chew S T H, Tan T, Tan S S, Ip-Yam P C A Survey of Patients’ Knowledge of Anaesthesia and Perioperative Care Singapore Med J. 1998 Sep;39(9):399402.

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The Bad Apples Amongst Us Doctors who become Serial Killers Over the centuries, the medical profession seems to have attracted more than its fair share of pathological criminals1. Doctors with narcissistic personalities and an overly inflated view of their own success are over-represented in the medical profession2. Some of these personalities may even overstep the mark, adopting a deity-like persona, determining when and how a person dies. This can transcend into something far more sinister….

O

F COURSE, MOST DOCTORS take their profession seriously and keep up to date with all the latest advances in treatments in their speciality and place utmost importance on their patient’s safety and well being. However, a catalogue of chilling incidences where

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doctors have not maintained their duty of care has damaged public perception and trust in the medical profession, whose primary purpose is to cure.

Primum Non Nocere, a cornerstone of the Hippocratic oath, means “First of all Do No Harm”. But what is it in the mindset of small sub-set of doctors who

feature was suspected of killing more than 60 victims during his life. His sole purpose was motivated by cashing in money by promising to help arrange escape routes for German occupied France4. He tricked individuals into his home, administered a lethal injection and watched his victims suffer. After mutilating their bodies, he later incinerated them.

In the United States and Zimbabwe, Dr Michael Swango or otherwise known as ‘Dr Poison’ also killed 60 patients, typically using a paralysing drug in an intravenous infusion. Michael Swango was a medical school graduate who interned in Ohio. After being convicted in Illinois for poisoning his fellow health care workers with rat poison and serving two years, he then practiced medicine in South Dakota, New York, and Zimbabwe.

In September, 2000, he was convicted of four murders in New York and Ohio5.

breach this oath and deliberately harm their patients?

Consultant psychiatrist Herbert Kinnell, writing in the British Medical Journal, noted that “medicine has arguably thrown up more serial killers than all the other professions put together”3.

There have been several documented examples of healthcare professionals who have preyed on vulnerable patients demonstrating a fatal fascination with power and death.

Dr Marcel Petiot is renowned for being the worst serial killer in French history, a 49 year old physician, pretending to be member of the French resistance

More recently, Dr Harold Shipman a British GP who may have murdered as many as 400 of his patients during his 24 year medical career has emerged as the most prolific serial killer in global history.

Although we are more than familiar with the characteristics of serial killers through their over representation in literature and cinema, evidence in the real world also proves that doctors can and do kill. ‘’Doctors are statistically more likely than any other profession to kill’2 says Dr Robert Kaplan, an Australian forensic psychiatrist.

“Medicine has arguably thrown up more serial killers than all the other professions put together.”

-Herbert Kinnell

When isolated cases have been brought to attention, medical boards have reassured us that such incidences were rare and few and far between. However, the general public remains unconvinced about the remaining number of, what they refer to as, ‘monsters’ that lurk behind the professional sphere of medicine, biding their time before they emerge as serial killers. However, these killers are not limited to doctors alone, but encompass an entire healthcare profession including; nurses, therapists, hospital workers and proprietors of care facilities for the sick and the elderly6.

The question remains whether it is

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feature working in the medical profession which shapes them into killers or whether sociopaths with predispositions to kill choose to become doctors? According to Dr Kinnell, it is the latter; the medical profession attracts people who have a ‘pathological interest in life and death’3.

Becoming a doctor opens up the opportunity to kill on a far wider scale...

One explanation considers the fact that doctors are just as likely to turn bad as anyone else in the general population. But for some individuals becoming a doctor is a well thought out move, associated with the gaining of power and control that overrides their responsibility for healing and helping.

But for others, becoming a doctor opens up the opportunity to kill on a far wider scale where victims are readily available for experimentation and attack allowing them to act on their predispositions.

Doctors also have access to a concoction of drugs, tools and have specialist skills and techniques taught to them through professional education i.e. injection, pharmacology and dissection techniques. They also possess the ability to kill and cover up certain types of murders, especially if their patients are elderly or terminally ill7.

Al Carlisle, a psychologist who worked with inmates at Utah State Prison describes serial killers as having divided souls or compartmentalized self, claiming that they present a public persona that appears to be ‘good’ while disguising a darker side that fosters pathological fantasies8. Can the same be said about doctors? It is fair to say that from the beginning they are taught to ensure a distinct separation between their personal and professional lives.

Robert Jay Lifton claims that doctors may be more susceptible to ‘doubling’ than any other member of professional groups where they can be the paradoxical healer and killer.

It seems that to be able to practice medicine, individual’s must learn to develop a ‘medical self’ in which they must become accustomed to dealing mundanely with the biological basics of humanity—blood, organs and corpses9.

This depersonalisation may be the key as

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to why doctors who kill genuinely feel it wasn’t them that was killing, it was their other persona.

Naturally, they become desensitized to death and learn to function under situations that would be unthinkable to the average person9. Over time, a few medical practitioners may even develop a fondness for the pain and suffering of their patients.

Such explanations reflect Dr. Michael Swango cases who killed his patients because it gave him a thrill and a feeling of power.

Other doctors have demonstrated an array of disgraceful motives for their killings such as: Dr. Marcel Petiot who killed out of greed for money; Dr Hawley Harvey Crippen murdered his wife in order to marry his mistress; Dr Thomas Palmer, the Rugeley poisoner, dosed a dozen of his family and friends with strychnine because they were a hindrance to his lifestyle; Dr Harold Shipman constitutes a profile that was driven to kill, simply because he could.

Shipman, who apparently had a charming bedside manner, was abusing drugs and forging prescriptions from an early stage in his career. He had a fatal fascination with death, dying and drugs which derived from his experience as a 17-year-old having to care for his dying mother. In his adolescent mind, there was a powerful connection between the visit from the family doctor and the relief that his injections of morphine brought to his mother’s suffering6. Following on from this association a notable characteristic of Shipman’s crimes was that 80% of his victims were women and most of which were elderly, whom he killed with lethal injections of diamorphine (legally prescribable in the UK). Despite all the evidence, Shipman proclaimed his innocence until the day he hung himself in prison in 2004.

Taking a look closer to home we reflect on the case of Dr James Latham Peters.

Peters worked as an anaesthetist at a late-term abortion clinic in Victoria over

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an 18 month period in 2008 and 2009.

He is currently at the centre of major allegations stating that he deliberately infected 44 women with hepatitis C. Prior to this scandal, he was a known drug user who received a suspended jail sentence in 1996 for forging more than 100 pethidine prescriptions for himself and his wife. Health Minister Daniel Andrews maintains that ‘‘… this is not about system failure; this is about, it would seem, the appalling, totally inappropriate behaviour of one particular person.”10 It is thought, if found guilty, Peters could face a 20 year jail sentence.

There is also the case of Dr Jayant Mukundary Patel. A surgeon who was at the centre of a scandal in 2005 was accused of gross incompetence while working at Bundaberg Base Hospital in Queensland, Australia. It is believed that Dr Jayant Patel, was allowed to practise for two years at the rural Hospital despite a 20-year history of botched operations in the United States.

However, a recent court hearing stated that two of the terminally ill cancer patients who were killed by Jayant Patel consented to the risky operations because it offered them a ‘’real chance of a cure’’11.

All the above cases highlight the major

flaws in the medical system that allows a tiny minority of medical practitioners, despite tarnished backgrounds of previous convictions and known histories of criminal behaviour, to continue practicing.

‘‘…this is not about system failure; this is about, it would seem, the appalling, totally inappropriate behaviour of one particular person.”

- Daniel Andrews

Although the specifics of every serial killing or malpractice scandal are unique; a common outcome concludes the need for a rigorous solution in the form of a regular centralised performance monitoring system. There is also a clear requirement for a central database of references, which would allow history checks to be completed to expose any individual with malign intent at the earliest opportunity.

However, the sad fact remains that even after this there will be some doctors who kill because they already learned how to exploit the oath of trust and thus may go unnoticed unless of course we educate our profession to engage in ‘whistle blowing’.

Thankfully, it isn’t every day that we find a psychopathic serial killer amongst the ranks of the medical profession. But we can no longer assume that every individual who does enter the medical profession will have the assumed altruistic motives to heal and cure people in their care.

SELINA VASDEV Whittle, B., Ritchie, J (2000). Prescription for Murder: The True Story of Mass Murderer Dr Harold Frederick Shipman. Warner.

2 Kaplan, R (2007). The clinicide phenomenon: An exploration of medical murder. Australian Psychiatry 15 (4): 299-304.

3 Kinnell, H. G (2000). Serial Homicide by Doctors: Shipman in Perspective. British Medical Journal, 321 (7276): 1594 -97.

4 Durden-Smith, J (2004). 100 Most Infamous Criminals, Metrobooks, New York.

5 http://en.wikipedia.org/wiki/Michael_Swango 6 Uschuk, J (2002). Tucson Weekly. Sept. 5-Sept. 11 7 Macintyre, B (2004). The dreadful truth is: doctors have always had the skill to murder at will. Shipman didn’t just kill patients, he killed our trust. The Times 8 Carlisle, Al. C (2000). “The Dark Side of the Serial Killer Personality,” in Serial Killers, San Diego, CA: Greenhaven Press.

9 Lifton, R. J (2004). Doctors & Torture. New England Journal of Medicine, 357.

10 Levy, M. (2010). Rise in hepatitis C cases linked to doctor. Theage. com.au /victoria/rise-in-hepatitis-c-cases-linked-to-doctor.

11 Rawlins, J (2010). Patel surgery offered ‘real change of cure’. http://www.abc.net.au/news/stories/2010/06/18/2930653.htm 1

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Dual-doctor Marriages:

Do doctor/doctor relationships work better than doctor/non-doctor relationships?

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Picture the situation. You’ve probably been there many times before. You’ve just got in from a long day shift at the hospital. You’ve had to stay two hours’ past the time you were supposed to finish and you’re feeling tired, stressed and hungry. So which would you rather come home to? A spouse who understands exactly the demands that your day has placed upon you, most probably because they’ve had a similar day themselves? Or the spouse who doesn’t quite understand but who has dinner waiting for you?

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he demands and stresses of medical life are always going to be unique. The professional life of a doctor is characterised by long working days and a pressure for efficiency. There are on-call shifts to deal with, night-shifts and difficult patients, and the constant fear of the implications of medical mistakes. So it would be easy to imagine that having another doctor as a partner would make life easier and make for a better partnership. But is this really the case?

Certainly much research that has been done into this topic concludes that dual- doctor relationships benefit from mutual understanding of the pressures of the job1. Mutual understanding of the long hours and the feelings of pressure can be a huge advantage.

This shared understanding can also lead to the related benefit of partners being more supportive of each other’s needs. A British study of dual-doctor marriages found that physicians in dualdoctor marriages were more supportive of their partner’s need for personal time3. A Norwegian study2 also found that physicians with same-profession spouses reported the greatest level of satisfaction with the support they received from their partners.

So what could be the negatives then, of being married to a fellow physician?

One clear strain felt by medic-medic

couples is the difficulty of balancing work and family life, when doing this around two high-stress, demanding jobs. When both partners work long hours it becomes difficult to find time for one another or for family. This may be compounded by inflexible shift patterns and unpredictable working hours.

Dual-doctor marriages are also associated with higher family income and more frequent enjoyment and satisfaction from shared work interests.

Another common problem for dualdoctor couples is that of whose career takes precedence. A study from 2010 found that there was often a need within dual-doctor couples to let one person’s career take precedence over the other 4. This happened both because of geographical constraints, such as the difficulty of finding two specialist jobs in the same area, and because of family considerations. A study of career development of British doctors in dual-doctor marriages found that more than half the female doctors surveyed chose a specialty based on its anticipated effect on their spouses and on child-bearing considerations.

Only 5% of male physicians considered these factors in selecting a specialty 5.

A study of US doctors’ dual-physician marriages concludes by saying “for female physicians in particular, marriage to another physician more often involves choices involving limitations in personal income and professional life in favour of filling family roles.”6 But it’s not all negative. More than

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feature one piece of research suggests that in dual-doctor couples, both members are more likely to share care-giving duties for children, compared to doctor/nondoctor couples 6, 7. Dual-doctor marriages are also associated with higher family income and more frequent enjoyment and satisfaction from shared work interests 6.

Medics who are in relationships with non-medics also often quote the advantage of being able to have a break from work and talk about things completely separate from the medical sphere.

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So what if you have a non-doctor spouse? Does having a spouse in a different profession have a different impact on a doctor’s life to being married to a fellow physician? One advantage, stated by many studies, of having a non-doctor spouse is the benefit of a different perspective 1, 8, 9.

Non-medic spouses may also be able to give you a valuable lay-person’s perspective of how actions taken by doctors are viewed. One doctor, interviewed for a study of British doctors’ marriages said that marriage to a non-doctor spouse was good for “keeping a sense of normality and perspective” 1.

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he practical advantages of having a non-doctor spouse may also reflect some of the negatives associated with dual-doctor marriages. Both male and female physicians with nondoctor spouses are more likely to have someone to provide practical support, in terms of family and household responsibilities than physicians with a fellow physician partner. In other words, rather than balancing two high-stress careers, there is someone there to ‘pick up the slack’, someone who is very likely to have more flexible or at the very least more predictable work hours.

Medics who are in relationships with non-medics also often quote the advantage of being able to have a break from work and talk about things completely separate from the medical sphere. Many doctors appreciate this reprieve, and it can be a welcome change of atmosphere at the end of a busy day. However, despite this welcome difference of mindset, many medics also quote the frustrations of trying to explain the stresses of medical situations to non-medic spouses, who have less understanding of the medical world.

Other disadvantages of having a non-medic partner can be friction caused to relationships from a lack of understanding of the long hours the medical partner works. Many non-doctor partners have difficulty understanding the physical demands of a medical career. This could lead to a perception of less emotional support in non-medic partnerships. This is reflected in research (quoted earlier) that support was perceived as greatest in dual-doctor marriages 2. This same study also found that conflict was greatest in marriages in which the physician partner reported long working hours.

At the end of the day the question of which type of marriage is better is effectively moot, as people will meet and fall in love with whomsoever they choose, irrespective of whether they happen to be a fellow doctor or not. All we can say for sure is, there are benefits and pitfalls of both being married to a fellow medic, and to having a nonmedical spouse. In the realms of love, “we need not think alike to love alike” 10.

KAREN TONKS is a Business Psychologist with an MSc in Organisational Psychology.

She now lives with her husband, an ED doctor, in Brisbane.

Sladden, J. Medical marriages. Student BMJ, 2004:12:472-473 http://careers.bmj.com/careers/advice/view-article.html?id=5.50 2 Østerlie W, Forsmo S, Ringdal K, Schei B, Aasland OG. Do physicians experience spousal support in their medical career? Tidsskr Nor Laegeforen. 2003 Aug 28;123(16):2296-9.

3 Johnson CA, Johnson BE, Liese BS. Dual-doctor marriages: the British experience. J Am Med Womens Assoc. 1991: 46(5):155-9; 163.

4 Buddeberg-Fischer B, Stamm M, Buddeberg C et al. The impact of gender and parenthood on physicians’ careers--professional and personal situation seven years after graduation. BMC Health Serv Res. 2010 Feb 18;10:40.

5 Johnson CA, Johnson BE, Liese BS. Dual-doctor marriages: career 1

development.

Fam Med. 1992 Mar-Apr;24(3):205-8.

6 Sobecks NW, Justice AC, Hinze, S, Taylor-Chirayath, H et al. When Doctors Marry Doctors: A Survey Exploring the Professional and Family Lives of Young Physicians. Annals of Internal Medicine February 16, 1999 vol. 130 no. 4 Part 1 312-319.

7 Gjerberg E. Dual-doctor marriages. Tidsskr Nor Laegeforen. 2003 Aug 28;123 (16):2300-3.

8 Mangan D. Doctor-doctor marriages: What makes them work?

Medical Economics 1999;24:54.

9 Myers MF. Medical marriages and other intimate relationships.

Med J Aust. 2004 Oct 4;181(7):392-4.

10 Quote attributed to David Ferenc.

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Narcissism amongst Doctors Why it can help create some great doctors whilst break others Napoleon had it. Picasso had it. Jack Nicholson’s film characters are famed for it.

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N AN EXTRAORDINARY PARTING shot, former opposition leader Brendan Nelson very liberally applied this label to his successor, Malcolm Turnbull.

It’s called narcissistic personality disorder1 - inspired by a mythical character who fell in love with his own reflection - and its symptoms are a preoccupation with one’s own success, power and brilliance coupled with a singular lack of empathy for others.

Dr Brendan Nelson famously stated that: “[Turnbull’s] got narcissistic personality disorder. He says the most appalling things and can’t understand why people get upset. 2” This summarises the DSM classification of narcissistic personality disorder which comprises a triad of “grandiosity, need for admiration, and a lack of empathy3”

Narcissistic personality disorder comprises a triad of “grandiosity, need for admiration, and a lack of empathy”.

“We can all be described as having these characteristics to some extent ... it’s only when they become very marked or fixed ways of behaving that you say someone’s got a clinical disturbance,” states Professor Carolyn Quadrio, a NSW Psychiatrist who has published on the subject of healthcare workers transgressing professional boundaries 4.

Freud believed that some narcissism is an essential part of all of us from birth. Andrew P. Morrison, who has authored a book entitled the ‘Underside of Narcissism’5, claims that in adults, a reasonable amount of healthy narcissism allows the individual’s perception of his needs to be balanced in relation to others.

But it is easy to see why having narcissistic tendencies, plus a good dose of obsessive behaviour, could benefit a medical career.

Certain doctors are often perfectionists; they’re sticklers for detail. Devoted to work and working hard and very concerned with productivity. Often they can be quite inflexible too.

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The problem arises when the focused dedication transgresses into pathological behaviour. The pathological behaviour exhibited by such a narcissistic doctor could include dishonesty, intentionally harming a patient, sexual harassment, and substance misuse. In fact, it is not uncommon to read about a doctor being reprimanded for more than one of these offences on difference occasions.

Dr. Collins, who is head of the Alcohol and Drug Recovery Center at The Cleveland Clinic in the US, reports that a big problem is the sense of entitlement of narcissists 6.

“Treatment hinges on the impaired doctor’s serious self-examination and recognition of mistakes. It is imperative that the doctor agrees to accept help and comply with monitoring.”

“Eventually, when they figure out that they really are in trouble, they have a sense of overwhelming guilt and shame.

Suicide can even be a major risk under those circumstances.”

Narcissism can also be a major factor underlying disruptive behaviour amongst certain doctors. Every healthcare worker will know at least one narcissistic doctor who would fit the description. They are easy to recognise as they often have a flagrant disregard of all hospital rules. Dr Collins characterises a typical narcissist as being someone who: “… is abusive, criticizes fellow employees, throws things in the operating room, curses people out, uses a lot of profanity, tells dirty jokes, makes racist remarks, parks in the handicapped space right next to the hospital, takes the CEO’s parking space.”

Unfortunately, this behaviour is not uncommon, especially in stressful acute care environments such as operating theatres, ICU’s, emergency departments and acute care wards.

Narcissistic behaviour in doctors does not always have to be related

feature to drug use, sexual misconduct or even mistreatment of colleagues. It permeates into the doctor-patient relationship in more subtle ways.

Dr John Banja, from Emory University coined the term ‘Medical Narcissism” 7 as the need for health professionals to preserve their self esteem leading to the compromise of error disclosure to patients. He states that most doctors “work on cultivating a self that exudes authority, control, knowledge, competence and respectability. …we dread appearing stupid or incompetent.”

By finding the act of admission of error too humiliating, narcissistic doctors are unable to communicate details of accidents or errors to patients.

Another narcissistic behaviour pattern amongst certain doctors is ‘Disruptive Behaviour’ which may include behaving: 1. Aggressive - swearing, physical intimidation, throwing objects 2. Passive - being chronically late, not responding to calls and providing inadequate medical notes 3. Passive-Aggressive - sending hostile emails and making derogatory comments about the department or hospital, refusing to do tasks Dr. Anderson Spickard is medical director at Vanderbilt University’s Center for Professional Health, in Nashville Tennessee and runs a course for ‘Distressed or Disruptive Physicians’ 8.

He said most disruptive doctors have narcissistic traits, meaning “they have a restricted ability to express warm and tender emotions, they’re overly perfectionistic, they insist that others submit to their way and they have excessive devotion to work to the exclusion of personal and interpersonal relationships.”

action often ensues and the full extent of their catalogue of disruptive behaviour is uncovered. By allowing the doctor to continue his work and disruptive behaviour, the hospital risks lawsuits from other staff for claims related to workplace stress and bullying.

Dr Spickard’s rehabilitation program is a 3 day residential program which allows referred doctors to self-examine, identify and reflect on problematic behaviours.

It is the identifying of their individual triggers which cause ‘emotional flooding’ that is the key step in their rehabilitation. Once identified, they are taught how to alter the neurolinguistic responses to these stimuli to overcome negative responses. The program has been operating for over 5 years now and when data was analysed to measure the impact of the program, 85% have had a reduction in problematic behaviour as reported by workplace colleagues.

Since almost every hospital clinician can reel off a handful of names of disruptive doctors who exhibit pathological behaviour patterns which affects the working lives of others, it seems blatantly obvious that a similar rehabilitation program to Dr Spickard’s is required in Australia.

By allowing the doctor to continue his work and disruptive behavior, the hospital risks lawsuits...

SELINA VASDEV

en.wikipedia.org/wiki/Narcissistic_personality_disorder; 29 August 2009 edition, Sydney Morning 2 Herald, Fairfax Media Publications Pty Limited 3 Diagnostic and Statistical Manual of Mental Disorders IV, American Psychiatric Association 4 Quadrio,C. Boundary Violations in Psychotherapy. May 2004 Vol 10 Num 3 5 Morrison, A. (1989), Shame: The Underside of Narcissism. Hillsdale, NJ 1

It is also recognised that with most of these ‘disruptive doctors’, their behaviour is tolerated until a crisis emerges such as patient injury or staff complaint. At this point, disciplinary

Rutledge, B. Narcissism affects many impaired physicians. Clinical Psychiatry News, Jan, 2007 7 Banja, J. Medical Errors and Medical Narcissism. July 2005 Vol 353:324 8 Samenow, C. A CME course aimed at addressing disruptive physician behaviour. Physician Executive. Jan-Feb 2008 6

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Another Fine Mess?

Is Racial Discrimination towards International Doctors Entrenched in Australia?

Australia is a multicultural environment with a high standard of living and has attracted increasing numbers of international doctors over the last two decades. In addition, Australia State and Federal Governments have carried out numerous recruitment marketing initiatives to attract, incentivise and procure doctors from around the globe to work and settle in Australia.

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charged with supporting terrorism, Dr Mohammed Haneef, arrest in July 2007 as being catalysts in the escalating negative public opinion to doctors of non-Anglo appearance.

Many overseas doctors cite the combination of the Jayant Patel from Bundaberg scandal and also the Gold Coast Doctor who was falsely

One only has to glance at a few of the bulletin boards on the internet to find statements from International Medical Graduates (IMGs) stating about how badly they were treated by patients, nursing staff and also their fellow medical practitioners. Is

S A RULE, INTERNATIONAL doctors have settled in a variety of rural, outer metropolitan and remote environments where there is a greater demand for their services and also a greater reluctance for Australian-trained doctors to practice.

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there institutional racism inbuilt into the healthcare system or are these doctors voicing their opinions about discrimination in the minority?

“There is no doubt that many patients have been more sceptical towards doctors of non-Anglo appearance since the Bundaberg enquiry. The high-profile media portrayal of Jayant Patel may have led some patients to come to the incorrect conclusion that overseas doctors are of a lower grade than their locally trained peers.” states one international doctor.

If we analyse scientifically, there has never been any hard evidence suggesting that IMGs have a higher number of complaints. When we analyse the data available, medical boards in four states have reported overseas-trained doctors had lower

rates of substantiated complaints about issues other than language than their Australian-trained colleagues.

When it comes to claims about legislated racism within the Australian healthcare system, no topic arouses greater abhorrence than the ‘10 year moratorium on International Medical Graduates’, Section 19AB of the Health Insurance Act 1973.

This rule explicitly states that doctors who completed their primary medical degree overseas are not able to access Medicare benefits for 10 years after first registering with the medical board as a specialist doctor. This would normally limit these IMGs to working in salaried positions in public hospitals where they do not bill Medicare for their income.

GPs (who derive most of their income from Medicare) and Specialists wanting to do private work are effectively

The high-profile medial portrayal of Jayant Patel may have led some patients to come to the incorrect conclusion that overseas doctors are of a lower grade than their locally trained peers.

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When we analyse the data available, medical boards in four states have reported overseas-trained doctors had lower rates of substantiated complaints about issues other than language than their Australiantrained colleagues.

unable to work. In addition, some public hospital specialists may be required to access Medicare benefits for part of their day-to-day income and the 19AB rule will naturally prevent them from obtaining employment.

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his ban on billing Medicare continues to exist for 10 years from when the doctor first registers with the Medical Board, even if the doctor obtains Australian Citizenship. IMGs can apply for 19AB exemptions providing the location where they want to work classifies as an District of Workforce Shortage (DWS) which generally means GPs and specialists are confined to non-metropolitan areas.

This then becomes legislated differential treatment of an Australian citizen based on their country of origin which clearly contravenes the International Charter of Human Rights. So how can it be that such open defiance of the United Nations Bill of Human Rights and legislated discrimination exist in a developed world Multicultural nation?

The Australian Doctors Trained Overseas Association describes the 10 year moratorium as an “affront to human rights and an international embarrassment for Australia.”

Most professional associations representing doctors believe this rule is unjust and have called for the

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scrapping of the 10 year moratorium.

However, it has been in existence for over a decade and it would be difficult to overturn without massive ramifications.

Potentially, it could deplete rural Australia of large number of IMGs who are only working there because these places have been granted 19AB exemption. If the 10 year moratorium is suddenly withdrawn, some of these IMGs may choose to abandon the Bush for a metropolitan position and create an even bigger workforce maldistribution than currently exists.

The 10 year Moratorium has been in existence since January 1997 and now, IMGs make up over 40% of the medical workforce of rural areas. However, sudden cessation of this repugnant law could create the biggest medical workforce crisis in Australian history. So for the time being, it appears as if the Federal Government are going to have to persevere with this embarrassing contravention of the Bill of Human Rights until someone dreams up a clever solution for finding more doctors for the Bush.

In conclusion, using the eternal words of Laurel and Hardy, “Well, here’s another fine mess you’ve gotten me into!”

Dr Anonymous An International Medical Graduate

finance

Growing your

medical practice to solo

from

symphony

the art of taking on associates for profit

As a doctor, most of us have the expectation that we will earn all our money from our own personal exertion. Very few specialists reach the point where they can extricate themselves from their business and let things run independent of themselves. The secret to creating a welloiled machine where a medical business is both scalable (i.e. it can be magnified by adding additional new specialists to the medical practice) and also capable of functioning without the principal specialist being present remain an enigma to most doctors.

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ost specialist practices in Australia have one or more Principal(s) who:

1. Spend several hours per week performing non-clinical tasks (e.g. IT duties, book-keeping, ad-hoc marketing,

and HR activities) – One fundamental rule of creating a systemised practice is that every member of the team should spend their time performing the activity that is the ‘highest utility activity’ for that individual. Since the hourly rate of specialist clinicians are very high, it is financial suicide for specialists to

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clinician being sapped.

Advantages of a Systemised, Scalable Business: 1. Principals can focus on their highest revenue-earning task (clinical work).

2. Additional Specialists can be taken on using a revenue-sharing basis.

3. Non-medical clinical staff can be taken on in paid employment to earn additional revenue for the practice e.g. therapists, practice nurses, etc.

Failure to ‘effectively delegate’ nonclinical activities to clerical staff either within or outside of the practice leads to the valuable revenue-earning time of the clinician being sapped.

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perform low-cost duties that include the likes of book-keeping, IT tasks and marketing. These should always be outsourced to free up time for the principals which could be better spent performing revenue-earning duties.

2. Trade under their own name (that is their name they were born with e.g.

John Smith Anaesthetic Services) – this cardinal error makes the business reliant solely on the professional reputation of the Principal and fails to create any transferrable asset in the event of the departure of the Principal. This is the main reason why 90% of specialist practices have zero Goodwill and minimal sellable value on disposal. The benefits derived from trading under a brand name and building up Goodwill cannot be overstated.

3. Do not document and standardise all their non-clinical business processes – failure to automate and standardise all non-core business processes is another cardinal sin that most specialists do not understand the benefit of. This unnecessarily requires the involvement of the Principal in non-clinical activities.

This failure to ‘effectively delegate’ nonclinical activities to clerical staff either within or outside of the practice leads to the valuable revenue-earning time of the

4. Principals are not bogged down performing non-clinical duties that they are not trained for and which also detract from their highest revenueearning capability (e.g. clinical work).

5. The system can function effectively even in the unexpected absence of the Principal allowing the Principal to gradually reduce his hours and ‘wind down’ his involvement in the practice.

6. Revenue earning capacity is no longer limited by the available time of the Principal.

7. The practice moves from a ‘sole trader’ model reliant on the personal exertion of the Principal(s) to a fully fledged ‘corporate entity’ and all the associated taxation benefits. (Disclaimer: You should seek specialist advice regarding this from your financial adviser) 8. Since the business is a now a transferrable entity which neither relies on the name or the presence of the departing Principal, one can expect a significant Goodwill value on disposal of the asset (Trade Sale).

Disadvantages of a Systemised, Scalable Business: 1. There is now an asset which is potentially sellable and could incur Capital Gains Tax on disposal.

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2. The new entity which takes on both clerical and therapist staff could have vicarious liability implications and may need additional insurance cover. Having said that, even a non-scalable entity trading in the name of the Principal would need appropriate Practice Indemnity Cover to insure against vicarious liability of the additional staff.

3. There is potential for damaging the brand name of the medical practice if any of the specialists perform substandard work or create negative publicity.

4. There is potential for bruising the ego of the Principal as the business is now no longer trading in his own name. Instead the practice is now being established in a trading name.

Why would a Principal choose to take on additional specialists as associates?

1. Increased revenue for the practice – the Principal will negotiate a revenue share agreement with the incoming specialist so that he/ she can walk in to a ‘ready-made’ business with the ability to slot in effortlessly and start ‘performing his craft.’

Most of the costs of the practice are fixed costs which do not increase with an increased number of clinicians e.g. Rent, Staff Salaries, Marketing, IT, Insurances (may increase marginally), Utilities, Telecommunications (again may have a small increase), Billing, Compliance, Accounting etc. This allows the practice to increase its revenues, with minimal increase in costs, hence increasing profit (Total Revenue - Total Expenses) generated and also the profit margin (Total Revenue – Total Expenses)/(Total Revenue).

COMPARISON BETWEEN AN AUTOMATED SYSTEMATIC SPECIALTY PRACTICES VERSUS CONVENTIONAL SPECIALTY PRACTICES.

Scalable

Non-Scalable

Operate under a ‘trading name’ e.g.

Melbourne Anaesthetic Group rather than the name of one of the doctors.

Trade under the name of the Principal e.g. Dr John Smith, Anaesthetic Services.

Have an established ‘referral base’ of referrers whose referral patterns are measured, monitored and augmented.

Rely solely on the professional reputation of the Principal for referrals.

Utilise the power of direct-to-consumer marketing to inform and educate about their services offered so that patients can contact them directly or request their GP to refer them to that particular practice by name.

Have no visible branding or direct-toconsumer marketing.

Have documented business processes for all important business functions such as Human Resources, Marketing, IT systems, Complaints, Data Storage, Compliance, Governance, Billing & Banking.

Have no documented business processes and just rely on processes which ‘have always’ been performed. Some business processes are just ‘in the memory’ of the principal or practice manager.

Have all non-core activities outsourced or have them delegated effectively, inhouse, by clerical staff.

Clinicians perform non-clinical work which should be able to be delegated to non-clinical staff.

This should include IT maintenance, Human Resources, Marketing (including measuring metrics) & Book-keeping.

Many key services are not performed or performed substandard e.g.: marketing, IT systems maintenance, HR, Complaints Handling etc.

The exact percentage split that the Principal is entitled to for providing this opportunity to the incoming specialist is dependent on:

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finance increasing the operating profit (EBIT: Earnings Before Interest and Tax), the asset value of the medical practice also increases. The asset value of a business can sometimes be calculated based on a multiple of EBIT. The exact multiple varies from industry to industry but is usually around 2-5 for medical practices on disposal.

3. Partnership law imposes strict duties on partners owed to each other.

Associateship allows practitioners to maintain a level of independence by conducting their own practice without being answerable to others.

4. There is no personal liability for acts of other associate practitioners.

Other Considerations about Associate Arrangements

Most of the costs of the practice are fixed costs which do not increase with an increased number of clinicians

1. Consider which expenses are to be shared between associates and Principal a. Established Goodwill in the trading brand name of the specialist practice – a name which already has a large market presence can command a higher percentage split for the Principal b. The Range of Services Offered – some associateship agreements include the full range of services from patient sourcing, information provision, appointment scheduling, full secretarial services, all plant & equipment, ancillary staff, billing and transcription. The more ‘allinclusive’, the more percentage split will be in favour of the practice owner rather than the associate. Typical splits vary from 50% for an all-inclusive service to up to 10% where the incoming specialists effectively bring their own patients and merely share rooms.

For providing this service to the specialist, the percentage of his gross revenue bills that can be kept by the principal varies from 15 to 40% depending on the strength of the brand and the particular specialty.

2. Increasing the Capital or Asset Value of the practice – By increasing the number of specialists in the practice and

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2. Payroll Tax implications may be relevant depending on how things are structured 3. Medical practitioners need to consider in detail what provisions will apply and what obligations outgoing Associates will have in the event of sale of an Associate’s practice, expulsion, death and incapacity. The method of terminating the Associateship should be set out in clear written terms.

4. Associates should not agree with each other about the fees that they charge their patients. By doing so they may breach the anti-competitive conduct and price-fixing provisions of the Trade Practices Act.

RAVI AGARWAL is Chief of Marketing at Marketing Doctors and assists Specialist Practices grow to their full potential through innovative marketing, structuring and business processes. www.MarketingDoctors.com.au

finance

Investing in a risk-averse world

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Risk and return. Two terms investors would be very familiar with. While most of us have a general idea about return, how many of us really factor in risk when making investment decisions?

Below we debunk some myths and offer tips on investing for success in a risk-averse world.

We are all irrational when it comes to making money.

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N THE AFTERMATH OF THE GLOBAL Financial Crisis, risk is now decidedly de rigueur, as governments, institutions, businesses and individuals grapple with the new investing paradigm. So, why are we grappling? Because we are fundamentally irrational when it comes to making money.

When faced with a sure gain, investors generally become more risk-averse; when faced with a sure loss, investors become risk-takers.

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Much economic and financial theory is based on the notion that individuals act rationally and consider all available information when making investment decisions. However, irrational behaviour and repeated errors in judgement have been well documented in studies in behavioural finance, a field that aims to better understand and explain how emotions influence investors and their decisions. The late Peter L Bernstein wrote in ‘Against the Gods’ (a seminal text on investment risk), that ‘human beings display repeated patterns of irrationality, inconsistency and incompetence when faced with uncertainty.’

For example, it is commonly accepted people feel a loss more acutely than they enjoy a gain. Investors typically find the loss of $1 twice as painful as the pleasure from receiving a $1 gain.

What is perhaps more interesting is when faced with a sure gain, investors generally become more risk-averse. But when faced with a sure loss, investors become risk-takers as their reluctance to crystallise or realise their loss becomes a stronger imperative than the loss itself [Tversky and Kahneman 1979].

Take risk personally An obvious question then is, ‘How much risk should I take when investing?’ And the answer to that is as individual as you are. The right level of risk for you should begin with an assessment of your appetite for risk in general; your lifestyle goals; your cost of living; your earnings and employment stability; your existing investments and their accompanying risk profile and finally, your age and when you plan to retire. When you take professional advice, one of the first things you should do is complete a thorough risk analysis, which helps the adviser determine which types of investments are appropriate for you.

Return and growth are critical to the decision-making process, but risk is what will keep you up night if you’ve invested based on income and capital objectives alone.

For medical practitioners especially, determining an acceptable level of investment risk is further complicated by the risks they already face in their chosen occupation. If you run a private

Top tips for investing for risk and return 1. Take a long-term approach, anything else is speculation. Besides, research shows that active trading usually only benefits the broker, who earns increased revenue off the back of transaction churn.

2. Don’t confuse experience and confidence with luck and chance. Human beings have a tendency to gamble and assume unnecessary risks.

Entertainment and ego are known motivators of people’s tendency to speculate.

3. Be flexible in your asset allocation. It may be smarter tactically, to NOT be invested in asset classes that are underperforming and be cashed up and ready for prime buying opportunities.

4. Don’t go overweight – no more than 4% in any single share.

practice, you need to consider the broader aspects of risk management, such as asset protection, business risk insurance, personal risk and estate planning, all of which create competing interests and additional costs when it comes to adequately protecting yourself, your business and your family.

There’s no such thing as a ‘sure thing’ with investing Unfortunately, there are very few guaranteed investment options and those that exist may not return much more than a bond or cash in the bank. Why? Because capital protection is effectively insurance and it comes at a price.

In the last Federal Budget, the Government announced measures that recognise the additional risk of investment gearing (or borrowing to invest). As such, investments with capital protected borrowings entered into after 13 May 2010 will be eligible for a tax deduction equivalent to the standard variable housing loan plus 100 basis points.

‘Take calculated risks. That is quite different from being rash.’

Good advice from the US General, George S Patton and it applies as much to investing as to military strategy. While the nature of investing involves a risk/return trade off, the current turbulence in global share markets has seen the rise of cleverly structured investments that offer the potential for upside gain, while adequately protecting against downside losses.

5. Invest directly wherever possible and practical and maintain control. This is usually more cost effective from both an outlay perspective and the ability to tax plan acquisitions and divestments to suit your tax position, not the fund managers.

6. Don’t get caught out by the ‘touchy feely’ syndrome. This is a tendency for people to overvalue things they’ve actually ‘touched’ or selected personally. This can happen with selecting shares or even more with residential property investment, where landlords suddenly become interior designers and overcapitalise on the asset.

7. Avoid advice paid via commission structures.

The conflict of interest is obvious enough, but an adviser who is remunerated purely by commission will invariably recommend a ‘product’, rather than a ‘solution’.

8. Use capital protection when investing in volatile assets, particularly if you are gearing (borrowing) into the investment.

9. Take professional advice to reduce the emotional risk of investing.

ROGER WILSON, Strategic Adviser at Peloton Private Clients Limited. He has worked within the medical industry and now advises professional practitioners how to build successful, taxeffective private practices.

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Planning what will happen after we die is not something many people look forward to addressing. However, it is important because not only will your loved ones have to deal with the grief of your “departure”, they may be left to manage the conflict and angst that can arise when you don’t leave a Will.

Are any of these scenarios relevant to you?

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F YOU DIE WITHOUT A WILL YOU are deemed to have died intestate and your assets will be distributed according to a standard government prescribed formula. Whilst these laws differ across the different states of Australia, we will look at some scenarios using Victorian legislation in order to outline some issues if a Will does not exist.

Married with children?

Most Australians believe that if they die without a Will their estate automatically passes to their spouse. Think again… In Victoria, if a spouse with children dies without a Will, their partner receives the first $100,000 and only a third of the balance of the estate. The rest will be shared between the deceased’s children, regardless of their age. Here’s an example - Sue’s estate comprises a half share of the family home worth

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Estate Planning What happens if you die without a Will? $500K, an investment property worth $400K and $100K of shares. Her estate is worth $1m. If Sue died without a Will, Paul her husband would only receive the first $100K and 1/3 of the balance (total $400K). Her two children would receive $300K each.

Separated but not divorced?

The formula mentioned above also applies if you are separated but not divorced. If you don’t have a Will in place, and are not yet divorced, your husband or wife could end up with a significant part of your assets. If you have recently separated you should consider who you would want to receive your assets and have a legal Will prepared accordingly.

Married without children?

Tom and Linda are a young married couple without children, they are involved in a car accident and both die.

In Victoria, the eldest of the couple is

deemed to have died first. This means that all of their combined assets are passed on to the younger spouse.

However in this case as they are also deceased the assets then get passed to the younger person’s parents.

In this example Tom is older than Linda, so he is deemed to have died first. All assets are transferred to Linda, but as she has also died, the entire estate assets are passed on to Linda’s parents leaving Tom’s family with nothing.

Estate executor and family trust Geoff was executor of his parent’s estate when he suffered a heart attack and his estate passed to his wife. Unfortunately, that meant she stepped in to control her parents-in-law’s estate. Geoff’s siblings were not happy especially as she became appointer of the family trust. As a trust does not form part of an estate she had complete control over all trust assets.

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A Comprehensive Will including provisions for Testamentary Trusts can ensure that your beneficiaries receive the assets in the most tax effective and flexible way. you want to receive them.

Single mum or dad?

Sarah and her only child Daniel are involved in a car accident and die. Sarah, being the oldest, is deemed to have died first. The estate assets are legally passed on to Daniel, but as Daniel has also died the assets are passed on to Daniel’s father - Sarah’s ex- husband.

If Geoff had a legal Will made that included passing the executor role to his brother, it would have avoided a lot of heartache.

Married with young children?

Have you considered who will look after your children if you both die? Who will manage their inheritance until they come of age? You need to identify your preferred guardians and talk to them about these and other lifestyle issues regarding your children.

Have you re-married? Do you have Super?

Perhaps you have older children from a prior relationship. Be aware that if you have Super it may automatically be left to your new spouse and your adult children may get none of it. Also be aware that a de facto may also be entitled to your super - not just a married spouse. Proper estate planning can ensure your assets are left to those

This outcome could be devastating for Sarah’s family - especially if Sarah and her ex-husband were not on good terms.

It is very important for Sarah to have a Will that states who the assets should go to in the event that something like this occurs.

tax provisions for minors which relate specifically to income generated by a Testamentary Trust, and minimise the tax that they’ll pay on income or capital gains from their inheritance - often saving them thousands of dollars.

Control by blood relatives Within a Comprehensive Will, you have the option to limit beneficiaries to ‘blood’ relatives, and determine exactly who does and doesn’t have access to the inheritance. This is increasingly an issue within split family structures, complex families, with multiple marriages, children and stepchildren and in particular, when there’s concern about funds falling into the hands of a beneficiary’s current or future partner or extended family.

There are Wills and then there are Wills A well drafted Will ensures that your estate assets are distributed to who you want. A Comprehensive Will including provisions for Testamentary Trusts can ensure that your beneficiaries receive the assets in the most tax effective and flexible way. Some of the benefits include: Asset Protection Through a Comprehensive Will, the people you leave your assets to can choose whether to receive their inheritance through a ‘Testamentary Trust’, which they control, as to receive the assets in their own name. If they receive the assets in a Testamentary Trust they will be protected from bankruptcy.

Tax Benefits With a Comprehensive Will, your beneficiaries can take advantage of

Restricting Access over 18 With a standard Will, a beneficiary can’t be stopped from receiving the funds when they turn 18. With an inheritance placed in a testamentary trust however, access can be restricted until any age often 25 yrs.

Life Insurance and Superannuation Proceeds Trust Protection from estate challenges or estranged partners.

As you can see most of us need a will and there are many situations where a standard will just might not do. In a time of ever increasing commitments, it is too often that your Wills are left neglected so if you don’t have a Will or your Will is out of date, then you should speak to your legal advisor.

Life Shield Lawyers www.lifeshieldlawyers.com.au

ANAESTHETICLife

33

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finance

Smart money goes GREEN Many investors still view their money as separate from their own identity.

They don’t think of their personal values or ethics when they are investing.

They don’t realise that their money can actually improve the world, or alternatively cause harm to things they hold dear.

J

ust like the purchasing decisions you make every day, you also have a choice when it comes to how you invest your money. Indeed, more and more investors are realising that the financial value of an investment is just one consideration when assessing its worthiness. Savvy investors also want to know how companies they invest in minimise their environmental impact, treat their employees, respond to feedback or objections from shareholders, and how they interact with the local communities they operate in. The consideration of these issues and how they fit with your personal values is

called ethical investment.

Ethical investment has several names, some people call it directed investment, others responsible investment. But the basic principle behind the concept is to enable you to integrate your personal values and social concerns with your investment objectives, using financially sound investments.

What’s driving ethical investment?

Investors are seeking more accurate company valuations

ANAESTHETICLife

35

finance Source: AMP Capital Investors Report 2006.

Forward-thinking investors are also aware that their portfolio needs to be responsive to the various issues confronting the world in the 21st Century.

W

hat ethical investors have been thinking for years has finally been proven by traditional finance houses. Research conducted by AMP Capital shows that over 75% of the value of a typical Australian company is tied up in unseen or intangible assets (as shown in the following chart). As the iceberg diagram shows, there is much more to consider than just the assets or financials of a company if you want a truly accurate valuation or understanding. An astute investor should also be asking about company’s environmental track record, employee relations and the remuneration of board members.

economy, global population growth, rising consumerism in developing economies and increasing healthcare needs. All of these issues are changing the way the companies, communities, employees, and consumers interact. Of course it follows those companies that fail to pay attention to these trends or fail to manage their intangible assets are likely to find less willing investors, thereby affecting their share price and ultimately performance. Conversely those companies that are making active steps to address these world issues will seize the opportunities which others are ignoring.

The iceberg effect

Everyone has their own set of ethics, values and opinions. You decide what’s important to you. Say, for example, you are opposed to armaments, woodchipping and alcohol, you would not wish to invest in companies involved in those industries. However, you might still be investing in them indirectly through your bank, superannuation or insurance bond. Issues that often raise concerns include arms, animal testing, alcohol, tobacco, gambling, chemicals, drugs, nuclear industry and pollution, as well as specific countries with repressive

Investors want to stay ahead of 21st Century trends Forward-thinking investors are also aware that their portfolio needs to be responsive to the various issues confronting the world in the 21st Century. Climate change and an ageing population are two important examples: others include unsustainable consumption of resources (like oil and water), the transition to a low carbon

36

ANAESTHETICLife

Which investments are more ethical?

finance

Light Green Funds

Has barely any “screen” Invests in companies involved in mining, tobacco and alcohol.

Mid to Dark Green Funds

Has a “negative screen” Excludes companies involved in mining, tobacco, alcohol and environmental destruction.

regimes.

various shades of “green”.

If you want to actively support certain industries you might choose to invest positively, by investing in companies with affirmative environmental programs such as recycling, energy efficiency, and pollution control. You may also like to invest in innovative companies that are helping to solve the problems of the 21st Century: clean energy, water and waste management, healthcare, energy efficiency, sustainable property, agriculture, mass transport and education.

Are you ready to start investing ethically?

You can invest directly in a company that meets your ethical values. Alternatively, you can invest in a managed fund that follows a methodology which matches your ethical views and financial goals. It is important to know however, that not all managed funds labelled as “ethical’’ will meet your ethical values. Ethical managed funds or investments come in

Firstly have a think about what’s important to you. What do you believe in? Are you living a life that’s consistent with your beliefs and priorities? If not, how can you?

You can start by investing your money in companies that have a positive impact on the environment and society. You can also avoid those companies or investments which cause harm.

If you are interested in ethical investment, speak to a professional.

A specialist adviser will be able to integrate ethical investment principles with conventional financial analysis.

And importantly, your recommended portfolio will be tailored to your ethical values and concerns.

Dark Green Funds

Has a “positive screen” Invests solely in companies which have a positive impact.

It is important to know that not all managed funds labelled as “ethical’’ will meet your ethical values. Ethical managed funds or investments come in various shades of “green”.

KAREN MCLEOD is an Authorised Representative (No. 242000) of Ethical Investment Advisers (AFSL 276544). We provide investment advice for ethically-minded and socially-conscious investors.

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 should not act on the information provided without seeking personal advice from an appropriately qualified financial planner. Information included from third parties has been reproduced with their permission. 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 liability for any errors in the data.

ANAESTHETICLife

37

ANAESTHETICLife

finance

Taking care of your financial needs throughout life’s stages As your life changes, so does your financial planning needs. In this article, we go through two key life stages to provide an indication of the type of financial planning issues that may arise for you and how they can be addressed.

Stage 1 – establishing a solid financial foundation

A

s a young professional, working hard to establish yourself in your medical career, the most effective way to start down the path of wealth accumulation and protection is to structure your assets correctly at the outset. Transferring assets to another structure in the future can be costly, with the prospect of capital gains tax and stamp duty, and can also give rise to the claw back provisions

under Bankruptcy laws.

To protect your assets from litigation, the fundamental rule is that assets should not be held in the name of the at-risk person. Instead your assets should be placed in structures that allow you to manage and control them and to also isolate them from the risks of your medical practice.

Common ownership structures include discretionary (family) trusts, often with a trading company behind

it when operating a business, and superannuation. A spouse who is not involved in the business may also be an appropriate owner of investment assets but this can depend on the spouse’s tax position, which often changes over time.

When deciding on the appropriate structures to use, there is typically a trade-off between asset protection and tax efficiency. This is similar to the trade-off between risk and return when seeking investment returns.

For example, gearing is a common

ANAESTHETICLife

39

finance

Superannuation is also the most protected structure from a risk management perspective strategy for accelerating wealth creation but careful consideration of how to hold the geared portfolio is required. The deductibility of interest expenses means that a geared portfolio is often held in the name of the highest income earner.

H

owever, from an asset protection perspective, it may be better to hold the portfolio within a family trust.

The trade-off is that this is not as tax effective as losses must be absorbed at the trust level and cannot be passed on to individual beneficiaries.

A balance also has to be struck between accumulating wealth for now and the future. Superannuation is a structure that often attracts little interest whilst we are in the early stages of our career but the tax savings mean that it is the preferred long term investment vehicle.

With limits on contributions, a proactive approach is needed to build up assets in superannuation whilst also building up assets in other structures. Strategies such as salary sacrifice and personal deductible contributions can be effective in managing personal tax and building long term wealth.

Superannuation is also the most protected structure from a risk management perspective, although contributions made to superannuation with the intention of defeating creditors can be clawed back under the

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ANAESTHETICLife

Bankruptcy laws.

In addition to structuring assets correctly, you should also arrange for appropriate professional, personal and general insurance to be in place. This will ensure that wealth accumulation can continue regardless of any adverse personal or professional developments.

Stage 2 – securing your financial future Once in the midst of your career, it is important to ensure you are making full use of the opportunities available to provide for your overall financial security. This is easier said than done as at this stage of your life, it may be difficult to see beyond repaying your mortgage, meeting expenses such as school fees and family holidays as well as managing your busy practice.

The wisdom of repaying non-deductible debt is well established as it provides a guaranteed return at an after-tax rate that can be difficult to achieve through other investments on a sustained basis.

Reducing non-deductible debt also opens up the option of debt recycling where you use the increased equity you have in your home for example to build up an investment portfolio of growth assets. This process replaces nondeductible debt with deductible debt and can be a tax effective strategy to accelerate wealth accumulation.

Although focusing on reducing your mortgage is a sound strategy, it is important to consider whether it should be repaid at the exclusion of other strategies. The concessional tax treatment of superannuation means that it may be beneficial to make use of contribution limits to build up your superannuation tax effectively. You can then withdraw a tax-free lump sum after age 60 to extinguish your mortgage.

Growing your superannuation over this period will also reap benefits even though it can be difficult to lock away funds at this time of life. For example, a superannuation balance of around $200,000 (plus) gives you the

option of establishing a self managed superannuation fund (SMSF) to gain better control and flexibility over your retirement assets. In the previous edition of Medical Life, we discussed holding your practice rooms in your SMSF as a way to make use of the property in your business, whilst also providing for your retirement.

During this stage, life events can also throw up challenges such as divorce, remarriage, retrenchment and illness. In the event of divorce, the powers of the Family Court mean that it can include all assets, irrespective of ownership structures, in financial settlements. It is becoming more common, particularly in the case of re-marriage, to put in place a Binding Financial Agreement to manage the split of assets in the event of a relationship break-down. Retrenchment is probably less of an issue for medical professionals but any career change can require a review of the structures you have in place and how your assets are managed. The prospect of illness and an interruption to your earning capacity means that your insurance arrangements must be up to date.

The receipt of an inheritance can also occur at this time and will open up further opportunities for you. Advice on whether to use the funds to repay debt or to add to your investments and whether to do this through the family trust or superannuation for example, can help to secure your financial future.

After stage 2?

In future articles, we will discuss some of these issues and strategies in more detail and also look at the third stage where, after a rewarding career, you are contemplating retirement and beyond.

Please note that if you want to pursue any of the suggestions presented, you will need to obtain specific advice to determine the best course of action for your particular circumstances.

FIONA HINRICHSEN is the Senior Financial Strategist at Accordius.

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Industry and co-operation are the hallmarks of the beehive. Wealth management requires a similar approach.

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We provide a distinct alternative to traditional stockbroker, financial planner, managed fund and self-managed options by integrating autonomous financial advice with individually managed discretionary direct investment services.

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If maintaining and growing your wealth in a transparent relationship is important to you, please visit www.accordius.com.au or call us on 03 8623 3378 to arrange a complimentary review of your financial affairs.

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ANAESTHETICLife

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risk management

Why are you afraid of NFR Orders?

Not For Resuscitation (NFR) orders are rapidly becoming standard medical practice. But some doctors are reluctant to issue them. Why?

Heroes

I

NTENSIVE CARE PHYSICIANS, ANAESTHETISTS AND emergency medicine physicians are all trained to use elaborate techniques to save a patient’s life. They assess the quality of their work by auditing their patients’ mortality rates. Death is a depressing subject, for doctors as well as lay people. Doctors in critical care specialties are unwilling to speak of the death of a patient as a satisfactory outcome.

An NFR decision is not a prediction that the patient will probably die. It is not a decision that more conservative types of therapy should not be given. Yet, some doctors see an NFR order as an excuse to withhold potentially lifesaving therapy. They shrug, and say, “Well, I didn’t bother, because the patient’s NFR.” Knowing this, some doctors will refuse to issue NFR orders, to avoid giving their night-shift colleagues an excuse to avoid putting in a proper effort.

Villains There is increasing public scrutiny of medical decisions from media and law firms, and it makes doctors nervous. The

risk management unrealistic portrayal of resuscitation in TV shows such as ER creates unrealistic expectations for patients and their relatives.

collude to make it an unwritten rule.

Then, if the patient dies, the doctor can face the relatives, shrug, and say, “I tried to do everything I could.”

To say that a person cannot live longer from resuscitation, or that the patient’s quality of life is so poor that even if she lived longer she would not benefit from resuscitation, may seem judgmental. An NFR order may, to a lay person, look like an immoral decision as to who deserves to live, or who the doctor desires to live.

Coping Mechanism 3

John Harris, British ethicist, has said: If we decide against resuscitation, or divert resources to more ‘worthwhile’ cases, or types of cases, we are treating these lives as less valuable, less worthy of preservation than the others whom we choose to help.

Coping Mechanism 1 A doctor may cope with his or her reluctance to issue NFR orders by attempting to resuscitate patients who really shouldn’t be subjected to those efforts. That doctor may choose to try to resuscitate a patient whose life could not possibly be prolonged by it, or whose quality of life is so poor that the patient would not benefit even if that life were prolonged.

Then, if the patient dies, the doctor can face the relatives, shrug, and say, “I did all that I could.”

Coping Mechanism 2 Some doctors have adopted a behaviour that has been described as “slow code”.

When a patient collapses, and the doctor knows that the patient is one who probably should have had an NFR order, he may choose to respond late to the Code Blue, and cynically go through the motions, appearing to attempt the resuscitation while not really trying.

The doctor wastes resources and diverts his psychological energy in something that will never benefit his patient. Such behaviour would never be codified in the hospital’s official policies. The staff

CPR is effective in restarting a patient’s circulation in up to 50% of cases.

However, only 5% to 15% of patients who receive CPR are discharged from the hospital alive. The remainder have had their circulations re-established only temporarily, and are destined to die during their admission. The patient may well live for another few hours, during which time he or she will probably be transferred off the general ward, to the intensive care unit.

A doctor may seek to avoid their own reluctance to issue NFR orders by resuscitating a patient, knowing that the patient will die soon anyway, but keeping the patient alive long enough to shift the patient from the doctor’s own ward. This will keep the ward doctor’s mortality statistics low.

It may also optimise the hospital’s funding. In Victoria, the WIES funding formula sometimes takes into account whether a patient lives or dies while on a general ward. However, there is no financial penalty for a patient who dies on a subacute unit such as a palliative care ward.

NFR orders are legal, morally safe, and are fast becoming a routine part of medical practice.

Then, if the patient dies, the doctor can face the relatives, shrug, and say, “The patient was alive while she was on my ward.”

A Way Forward NFR orders are legal, morally safe, and are fast becoming a routine part of medical practice. They are recognised by the courts as a legitimate approach to a patient who is dying. Doctors need not make excuses or invent fiction to justify an NFR order. More guidance from senior medical staff and educational institutions is required, to make NFR orders an effective tool in the hands of practicing clinicians.

DR RICHARD CAVELL is a medical practitioner who specialises in medical law.

Cavell, R. Not-for-resuscitation orders: The medical, legal and ethical rationale behind letting patients die. (2008) Vol 16, pg 305. Journal of Law and Medicine.

ANAESTHETICLife

43

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risk management

Anaesthetic Case Report

Opioids in Head Injury Patients Miss VA was a 16 year old girl who was admitted to the Royal North Shore Hospital in 2005.

S

HE HAD BEEN PLAYING GOLF when she was struck by a golf ball behind her right ear. After the injury, she was vomiting and disoriented, but conscious. A CT showed that she had a depressed skull fracture of the right temple.

She was admitted to the neurosurgical ward, in the room furthest away from the nurses’ station. She was managed partly by an intern who was experiencing her first day on the neurosurgical unit.

Miss VA weighed about 67 kilograms and had never been prescribed opioids before. Multiple treating units prescribed analgesia to her during her admission, leading to multiple redundant prescriptions for opioids. She was

prescribed paracetamol and codeine phosphate separately, in addition to Panadeine Forte, oxycodone, tramadol and morphine.

At one stage an anaesthetic registrar increased the dose of oxycodone, but did not record a maximum permissible daily dose. One of the prescriptions was written illegibly, meaning the nurses may have fallen back on the more legible prescriptions for the clarity of their writing rather than their pharmacological efficacy.

In the early hours one morning, after receiving multiple doses of opioids, Miss VA died. Her father was asleep next to her bed at the time. Her death was, of course, investigated by the New South

ANAESTHETICLife

45

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risk management Wales Coroner.

The Coroner, Magistrate Milovanovich, found that Miss VA died from respiratory depression due to the depressant effect of opioid medication (in the context of a head injury). One medical expert told the Coroner that the amount of opioid medication was “outside what I would have prescribed and I think outside probably (what) any neurosurgeon would have prescribed”. He also thought that the patient should have been in an ICU or HDU. The lesson for those handling analgesia in head injury patients is to understand that opioid prescriptions can lead to respiratory depression and decreased conscious state.

The evidence in this case suggested that for head injury patients, doctors should: •

•

Write a maximum daily dose for opioids, and that if medications are intended to be prescribed in the alternative, the word “OR” should be written clearly between them on the drug chart.

Clearly apportion responsibility for prescribing analgesia, and create hospital wide pain management guidelines

He stated that when confronted by the existence of a Panadeine Forte prescription, the registrar paused, or looked shocked. He concluded that the registrar was not aware of the existence of the Panadeine Forte prescription, and sent volumes of correspondence to many of the witnesses. The Coroner described this correspondence as “an unnecessary and unfortunate side issue”, and made a suppression order preventing their publication.

The Coroner criticised: The Coroner went on to say: •

“The wisdom, albeit for good intentions in regard to privacy, of placing (Miss VA) in a room furthest away from the Nurses station.” The fact that the patient was unobserved while receiving these medications meant that respiratory depression could not have been noticed until it was too late.

A senior staff specialist anaesthetist interviewed the anaesthetic registrar after the patient’s death, and wrote a letter to the Coroner raising concerns.

There is little doubt that the NSW Health System, while certainly staffed by dedicated professionals is labouring under increased demands and expectations from the general public.

Unfortunately the same issues are invariably identified, not enough Doctors, not enough Nurses, inexperienced staff, poor communication, poor record keeping and poor management. These are systemic problems that have existed for a number of years and regrettably they all surface in the death of (Miss VA) In response to Vanessa’s death, the New South Wales Department of Health has produced the document “Guidelines for the administration of analgesia and the use of anti-convulsant therapy in the treatment of mild closed head injury”, dated December 2007. Doctors who prescribe analgesia, particularly opioids, in the context of head injury would be wise to familiarise themselves with these guidelines.

The Coroner also said, in his experience with many cases:

DR RICHARD CAVELL is a medical practitioner who specialises in medical law.

ANAESTHETICLife

47

Health Professionals go to

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Interested in advertising in this free publication sent to every Australian Anaesthetist? (circulation = over 3,300) Contact our advertising team on media@medical-life.com.au

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risk management

I’m Sorry – apologising without admitting liability Medical errors can be difficult to disclose. Even though doctors, ethicists, hospital executives, patient safety experts and accrediting organisations all agree that being transparent and apologising to the patient is the ‘right thing to do’, managing an adverse event can be difficult for the practitioner involved.

W

HETHER IT IS A CHIPPED tooth or a nerve paralysis, an anaesthetist will naturally feel upset in proportion to the degree of harm when having to explain to the patient or family that the procedure which was intended to improve the patient’s health has inadvertently caused them harm.

Each of the Australian states and territories has legislation which allows expressions of regret to be made without being an admission of liability. An aim of this protective legislation is to create an environment where doctors can feel comfortable apologising to patients.

A recurring theme in the complaints

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risk management

A recurring theme in the complaints received from patients and their families by the various disciplinary bodies is a breakdown in communication

received from patients and their families by the various disciplinary bodies is a breakdown in communication. While most procedures go according to plan, inevitably the unforeseen will occur and an adverse event will unfold. So much hangs on good communication with the patient, before, during and after a procedure. A patient with whom you have established a good rapport during the pre-anaesthetic meeting will likely be easier to speak with if something unexpected or untoward occurs.

It is also important to act quickly. The diagram below depicts what happens after an adverse event and the impacts of a delayed apology. Whilst the level of the doctor’s sense of responsibility decreases, the patient’s degree of anger increases. This mismatch then causes a growing level of difficulty in doctor– patient communication.

While a culture to remove blame and shame is rightly advocated, it is difficult for the error-involved anaesthetist to cope with this emotional burden while maintaining a robust sense of professional accountability. Efforts to avoid casting blame must not lose sight of the feelings of guilt felt after an error, even in the absence of external criticism.1 The internal criticism of the caring doctor

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remains strong.

Open, honest, timely and concerned communication is a most important factor in maintaining a therapeutic relationship after an adverse event.

When things go wrong, patients and their families want to know what happened and why, and taking an honest and compassionate approach is the responsible thing to do.

Immediately after an adverse event, doctors may themselves be searching for answers too, and it is appropriate to acknowledge the limits of what is known and agree to provide more information as details become available. When honesty and reason are applied, patients and their families will usually respond in kind.

A sincere apology, while not admitting to fault, can comfort the patient, bring forgiveness to the doctor and restore trust to their relationship. Apologies have great potential to heal and we should aim to treat other people the way we would like them to treat us or our families.

When we are injured, we hope to be treated with kindness and compassion, not abandoned or ignored. In many cases, the difference between forgiveness and anger may be as simple as a timely meeting or a telephone call. 2

risk management

risk management

Both in your verbal and nonverbal behaviour, showing concern is better than trying to be cool and detached or legalistic.

In managing an incident which has resulted in unintended clinical harm to a patient, it is generally appropriate for the treating doctor to: acknowledge to the patient that an adverse event has occurred acknowledge the patient’s distress and unhappiness at the outcome apologise for what has occurred provide the known clinical facts take steps to put things right where possible and discuss what ongoing care is needed or proposed.

When talking with a patient about an adverse event, you need to be aware of the risk, when expressing regret, of inadvertently admitting liability.

An admission of liability: ‘I’m sorry I did this to you’ — is a statement that acknowledges a person’s liability for damage caused to another.

An expression of regret: ‘I’m sorry this happened to you’—is an expression of sorrow for the harm experienced by the patient.

Both in your verbal and non-verbal

behaviour, showing concern is better than trying to be cool and detached or legalistic. Your tone should be collaborative, e.g. ‘This wasn’t the outcome either of us wanted or expected’ or ‘Let’s see how we can sort this out’.

The meeting with your patient should not be rushed and it is important to listen to and acknowledge their concerns.

The event in question may well be one you would need to advise your medical defence organisation or hospital administration about as a requirement of your indemnity policy. But it may be helpful anyway to discuss this with a medico-legal adviser and talk about apologising appropriately.

The process of apology is not only good clinical practice but also good medicolegal prophylaxis, although there is no certainty that apologies reduce litigation.3

Trainees’ (2007) 22 Journal of General Internal Medicine 988-996 2 Marie Bismark and Ron Paterson, ‘ “Doing the right thing” after an adverse event’(2005) 118 Journal of the New Zealand Medical Association 1219 http://www.nzma.org.nz/journal/1181219/1593/p://www.nzma.org.nz/journal/118-1219/1593/ 3 David M Studdert, Michelle M Mello, Atul A Gawande et al, ‘Disclosure Of Medical Injury To Patients: An Improbable Risk Management Strategy’ (2007) 26 Health Affairs 215-226 http:// content.healthaffairs.org/cgi/content/full/26/1/215?ck=nck at 16 June 2010

Lauris C Kaldjian, Elizabeth W Jones, Barry J Wu et al, ‘Disclosing Medical Errors to Patients: Attitudes and Practices of Physicians and 1

DR JOHN WILLIAMSON, MA, MB BS, MRCS LRCP, MRCGP, Dip. Comm. Emerg. Med.

Dr Williamson is a Medico-legal Adviser with Avant, Australia’s leading medical defence organisation. John has in excess of 18 years clinical experience and more than a decade in medical defence organisations with experience spanning general practice, medical law, medical ethics and claims management.

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WORK AND TRAVEL AROUND AUSTRALASIA WITH

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LocumBank offers a FREE service to all locum doctors and specialises in organising mutual recognition medical registration, health service documentation, invoicing for doctors working under an ABN, flights and accommodation, plus regular updates on available shifts.

If you are interested in travelling or you have some leave coming up, why not consider a locum in Australia or New Zealand? Amazing scenery and unique career experiences available, from an urban city centre hospital to retrieval work in an outback community, at LocumBank we have a shift to suit everyone!

Listed below is a small selection of positions currently available. If you are interested in a vacancy or would like further information on other available opportunities, please contact us on 1300 4 LOCUM or email info@LocumBank.com.au Alternatively you can visit our website at www.LocumBank.com.au for further information or to sign up to receive a weekly shift list.

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careers

MEDICAL

INTERVIEWS Demystified Unlock the secret of winning at medical job interviews

A

T ONE STAGE OR ANOTHER IN YOUR career, most doctors will have to go through a medical interview process.

In general for trainees, these are often competitive, stressful and a step into the unknown.

Interview season for registrars seeking accredited positions is fast approaching. This is also a time where many final year advanced trainees will applying and interviewing for their first consultant jobs. Along with a polished CV and glowing references, good interview skills are a major determinant of success in applying for your preferred position.

The distinction between each registrar applying for accredited positions is very subtle. Most, if not all, will have the mandatory qualifications necessary to be eligible. The main differences will be in their academic achievements and the ability to answer difficult questions about hypothetical scenarios.

The Interview Panel The registrar selection panels can be formed by the either the speciality college or the health service. The college formed panels are made up of senior specialists who also often perform a variety of other college committee

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careers roles. The health service selection panels comprise of a panel of senior staff including: 1. Director/ Deputy Director of the Department 2. Medical Director/ Clinical Director of the hospital 3. Supervisor of Training for the department 4. Other senior consultants within the Department 5. Non-medical staff e.g. Human Resource Managers A similar health service panel is used for interviewing candidates for new consultant positions.

This is where the similarity between registrar and consultant interviews stops. Registrar interviews focus on assessing whether the candidate is a safe, compliant, motivated trainee who is academically equipped sufficiently to pass the exams.

Consultant interviews have a greater focus on reviewing potential non-clinical contributions that the candidate can offer the overall department: • • • •

Non-medical managerial skills – leadership, organisation, ethics, conflict resolution Ability to increase the department’s status – research, education, audits, committee work Areas of ‘Unique Expertise’ – areas of non clinical knowledge such as extensive medico-legal experience Interpersonal skills and personality

Many people believe the subject matter and questions asked in interviews are vastly diverse, however this incorrect. The majority of medical interviews are based on a standard format.

Basic Anatomy of a Medical Job Interview Most medical interviews will last between twenty minutes to an hour and will generally consist of questions asked on four topics. The exception to this rule is where there is a Structured Interviews format, such as the RACS SET interviews, where the questions are not necessarily in the same order but the content is often still similar.

Your suitability for a particular career path is likely to be selected on the basis of approximately ten questions. The importance of having practiced answering questions on all these topics cannot be overemphasised.

General Interview Advice 1. Listen carefully to the question. Don’t make them ask it more than once 2. Make eye contact with the interviewer before speaking.

Initially address the panel member who asked the question and then glance around to also engage the entire panel 3. Adopt a relaxed posture and sit squarely in the chair 4. Keep to the point and aim to be precise; give a full answer and do not waffle. A good method is to give a framework to

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Background, Training, Motivation Why do you want to join this department?

What can you offer us?

Where do you see yourself in five years time?

Communication, Leadership Skills How do you go about resolving a conflict?

What is the difference between management & leadership?

How do you respond to criticism?

Research, Teaching, Quality Assurance What did you gain from your research?

Tell us about your worst teaching experience as a teacher.

What do you understand by the term Quality Assurance?

Difficult Colleagues, Ethics One of your consultant colleagues is underperforming.

What do you do?

What do you understand by the term Quality Assurance?

One of your juniors keeps contradicting you in front of patients. What do you do? your answer e.g. ‘There are three aspects to this; one...’

5. Structure your answer; it should be logical and clearly understood 6. Do not speak too quickly. Try to speak about 20% slower than your normally would 7. Ensure you are professional and demonstrate controlled enthusiasm and drive 8. At the end of the interview take your leave as smoothly and politely as possible. Thank the panel for their time through the Chairman How to answer “Do you have any questions?”

You should always come to an interview armed with some questions. Saying that you don’t have any questions is a sign of disinterest and apathy. Ask sensible, leading questions that give you an opportunity to ‘promote’ your suitability if the answer provided by the interviewer shows an opportunity.

Some examples of this include: What are you looking for in a new consultant?

Are there any major service reforms planned?

What are the teaching and research opportunities?

What are the links with the medical school?

What is the relationship between clinicians and management

careers

Many people believe the subject matter and questions asked in interviews are vastly diverse, however, this is incorrect.

like?

What is the scope for service development?

How to Answer Individual Questions In essence, the decision about your suitability for a particular position is going to be decided on a series of 5-15 open-ended questions. Here are some simple rules in providing excellent answers for every question: 1. Never answer the question directly 2. Make sure your answers are structured and illustrated with a real-life example 3. Always conclude your answer to create an ‘obvious endpoint’ 4. Make the interview panel ‘like you’

A better and more structured answer would be: The audit cycle is a continuous process where existing practice is judged against set standards. Step one is for the standard to be set. Step two involves judging existing practice against those set standards. Step three is about presenting and discussing the data comparing existing practice against the set standards and step four involves changing current practice to move nearer to the standards of best practice. Practice is then re-evaluated in a cyclical process to further enhance clinical practice in an ongoing, ever-improving system.

This answer demonstrates great knowledge but zero experience.

An outstanding answer would be:

The most common mistake made in interviews is that candidates answer questions defensively to try and avoid saying something silly. You should try to do the exact opposite.

You should be providing confident answers demonstrating your knowledge and experience. Most candidates focus on demonstrating knowledge and forget to illustrate this with a real life example.

The above knowledgeable answer followed by an illustration demonstrating application of knowledge “...In my last audit on the discharge process at XY hospital we decided to set our standards by looking at the policies set...”

Structuring your answers

Typical question: Tell me about the Audit Cycle?

Your goals in every answer should be to:

A common basic response would be:

1. Give the interview panel the idea that you have organised thinking 2. Make your answers as easy as possible to listen to 3. Effectively get your message across to the interview panel 4. Demonstrate experience by illustrating your theoretical answers with personal situations

Audits are a method of comparing the current standard of clinical care to a gold standard or an industry set standard.

Ideally, the results are measured, evaluated and fed back to the relevant entities to complete the audit cycle.

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careers A recommended structure to use when answering interview questions is:

Recommended Structure for Answering Questions

Typical Question with Examples:

What makes you a good team player?

Listen Attentively – After being asked the question, remain quiet for 5 seconds (write notes as required)

Introduction – start the answer with a “Motherhood Statement” and describe what structure you will answer the question with.

Body – Go through the main part of your answer with the examples

Think about three skills you want to ‘promote’ about yourself during the answer.

In this case, you could be thinking about promoting your Communication Skills, Organised Thinking Ability and your Extensive Experience in working in a team.

Motherhood statement – “Most medical processes involve teamwork and the ability to safely and harmoniously work as part of a diverse team is mandatory in every medical profession.”

Describe structure – “I’m going to identify some key skills which make a good team member and illustrate how these contribute to effective teamwork” “Teamwork involves a variety of key skills such as: - Good communication - both speaking and listening, respectfully and clearly - Commitment to a shared goal and ability to take on any designated role within the team - Decision Making – has to be objective and effective to avoid ‘dilution of responsibility’ where a team makes a poor decision because no individual wants to step up and take responsibility.

My most recent example of effective teamwork is well demonstrated by a recent Cardiac Arrest I attended where I was the team leader and ……

There was clear communication of…., There was an implicit commitment to a shared goal (the resuscitation of the patient) and I delegated roles for airway, circulation and scribing to others in my team….”

Conclusion – Final sentence linking the question asked, any examples quoted, the skill learnt and the position you applied for.

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“In summary, teamwork relies on a number of key facets of which I identified clear communication, effective decision making and commitment to a shared goal as being the most important.”

Similarly, in the post as a ……that I am interviewing for, great leadership, excellent followership and good team working are important in….. where interaction with …… is an everyday part of the job.”

careers List of the most common questions asked in Medical Interviews for Consultants and Registrars: BACKGROUND, TRAINING, MOTIVATION: Take us through your CV Why do you want to join this department?

What can you offer to this department?

How does your training meet the needs of the post?

What makes you think that you are fit to become a consultant?

What are the advantages and disadvantages of employing locum consultants?

Where do you see yourself in 5/10/20 years' time?

How do you see your career developing over the next 10 years?

Looking back at your training, what did you like the most and the least?

If you had the chance, what would you change in your training?

Why should we give you this job?

What was your greatest professional challenge in the past 5 years?

What do you like the most and the least about this specialty?

How do you identify your weaknesses?

What do you think will be your biggest challenge in this post?

How do you measure success?

GENERIC, COMMUNICATION & LEADERSHIP SKILLS: How would you describe your communication skills?

What makes you a good communicator?

What is more important: good communication or good clinical skills?

Give an example of a situation where you failed to communicate appropriately.

Give an example of a non-clinical situation where your communication skills made a difference to the outcome of a project.

How can you show empathy through an interpreter?

What makes you a good team player?

Give an example of a situation where you made a difference to a team.

Give an example of a dysfunctional team in which you worked. How did you deal with it and what did you learn from that experience?

Tell us about your management experience.

What is the difference between management & leadership?

Can you learn management by going to management courses?

Do doctors need management skills?

What does leadership mean to you and when do you exercise it?

What makes you a good leader?

Give an example of a situation where you showed leadership.

Are leaders born leaders or can you learn to become a leader?

What type of leader are you?

Are you a leader or a follower?

What makes a good team?

How do you deal with stress?

Give an example of a situation where you showed initiative.

How do you implement change in a unit?

How do you go about fighting resistance from others when you want to change something?

In what circumstances have you had to influence others and how did you achieve your objectives?

How possible is it to motivate and develop junior doctors in the current climate?

How do you motivate others?

How would your boss motivate you?

How do you go about resolving a conflict?

Tell us about a conflict which you had with a colleague?

Tell us about a time when you had to deal with a conflict within your team?

What skills have you got which make you a good consultant?

Would you be happy being an average consultant?

What skills do you feel you need to improve the most?

What are your strengths?

What is your main weakness?

How would your colleagues describe you?

How would your patients describe you?

How do you know that your colleagues trust you?

How do you respond to criticism?

RESEARCH, AUDITS, TEACHING: Tell us about your teaching experience.

How do you cope with teaching multidisciplinary groups?

Tell us about Problem-Based Learning? What are its pros and cons?

What kind of teaching do you like/dislike the most?

Tell us about your worst teaching experience as a teacher.

What have you learnt from the teaching courses you attended?

Do you think that anyone can be taught?

How would you enthuse a junior doctor who had shown an interest into your specialty to join the specialty as a career?

What do you understand by the term Quality

• How to Succeed at the Medical Interview (HOW - How To) by Chris Smith and Darryl Meeking (Paperback - May 2, 2008) • The Medical Job Interview: Secrets for Success by Colin John Mumford (Paperback - July 1, 2005) • How to Wow ‘em at Your Next Job Interview.: An article from: Family Practice News by Nathan D. Childs (Digital - July 28, 2005) – HTML • The Physician in Transition: Managing the Job Interview by Don L. Double (Paperback - Jan. 1997) • www.medicalinterviewpreparation.co.uk by Dr Nalin Wickramasuriya • Consultant Medical Interview: All you need to know by Anonymous (Paperback - Oct. 1, 2009) www. consultantmedicalinterview.com

Assurance?

What is the difference between a good teacher and an excellent teacher?

Other than by attending courses, how would you improve your teaching skills?

Tell us about some of the negative feedback that you have received following your teaching sessions.

Tell us about your research experience.

What is your understanding and experience of research governance?

What did you gain from your research?

Do you think that all trainees should do research?

What is the role and importance of research for a junior trainee?

How do you go about seeking ethical approval?

How would you go about seeking funding for your research?

How do you keep up to date?

How do you identify your weaknesses and deficiencies?

What contribution can you make to risk management?

Do you believe in a no-blame culture?

When did you last have to complete a critical incident form?

How would you encourage your team to complete critical incident forms each time it is appropriate?

DIFFICULT COLLEAGUES & ETHICAL ISSUES: One of your consultant colleagues is underperforming or his quality of care is unsatisfactory. What do you do?

One of your juniors complains to you that they are being bullied by another consultant. How do you handle the situation?

You receive a complaint from one of the nurses that a consultant has been sighted taking opiates from the drug cupboard. How do you handle this complaint?

One of your junior colleagues comes in late by over 20 minutes repeatedly. What do you do?

One of your juniors keeps contradicting you in front of patients. What do you do?

A senior consultant turns up drunk for work one morning. How do you handle the situation?

You overhear two nurses talk about the fact that one of your registrars was taking cocaine last Friday when he went clubbing. How do you address the situation?

Assuming that you report a colleague's bad performance to your clinical director. What would you expect him to do about it?

What difference do you make between lack of fitness to practice and underperformance?

CORRINE TAYLOR is the Director of International Medical Recruitment www.IMRmedical.com and leads a 25-person team in assisting Australian hospitals source doctors from all the over world to fill vacancies of all grades and specialties.

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medical legends

AugustBier

(1961-1949)

August Bier was born on November 24, 1861 in Helsen, Germany. He was the son of a surveyor, Theodor Bier (1822– 1898) who nurtured his son’s interest in scientific problems and nature.

H

e graduated from a German high school with distinction in 1881 and began his medical studies at the University of Berlin in the same year. After graduating, he became a general practitioner in a nearby village and then Bier took up a

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position for a short period as a ship‘s surgeon, which allowed him to travel to many distant places.

At the hospital in Kiel where Bier worked as a surgical assistant, operations were usually performed with ether or

medical legends chloroform anaesthesia. Local anesthetic techniques with cocaine (usually local infiltration) that had been developed

by Carl Koller had not become popular at that stage. In addition, the large cocaine doses required for long duration surgery or to cover large body parts meant this technique was not practical.

The general anesthesia of the day was also flawed, as it had a high risk of postoperative complications such as “ether pneumonia”, prolonged, intractable nausea and vomiting, poor surgical conditions, etc. All these factors inspired Bier to look for an alternative anaesthetic method.

Whether Bier had the original idea for this anaesthetic technique, or whether he had been inspired by the published literature, remains unclear. He did, however, have a close relationship to Heinrich Quincke, a physician at Kiel.

Quincke had been working on the physiology of cerebrospinal fluids as early as 1891 and had reported on spinal punctures for the successful treatment of hydrocephalus and so we can probably assume that Quincke had acquired detailed knowledge from the contemporary literature which could well have included an article published by the neurologist James Leonhard Corning from New York on the injection of cocaine into the subarachnoidal space. Due to this, there is still some contention about whether the ‘true’ father of spinal anaesthesia is indeed Bier or in fact Corning.

Bier’s breakthrough in spinal anaesthesia was made in 1898 when he performed the first planned spinal anaesthetic on a series of 6 patients for lower extremity surgery. Each of them received a spinal dose of cocaine and did well except for having nausea, vomiting and headache afterwards. After this series, Bier planned to receive a spinal anaesthetic himself, administered by his assistant, Dr. Hildebrandt. Unfortunately, although the spinal needle was placed correctly, with CSF flowing freely from it, the syringe was only then discovered to not fit the needle. As a result, Dr Bier

had a large CSF loss and subsequently gained first-hand knowledge of the unpleasant nature of a severe post-dural puncture headache. Dr Hildebrandt instead became the recipient of a spinal anaesthetic from Bier, which was successfully achieved, using cocaine as the local anaesthetic.

After the injection, Dr Hildebrandt’s legs became numb and the two celebrated their success with wine and cigars.

The profound analgesia of his legs was demonstrated with repeated kicks to Dr Hildebrandt’s shins, which was naturally unproblematic, until his legs regained their sensory responses.

It took only an additional ten years after Bier‘s experiments with spinal anaesthesia for him to invent another technique for local anaesthesia: the so called “Bier block,” or intravenous regional anaesthesia (IVRA). He introduced this technique in 1908 at a meeting of German surgeons in Berlin.

Even though the initial excitement about this procedure was high, it never reached the level of popularity that August Bier anticipated.

The reason might have been that the technique required some time to work and also, after releasing the tourniquet, pain reappeared immediately. Some patients even suffered from pain in the

area of surgery and the location of the cuff. Another problem was that if the surgery turned out to be more difficult than expected, a second dose of local anaesthetic could not be administered due to fears of local anaesthetic toxicity.

In addition, there was a risk of an adverse reaction to the local anaesthetic when the tourniquet was released and the drug was distributed throughout the whole body, possibly resulting in severe complications.

During the 1960, with the availability of safer local anaesthetics, this technique’s popularity spread throughout Europe and North America.

So it appears, much to the dismay of a few proud anaesthetists, that the probable father of Spinal Anaesthesia (and also Intravenous Regional Anaesthesia) was actually a surgeon.

DR. B. MARNE Surgical Registrar, Melbourne

It took only an additional ten years after Bier‘s experiments with spinal anaesthesia for him to invent another technique for local anaesthesia: the so called “Bier block,” or intravenous regional anaesthesia (IVRA).

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After much anticipation and fanfare, the iPad has finally been released in Australia. We managed to get hold of one and can now offer a unique perspective for its use in the medical community. For the last few weeks I’ve been using the iPad, and these are my initial impressions: Portability

P

ortability is crucial for the iPad to be effectively used in the medical field. But, to be honest, I can’t see myself carrying it around with patient charts and other essentials without a bit of a struggle or pulling off some sort of a juggling act.

The iPad is thin, measuring just 13.4mm in depth. The edges and corners are smooth and tapered, making it look even thinner. But don’t let that fool you.

This gadget sure feels like it’s heavier than its stated 0.7 kg weight. Yet, the heavy feel is actually almost welcome and reassuring. It makes the iPad feel sturdy, giving the impression that it is constructed of quality materials – almost reassuring you that in case you drop it (provided you have a good protective case) – it will not break easily. This kind of build and workmanship has become the hallmark of any Apple device.

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Quick enough for Healthcare Point of Care Use When Apple revealed the iPad’s custom designed 1GHz A4 processor, techies immediately took notice. Apple wanted a chip that has outstanding battery life and delivered high performance while running multiple applications.

They achieved this by customizing and improving the previous versions of the processors of the iPhone.

So is it quick enough? Well, during a doctor-patient interaction, we are fully aware of the importance of speed.

Good thing the iPad delivers on this aspect. I just cannot overemphasize how lightning-fast the iPad is. Applications load and run much faster than on an iPhone.

Surfing the web with this gadget is a relative breeze compared to using your average run-of-the-mill desktop

alpha or laptop. I compared the load times of different websites using a one-year old Macbook Pro versus the iPad, and the latter won hands down. Plus, websites appear exactly as designed for a computer screen. You don’t have to bother waiting for a below par mobile version of the website to appear.

This is great news to electronic health vendors, whose software is often heavy on system resources, and slows down the performance of devices. Medical app developers and EMR (electronic medical record) vendors can confidently develop robust and feature-rich applications to maximize the iPad’s covert power.

Beautiful Display Crystal-clear. Gorgeous. Breathtaking.

Just some of the words I can use to describe the 9.7 inch LED, multi touch, 1024 by 768 pixel display. Viewing radiology images on this device is going to be so much easier on the eyes.

However, the only apps that can fully take advantage of this display are the ones which are customized for the iPad. iPhone apps will run on the iPad but will be heavily pixelated until they are customized for the iPad. More on this issue later.

Keyboard Initially, I found the keyboard frustrating to use. I needed to assume an awkward position with my fingers, and there was no feedback when you press the keys. If I had to write this review after one day, this section would have been negative.

However, as I used it more often, I actually found the keyboard to be relatively functional. It grows on you, as the iPhone keyboard did. It took a little getting used to, but I got the hang of it in a short time. There are a wide variety of accessories for the iPad being offered.

Apple is selling its own keyboard dock that will connect to the iPad and act as a stand. Otherwise, the Apple Bluetooth keyboard could be a more practical option.

Handwriting recognition capability for

the iPad is going to be a key feature for healthcare point of care use. It has yet to be developed, but software updates or new apps will hopefully jump on the bandwagon soon enough.

Battery Life The battery life is certainly notable.

Apple claims it can run for about 10 hours, but other users have managed to squeeze even more hours out of it.

Based on my own experience, I have to agree that the device has a long battery life. This fact is a definite advantage over all other tablets in the market today.

If you want to use the iPad as a tool in your practice as a medical reference, or as a means to show patients pictures or videos, or jotting down notes; be assured, the battery life will not be an issue for you.

Case If you intend to use the iPad in your medical practice, I recommend the Apple iPad case. It encloses to protect the iPad’s screen, and can also be made to stand just like in the picture above.

This case allows you to talk to a patient while using the iPad keyboard and apps in a convenient way. It will allow multitasking during patient care. Once more, handwriting recognition will be an essential feature.

Conclusion Overall, I was satisfied with my experience with the iPad. It is significantly faster than I expected, and the brilliant display is a big plus factor.

So does this mean medical professionals should run and buy an iPad for clinical use? No, not quite. I am not totally convinced. Presently, the biggest issue is the lack of medical applications for the iPad offered in the App store. As, ultimately, the iPad is only as good as the App Store. Until we see some Australian developed medical apps, the iPad will always be more of a gadget than tool in the medical environment.

...the device has a long battery life. This fact is a definite advantage over all other tablets in the market today.

DR. L. CHUNG Emergency Medicine, Sydney

Apple iPad – Starting from A$629 www.apple.com/au/ipad

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travel

SRILANKA

ignites all the senses Islands have a way of captivating you and the teardrop-shaped island of Sri Lanka captivates around every corner. Sri Lanka’s heady mix of idyllic Indian Ocean beaches, crumbling Dutchcolonial architecture, stylish boutique hotels, ever-changing landscapes and an exotic blend of tastes and aromas ignites all the senses. After three decades of struggle, peace has returned to Sri Lanka and the island has emerged as one of the world’s hottest new destinations.

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G

REETED BY OUR DRIVER AT Bandaranaike International Airport, we are soon whisked away and heading down a small, secluded road which opens up to reveal an expanse of tropical gardens.

We have arrived at The Wallawwa, an antique manor house built in the 18th century which is now a boutique hotel.

Our first Sri Lankan breakfast here is a new experience. We try small bowl shaped pancakes known as hoppers and dip them into a fragrant curry, followed by buffalo curd served with treacle.

Sri Lanka’s ancient cities and crumbling temples is the first leg of our trip. Vil

Uyana is our base and it is rustic luxury at its finest – modern thatched villas, expanses of glass, polished concrete, and plunge pools. Later in the day we cycle along rural backroads passing by villages, paddy fields, ancient water reservoirs, and temples on the way to the ancient UNESCO World Heritage listed Sigiriya rock. One of the highlights of climbing the rock is viewing a collection of ancient frescoes of female forms painted directly on the rock itself. Back at Vil Uyana, an ancient Ayurvedic spa treatment of warm oil and soothing massage is calling.

The next day we are off to explore the stunning ruins of Polonnaruwa on foot.

The royal capital of the ancient Sinhalese and Chola kingdoms between the 11th and 13th centuries, it was once a thriving commercial and religious centre.

After a good dose of Sri Lankan history and culture we make our way to Kandy, set deep in Sri Lanka’s hill country. This region is stunningly lush with green landscapes and cool mountain air. We overnight at the seriously luxurious Kandy House, which was once home to a

local Kandayan Chief. Dinner tonight is a full Sri Lankan curry banquet consisting of nine dishes, with each dish carefully prepared by the executive chef to complement the other.

The Bogawantalawa Valley is the heart of Sri Lanka’s tea country and is where we will spend our next few days. Rolling hills carpeted with lush, green plantations of tea, tall eucalypts, and colourfully clad tea pluckers together paint one of Sri Lanka’s most scenic landscapes. Spread throughout the valley are four classic colonial bungalows – originally built for British tea estate managers in the days of the Raj, they have been beautifully restored. Trekking from bungalow to bungalow over the next few days, we follow the trails of the planters of old Ceylon. Our stay here is like stepping back in time – fine old world English luxury complete with butlers and traditional high tea.

It is an early start one morning so we can join pilgrims on their journey to the sacred Adam’s Peak. A trail of sparkling lights illuminates the path as we climb Sri Lanka’s holiest mountain which has

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travel

We try a variety of full-bodies, light, delicate and fragrant teas, becoming tea experts along the way.

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been a site of pilgrimage for over 1000 years. It is a change of pace another day when we join the Planter in Residence at a local tea factory to learn about and sample some of Sri Lanka’s exquisite teas. Complete with a spittoon, we try a variety of full-bodied, light, delicate and fragrant teas, becoming tea experts along the way.

Sri Lanka’s south coast and the 400-yearold Galle Fort is our next stop. A UNESCO World Heritage Site built by the Dutch, Galle Fort was the main port for Sri Lanka for more than 200 years. Amangalla, one of Sri Lanka’s most historic and opulent hotels, is our base for this part of the journey.

After a day to ourselves exploring Galle Fort’s eclectic collection of colonial buildings, surrounding ramparts, and artisan vendors, we are back on our bikes to discover Sri Lanka’s south coast.

Cycling is a great way to experience the villages, tea and spice plantations, radiant green rice paddies, coconut groves, and temples. There are beaming smiles from the locals along the way and cold towels when we arrive at Kahanda Kanda – a stylish boutique hotel located on a working tea estate. We soon find

ourselves cooling off in the pool and ordering lunch from the menu that features estate grown produce prepared by chefs trained in Thailand. Luckily, the ride after lunch is mostly downhill on the way to Wijaya Beach for a swim and sunset cocktails at the beach club bar.

We make good use of the hydrotherapy baths back at Amangalla’s spa to revive our legs on our return, and later that night celebrate our riding achievements with dinner in the elegantly restored Sun House Restaurant.

Rounding out our Sri Lankan odyssey, we leave Galle passing by a string of beach towns on route to Colombo, Sri Lanka’s capital, and lunch at the stylish Gallery Cafe.

NATHAN WEDDING is the founder of Seven Skies Luxury Adventure Travel.

He has travelled extensively around the globe seeking out the world’s best adventure destinations, sourcing luxurious and stylish places to stay, and discovering the best regional cuisine on offer. Nathan is a former university academic and professional sea kayak guide. www.sevenskies.com.au

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lifestyle

Interview with JAMESGRIERSON co-owner of Albion, Kuala Lumpur

In this edition we head over to Kuala Lumpur, Malaysia to talk food and travel with the latest restaurateur making his mark in the vibrant KL food scene.

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A

RELATIVE NEWCOMER TO Kuala Lumpur’s restaurant scene, Albion restaurant is quickly gaining a reputation as a top place to eat. Here Albion co-owner James Grierson talks about his life, and his latest venture, Albion.

What is it that you do exactly?

JAMESGRIERSON: I co-own a restaurant called Albion located in the Bukit Bintang area of Kuala Lumpur, Malaysia. I run front of house whilst Colin, my partner, runs the kitchen.

What do you enjoy most about what you do?

JAMESGRIERSON: I have a great passion for food, drink and people.

Involvement in this industry sates my appetite for all three. Every day is different. Every day is hugely gratifying.

To meet new people and experience, vicariously, their enjoyment of what we offer at Albion is what it’s all about.

When they return for more, I know we are on the right track.

What would you say are the 3 best places you’ve ever stayed?

JAMESGRIERSON: Bachelor Hall, St James, Barbados – It’s a mansion right on the beach and one memorable evening I watched the sunset with a glass of whisky in one hand and my Walkman playing Beethoven in the other. Bliss! The Mandarin Oriental Hotel(formerly the Oriental), Bangkok Thailand – An obvious choice, I know, but it is amazing with gorgeous French and riverside restaurants. I love being pampered and took full advantage of the facilities. Service is impeccable. The Park Hotel, Kenmare, Ireland – On the ring of Kerry and steeped in near-prehistorically calm countryside. This is an expertly run hotel with a terrific restaurant. It is in a stunning location and if you can’t relax here you need a shrink or a few glasses of Paddy!

What’s been your most memorable dining experience to date?

JAMESGRIERSON: Eating Marco Pierre White’s food at his first venture called Harvey’s in Wandsworth, London.

Powerful, sexy, imaginative brilliance. His signature dish was a Stuffed Pig’s Trotter.

Wow! The Guvnor. I was very touched at the kind words he said about Keith Floyd after Floyd’s death last year. I am a huge fan of Floyd.

Have you rubbed shoulders with the rich and famous, either through your work or your travels?

JAMESGRIERSON: Yes, lots. I was a professional musician for 20 years prior to coming into this industry so met a plethora of stars: Sir Paul McCartney, Sting, Sir Bob Geldof (who was my neighbour in London), Ozzy Osbourne, Annie Lennox, Nigel Kennedy, Sir Cliff Richard and Sir Elton John. Sounds like I won’t meet anyone who isn’t titled!

As a restaurant manager I served Meryl Streep, Pierce Brosnan, Sir David Frost (there I go again!), Lord and Lady Gilmour, Diana Princess of Wales, The Duchess of York, Nigella Lawson, The Spice Girls, Lord Pinter, Lord Webber, Michael Gove MP, The Monty Python team, Alan Parker and Delia Smith.

What currently ranks highest on your travel wish list?

ALBION, Modern Brititsh Dining & Bar, 31, Jalan Berangan, 50200 Kuala Lumpur www.albionkl.com

JAMESGRIERSON: I have a great yearning to visit India and Nepal. This will take up a lot of my time to do comprehensively and time is something I don’t have at the moment, as I’m running a new business with a view to expansion. But, the dream is there and once Albion has washed its face(s), Colin and I can pack our bags and head for the airport. My previous employer, Camellia Panjabi, was Marketing Director of Taj Hotels and she would love to be our guide in India!

The article is brought to you by DR. PAUL JOHNSON and a team of guest writers.

Paul has worked in the travel industry for some 25 years and has travelled extensively. http://www.aluxurytravelblog.com/

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lifestyle

No wine thanks – I’m vegetarian

Is it just me, or does Masterchef have an awful lot to answer for?

Those of us who used to put dinner on the table are now ‘Plating Up’ (and then suffering a nervous wait while the recipients discuss the relative merits of continental versus curly parsley as garnish).

F

RANKLY, FOOD IS COMING UNDER far too much scrutiny for my liking. Suddenly 8 year olds can cook, 10 year olds are going to hatted restaurants, and everyone’s a critic! And has anyone else noticed the concomitant increase in food fussiness?

We recently hosted a dinner party, and

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I am mightily relieved that I thought to ask in advance if our guests had any dietary requirements. I received the following list: No dairy; no seafood; no mushrooms; no smelly vegetables... what???

As the partner of a vegetarian, I am

lifestyle accustomed to working with some culinary boundaries, but that was one tough menu to put together.

the juice has been fermented, matured, blended, and fined, before being bottled and labelled.

Now even vegetarians are challenging the old norms. Some will tolerate seafood, some won’t; some (apparently) find white meat acceptable, and so chicken is OK. Some even confess to an occasional naughty bite of bacon. It’s a free world. I am not concerned about definitions, but guidelines are important.

The initial crush produces high quality free run juice which, which contains very low levels of phenolic substances.

(Phenolics are found in the skins and seeds, and have a bitter aftertaste) Free run juice makes for high quality wines, but in most cases, commercial reality necessitates greater extraction, and so the skins are pressed to supplement volumes. Pressed juice has much greater contact with skin, stalks and seed, and is typically higher in phenolics.

The rule of thumb in our house is to serve ‘nothing with a face’. The face rule is a fairly practical guide, although it has opened the way for some compelling discourse regarding prawns, and what constitutes an actual face.

For many years my signature dish whole baby Snapper with lemongrass, ginger and coriander – was relegated.

But happily, we have reached a point of compromise where this delicious dish may be served at dinner parties, with a strategically placed napkin draped across the fish’s face: Snapper in Hijab.

I sincerely hope that’s not offensive to anyone, but the fact is that vegan/ vegetarianism is a political and ethical minefield. Even your favourite glass of wine isn’t exempt...

I was recently approached by someone who had read about ‘vegetarian wine’.

She was amused and intrigued, and asked for some recommendations.

Unfortunately, I couldn’t confidently give her any, because although animal products are routinely used in winemaking, Australian laws do not require disclosure of this on the labels. Don’t get me wrong: our wine labelling laws are known to be among the strictest in the world, but even so, we are not required to declare the use of animal products in the winemaking process unless they are prescribed Allergenic substances.

The delicious simplicity of your favourite glass of wine belies the complex processes it has been exposed to on its way into your eager hand. Grapes have been harvested, crushed and pressed;

Fining uses protein agents to remove those ‘hard’ phenolics from the wine.

It’s not unlike the process of clarifying a consommé (which apparently any six year old can now do, thanks to Masterchef). Fining agents typically include egg white; skim milk; gelatin; and isinglass. Most people would be aware that the innocuous-seeming gelatin is in fact derived from the boiled bones, skins and tendons of animals, which makes it fairly repugnant to vegetarians (even on-the-cusp bacon nibbling ones). Isinglass is less well known, but is prepared from the dried swim bladders of fish (Beluga sturgeon, originally).

Because casein, egg white, and milk products are Allergens, they must be declared on a wine label. But gelatin - which is one of the most commonly used fining agents in white wine - and isinglass are exempt.

So I’m afraid it’s bad news for the vegetarian traditionalists.

The delicious simplicity of your favourite glass of wine belies the complex process it has been exposed to on its way into your eager hand.

Me? I like everything - especially wine.

The only ‘face rule’ that I have to apply is my own, and it has a lot to do with smiling.

GILLIAN HYDE is from The Wine Society, Australia’s oldest and largest not-for-profit wine cooperative. Established in 1946, by a wine loving surgeon who recognised that it would be simpler to source fine wines collectively with his friends. www.winesociety.com.au

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lifestyle

FERRARI’S fastest ever road car has landed in Australia, with the first example of the blistering new 458 Italia supercoupe making its local debut in Queensland last month.

First Ferrari 458 lands Down Under

T

70 ANAESTHETICLife

HE FIRST AUSTRALIANdelivery 458 was air-freighted directly from Italy for its local debut, where no fewer than 19 orders from well-heeled Queenslanders have been booked despite the 458’s stratospheric price tag of $526,950 plus on-road costs.

prospective Queensland buyers at a customer drive day at the Mt Cotton circuit recently.

The sunshine state is the fastest growing Ferrari market in Australia as well as the biggest on a per-capita basis – and now comprises 20 per cent of Ferrari sales nationally, with 35 per cent going to both New South Wales and Victoria.

Australia’s first 458 was driven by

With more than 120 orders received nationally for the 458, however, Ferrari’s newest model is sold out in Australia for more than a year.

Between 50 and 60 examples of the 458 will land in Australia this year, with the first customer cars due to arrive from late August, including six for Queensland.

Australia’s allocation for next year won’t be confirmed until December, but Ferrari says that customers who place a 458

lifestyle

only the 430, but the lightweight 430 Scuderia, which was last sold at $573,700 plus on-road costs or about $640,000 driveaway.

Without its volume-selling model for the majority of this year (the last 430 to be built for Australia arrived here in October last year), the local distributor plans to sell about 100 cars in Australia this year, plus 10 in New Zealand.

That’s about the same as the number sold in 2009, when the global financial crisis struck Australia’s new car market, but well down on the 163 Ferraris sold in Australia in 2008. order now could expect to take delivery no earlier than September 2011.

As usual, that has led to a number of offers from potential customers willing to pay a significant premium to own the latest Ferrari without waiting in line, as well as from speculative buyers hoping to cash in on the demand for Ferrari’s wild new coupe by immediately on-selling their 458 to make a quick profit.

At about $527,000, the 458 is around $66,000 more expensive than the model it replaces – the 430 coupe ($460,900).

But Ferrari points out the 458 is superior in every measure of performance to not

This year the sales split is expected to comprise up to 60 examples of the 458, 50 California convertibles and about 10 versions of the near-$700,000 599 GTB and 612 Scaglietti V12 flagships.

Dealerships expect that some 90 per cent of 458 customers will be existing Ferrari owners, with 40 per cent of them purchasing an additional Ferrari, rather than replacing their existing model.

The 458 is powered by a 419kW/540Nm 4.5-litre V8 matched exclusively with Ferrari’s ‘F1’ seven-speed sequential double-clutch gearbox, which dispenses

with the six-speed manual that was also available on its 430 predecessor.

Weighing just 1380kg, Ferrari’s newest two-seat coupe is 70kg lighter than the 430 and accelerates to 100km/h in 3.4 seconds, eclipsing the 430’s four seconds and making it both lighter and faster than the stripped-out 430 Scuderia and quicker at Ferrari’s Fiorano test track than even the discontinued Enzo flagship.

"Australian deliveries have started a little earlier than planned because the interest in this remarkable car has been so great that the car has been air-freighted to Australia," said the general manager for Ferrari in Australia and New Zealand, Kevin Wall.

"Even before it was announced we have had Australian clients expressing interest in the 458 Italia and, once its specification was announced, revealing it to be, even

by Ferrari standards, a technical tour de force, interest has climbed dramatically and shows no sign of slowing.”

MARTON PETTENDY has covered the automotive industry for 16 years and is regarded as one of Australia’s leading motoring journalists. Read more luxury car reviews at GoAuto.com.au © GoAuto.com.au 2010

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Dreaming of a Seachange?

Whether you want to explore more of what Australia has on offer or are considering a New Zealand adventure, at International Medical Recruitment we have something for everyone.

International Medical Recruitment (IMR) is Australasia’s largest medical recruitment agency, with over 9 years experience recruiting high quality medical professionals to positions throughout Australasia.

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We are flexible to assist in any stage of the recruitment process to ensure a smooth transition from beginning to end with doctors always encouraged to ask our professional advice and assistance.

Our Senior Medical Recruitment Specialist, Ms. Mariko Mitrevski, works exclusively with Anaesthetists and is able to offer information and advice on Anaesthetics positions throughout Australia and New Zealand. Mariko has over 4 years experience as a Senior Medical Recruitment Specialist for IMR’s Anaesthetics division. During this time Mariko has worked on various major recruitment contracts and has extensive experience working closely with hospitals across Australia and New Zealand.

an interest in relocating to Australia and New Zealand. We also have an extensive database of highly qualified doctors available, allowing us to closely match applicants to your selection criteria and shortlist them in accordance with your human resource requirements.

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ANAESTHETICLife

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June/July 2010 2010 JULY/AUGUST

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HOW TO MAKE YOUR MEDICAL PRACTICE

EXPLODE WITH REFERRALS The secrets of a successful practice exposed

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Another Fine Mess?

Is racial discrimination towards international doctors entrenched in Australia?

the impact on Australian Physicians

How to tell if you’re a

Narcissism Amongst Doctors

GOOD or GREAT Physician -the subtle differences

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entrenched in Australia? towards international doctors Is racial discrimination

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Another

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