PSYCHIATRYlife JANUARY/FEBRUARY 2011
health...wealth...lifestyle...
First Steps as a new psychiatrist
What to do Immediately after you get your Letters
To Gap or Not To Gap Out-of-pocket Costs and the Psychiatrist
Bullying in Medicine Is it Endemic in Australian Hospitals?
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Altruism in Medicine... Is it declining?
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Highlights
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Altruism in Medicine Is it Declining? - Part 1: The History of Altruism
Bullying in Hospitals Is it Endemic in Australian Hospitals?
To Gap or Not to Gap Out-of-pocket Costs and the Psychiatrist
First Steps as a New Psychiatrist What to do Immediately after you get your Letters
Departments 07 Features 30 Business & Finance 50 Risk Management 54 Careers 59 Medical Legends 62 Boutique 64 Travel 69 Lifestyle
contents FEATURES
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Great Minds Think Alike... Or Do They? Different Types of Intelligence and Medical Specialty Choice
Altruism in Medicine... Is it Declining? - Part 1: The History of Altruism
Bullying in Medicine Is it Endemic in Australian Hospitals?
To Gap or Not To Gap Out-of-pocket Costs and the Psychiatrist
07 14 20 24
BUSINESS & FINANCE
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QE2 vs. Austerity What are the Ongoing Implications for Your Portfolio?
30
The Perfect Psychiatry Website
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Self Managed Supers’ Clean Bill of Health What’s Holding You Back?
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First Steps as a New Psychiatrist What to do Immediately after you get your Letters
What's New in Risk Insurance A Market Update
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JANUARY/FEBRUARY 2011
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RISK MANAGEMENT
Do Specialty Colleges Owe a Duty of Care to Examination Candidates?
50
An Unusual Case of Rectal Bleeding in an Infant
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Careers
The Secret to Creating a Lifestyle in Medicine Part One
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MEDICAL LEGENDS
Elin Kraepelin
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BOUTIQUE
Valentine's Day Gift Ideas
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TRAVEL
Where in the World Can You Find the Most Extravagant Spas?
64
LIFESTYLE
Just What the Doctor Ordered… Dr Gilbert Phillips, Neurosurgeon and Wine Lover
Espresso Nation Australia’s Passion for Coffee Explained
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editor’s note
H
appy New Year and welcome to the first edition of 2011.
Looking back, 2010 was the launch year of Psychiatry Life. Our team have worked tirelessly to ensure that every edition discusses topics that push the boundaries of traditional medical journalism. Since our first edition, we have continued to improve our editorial, design and quality by taking your comments and suggestions on board. To continue this improvement, we are currently undertaking the Psychiatry Life Survey 2011 and would be grateful to all our readers who can take a few moments to fill this out. (Details on Page 12 & 13). It’s a short, simple survey which provides us with valuable information on how to improve what the magazine has to offer and is the best way to voice your concerns, share your compliments and promote your suggestions. There is also a $15,000 medical practice marketing package up for grabs for one entrant! In keeping with tradition, the Psychiatry Life team have also made a New Year’s resolution. But unlike many others which are usually broken within the first 4 days, this is one we intend to keep. We will keep on providing a publication that is relevant to your medical specialty, educates you on the nuances of medical business/finance and entertains you with information about recreational interests and luxury items. As always, we aim to be the publication that reflects issues of health, wealth and lifestyle for Psychiatrists in Australia. We are continually expanding our editorial committee and are keen to welcome other medical specialists who wish to voice their opinions to their peers. Regards,
JANUARY/FEBRUARY 2011
Selina Vasdev
Editor selina@medical-life.com.au
Ravi Agarwal
Business Editor Marketing ravi@medical-life.com.au Contributing Sources
Dr Sud Agarwal Dr. Tony Blinde Dr. Richard Cavell Dr. James Nguyen Karen Tonks The Psychiatry Life magazine is published bi-monthly by Medical Life Publishing Pty Ltd. Psychiatry Life & Medical Life Publishing are proud to be independent of any academic institution or professional association. Suggestions, content ideas or complete articles written by readers are welcome and will be reviewed by the Editorial Committee. Please direct all inquiries and submissions to: Medical Life Publishing PO Box 2471, Mount Waverley VIC 3149
Selina Vasdev Editor
The information contained in this magazine, while believed to be correct, is not guaranteed. Medical Life magazine and its directors, employees and consultants do not accept any liability for any error, omission or misrepresentation in relation to the Information. Nor does it accept any loss, damage, cost or expense incurred by any person whatsoever arising out of or referable to the Information displayed within the magazine. The Editor has the right to omit or edit contributions for style, space or legal concerns. Any view expressed in Medical Life magazines are not necessarily the view of the Medical Life Publishing. No part of this magazine can be reproduced or copied without the express prior consent of the publisher.
Phone: +61 (03) 9001 6373 Fax: +61 (03) 8677 9554 Email: mail@medical-life.com.au
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Great Minds Think Alike... OR DO they? Different types of intelligence and medical specialty choice. Within the medical profession, it is a commonly accepted belief that there are differences between doctors from different medical specialties. But how real are these differences? And could different forms of intelligence be differentially used within the different specialties?
F
or years it was generally accepted that there was just one measure of intelligence, IQ (Intelligence Quotient) - that which can be measured by standardised intelligence tests. The term was devised by the German psychologist William Stern in 1912 and was based on the notion that we all have a set level of general cognitive ability, our level of capability to understand logic, solve problems and reason. However, what happens when we have individuals who excel at one type of reasoning but perform poorly in other areas? Einstein famously failed his university entrance exams and performed poorly in high school tests. Yet he is regarded as one of the greatest thinkers of the 20th Century. Obviously the tests he was sitting didn’t measure his ‘type’ of intelligence.
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Einstein famously failed his university entrance exams and performed poorly in high school tests. Yet he is regarded as one of the greatest thinkers of the 20th Century.
In 1983 Harvard professor Howard Gardner proposed his Theory of Multiple Intelligences. This theory stated that there were at least 7 different types of intelligence, and that an individual could have high levels of any one or more of these types of intelligence, sometimes to the detriment of the others. So which of these intelligences would lead one to a choice of a certain medical specialty? And which forms of intelligence are most useful to those in say, Surgery as opposed to say Anaesthetics? The first, and perhaps most obvious observation is that a high level of visualspatial intelligence will be especially useful to those working in or wanting to work in surgery. Durkin (2010) states:
“In order to understand anatomical relationships thoroughly, a doctor must be able to think structurally, to visualise in three dimensions. Before making the initial incision, the surgeon will have a mental blueprint of that part of the patient’s body in which the operation will occur.” Doctors who have a special strength in this area may well be drawn to Surgery as a career choice, and may make very good surgeons as a result. Surgeons may also tend by be high on the bodily-kinaesthetic form of intelligence as they have to be very aware of their hand’s movements and be very precise in making these movements. Good motor control and motor-memory may well be a valuable tool to a budding surgeon. However, in contrast to specialties that demand more patient contact, those working in the surgical subspecialty may have less need for Gardner’s “Interpersonal intelligence”. This form of intelligence describes those who are especially sensitive to others’ feelings and emotions, and who are able to use this information to facilitate good relationships with others. Whilst many surgeons may well also have these abilities, these are not as important as other skills to becoming an excellent surgeon. Gardner’s idea of ‘Interpersonal intelligence’ is very closely related to the concept of Emotional Intelligence (EI),
The EIGHT types of intelligence 1
3
2
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Verbal-linguistic Intelligence This is the ability to work well with language. Those with this form of intelligence could easily learn a new language and are good at reading and writing. They will be able to write eloquently, will enjoy debates and arguments, and will usually have a large vocabulary and enjoy learning new words and their origins. Logical-mathematical Intelligence This is the ability to apply logic to systems and numbers. People who have this type of intelligence are natural problem solvers. They usually perform well on traditional IQ tests. Engineers, scientists, economists and mathematicians have this type of intelligence.
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Visual-spatial Intelligence This is the ability to perceive the world visually and re-create it without physical stimuli. This type of intelligence allows you to think in terms of visual space. People with this form of intelligence are usually very good at picturing shapes or objects as they would look from different angles in their mind’s eye, without needing to see the object in front of them. Bodily-kinaesthetic Intelligence People with this type of intelligence learn best through bodily movement. They usually excel in physical activities such as dancing and sports. A person high on this form of intelligence will have excellent motor skills and memory for motor movements.
F E AT U R E S a paradigm that is becoming ever more commonly considered in the medical world. Emotional Intelligence is the ability to monitor one’s own and others’ feelings and emotions in order to guide one’s thinking and actions. EI involves skills that are important for many medical disciplines, such as communication skills and interpersonal awareness. Borges (2009) found that medical students’ EI was typically slightly above that of the general population of college age adults, demonstrating that this form of intelligence is a quality that most doctors probably possess in some measure. It makes sense that Emotional Intelligence would be an important trait for many medical specialists to possess. Doctors with good communication and interpersonal skills are less likely to receive patient complaints and more likely to play a major role in reducing medical errors (Weng et al., 2008). Levinson et al. (1997) demonstrated an empirical link between doctors’ communication behaviours and subsequent malpractice litigation in the US. Emotional Intelligence could be extremely useful to doctors who have a substantial amount of patient contact, such as Psychiatrists, GPs and all patientfacing doctors. Stratton & Elam (2005) state that EI could enhance a Physician’s performance through building the rapport and trust necessary to establish a solid patient-doctor relationship. In a recent study, researchers found that doctors’ Emotional Intelligence were positively associated with higher patient trust as well as better patientdoctor relationships (Weng et al, 2008).
This is important as the patient-doctor relationship was also found to mediate a patient’s overall satisfaction with the physician. Stratton & Elam (2005) further put forward the argument that EI may moderate Physicians’ abilities to understand patients’ responses to treatment regimes, thus improving patient adherence. So EI or Gardner’s Interpersonal intelligence could be of great importance to doctors who work extensively and closely with patients,
Doctors with good communication and interpersonal skills are less likely to receive patient complaints and more likely to play a major role in reducing medical errors. as high levels of this form of intelligence should significantly enhance their patient relationships and may even influence clinical outcomes. So what types of intelligence would be useful to Anaesthetists? An interesting anomaly in the Emotional Intelligence literature is a study by Talarico et al. (2008) which found that Emotional Intelligence was not significantly related to performance in Anaesthetics residents. This may of course have a lot to do with the fact
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Interpersonal (or Emotional) Intelligence This is the ability to empathise with people—the skill of understanding the moods and motivations of others. People with this intelligence work best in fields where they interact with others on a daily basis. The concept of Emotional Intelligence (EI) is related to this type of intelligence and will be discussed later.
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Intrapersonal Intelligence This is the ability for self-analysis and reflection. People with this form of intelligence have good self-understanding and tend to be deep thinkers, often being introspective. They like to spend time pondering on deep issues.
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Musical Intelligence Those with this form of intelligence are good at making or composing music, or have the ability to understand and appreciate music. People with this intelligence typically have good pitch, can sing and can play several different musical instruments. Recently Gardner added an eighth intelligence:
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Naturalistic Intelligence This is the ability to appreciate nature and the outdoors. Those with this form of intelligence will have a good understanding of how environmental cycles work, a natural instinct for direction and the ability to understand their natural surroundings.
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F E AT U R E S of this intelligence, which could explain why Talarico et al (2008) found no link in their study of EI and Anaesthetists. So it is apparent that different medical subspecialties may require very different types of intelligence. Emotional or Interpersonal intelligence may be of particular importance for Physicians who have a lot of interpersonal contact with patients, whilst surgeons may benefit most from visual-spatial intelligence and anaesthetists may require high levels of logical-mathematical intelligence.
As doctors we need to exhibit high enough levels of all these types of intelligence... that performance for Anaesthetics residents may be more heavily related to clinical outcomes, as well as patient satisfaction outcomes. Therefore success as an Anaesthetist may depend on other forms of intelligence, such as logicalmathematical intelligence. This form of intelligence enables an Anaesthetist to have the skills needed to make rational judgements about the risk vs. safety of a patient, as well as making quick mathematical calculations regarding drug levels. Other valuable qualities for an Anaesthetist are the ability to remain calm under pressure and level-headedness, both skills which could be linked to a form of Emotional Intelligence, the ability to keep one’s own emotions under control. This is a form of EI not often measured in typical studies
Clearly, as doctors, we need to exhibit high enough levels of all these types of intelligence to firstly, be accepted to medical school, then to acquire and retain the expected amount of knowledge and to problem-solve throughout the course of this demanding job. But perhaps in medicine the most important qualities are commitment and a drive for hard work. A recent study by the British Medical Association showed that when it came to predicting performance and career outcomes across a range of medical careers, academic achievement measures (Year 12 exam results) predicted performance and career outcomes far better than an intelligence test measure (McManus et al, 2003). Career outcomes such as performance in undergraduate training, performance in post-registration house officer posts and time to achieve membership qualifications were all predicted by doctors’ year 12 exam results whereas intelligence did not independently predict any of these career outcomes. This demonstrates that in the world of medicine, motivation, determination, and capacity for hard work may prove more important than innate levels of any type of intelligence. Karen Tonks, Psychologist
References: Borges, N., Stratton, T., Wagner, P., & Elam, C. (2009). Emotional intelligence and medical specialty choice: findings from three empirical studies. Medical Education, 43 (6), 565-572 Durkin, J. (2010). What Attributes do doctors typically have? http://www.jocrf.org/resources/AptitudesofPhysicians.html Levinson, W., Roter, D.L., Mullooly, J.P., Dull, V.T., Frankel, R.M. (1997). Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA, 277: 553559. McManus, I. C., Smithers, E., Partridge, P., Keeling, A., Fleming, P. (2003). A levels and intelligence as predictors of medical careers in UK doctors: 20 year prospective study. BMJ 2003; 327 : 139 doi: 10.1136/ bmj.327.7407.139 (Published 17 July 2003) Stratton, T.D, Elam CL, Murphy-Spencer AE, Quinlivan SL. (2005). Emotional intelligence and clinical skills: preliminary results from a comprehensive clinical performance examination. Acad Med. 80(10 Suppl): S34-S37. Talarico, J., Metro, D., Patel, R., Carney, P., Wetmore, A. (2008). Emotional intelligence and its correlation to performance as a resident: a preliminary study. Journal of Clinical Anaesthesia, 20 (2), 84-89. Weng, H., Chen, H., Chen, H., Lu, K., Hung, S. (2008). Doctors’ emotional intelligence and the patient-doctor relationship. Medical Education, 42(7), 703-711. Pictures: Page 4 & 8, "Albert Einstein" by manfrys http://www.flickr.com/photos/manfrys/2134586133/ Page 9, "ANGER!" by Amy McTigue http://www.flickr.com/photos/amymctigue/3543454897/ Page 10, "Hard work can hurt" by normalityrelief http://www.flickr.com/photos/normalityrelief/3075723695/ Images licensed under a Creative Commons Attribution 2.0 Generic Licence http: / / creativecommons.org/ licenses/ by/ 2.0
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Altruism
in Medicine... Is it declining? Part 1: The history of altruism
‘Altruism: unselfish concern for the welfare of others.’ ‘Selfish: chiefly concerned with one’s own interest, advantage, to the exclusion of the interests of others.’1
PSYCHIATRYlife
F E AT U R E S
H
ow did ‘altruistic behaviour’ develop? Why has it endured? Is it in danger of dying out?2 Does it even matter if it does? More importantly, what does all this have to do with Medical Practice in the 21st Century?
The following is Part 1 of a short 2 part review of an enormous topic. These are probably not the sort of philosophical ruminations that most people have every day. After all, the considerations of running a busy practice and keeping everybody happy so that the work continues to come in so that the family has a roof over their head, food in their stomachs and iPads in their school bags are somewhat more pressing and preoccupying. However, ‘altruism’ is what gives the great majority of us the drive and determination to succeed in our personal lives, by fostering lasting relationships with our friends and family and as Medical Professionals, ensuring we give the best we know how to our patients. So it is worth spending a little time to review the topic.
The Origins of being nice. There are a number of theories that variously invoke genetics3 4, evolution5, social biology, different schools of belief and winning Stone Age conflicts6. A possible mechanism for the evolution of the very first altruistic gene/cell (represented by present day Volvox carteril) makes absorbing, if somewhat heavy reading7. But putting that to the side, the overall gist of all proposed theories suggests that it was only because ancestral Homo sapiens developed ‘the trait’ and helped each other with the hunting, fishing and fighting that we had any chance of survival and growth. An interesting and recent theory, carefully researched and presented, would suggest just how close we previously came to
...‘altruism’ is what gives the great majority of us the drive and determination to succeed in our personal lives...
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The trait works in many people, as evidenced by the hundreds of thousands of people who perform unsung acts of generosity and bravery on a daily basis.
extinction, before learning together, for each other.
to
work
In his book, ‘Them + Us’8 Danny Vendramini presents persuasive evidence that from about 100,000 years ago until only fairly recently, Homo sapiens were the primary food and sexual prey for Homo neanderthalensis, the ‘peak predator’ of the era. So attractive were they that around about 50,000 years ago, there were very few of our ancestors left. Then… something changed. That something could well have been the development of the ability to work and fight together in a way which gave the struggling proto-Humans the tactical advantage over their now surprised former predators. The slow, dim ones already having been eaten, left the faster clever ones to breed, thereby passing on the ability to run faster... and together. By becoming co-operative, Cro-Magnon man was born and over the next 25,000 years or so, co-operatively wiped out Homo neanderthalensis, the last of whom died about 25,000 years ago, in Gorham’s Cave, near Gibraltar.
So what? Vendramini makes the case that our violent and aggressive ‘modern human nature’ is a result of those approximately 25,000 years of predation. Our ancestors had only survived by developing a serious and deadly dislike of anything
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that was remotely ‘not like Us, but like Them’. Unfortunately, with no more Homo neanderthalensis to take on, this previously practical propensity was (likely) turned against fellow CroMagnons who, unhappily for ‘Them’, talked, walked or looked different to ‘Us’.
settlements. Shacks turned to hamlets, that grew into villages which developed into cities. The strong leader of the tribe became the strong village leader who became the king of the city and then with conquests, king of the land that became the nation.
It is only because the development and survival of constraining and socialising behaviour that such violence and aggression has not (yet) caused the extinction of Homo sapiens through uncontrolled in-fighting. Altruistic behaviour (the trait) was one aspect of this social behaviour and its persistence can be traced to the advantages that it gave to the individual, clan or tribe that exhibited it.
Surpluses allowed humans the luxury to start asking questions like ‘Why?’ ‘What?’ and ‘When?’ Such questions gave rise to Religious, Philosophical and Scientific specialists (Astronomy being amongst the first) who sought to understand but very quickly realised the potential to control. Production of excess and increasing specialisation led to the need for exchange of goods and labour and this led to barter and hence monetary systems.
For some ‘do unto others as you would be done by’ is the mother and father of all commandments. It is after all THE core value of all successful civilised societies.
The increasing size (See ‘The Dunbar Number’ later) and complexity of human settlements required increasing civil administration and ‘laws’. The inevitable friction between adjacent settlements often led to competition for resources and increasingly deadly wars.
The concept of ‘I’ll scratch your nits and you scratch mine, in a few moon’s time’, deferred gratification or saving goodwill (not in such words) would have acted to bind individuals together, make one individual more reliable as a cave companion, hunter, fighter or potential mate, thereby ensuring the trait carried on.
The direct consequences of being nice. (A very very short history of the human race...) It was the invention of agriculture about 10,000 years ago in the Fertile Crescent of Mesopotamia and the Levant that freed man from the need for and dangers of forever foraging. In turn it required that he give up wide roaming and hunting and settle down. Settling down was the stimulus for buildings as durable as caves but more readily available, for protection from danger and the elements and safe storage of excess produce for lean times. Food security led to an increasing population which in turn led to an increasing size of
None of these changes would have occurred had the Homo sapiens not developed the ability to co-operate with his immediate fellow and of course, as populations grew and coalesced, with his newer neighbours. Because of the success that came from the trait, it was carried forward. Homo sapiens survived and multiplied to become the dominant animal on the planet today.
Are only humans nice? The answer to the question is ‘No’. Homo sapiens are not the only species to display such behaviour. It is commonly seen in many colony animals such as termites and ants where a particular caste will be sacrificed to protect the colony and queen against invasion and attack.
F E AT U R E S
Moving to higher animals, there are many well recorded accounts of dolphins protecting humans from sharks or rescuing them from drowning. Elephants not only experience a prolonged period of mourning for their dead but demonstrate extraordinary concern for the safety and welfare of other species, including man. Many of the higher primates display behaviour that can only be described as altruistic. A quick Google on ‘altruism in animals’ records approximately 440,000 results. Clearly there exists a spectrum of sentience, self-awareness and the potential for intra and inter species cooperation throughout the animal kingdom, including many, but sadly not all, humans! In fact, there are really strong indications that other animals are quite capable of taking revenge for human cruelty9. The trait works in many people, as evidenced by the hundreds of thousands of people who perform unsung acts of generosity and bravery on a daily basis. For instance, there are many volunteer organisations here in Australia, who, with minimal government funding, willingly perform vitally necessary functions. The SES being a case par excellence. It is easy to dismiss such action as due to the (sub)conscious anticipation of later reward, perhaps money from a will, acknowledgement of their humanity, and
glowing praise from adoringly thankful onlookers. That does not explain the dangers that some people put themselves in. Sometimes altruistic impulses can end in tragedy, as when a person drowns trying to save an animal (which survives). This would sadly suggest that sometimes the trait overrides common sense which certainly is not a good thing because we want altruistic people to survive, not die in the act.
Being nice and Medicine. (Medicine: The ART of healing). If altruism did not exist within the animal kingdom it would have needed to be invented for our professional ancestors to achieve the remarkable successes they had. Where would the many great and brave pioneers responsible for early Medical developments have gained the inspiration and courage to do the things they did? Even if not the entire reason it must contribute significantly. We can imagine the sweating shaman prancing around the comatose chief of the tribe with great vigour, blowing smoke and shaking boney things, to cure his rapidly expanding subdural. Whatever the outcome for the hapless chief and the unhappy shaman, this was perhaps the origin of medical altruism.
• 1898 Bier experiences the first intrathecal anaesthetic and the first ‘low pressure headache’! • 1929 Forssman catheterised his own right atrium. He is sacked but shares a Nobel Prize. To this day there are many Medical Practitioners who regularly do far more than is expected of them. The large numbers of Health Professionals who work for medical benefits and charities, in underprivileged areas both at home and abroad, humanitarian aid workers etc. would suggest that, in the absence of ulterior motive, these people possess a more ‘expressive’ altruistic trait. Whatever it is and whatever the actual motives, in simple terms it can be described as doing the best one knows for others. It may be a little hard for some to understand or even describe but the world in general and the profession in particular would be very different if such drives were absent. (It is obviously of critical importance that the pathologically driven and dangerously overworked are not mistaken for ‘eager altruists’ and receive help accordingly.)
But what is it? It is a satisfaction that is shared by the patient/recipient who recognises that this is somebody who respects them as worthy
Whatever it is and whatever the actual motives, in simple terms it can be described as doing the best one knows for others. The principles were codified in Greece, about 500 BC, by Hippocrates. Since that early anxious moment there have been any number of Great Moments in Medicine, some of which were in fact ‘altruism by proxy’ and most of which would not pass a Modern Ethics Committee! Just a very few examples: • 1796 Jenner ‘vaccinates’, his son based upon the clinical observations of milkmaids...
of that extra attention and consideration and does not look for any tangible reward for what they do. The reward is the satisfaction that comes from knowing that a difference has been made and that it has been because of a personal decision to do what is known to be right. Unfortunately such activity rarely receives the attention it should which is a shame because it is attending to the seemingly simple act by doing that little bit extra; giving more of one’s time, thinking what small but critical changes and comforts
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Many people in Westernised societies are becoming more alone and self-absorbed in the midst of crowds.
can be provided or doing something in a different way. It is these activities that make Medicine an Art and not just ‘a job’.
Are some of us less altruistic? It is hard to measure precisely but the answer to this would seem to be ‘Yes’. Various surveys and studies indicate that job satisfaction is decreasing in medical personnel around the globe, overseas10 11 12 in Europe13 14 and Australasia15 16 . It appears that altruism decreases when people are dissatisfied with their own circumstances.17 This is not really hard to understand. Whilst some may distract themselves being busy, others will not be able to do so. This decline in altruism is not limited to Medical Practitioners and would seem, worryingly, to be a fairly widespread problem. Altruism requires empathy, and this seems to be on the decline18. For a species that survives through cooperation this is not a good thing.
Why? Unfortunately, it would seem that we are actually being encouraged to lose what empathic capability we had. ‘Popular’ TV shows providing prizes for portrayals of people suffering unpleasant and painful misfortune can only encourage this decline, even if they are more a symptom than the cause. Self-interest is promoted blatantly and subtly in advertisement for anything from cars to crackers. The ‘Me oh My, I want it NOW’ generation is growing at the expense of concern for others and the broader cost to society of unsustainable greed. There are many ways that the Human being can be ground down and demoralised and these are just some of the ways. This will be expanded upon later. Many people in Westernised societies
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are becoming more alone and selfabsorbed in the midst of crowds. This trend is encouraged by the technology that we have that allows a great deal of ‘socialisation’ to occur ‘on-line’ or cocooned from those around. This may be a useful survival tactic but carried to extreme, it is disastrous. Individually this can lead to people walking under cars or even buses, active ear phones in-situ. Collectively it can lead to an inability to work co-operatively for the benefit of all. Personal and social political apathy is a sign of pathology... Norwegian rats are often used as a good model for some higher, human behaviour. Studies of crowding in these animals shows very clearly that behavioural and social norms break down in ways that mirror human societies today.19
The Dunbar Number. There are simply far too many of us crammed together in too small a space for the trait to have full expression. It is quite clear from a number of studies that the optimum size for a community to really properly function with cooperation is 150 - 200 individuals20 (The Dunbar Number) and anything much above this becomes
socially ineffective. Smaller groups will form that will adopt their own standards which may conflict with those of the parent group. It is easy to see how conflict and conflicting ideas, attitudes, moral codes and action can result. Hence, the need for ‘social constraints’, laws, police and unfortunately, Lawyers. It appears the Dunbar Number is a simple way of quantifying the number of social connections and hence the co-operative capacity our cerebral cortices are ‘hard neuroned’ to handle. In the event that we cannot quickly increase it, we have a problem that will have to be solved by other means... Altruism in Medicine... Is it Declining? Part 2: 'The reasons why' - a further discussion in to the reasons behind the decline is to be continued in the next edition. Dr. Tony Blinde, Melbourne
References : 1 Collins Concise Dictionary. 2 10.3949/ccjm.75.Suppl_6.S33 Cleveland Clinic Journal of Medicine November 2008 vol. 75 Suppl 6 S33-S36. 3 Numerous but see British Psychological Society (BPS) (2010, October 14). “Selfless’ genes attract mates.” 4 University of Nottingham (2008, October 15). “‘Being Altruistic May Make You Attractive.” 5 The Independent/UK January 10 2008. “Evolutionists At War Over Altruism’s Origins.” 6 By Samuel Bowles. Science, Vol. 324 Issue 5932, May 5, 2009. “Did Warfare Among Ancestral Hunter-Gatherers ..” 7 Mol Biol Evol (August 2006) 23 (8): 1460-1464. “Evolutionary Origin of the Altrustic Gene.” 8 kardoorair Press, Danny Vendramini ‘‘Them + Us.” 9 Jason Hribal .. Fear of the Animal Planet - The Hidden History of Animal Resistance. Counterpunch. 10 Job satisfaction .. in Turkey S Bodur, Dept Public Health, Uni Konya, Turkey. OccMed Vol 52, No. 6, pp 353-355, 2002. 11 Leigh. Arch Intern Med, Vol 162, July 22, 2002, p 1580-1. 12 Human Resources for Health 2010, 8:26doi:10.1186/1478-4491-8-26. 13 Psychological morbidity.. BMJ 1998; 317 : 511. 14 J Health Polit Policy Law. 2008 Dec;33(6):1133-67. 15 Anaesth Intensive Care. 2008 Mar;36(2):214-21. 16 Anaesthesia. 2003 Apr;58(4):339-45. 17 www.businessperspectives.org/journals.../PPM_EN_2005_04_Arciniega.pdf 18 The Empathy Deficit, Keith O’Brien, Boston Globe, Oct 17 2010. 19 Calhoun, John B. Various … Google ‘calhoun rat studies’. 20 R.I.M Dunbar, “Neocortex size as a constraint on group size in primates,” Journal of Human Evolution (1992), vol. 20. Pictures: Page 16, "e la chiamano estate" by nettaphoto http://www.flickr.com/photos/nettaphoto/215109874/ Page 17, "Mercedes Bends and Altruism Rules." by Newtown grafitti http://www.flickr.com/photos/pinkcotton/3736850281/ Page 18, "200/365: Lonely in the crowd" by Janine http://www.flickr.com/photos/normalityrelief/3075723695/ Images licensed under a Creative Commons Attribution 2.0 Generic Licence http: / / creativecommons.org/ licenses/ by/ 2.0
“The tears ran down my face, hidden by my surgical mask. My consultant continued relentlessly, 'Why can't you do this? It really isn't hard. Are you stupid? Can't you see how to help me?'” PSYCHIATRYlife
Bullying in Medicine
Is it endemiC in Australian Hospitals?
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his quote is taken from an account of one Junior Doctor’s experience of bullying in a surgical training post, published in the British Medical Journal. The Junior Doctor goes on to say, “The atmosphere in the operating theatre was tense. The criticism continued, if not with words, then with sighs and angry tutting. The staff had all seen this happen many times before—hard working, pleasant trainees reduced to nonfunctioning wrecks in the space of an operation. ... I didn’t know what to do. I felt uncomfortable continuing in such distress. Either my consultant didn’t notice or she didn’t care. I wondered what would happen if I asked to leave and decided that it would probably just make things worse for me. I stayed. Three hours of hostility and criticism. At the end I ripped off my mask and gloves and turned, only to find her standing behind me. She registered my swollen eyes and tear stained face in complete silence. I have never seen such a cold, emotionless stare, and I hope never to again.”1
This case documents a phenomenon that we most likely have all seen happening around us in hospitals and practices where we work – workplace bullying. Workplace bullying is surprisingly common, and is becoming more so. In recent surveys carried out in the UK, the US, Australia, and European Union, the percentage of people who had been bullied in their workplace ranged from 8 to 20 per cent2. In medicine this figure is even higher. A recent study in an NHS trust in the UK found that one third of medical staff reported having been bullied in the previous year3. This proportion
was replicated two years later with a similar study finding that 37% of Junior Doctors in the UK reported experiencing bullying in the preceding year 4. Tim Field, founder of a national workplace bullying advice line in the UK, states that healthcare sector staff comprise about 12% of the 5000 calls his service receives yearly, ahead of social services (10%) and the voluntary sector (6-8%). According to Field, experiences such as the one described here are common. It’s not just in the UK that this worrying state of affairs is the case. In the United States, several studies report a culture of mistreatment or bullying of medical students throughout their medical school years, with this pattern often continuing well into the early training years5, 6. In Australia the situation was regarded as so serious that the Queensland Government set up a Workplace Bullying Taskforce. This Taskforce was commissioned with producing a thorough report on the extent of bullying in workplaces across Australia, and devising a strategy on addressing this problem. One Specialist Registrar in Forensic Psychiatry writing in response to the account of bullying outlined above says “My medical experience spanning four countries in the last 20 years is sufficient for me to declare that the kind of bullying described here is not unique to the United Kingdom.”7 So what causes bullying and why do some people bully? Firstly, let’s take a look at the kinds of behaviours that constitute bullying – you may well recognise some of these from observations of your colleagues or peers. Lyn Quine, in her study of bullying amongst
PSYCHIATRYlife
F E AT U R E S
Junior Doctors, asked participants to fill in a questionnaire which listed bullying behaviours and asked doctors whether they had experienced these in the preceding year. Some of the items listed included; “Persistent attempts to humiliate you in front of colleagues”, “Persistent attempts to belittle and undermine your work”, “Withholding necessary information from you”, “Shifting goalposts without telling you” and “Persistent unjustified criticism and monitoring of your work” (for the full list of bullying behaviours see Quine, 2002). Alarmingly, 84% of the Junior Doctors surveyed reported having experienced at least one of these bullying behaviours (although most would not consider themselves as having been “bullied” in the past year). A general definition of workplace bullying is “a form of physical or psychological harassment”. The Queensland Government Workplace Bullying Taskforce defined bullying as: “repeated behaviour directed at one particular individual which is offensive, intimidating, humiliating or threatening, and which is unwelcome and unsolicited”.
bullies often pick high-performing, ‘threatening’ individuals as their targets speak volumes of the bully’s motivation to intimidate and therefore eradicate the ‘threat’. In this way, bullies can be motivated by jealousy, lack of knowledge, fear or insecurity. In clarifying the common targets of bullying, Tim Field comments “The stereotype of a “victim” as a weak inadequate person who somehow deserves to be bullied is giving way to the realisation that bullies, who are driven by jealousy and envy, pick on the highest performing and most skilled staff, whose mere presence is sufficient to make the bully feel insecure. Threats (of exposure of inadequacy) must be ruthlessly controlled and subjugated. Those who can, do. Those who can’t, bully.”8 Although many have observed that medical bullies often pick high-performing individuals as their targets, there is another side to the coin in that some observers have highlighted another ‘type’ of victim. Kristin Becker, a consultant in Clinical Genetics observes “Bullies often seek out easy targets: people with a passive nature who do not have much self confidence.”8 So it may be that, just like the very nature of the bullies themselves, different types of person could become targets of bullying for very different reasons.
In Australia the situation was regarded as so serious that the Queensland Government set up a Workplace Bullying Taskforce.
So what causes some people to become bullies and not others? Within the medical sphere, bullies most often come from the higher ranks of medicine and bullying is almost always perpetrated against those in lower or training grades. However, this is not always the case and doctors may be bullied by their peers or even their juniors7. Bullying by same-level colleagues often takes the form of victimisation and undermining of one particular individual – embarrassing them in front of colleagues or juniors, undermining their decisions and generally making life more difficult for this person. Daphne Austin, a Consultant in Public Health comments “I have observed quite unacceptable behaviours which at best can be considered unprofessional and at worst abusive.”7 Sadly, many doctors within senior positions may not even realise that they are ‘bullying’ their peers or juniors. Graeme Mackenzie, a GP from the UK remarks “Unfortunately, many senior doctors are unaware that they have a problem. Only psychopaths are horrible and enjoy it. Most people are rude and horrible because they feel anxious, stressed, and put upon, and these emotions drive chronic bullying and rudeness. Elevated rank leads to years of this behaviour being unchallenged, which removes any chance of insight developing.”8 Many also argue though that bullying is the result of personality disorders – that doctors who bully do so out of a deep-seated sense of inadequacy and insecurity7. They use bullying as a way of making themselves feel more powerful. Observations that
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Whoever the victim, the targets of bullying often have little recourse to complain or address the problem, as they fear for the consequences on their career. Many medical job applications rely on good references from previous job posts and doctors fear being labelled a “trouble maker”. Dr. Agell, a Consultant Psychiatrist, points out, “The imbalance of power is the most important factor in determining inaction. ... If a bullied person was capable of ending the incident they would do so.”7 Junior Doctors being bullied often assume (perhaps correctly) that the more senior doctor perpetrating the bullying will have more powerful connections than they do, and therefore the consequences for the Junior Doctor’s career will be more farreaching than those for the “bully”. For senior doctors suffering at the hands of bullies, the situation can be even more complex. Consultants or Registrars being bullied by colleagues or juniors may feel inadequate at not being able to ‘handle’ the bullying situation themselves, despite research showing that bullies often deliberately choose individuals they see as competition. Doctors in the senior levels of their careers also suffer from the pressure of the repercussions on their career of reporting an incident of bullying.
F E AT U R E S
So what can we do to address the problem of bullying in hospitals? On an individual level, if you are being bullied it is important to keep a note of incidents, to record times and dates, and to enlist witnesses who will corroborate your experiences. Go to your Clinical Supervisor or a similar individual who you respect and get along with. Even if the bully is never formally disciplined, a paper trail will have been laid such that if similar incidents occur in the future, greater notice will be paid and the bully will be more likely to be picked up. At an organisational level, John Boulton, a professor of medical practice in Australia, suggests that further training in doctordoctor communication skills may be the way forward7. Although medical students are now routinely taught doctor-patient communication skills, if they were given situations to role-play designed to mimic common medic-medic interactions maybe they would be better equipped to deal pro-actively with dysfunctional situations in the workplace when they arise. He comments “If the traumatised young doctor whose story we heard had had the opportunity to role-model a communication strategy based on a solid theoretical understanding of dysfunctional power play, then perhaps she could have been able to look the surgeon in the eye at the end of the operation and say, “Your behaviour was unacceptable; I am seeking advice from the Human Resources department on the avenues available to lodge a formal complaint, and I intend to lobby for your removal as a supervisor”.”
Within the medical sphere, bullies most often come from the higher ranks of medicine and bullying is almost always perpetrated against those in lower or training grades.
The symptoms and signs of the presence of a bully often stare us in the face. We need to learn to pick up on these signs and provide more support for those in our workplaces who may be on the receiving end of bullying. The Queensland Government Workplace Bullying Taskforce provides guidelines on dealing with bullying. We must, as a profession, clamp down on the idea that ‘tough’ management is somehow beneficial to our doctors. If we can do this, we minimize the risk of losing potential good doctors who will, if treated right, lead our profession into the future. Karen Tonks, Psychologist
References 1. Personal Views: Bullying in medicine. BMJ 2001; 323:1314. 2. Graves, L. (2003). The Big Fight. Personnel Today, Jan 2003. http://www.personneltoday.com/ articles/2003/01/21/17061/the-big-fight.html 3. Quine, L. (1999). Workplace bullying in NHS community trust: staff questionnaire survey. BMJ 1999; 318:22832. 4. Quine, L. (2002). Workplace bullying in junior doctors: questionnaire survey. BMJ 2002;324:878–9. 5. Daugherty, S.R., Baldwin, D.C. Jr., Rowley, B.D. (1998). Learning, satisfaction, and mistreatment during medical internship. JAMA 1998;279:11949. 6. Kassebaum, D.G., Cutler, E.R. (1998). On the culture of student abuse in medical school. Acad Med 1998;73:114958. 7. Responses to ‘Personal Views: Bullying in medicine.’ BMJ 2001;323:1314 doi:10.1136/bmj.323.7324.1314 8. Bullying in medicine. Editor’s Choice – Letters Page. BMJ 2002; 324:786 doi: 10.1136/bmj.324.7340.786/a
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Out-of-pocket Costs and the Psychiatrist
N
othing seems to provoke the anger of patients and politicians more than when psychiatrists charge large out-of-pocket costs, or gaps. However, as with every controversial subject, there are two sides to the story.... There is the free-market, economic theory which dictates that all doctors are independent contractors who value their time at different rates and so can determine their prices at whatever rate they choose. If the patient’s health fund is not willing to pay that price, then the gap is borne by the patient. When explained to an accountant, banker or lawyer, this argument makes perfect sense and would typically be greeted by a nonchalant ‘of course’.
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F E AT U R E S and has been used by numerous private medical practitioners on their websites to justify their charging of AMA rates. A personal analogy that I would like to introduce is when I hired a photographer for a family event and tried to negotiate his rather lofty price. His rebuttal was that he has placed a fixed dollar value on his time. If his services were to be engaged, then the cost was to be a fixed cost based on the amount of time he devotes to the task. What I would like to pay for it is immaterial. He simply wants to meet the dollar value he has attributed to one unit of his time. This concept has been paralleled in clinical practice where doctors have costed out their time and decided what each unit of time should be worth. If a case brings in remuneration below that, then a gap is added to make up the difference and bring it up to the value assigned to one’s time. However, it isn’t always that simple… There is a substantial body of people who wholeheartedly believe that charging above the MBS scheduled
fee, or even above the full health fund rebate, is greedy opportunism. How did this dichotomous understanding of out-of-pocket costs originate? These dichotomous views have a lot to do with the potent marketing employed by private health funds. With frequent usage of euphemistic terms such as “Top-Hospital cover” [HBA], “Gold Plus cover” [GMHBA], “Blue Ribbon cover” [Medibank], patients are easily misled into believing that because they have paid larger health fund premiums, they are less likely to receive out-of-pocket costs. The patients totally fail to see that these grandiose names actually reflect the reduced co-payment they make to the health fund when they claim, rather than the rebate paid to doctors. Additionally, patients utilising these so called toplevel cover schemes firmly believe that the health fund pays the doctor a higher rebate because they have chosen a higher level of cover than the bargainbasement variety. All this contributes to the common misconception that doctors are feathering their own nest
The patients totally fail to see that these grandiose names actually reflect the co-payment they make to the health fund when they claim, rather than the rebate paid to doctors.
If we examine the failure of Medicare rebates to be indexed to the Average Weekly Earnings (AWE) index or even the Consumer Price Index (CPI) since the advent of Medicare, we find that today’s rebates from Medicare are effectively being devalued. In fact, with each additional year (and inadequate increase in MBS rebates), the real earnings of doctors are decreasing incrementally. Therefore, to neutralise the difference between the ever escalating CPI (used to represent the cost of living) and the modest increase in Medicare rebates, doctors would need to charge an ever-increasing gap fee. This was the rationale used by the AMA in their “Why is there a Gap?” campaign
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the allotted time for another appointment and repeating the initial (usually more expensive) consult provides a cheaper option, then some patients may exercise their consumer rights and seek an alternative healthcare provider.
“Consumers will be willing to buy a given service, at a given price, if the marginal utility of additional consumption choices is equal to the opportunity cost determined by the price.” at the expense of ‘helpless’ patients. With the advent of informed financial consent and the glitzy, political propaganda behind it, voters too were easily fooled into thinking that their outof-pocket costs would be diminished when they could easily walk away and ‘shop around’. This clearly does not apply to most psychiatrists as patients usually accept the one they are referred to by their GP or the one recommended by another allied health worker. Then after waiting the necessary waiting period for either a consult, they finally meet the psychiatrist to whom they have been referred. It is at this first meeting that any out-of-pockets are disclosed, usually after a history and mental state examination have been performed and a therapeutic relationship has been established. There is very little opportunity for a patient to exercise any consumer choice, particularly if their underlying psychiatric condition needs urgent attention, if they feel that they have already established a good doctorpatient relationship or they don’t want to risk offending their GP by questioning his choice of specialist. Also, the patient will realise that both the financial cost and opportunity cost of rescheduling another appointment with the GP, waiting for another appointment with a different psychiatrist and then enduring another long initial consultation will be substantial. In fact, most would agree that this would be too laborious and expensive a process and it would be far
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simpler and cheaper to continue with their current psychiatrist, albeit that his costs are astronomical. On the other hand, there is a small number of psychiatrists who choose to diligently no-gap all their patients. They are contented with the remuneration offered by Medicare and the private health funds. There is also a small minority of these perennial ‘no-gappers’ that choose to take it one step further by casting aspersions on their less-altruistic colleagues who are charging gaps. It is perhaps this group of psychiatrists who have chosen to voice their discontent with the idea of out-of-pocket costs that makes some of the remaining psychiatrists wince with a small sense of shame. After a substantial discussion with an economist, I was enlightened to hear the application of a microeconomics model to the costing of healthcare and the sensibilities of prospective, informed financial consent: “Consumers will be willing to buy a given service, at a given price, if the marginal utility of additional consumption choices is equal to the opportunity cost determined by the price.” In plain English: If the costs incurred in cancelling any further consultation by their current psychiatrist, rescheduling with a lower cost service provider, waiting
If we make the basic assumption that a patient will have taken a day off work to attend the appointment, it becomes even more unfeasible that he or she will decide to cancel for monetary reasons alone. So according to my economist friend, psychiatrists have almost free reign to charge whatever fee they decide is justifiable. It appears to be a situation in which the consumer has limited supply choice whilst the psychiatrist has uncontested demand. However, few psychiatrists would be swayed by an economic model alone. There are many other social, political and logical reasons why psychiatrists would not simply charge the highest fee they possibly could. These include: • Genuine altruistic concern for the patient, especially pensioners and lowincome earners • Apprehension about upsetting a patient who is already unwell or distressed • Concern over potential loss of work, if the patient reports back to the GP or allied health practitioner who had made the original referral • Concern over “discovery” by peers who express disdain / disapproval for large out-of-pocket costs • Fear of a complaint from the patient regarding excessive fees to the Medical Board or other official body. In closing, it is clear that the supply and demand of psychiatrist services does not follow a typical, elastic supplydemand curve and that informed financial consent may not be the panacea promised. More realistically, a complex interplay of altruism, fear, sycophantism and humanistic concern prevail when deciding how to charge patients. Dr. James Nguyen
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Part3 The
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ONE DAY BUSINESS COURSE Setup & Review COVERING •• Practice Accounting Concepts • Banking & Finance • Financial Planning • Indemnity & Risk • Marketing & IT
T
his is a one day intensive and practical course catering exclusively to medical doctors who are establishing a medical practice or who would like to improve the efficiency of their current practice. (CPD points allocated) Throughout your specialist training program you develop excellent clinical skills, however it is
recognised that there is a general lack of information provided to doctors on managing the business aspect of their medical practice. Business experts will offer advice in a program that will enable delegates to establish, maintain and promote their medical practice and effectively drive their business forward.
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QE2 vs. Austerity What are the ongoing implications for your portfolio?
You would be forgiven for thinking QE2 is an acronym for Queen Elizabeth II, however in the world of finance this term has utmost importance for global growth. In the US, Ben Bernanke and his team at the Federal Reserve unveiled on November 3rd a second round of “quantitative easing� to the tune of US $600 billion over the coming 8 months. This is equivalent to about 4% of the US economy’s annual output, which is a staggering number, but far less than the original $1.75 trillion of QE throughout early 2009 to early 2010.
QE2 is a strategy based on pushing people out of safe-havens and into riskier investments.
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Quantitative Easing Defined
T
he reality is that QE and now QE2 is a relatively new term for an age old method of stimulating the economy. With US interest rates near to 0%, the best available method to stimulate the economy is to hit the printing press; or technically the US government buying back Treasury Bonds. In its simplest form, the methodology involves the US Government buying Treasury bonds to loosen monetary policy and cause Treasury yields to fall. This will push investors away from safe-haven investments and into riskier assets with a higher expected return. Banks are likely to be beneficiaries and they will in turn loosen their stance on lending, creating liquidity in the market and reducing the cost of funding for other corporates. A lower cost of capital and greater
liquidity will drive profits, investment opportunities and greater employment; ultimately creating shareholder value and GDP growth. While great in theory, whether investors will bite is a key issue. Behavioural finance shows that investors like to be pulled into investment opportunities but resist being pushed. QE2 is a strategy based on pushing people out of safehavens and into riskier investments. Economic data from the US has produced mixed results since the initial QE in early 2009. The initial QE package did little to restore confidence as growth and employment remained subdued. However, many would argue it saved a likely “Great Depression” event. Since the announcement of QE2, economic data has been generally improving with consumer confidence up and share markets have rallied in
Europe’s two biggest economies, the United Kingdom and Germany, are now taking the “austerity” approach, which can loosely be defined as belt-tightening or cutting of public spending to reduce fiscal deficits.
anticipation of further upside. We have welcomed the positive data; however GDP growth remains relatively subdued and unemployment bucked its recovery and unexpectedly rose to 9.8% - hardly positive. Europe in the Opposite Direction Across the North Atlantic Ocean, parts of Europe are actually doing the opposite. After years of debt-fuelled growth, both publicly and privately, concerns regarding public finances are
at an all-time high. Europe’s two biggest economies, the United Kingdom and Germany, are now taking the “austerity” approach, which can loosely be defined as belt-tightening or cutting of public spending to reduce fiscal deficits. This is very different to Ireland, Greece, and other troubled European nations who are clearly in crisis management. Germany, led by Chancellor Angela Merkel, has announced their most ambitious austerity plan since World War 2. The aim is to save $80 billion by
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B U S I N E S S & F inance So what does this all mean? In the shortterm, you can expect to see an uptick in American GDP growth; however belt tightening and structural change is inevitable in the long-term, which will impact on enduring growth. The US is already on the borderline of surpassing its debt ceiling of US$14.294 trillion and forecasts suggest this will be breached in March/April 2011. Congress is likely to extend the debt limit, but any political conflict could cause significant volatility on global markets. Our Views
Even the world’s most influential economist, John Maynard Keynes, supported QE over Austerity during a large-scale downturn. 2015 but large-scale public job losses are expected including 40,000 job cuts in the armed forces and 10,000 federal ministry civil servants. The United Kingdom plans to save £81 billion by 2015 including welfare payment cuts to the tune of £7 billion and a whopping 490,000 public-sector jobs cuts. Theoretically, implementing austerity during a contractionary phase will create large-scale unemployment, put downward pressure on inflation (potentially deflation) and exacerbate the negative effects on GDP.
comfort from the fact that Governments are finally acting responsibly and paving the way for a better future, which may create confidence and therefore increase their risk appetite. Impact and Likely Effects The UK and Germany are arguably taking the higher risk stance – belt tightening may appear to improve the public finances, however, the Great Depression is a practical example of the risk associated with this strategy. The shortterm result is largely unpredictable and the longer-term impact will be dependent on the success of the austerity plans. Only time will tell.
This was the effect during the Great Depression from 1929-1933, where Governments desperately tightened belts to ensure sovereign debt defaults were kept to a minimum. It wasn’t called “austerity” at the time, but the overall result was disastrous.
The US is also taking a risky stance, however the risks appear to be longerterm in nature. Should the Fed’s QE2 efforts fail, do they continue to QE3? And if so, what if that fails? The hole in the public coffers could get deeper.
Even the world’s most influential economist, John Maynard Keynes, supported QE over Austerity during a large-scale downturn. However, supporters of austerity claim that this time is different. Mums and Dads in the United Kingdom and Germany may take
On the contrary, there is also the risk QE2 will work too well and drive inflation to dangerous levels – but this risk appears small. Regardless of the outcome, US public debt will be dangerously high, leaving the next generation to pay the bill.
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As an investor, we still see the best opportunities in the Emerging Markets in the medium term; but even emerging markets are not without risks. On face value, this is an obvious portfolio allocation with outstanding growth and comparative public balance sheet strength. To our minds, the main concern is valuation and potential bubbles like that seen in Japan during the 1980s. A key risk that is often overlooked when investing in emerging markets is the “transfer of wealth effect” caused by foreign speculative flows. If QE2 or austerity works and the developed economies turn the corner encountering a period of outstanding growth, foreign investors are likely to quickly rebalance their portfolios, causing a flow of funds out of emerging markets and back into the developed economies. This could be a catalyst for a downturn in emerging markets investments. All in all, uncertainty creates opportunity. A close eye may identify an undervalued Dow Jones, DAX or FTSE as a more attractive investment proposition than an overvalued emerging market. However, based on current circumstances, our stance is that investors should remain overweight to emerging markets for the foreseeable future. Lachlan Partners is a Private Advisory Firm focused on client needs and financial goals with offices in Melbourne, Sydney and Brisbane. Roger Wilson (Partner) and Scott Dixon (Advisor) can assist you with your portfolio needs. T: (03) 9605 9200. www.lachlanpartners.com.au
Protect your investments in 2011 2011 is shaping up to be a challenging year for investors - getting the right advice will make all the difference. Lachlan Partners is bringing together some of Australia’s foremost experts at their key seminars to be held in March 2011 across the Eastern Seaboard. Our eminent speaking panel includes Chris Caton
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B U S I N E S S & F inance
The Perfect
psychiatry
Website
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B U S I N E S S & F inance
Put yourself in the shoes of a patient. You or a member of your family have a medical issue. Before going to the GP, what do you do? More often than not, it involves going to Google for the complaint. The largest survey of patient internet use published in 2006 indicated that around 60% of patients were using the internet to access information prior to seeing their family doctor. In the case of chronic conditions and cancer diagnoses, this figure was even higher. Based on the increase in internet availability and internet usage that has occurred since 2006, the number of patients consulting Dr Google before they consult a GP may be even higher.1
A
fter confirmation of their selfdiagnosis by their GP, if the patient needs a referral to a specialist, the patient can take one of two paths:
a.) Their GP advises them to visit the specialist to whom he would normally refer patients to for that particular condition. It is likely this behaviour would be more prevalent in patients who are older, of a lower socioeconomic status and less educated. It is also much more likely if the medical condition is an acute condition and also if it is a common condition where the treatment options are very much standardised.
In my article in early 2010, I talked about the increase in the number of patients using the web to post opinions and/or grades (both good and bad) about their experiences with clinicians. Granted, that isn’t something you can totally control, but you don’t want those grades to be the first thing to show up when someone Googles the name of your practice or principals. Instead, you should create a customised website offering: • An up-to-date bio of yourself • Clinical information regarding the range of clinical conditions you see
ly about to how market your practice in a variety of ways. Internet marketing is one of the most cost effective ways to increase awareness of your practice to patients and referrers. It saves you and your staff time Firstly, your website lets you provide value-added services for your existing and new patients. By simply putting basic information about consulting times, location of your practice etc. will save your receptionist several hours a year fielding the same questions from numerous patients e.g. how to get there, parking facility, etc Enhance your practice credibility
b.) The patient accepts their GP’s primary diagnosis and discusses the condition with the GP. The patient then presents the information he has sourced from the internet and may engage in a frank discussion with the GP and suggest a referral to the specialist he discovered on the internet. Often this patient would have attempted to verify the ‘quality’ of this specialist through doctor-rating websites, discussion forums and even Google Scholar. This is undoubtedly more common in younger, more educated patients and it has probably become more common than the GP recommended option when patients choose a private obstetrician, plastic surgeon, oral/ maxillofacial surgeon or laser eye correction.
• A list of your qualifications and experience
With potential patients using the internet for everything from self-diagnosis to looking for directions to a practice, it is now essential that medical practices have their own website. Not only does it give patients a one-stop location for everything they need to know about you and your practice, but it also allows you to have more control over the user-generated content that is slowly accumulating about you on the internet.
• Is there a primary message that you wish to convey to patients or referrers?
• Office photos that will help patients know exactly what to expect when they visit • Differentiating factors separating you from other psychiatrists in your specialty group With any form of marketing it’s important to start with the end in mind. What is your intended outcome? For most doctors the primary driver is simple, they want more patients. However, it’s important to look a little deeper as to what other outcomes can be achieved.
• Do you want to highlight differentiation between your practice and the one down the road? • Do you have a particular subspecialty that you want GPs to know about?
Patients are thirsty for information and many will use the internet to find information. However, the filter that patients use to distinguish credible from the farcical is a little crude. A survey2 in the Journal of the American Board of Family Medicine suggests that patients are greatly influenced by endorsement from Government or Authoritative Bodies. E.g. University, Specialist Colleges or endorsements from other educational bodies are very powerful. However, there are certain factors which are instant credibility killers: • Promoting or selling any product on the website (e.g. supplements or equipment) • No visible ‘seal of approval’ as judged by the patient • No mention of when the content was last updated or if the appearance/ information seems out-of-date
Over the last few articles, I’ve talked brief-
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B U S I N E S S & F inance International referrals The Australian healthcare system is one of the best in the world and thousands of patients come from overseas to our shores for treatment. There is a rapidly growing market of wealthy, healthcare consumers from South East Asia in particular who seek Australia as the place where they would rather have treatment. A website is very valuable for informing foreign nationals about your medical expertise and sub-specialty.
up huge and highly tailored responses, within hours of making a campaign. One major disadvantage is the price - you are directly paying for each and every click you receive. Natural or organic search engine rankings, although they take much longer to implement, have no direct cost. The only cost is that associated with the strategies used to achieve the higher rankings in the major search engines. So how do you do it? What do the search engines look for? This is a topic which has literally thousands of books, articles and website dedicated to it. Although, Google keeps the exact algorithm which it uses to determine organic rankings a secret, the key factors it analyses are: • Keyword density of the search term
intact, so that each of the article directories is linking to your site e.g. findarticles. com, articlebase.com, etc Offline promotion is even more important, and you need to tell everybody about it. Print the website address on your business cards and your stationery – and display it in your waiting room. Remember, this website reinforces your brand... it’s a 24 hour representative for your practice. You need to have realistic expectations of what your website can do for you. The potential is directly proportional to the investment you make into it. An investment of less than $5000 will probably buy you a generic template-driven website which will suffice but will not give you the full potential of a custom built $10,000 website.
The key driver of traffic to your website in Australia is Google.
Be unique There are many doctors out there who have template driven websites which are nearly identical to their peers. This can be confusing to patients and potentially dissuade them from using your services. The key driver of traffic to your website in Australia is Google. A whole industry is dedicated around ‘search engine marketing’ where companies strategically optimise every element of their website to ensure high rankings. Most of this is just overkill for the medical professional. However, at the most basic level, there are two types of search engine marketing, the paid method, or pay-per-click, and the unpaid method, natural search engine results. The paid method, or pay-per-click (PPC), involves bidding and paying for specific search terms or keywords. Google Adwords is the dominant market force in PPC marketing. One advantage to using PPC is that you can quickly dial
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• Inbound links to your website – the quality of the links is more important than the quantity • How 'easy' the website is to 'read' by the search engine spiders
In this day of the internet savvy healthcare consumer, it is likely that your website is probably how the vast majority of patients will make their first impressions of you and so it makes sense to put some thought into it.
• The title, description and ‘meta tags’ of each web page One of the most important things to do to build a strong natural search engine ranking is to increase your link popularity. Link popularity is the number of web sites, other than your own, that link to your web site. Some of the best ways to do this include: • Listing your web site with many web directories that are related to your web site’s content e.g. healthengine.com.au • Asking other web sites to add your site to their links page (link exchanges) • Submitting articles to the various article directories with your web site link
Ravi Agarwal is the Chief of Marketing at Marketing Doctors and assists medical specialists throughout Australia to build their medical practices. www.MarketingDoctors.com.au
References 1 Susannah Fox, “Online Health Search 2006” (Pew Internet Project: October 29, 2006). (http://www.pewinternet.org/Reports/2006/ Online-Health-Search-2006.aspx) 2 KL Schwartz et al. Family Medicine Patients’ Use of the Internet for Health Information: A MetroNet Study. The Journal of the American Board of Family Medicine 19:39-45 (2006)
AUSTRALIA’S ONLY MEDICAL PRACTICE MARKETING SPECIALISTS
• Develop a highly targeted strategy to build a loyal referrer base • Create a highly visible online presence (Web Design, SEO) • Streamline the non-clinical functions of your practice to take on associates for profit • Harness Social Media to attract patient referrals • Utilise offline Marketing methods to enhance referral sources, patient leads and encourage patient loyalty
Contact us for a FREE marketing health check for your practice
(03) 9008 6348 info@MarketingDoctors.com.au Marketing Doctors operates within the AMA Code of Ethics guidelines on Advertising
www.MarketingDoctors.com.au
Self Managed Supers’ Clean Bill of Health What’s Holding You Back? In February of this year, Jeremy Cooper, chairman of the Super System Review (entitled “the Cooper Review”) addressed a conference of superannuation professionals in Melbourne at which he made the observation that “self managed superannuation funds (SMSFs) may be the way of the future as more people seek more information and control over their retirement savings”.
I
t was particularly interesting to hear this from the man charged with undertaking a comprehensive review of Australia’s superannuation system, focussing on its governance, efficiency, structure and operation.
...the Review Panel concluded that the SMSF sector was largely successful and well-functioning.
Jeremy Cooper’s view was reinforced in the final report into Australia’s Super System, submitted midyear to the government, in which the Review Panel concluded that the SMSF sector was largely successful and well-functioning. The Review Panel focussed on some issues, which, for the most part, did not directly relate to trustees and members,
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B U S I N E S S & F inance
Given their increasing popularity and Cooper’s strong endorsement, it is wise to ask the question that if the head of the Super System Review thinks a SMSF is the way of the future, what would be the factors holding one back from establishing such a fund?
regular statistics which show: • SMSF numbers have increased approximately 50% in the past 5 years (from 290,000 to 430,000) • some 90% of these SMSFs are either 1 or 2 member funds • based on the latest quarterly data, the fastest growing segment are those in the 35-44 age bracket and • the average SMSF balance is now some $900,000 (and still growing) Given their increasing popularity and Cooper’s strong endorsement, it is wise to ask the question that if the head of the Super System Review thinks a SMSF is the way of the future, what would be the factors holding one back from establishing such a fund? Why a SMSF may not be for you ? The most common reasons put forward for not pursuing this path include the following:
but instead to service providers to SMSFs and the wider regulatory framework. Some SMSF Facts for Starters As at June 30th, 2010, SMSFs already held the largest proportion of superannuation assets accounting for 31.9% of assets, according to APRA (the Australian Prudential Regulation Authority) followed by retail funds with 27.7% and next, industry funds with 18.4%. In terms of the composition of these funds, the ATO (Australian Taxation Office) which regulates SMSFs, provides
• cost (to take advantage of a SMSF, the combined members’ super needs to be of a reasonable size to defray the costs. Most service providers in this space suggest a minimum of $200,000 to begin with, which the ATO confirms on its website) • time (allocated to not only manage the fund investments but also to keep the necessary records/documentation) and • responsibility (as the ”controller” or specifically trustee of your own fund, you are responsible for the decisions and operation of the fund with the need to comply with superannuation regulation) There is no doubt the balance consideration is very important and the
easiest to assess. Many an adviser would have difficulty in justifying establishment of a SMSF for anyone with less than $200,000. As to other reasons, it is a matter of degree and goes to one’s preparedness to delegate responsibilities to other service providers. eg. investment advisers. A self managed super fund is like your own “self managed” practice. You retain responsibility for the day to day operations of your own practice but involve others in its management and administration. The same concept can apply to a SMSF. You can self manage as much of it as you want to. But this doesn’t preclude you from engaging other service providers at any time, the role of which the Cooper Review clearly acknowledged. The trick is obviously to find those people with the requisite competence and who can provide value over and above any fee they charge. Many people see this as the most daunting aspect with the term “self managed” being too strictly interpreted. This is not to make light of the responsibilities associated with it but to point out there is a lot of help at hand. And engaging experts in chosen specialities can not only provide you with the opportunity to enjoy the advantages of such a structure but also to maximise it. But why a SMSF should be considered ? As you can gather a SMSF is not for everyone. For someone to embark down this path, they should only consider this if they
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B U S I N E S S & F inance have a desire for greater control over their: • investment choice • overall investment costs; and after tax performance, remembering • tax is by far the greatest investment expense. The first point goes to the heart of Jeremy Cooper’s earlier assertion of “more people seek(ing) more information and control over their retirement savings”. For those in the medical profession, a SMSF provides a compelling reason for putting practice rooms into a SMSF (the subject of our June/July 2010 article) along with other sundry investments. Invariably though, benefits aside, the decision can boil down to the cost and performance of current arrangements versus the potential cost and possible performance that could be generated through a SMSF. In accessing the features of a SMSF, logically one would expect a premium be paid for this. Interestingly, what appears on the surface to be a premium, when analysed, can be quite the contrary. Essentially the costs for a SMSF are clear and controllable. At every stage accounting, trading and administration - you know what you are up for. As you determine the level of involvement, you have greater control over the costs incurred in operating your SMSF. Whereas the costs for say a retail fund can be difficult to calculate even for those who operate in the industry. Part of this derives from the typical fund of fund structure employed whereby the retail fund charges a fee at one level for access to the underlying investment options (can be up to 0.50%) and the individual fund managers, which it engages to manage money, charge their own fees at another level (up to 0.80% for equity options), with this reflected in their unit price. Research house, Chant West, commented in March 2008, that because the majority of investment managers failed to disclose underlying fees, it was almost impossible to compare super offerings. It conservatively estimated that quoted
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Research house, Chant West, commented in March 2008, that because the majority of investment managers failed to disclose underlying fees, it was almost impossible to compare super offerings. It conservatively estimated that quoted fees understated true costs by as much as 0.30 to 0.60%. This fees within fees was dubbed the “Russian Doll syndrome”.
fees understated true costs by as much as 0.30 to 0.60%. This fees within fees was dubbed the “Russian Doll syndrome”. And then even if you feel you have a grasp on costs, the real rub comes when looking at performance, suffice to say a 10% return in a SMSF is likely to mean more to you than a 10% return in a retail fund. This stems not only from the flexibility to manage tax in a SMSF eg. by deferring contributions tax until the end of the financial year but also from the clear entitlement a SMSF provides, with the following three examples, the first of which was raised in the recent Cooper review, demonstrating the point: • for life insurance premiums paid by a retail fund, Cooper quoted “members do not always get an appropriate allocation of the tax deduction for their share of the premium paid by the fund”; • with franking credits attaching to Australian share investments, such franking credits are typically applied by a fund against all tax liabilities of the fund such that a member may not obtain full advantage of their proportion of those franking credits; and
• where a member moves into pension phase in a fund, any accumulated deferred tax liabilities in respect of unrealised capital gains become no longer applicable, but the release of this “burden” is often reflected in all member accounts not just those who have moved into pension phase. So, as long as the investments “work” to a comparable level, costs can be regulated and tax managed to your benefit, the responsibility and the paperwork associated with a SMSF become worth the effort – and that is only if you don’t want someone else to handle this ! Why sell yourself short by not exploring the SMSF option, if you desire control ? Mr Cooper clearly thinks you should. Geoff Greetham, BEc , CFP, CPA Geoff is a co-Executive Director of Accordius, a privately-owned personal funds management business, based in Melbourne, specialising in SMSFs . Accordius can assist you in providing advice on and managing investments for SMSFs.
Nurturing Nurturing your your medical medical
wealth wealth How personal are your investments? How personal are your investments? Are your investments tailored to your needs? Are your investments tailored to your needs? Do you always know what you are invested in? Do you always know what you are invested in? Are your investments structured to allow for Are yourtax investments structured to allow for effective management? effective tax management? Are you aware of all the fees being charged against Are youinvestments? aware of all the fees being charged against all your all your investments? Is the person making investment decisions on your Is the person making on your behalf a full time fund investment manager or decisions just a behalf a fullmanager? time fund Do manager ortheir just own a relationship they do relationship manager? Do they do their ownof research or just follow the recommendations research or just follow the recommendations of others? others?
AT ACCORDIUS we know that you have worked hard to create your wealth. We work one-to-one providing them with your AT ACCORDIUS we know with that our you clients have worked hard to create Individually Accounts that areclients tailored to maximise wealth. We Managed work one-to-one with our providing themreturns. with Individually Managed Accounts that are tailored to maximise returns. We have the flexibility to either work with your own financial advisor or, required, provide high quality, unaligned advice. believeadvisor in Weif have the flexibility to either work with your ownWe financial complete investment transparency. You can see every transaction made or, if required, provide high quality, unaligned advice. We believe in on your behalf. complete investment transparency. You can see every transaction made on your behalf.
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F Rst Steps AS A NEW
PSYCHIATRIST
This full article with web links to all the documents mentioned is available at: www.Psychiatry-Life.com.au
T
here you’ve done it… Finally crossed the line…. Driven past the chequered flag. That goal that you set yourself 1215 years ago when you were 18 years old about becoming a specialist…. You’ve now achieved it. So first of all congratulations! Then the excitement slowly turns into fear as you think about the mountain of paperwork and red tape that lies before you. Well, here is the new psychiatrist’s guide to cutting through the red tape as you transition from registrar to specialist. Approval of all Training Requirements by RANZCP The first step is providing all the
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paperwork to meet all the RANZCP requirements for admission to fellowship as listed on the RANZCP website. This will involve submitting all your paperwork to prove completion of your training terms, any mandatory projects and to be upto-date with all College fees due. Once you receive formal notification from the College as either a letter or certificate, you can start initiating all the other steps. Register as a specialist with AHPRA (The new national medical board) Until recently you would have held General Registration (or some form of Limited Registration for international graduates). Now, officially AHPRA want new specialist psychiatrists to complete form ASPC-03 ‘Application for
B U S I N E S S & F inance
Summary of Steps
1 2 3 4 5 6 7 8 9 10 11
Complete all training requirements for RANZCP
Register as a specialist with AHPRA (The new national medical board) Register with Medicare Australia as a specialist Psychiatrist Obtain Medical Indemnity cover as a specialist Psychiatrist
Register with all the Private Health Funds as a Provider Decide on who is going to do your Billing for you
What to do Immediately after you get your Letters specialist registration for a medical practitioner (currently holding general registration)’ which costs nothing but importantly allows you to use the term ‘Specialist’ to describe yourself. This is a new process that has only come into effect this year due to the merger of all the state medical boards. You will need a certified copy of the RANZCP fellowship certificate to send with this application. Register with Medicare Australia (formerly the Health Insurance Commission)
This is a process that may be completely foreign to most newly qualified psychiatrists. You would have had very little contact with Medicare Australia in the past. However, in the very near
Obtain accreditation with all the Private Hospitals you want to work at Speak to an Accountant to make sure you are structured correctly to earn money in the most tax-effective way Open a Bank Account Create a Business Card
Tell people you are open for business and start networking with GP’s
future, the Medicare Provider Liaison phone number will probably be on speed dial on your phone. Registration as a specialist psychiatrist is what will give you Medicare billing rights – ‘Access to Medicare’. There are four (and potentially more) forms to fill in here: 1. Application for recognition as a Specialist or Consultant Physician Allowing you access to rebates that are marked as specialist psychiatrist only 2. Application for an Initial Provider Number for a Medical Practitioner - Which will issue you with your first provider number so you can commence accessing Medicare benefits and private health fund rebates
3. Provider Registration for EFT payments – So you can speed up all payments from Medicare and to save trees by receiving all your payments electronically rather than by cheque 4. Application for an Additional Provider Number for a Medical Practitioner - This form to be filled in for every additional location where you will work Now the official stance from Medicare Australia is that you are supposed to have a different provider number for each location you work at. So for psychiatrists that do fractional work across a variety of public and private hospitals, this could mean having 5 or more different provider numbers.
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B U S I N E S S & F inance Medical Indemnity Cover as a Specialist Psychiatrist Up until now, whilst working as a registrar, you have enjoyed the luxury of having Medical Defence Organisation (MDO) cover for little over a hundred dollars. That is about to change. Your premium as a consultant is mainly dependent on what you declare as your ‘Gross Billings’ which basically means your total private practice earnings pre-tax. If you do more public hospital work and minimal private practice, your bill could be under a $1000. With increasing private practice and ‘gross billings’, your premium will proportionally increase too.
Australia. Registering with each of them can be very time consuming so most people register with the largest ones initially and then the smaller ones only if they encounter patients who are insured by those funds. The major health funds in Australia: • Medibank Private • BUPA (formed by the merger of HBA, MBF, NRMA, SGIO, Mutual Community) • Australian Health Services Alliance (which consists of around 30 of the other health funds) • NIB • HBF
Up until now, whilst working as a registrar, you have enjoyed the luxury of having Medical Defence Organisation (MDO) cover for little over a hundred dollars. That is about to change.
There are currently five Medical Defence Organisations which offer medical indemnity cover for specialist psychiatrists in Australia. These are: • AVANT (www.avant.org.au) • MIPS (www.mips.com.au) • MDA National (www.mdanational.com. au) • MIGA (www.miga.com.au) • InVivo (www.invivo.com.au) In addition, there is a medical indemnity broker, Medselect (www.medselect. com.au), which obtains quotes from multiple organisations and then presents you with the range. There is no fee to you for their service but they do receive a commission from the insurance company. Register with all the Private Health Funds By this stage, I am assuming you now have completed all the above steps and have received written documentation back from each organisation. There are around 40 major private health funds in
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• HCF • GMHBA • Australian Regional Health Group (consisting of St Luke’s, Cessnock & District, Mildura Health and Latrobe Health) • Your State Work Cover Authority • Your State Road Accident 3rd Party Insurer (e.g. TAC in Victoria) The registration documents for all the above funds are downloadable from the web address given at the start of this article. Decide who is going to do your Invoicing and Billing The options available to you are: 1. 2. 3. 4.
Yourself A secretary A billing agent Rooms staff
If you have your access to administrative staff then this is simple. If you are a new psychiatrist starting out, and want to keep costs low, you can either buy some
billing software to do the billing yourself or outsource it to a billing agency. Realistically, each unit of your time is better spent earning income as a psychiatrist rather than chasing bills and spending hours on the phone whilst on hold to the health funds. With a billing agent, you fax all the patient details to including details of the MBS codes performed for a fixed percentage of the value of the invoice. Their rates should include debt collection, follow up and they should also provide you with good monthly accounts statements. The medical billing agencies operating Australia-wide that provide all these services are listed below. The fees for all of them are 5% of gross earnings: • Clear Billing (www.clearbilling.com. au) • MedicalBilling (www. medicalbillingservices.com.au) • MedProBilling (www.medprobilling. com.au)
B U S I N E S S & F inance
There may be an astute relative who would make a great administrator in the family. psychiatrists in solo practice are some form of trust based structure, commonly with a service entity (if they own their rooms). Psychiatrists who are associates (non-partners) in a group practice will often use a trust based structure too, the exact type depending on their revenue share arrangement. There are also some psychiatrists who use a company or even practice as sole traders in their own name. Speak to a medical accountant to determine the optimal structure for you. Apply for an Australian Business Number
Register for accreditation with all the private hospitals This can be particularly frustrating as there are so many forms to fill in and each hospital usually requires a separate form to be filled in. First decide which hospitals you want to work and would like to apply for accreditation and then print the forms out and fill them in. Make sure you allocate at least half a day to do this as it can be a very laborious process. In addition, most private hospitals will ask you for the names of two or three referees who they will contact. Whoever you choose as a referee is likely to be bombarded with lots of paperwork so you should warn them about this in advance. The full list of private hospitals and links is provided on the internet version of this document. Speak to your Medical Accountant Depending on how much you are likely to earn in private income and also your individual financial situation, the recommended structure you should use to earn this private income may vary. The most common structures used for
Market your Referrers
Name
to
Potential
This is probably the step that baffles most new psychiatrists. How to attract referrals from GPs and other referrers. There have been many detailed articles covering this topic and I have listed some of the links on the web version of this article. The usual requirements are to make sure you have a business card, a website and some form of print collateral explaining your services which you perform. This should then be made available to GP’s and other referrers within your catchment area.
Whatever trading entity you end up using, remember it needs to be registered for an Australian Business Number, a Tax File Number and possibly GST
Conclusion
Registration. This can all be done online at www.abr.gov.au or via your medical accountant.
investing it wisely is just as important.
Open a Bank Account You will need to open a bank account in the name of the business entity that is earning income. Your business bank account will possibly need BPAY and/or Merchant Facilities to accept EFT and credit cards from patients for out-of-pocket fees. (If your billing and invoicing is being done on your behalf then this step can be ignored). These facilities are both available from all the big banks so it may be worth shopping around for a good quote. BPAY costs around $500 for a once-off establishment fee and then usually approximately $1 per transaction. Merchant Services (to accept credit cards) varies on the number of transactions but expect to pay between 1.2 and 2.5% of the transaction amount in bank fees.
Best wishes on the journey that lies ahead. Income generation is only half the game,
This article was written with the intention of guiding new psychiatrists on the administrative burden they first have to navigate when they qualify. Please visit the Psychiatry Life website (www. psychiatrylife.com.au) to download this article and all the Medicare, AHPRA and Health Fund and Private Hospital documents mentioned. ďƒ¨Adam Faulkner is a Medical Wealth Strategist at Mediq Financial Services and advises Psychiatrists on structuring, investments and finance. Please visit www.mediqfinancial.com.au or call 1300 589 527
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What’s New in
Insurance A M ar k et U pdate
Managing financial risk remains a major consideration regardless of one’s income level or stage in life. This article provides an update on some innovative and customer-friendly initiatives now available across the Australian Life and Disability insurance market. Of course, “new” does not unilaterally mean “better”. Your circumstances may benefit from some, or possibly many of these new offerings. But starting with a heightened awareness of ‘what’s out there’ helps you know when you’re getting up-to-date and pro-active risk management advice.
PSYCHIATRYlife
B U S I N E S S & F inance
Loyalty programs and credit card payments
O
ne leading Australian insurer has recently announced an exclusive partnership with Qantas which provides one frequent flyer point for each dollar spent on premiums (with a maximum of $20,000 per policy per annum). Additional points can be earned simply by paying premiums by credit card. Fortunately, most insurers do not apply a surcharge for credit card payment and there are even a number of insurers who take American Express and Diners Club. Critical illness events now covered The most dynamic area of product innovation has been Critical Illness cover (also known as Trauma). This cover pays out a lump-sum amount on diagnosis of a serious medical event such as cancer, heart attack or stroke. Importantly, payout events do not require the individual to be ‘disabled’ before, during or after the event. The big news here is that the criteria of medical events have generally become easier to satisfy. The other major advancement has been the introduction of partial payments for events such as low grade melanomas, prostate cancers at T1, carcinoma in situ, partial blindness and partial deafness. Bear in mind that a lot of older Critical Illness policies do not even include now ‘standard’ events such as cardiomyopathy, kidney failure and benign brain tumours.
Work up to 10 hours per week whilst on claim for total disability Under most income protection policies, disability is defined in terms of one’s inability to perform their work duties. While this is an intuitive way to define disability, it can be restrictive for selfemployed medical specialists. The inherent problem with the standard ‘duties-based’ definition is that working even one hour per week jeopardises the payment of a benefit under ‘total disability’. If you are able to put aside a sickness or injury to consult with patients or meet with staff, suppliers or business partners, you put your benefits at risk. As an example, a psychiatrist who is physically unable to keep up his/her regular work schedule but could still perform a lighter work load, would be faced with the dilemma of either forgoing income protection benefits or forgoing income from patient care. In the last 12 months, the majority of leading insurers have added clauses to their professional income protection policies providing a second means of assessing ‘total disability’: namely, the inability to work 10 or more hours per week. Under the market-leading policies, you can return to work for up to 10 hours per week with no reduction in benefits paid, regardless of the earnings you generate during these 10 hours. Increased levels of cover now available – great news for medical specialists
Be rewarded for being healthy While insurers customarily charge more to new applicants with ‘sub-standard’ health, they have not previously offered a discount for being healthy. This has recently changed, with the introduction by one insurer of a 20% premium discount for policy holders who demonstrate a healthy lifestyle. To be eligible for the discount you must be between 30 and 50 and have been a non-smoker for more than 5 years, with a favourable family history and driving record.
High income levels and financial commitments necessitate substantial levels of cover. Insurers have historically curtailed the maximum levels of cover available to new applicants. Only recently, income protection benefits were limited to a maximum of $20,000 pm ($240,000 pa). This is simply inadequate for most high earning medical specialists (especially considering that benefits are still tax-payable). Fortunately, maximum levels have recently been increased to $40,000 pm with most insurers and even $60,000 pm with
While insurers customarily charge more to new applicants with ‘sub-standard’ health, they have not previously offered a discount for being healthy. PSYCHIATRYlife
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B U S I N E S S & F inance certain providers. As a guide, an income (after business expenses) of roughly $1,160,000 is required before cover can reach $40,000 pm. Increased maximum levels for other product types can be seen in the table. Ownership via super Determining the most appropriate owner of your policies is a technically complex question which will be discussed in future articles. As far as product innovations go, it is worth noting that many insurers now permit the ownership of Life, TPD, Trauma and Income Protection in a superannuation environment. Again, the Cover Type
Pays out in the event of:
Previous Maximum Levels Today's Maximum Levels
Life
Death
No limit (although levels must be justified financially).
TPD
Permanent disability and inability to work again
$3,000,000
$10,000,000
Critical Illness / Trauma
Medical events such as cancer, heart attack and stroke
$2,000,000
$10,000,000
Income Protection
Temporary disability
$20,000 pm
$60,000 pm
Business Expense Cover
Temporary disability whilst paying for business expenses
$20,000 pm
$60,000 pm
Needlestick Cover
Occupationally acquired HIV, Hepatitis B or C
$400,000
$1,000,000
Child Cover
Your child suffers a critical illness or death
$200,000
$500,000
suitability of this will vary greatly from person to person, depending on factors such as their current age, years till retirement and cash-flow situation and changing legislation. A policy feature so valuable that insurers no longer offer it This article has introduced you to the most newsworthy recent initiatives in Life and Disability Insurance. But not all changes are improvements. There are a number of features on older policies which have been discontinued by insurers, as they were simply too ‘good’ (meaning expensive to the insurer) to continue offering to new customers. The prime example of this is a feature on some income protection policies called a ‘Lifetime Benefit’. This feature generally means that a claim will continue to be
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paid to a claimant for the rest of their life – even after the policy would have otherwise expired (typically at age 65). An ongoing payout of $20,000 pm continued for an additional 20 years equates to roughly $5m of additional benefits. Clearly, you can see why insurers have discontinued offering this policy feature. Is what’s new right for YOU? While many of these product innovations are exciting, they must be evaluated in
context. Adjustments to your current policies may well be justified, but only after careful and impartial consideration. For time poor professionals, working with an advisory firm with expertise and integrity can provide tremendous value to ensure you and those who depend on you are optimally protected. Aaron Zelman, is a partner of specialist risk advisory firm, Priority Life. He can be contacted at aaron@prioritylife.com.au, 1300 12 24 36 or after hours at 0412 366643.
Disclaimer: This advice may not be suitable to you because it contains general advice that has not been tailored to your personal circumstances. Please seek personal financial and tax advice prior to acting on this information. Before acquiring a financial product a person should obtain a Product Disclosure Statement (PDS) relating to that product and consider the contents of the PDS before making a decision about whether to acquire the product. The material contained in this document is based on information received in good faith from sources within the market, and on our understanding of legislation and Government press releases at the date of publication, which are believed to be reliable and accurate. Opinions constitute our judgement at the time of issue and are subject to change. Neither, the Licensee or any of the National Australia group of companies, nor their employees or directors give any warranty of accuracy, nor accept any responsibility for errors or omissions in this document. David Davidson Financial Services Pty. Ltd. trading as Priority Life is an Authorised Representative(s) of Apogee Financial Planning Limited ABN 28 056 426 932, an Australian Financial Services Licensee, Registered office at 105 –153 Miller St North Sydney NSW 2060 and a member of the National Australia group of companies.
R I S K M A N A GE M EN T Dr SY obtained an MD from Sarajevo in 1964, and a radiology diploma from Zagreb in 1973. He then practised radiology for 20 years in Croatia and Yugoslavia.
H
e later emigrated to New Zealand, where he was provisionally registered to practise medicine in 1994. For several months he worked in radiology, and received some further training in radiology. From 1994 to 1999, he attempted the examinations to become a Fellow of the Royal Australian and New Zealand College of Radiologists. Unfortunately, he failed the radiology component, not once but four times in a row, but managed to pass the pathology component on his third attempt. In 1999, he sought a review of his papers. He claimed that the appointed reviewer had only spent 15 minutes with him, and that this short interaction was not enough to satisfy him as to why he had failed. He immigrated to Australia during these attempts, and in 2002, he became an Australian citizen. Since arriving in Australia, he has never been registered as a medical practitioner, and has altogether failed to find work as a doctor in this country.
Do specialty Colleges owe a duty of care to examination candidates?
The College is alleged to have breached its duty of care Dr SY initiated legal action in 1999 in the New South Wales Supreme Court. He claimed that the College had a duty of care towards him in respect of the conduct of its examinations, and a duty of care to undertake a proper review at his request. He claimed that these duties had been breached, and that he had suffered economic loss as a result. He claimed compensation from the Supreme Court. He also initiated action in the Federal Court, asking for a court order to have him registered as a Fellow of the College. Dr SY stated in court documents that the “exam has no professional or ethical merits�, that the “oral part is practically impossible, cogently revealing farcical
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The existence of a duty of care is a cornerstone of the law of negligence. If the College owed him no duty of care, then it could not be held liable for negligence.
R I S K M A N A GE M EN T
nature of the process”, and that his experience at the review “clearly exposed heavy manipulation barely different from open fraud.” The existence of a duty of care is a cornerstone of the law of negligence. If the College owed him no duty of care, then it could not be held liable for negligence. Problems with the doctor’s presentation of his case Since Dr SY had little money, he was unable to hire legal expertise and so represented himself. His problems with the English language were obvious to the judges who heard his case, and at one time he spoke to a judge through his son. His court documents were hand-written. In order to present his case he called upon a number of laws , from the Trade Practices Act to the Corporations Act, the Australian Securities and Investments Commission Act, to the Freedom of Information Act and the Privacy Act. However, the judges were unable to fully follow the legal arguments that Dr SY was trying to make. One judge found his court documents difficult to understand, and said that the way he put his case was “inherently confused”. However, the judge gave him credit for his efforts, stating “It is readily apparent that the applicant has been untiring in his endeavours to secure qualification to practice radiology earlier in New Zealand and now in Australia. He has undertaken a study of legal authorities with a view to pursuing [court action] in that regard. The extent of his persistent legal research as a legally unqualified litigant has been somewhat remarkable for a person having the handicaps of language, an absence of local secondary and tertiary qualification and of course an absence of any Australian academic qualification and experience.” Do the Specialty Colleges owe a duty of care? The judges valiantly attempted to make sense of the case regardless. One question that immediately arose was: Does a College owe a duty of care towards examination candidates? This College claimed “no” - that it has no duty of care to candidates.
However, one judge of the NSW Supreme Court thought that it was arguable that, if the College was the doorkeeper for granting persons with appropriate professional competence the right to practise in a particular medical specialty, then there might be a duty to conduct the examinations and the review of the examinations with due care. Another judge also pointed out arguments that favour the view that a duty of care should exist: • the College of Radiologists is a nationally recognised body for setting the standards and administering the exams required to allow recognition and registration as a specialist in radio-diagnosis, and • the College also effectively determines whether a candidate will be able to practise as a specialist radiologist Dr SY’s case was thrown out – but not because there was no duty of care However, owing to the doctor’s lack of legal training, the courts were not able to proceed with the case. Dr SY had four opportunities to properly put his case to the courts, and each time the judges decided that the legal documents that he had drafted were defective. In 2009, on his fourth attempt, the Supreme Court threw out his claim once and for all. The judge pointed out that by that stage, the legal proceedings had been going on for 9 years at “considerable expense”. So the College won the case, but not because it proved that it had no duty of care. The question has yet to be answered The question of whether the College of Radiology, or even any of the Specialty Colleges, owe a duty of care to examination candidates has still not been answered. If the answer is “no”, then candidates would be unable to sue for negligence. But, if the answer is “yes”, then there is a possibility that the Colleges will see litigation in future from failed candidates who are unhappy with the result. Dr Richard Cavell
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R I S K M A N A GE M EN T
An unusual case of rectal bleeding in an infant Ms HBA’s son was 6 months old when she took him to a hospital emergency department, stating that he had had three weeks of diarrhoea, with bright red bleeding. Fresh blood was seen on his nappy, but no diagnosis was made at the time and he was discharged.
H
is mother returned with him ten days later with more rectal bleeding. Again, no diagnosis was made. The infant was taken to several additional hospitals, and was eventually admitted to one of them for investigation. Chronic ulceration of the rectum He had a gastroscopy, colonoscopy, and examination under anaesthesia. The surgeon reported that his anal sphincter tone was lax, and that he had anal fissures and rectal ulcers. His rectum showed “contusion, graze, arcuate scratches” and chronic ulceration. While he was in hospital, the nurses stated that his mother handled him roughly, and that his bleeding resolved whenever she
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R I S K M A N A GE M EN T problems were due to “lactose and dairy intolerance.” Report to the Child Safety unit A staff member of the hospital, concerned that the child’s symptoms and behaviour could be caused by abuse, made a report to the Child Safety unit. Ms HBA denied harming her child, pointing out that she was helping her child and had taken him to several hospitals as she was “very anxious”. However, she did admit that she had not wanted this baby and felt that she had not bonded with him. She also confessed that she was unhappy with her marriage and felt that she received little assistance with raising her children. She was referred to a psychiatrist and eventually admitted that she was inserting her finger, covered with a nappy wipe, into the child’s anus and roughing up the mucosa to cause bleeding. Her reason was that she wanted to get attention for her own problems with her relationship and
relating to her actions. Four psychiatrists interviewed her and provided reports to the judge. The judge concluded that she was “very motivated to be diagnosed as suffering from a mental illness” because once she knew that she might be charged for harming her children, she started to believe that a diagnosis of a mental illness might change that. He also concluded that “it seems likely that what is described as hearing voices at the… time, is really only your thoughts which present as words spoken out loud in your head.” Ms HBA conceded that she deliberately and knowingly caused pain to her child. The judge further identified that she initially “not only denied the conduct but successfully covered it up and continued offending.” Another judge noted that “she deliberately inflicted cruel pain on her baby over a lengthy period,” and that “she chose to conduct herself in a manner which she knew caused pain and injury to the child.” The judges did not believe that she was psychotic.
The nurses stated that the mother seemed keen to demonstrate to them and other patients’ mothers how much she knew about her child’s syndrome
was absent from the hospital. They also noted that the baby was very resistant to having his nappy changed. When the nurses laid him flat and removed his nappy, he screamed. One nurse wrote: “[Child] was extremely resistant to examination of his anus (clenched buttocks, rigid extended legs, cried/ whimpered). He remained elevated off the bed for several minutes due to distress/ defensive posturing.” The nurses stated that the mother seemed keen to demonstrate to them and other patients’ mothers how much she knew about her child’s syndrome. The infant’s mother, Ms HBA, was 29 years old and had two other children who did not have similar symptoms. Ms HBA stated that she felt the infant’s
feeling of isolation. She had inserted her finger into her son’s anus several times a week for 14 months. On many occasions, this activity had caused fresh bleeding which she then saw as a reason to take the child to the doctor in the hope of receiving attention for her social problems. When told that she might end up in legal trouble for her actions, she stated that she was hearing voices and had done so since her teenage years. A CT of her head revealed agenesis of the corpus callosum (a condition which is more common in schizophrenics). A psychiatrist formally diagnosed her with agenesis of corpus callosum, chronic hallucinatory psychosis and Munchausen Syndrome by Proxy. He offered an alternative to the latter diagnosis of Factitious Disorder by Proxy.
Permanent damage to anal mechanism Her son is now 5 years old, and has permanent damage to his anal sphincter tone and permanent loss of sensation of rectal distension. He has daily faecal soiling and a pre-occupation with his anus. He inserts his fingers into his anus regularly and touches other people inappropriately. Ms HBA pleaded guilty to all of the criminal charges and was sentenced to a minimum of 16 months’ jail. Her husband left her and the authorities removed all three of her children. A judge described this as an “additional punishment” for her. Dr Richard Cavell
She was charged with several crimes
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The Secret to Creating A Life or career? So many doctors struggle with sacrificing one to have the other believing that a successful career in medicine doesn’t fit in with an incredible lifestyle. There is a way you can have both.
A
happy balance of life and a successful medical career is something everyone wants, but sadly very few have. Yet it is totally achievable, but not by using outof-date thinking that worked in a medical system 50 years ago. There are certain things you must address to be able to create a lifestyle that supports your choice to enter the medical profession, and it starts with your beliefs and mindset about medicine. In this two-part article (the second part will feature in the next edition) we will delve into what you need to master to achieve a career and a life. Part One will uncover the knowledge you need and Part Two will reveal how to integrate that knowledge to create the lifestyle you deserve. So what is this thing that determines whether you can create a lifestyle as a practicing doctor? Although a bit of a buzz word these days, it’s not a word that is used much in the medical world, although it does control how we look at and how we practice medicine, I’m talking about...Paradigms.
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CAREERS C A R EE R S
the list goes on. Growing up your mind is completely open and usually other people’s rules and paradigms are forced upon you, and because you strive to fit in you adopt their paradigms and these end up creating controlling beliefs that determine how you live. One common paradigm in medicine, that has been created and perpetuated by a medical system that is out of date in today’s world, is that doctors must make huge sacrifices in their personal lives to practice medicine. While you might read this and say “well that’s true” are you open to the fact that there might be another way? That doctors can have really fulfilling personal lives and also great careers, that it’s possible that a great personal life can actually complement a doctor’s career? That’s a shift in the paradigm. The bottom line is that you’ve got these things that you didn’t even know existed and you never created, but they still control your life and everything you do!
want and the lifestyle you deserve than just paradigms. Let’s now take a shift sideways to talk about two cycles; the cycle of ignorance (or the formula for losing) and the cycle of success (or the formula for winning). These cycles are in fact a shift in your paradigm, they are a new way of looking at success or failure. Both these cycles are very similar, with subtle differences. But it is these subtle differences that will transform the quality of your life. Cycle of Ignorance – Formula for Losing Let’s cover the cycle of ignorance first, or the formula for losing. This is the way most people live, which is why most people aren’t living the lives they want. The starting point for this cycle is your present results. Your present results are the result of the past; they’re not your future. But most people use their present results as the starting point for how they look at the world and how they live. The cycle maintains that
Part
lifestyle in Medicine ONE Paradigms A paradigm is an organised set of beliefs that controls how you think, feel and act in a certain situation. Paradigms act as a filter through which you interpret and process the world. Nothing in your life escapes their influence. Paradigms are incredibly powerful. But who created the paradigms that you are living with and that control your life? Did you? Or did someone else? The bad news is that generally, others have created the paradigms that you live with. Sometimes consciously, sometimes unconsciously, your paradigms have been created by parents, teachers, peers, the establishment, society...and
Time to panic? Not exactly! The good news is that once you are aware of your paradigms and know how to use some simple yet powerful tools, you can create your own paradigms that work to serve you. There is no point or value in suggesting to you what paradigms you should adopt, that’s for you to decide. What is healthy is to question your paradigms and to ask if they really work for you, because if they are limiting you in some way then maybe it’s time to look for a better alternative. By changing your paradigms you can change the quality of your life forever. So we’ve established that paradigms are controlling how you think, feel and act. But there’s more to success or failure in creating the medical career that you
their present results determine their thoughts, which determine how they feel, which determine their actions, which in turn cause more results. So if people are starting with poor results, this will dictate poor thoughts, which will result in poor feelings, causing them to take poor actions, which will inevitably lead to even more poor results. It’s a vicious cycle, and it doesn’t get any better. For example, a doctor might be continually working 70 hours a week. As a result they may start to think negatively about their colleagues and their patients, which makes them feel overwhelmed and depressed, which causes them to be critical and angry with all the people around them, even those at home, which feeds back in to this downwards spiral.
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C A CAREERS R EE R S Cycle of Success – Formula for Winning Even if most people fall into this negative trap, thankfully there is a way out of it. That is the cycle of success, or the formula for winning. For this cycle, we don’t start with our current results; we shift it around and start with quality thoughts, with quality ideas, with defined goals. We let our quality thoughts determine how we feel, which then determines quality actions, which ultimately brings quality results. Then we’re in a position to look at those results and to produce more quality thoughts or goals. This is the cycle of success; it’s a cycle that grows upon itself causing an ever increasing quality of life. A doctor who is living with the cycle of
you can achieve. The point of a goal is to stretch yourself and it’s not just about achieving the goal but about the person you become while striving for that goal. These goals are inherently boring, such as having the goal of just making it through each week until your next holiday. People get fed up of these goals so quickly, we need to move on to level two goals. Level two goals are goals that you ‘think’ you can achieve. They’re not emotionally charged but they do stretch you that little bit more, such as having the goal of cutting down from 70 to 60 hours a week. The problem here, like with any goal that you move towards, is that you move away from something else. For example, this might be your colleagues who say that you should be doing more. Your colleagues
Doctors can have really fulfilling personal lives and also great careers, that it’s possible that a great personal life can actually complement a doctor’s career.
success might start with the thought “I’ve seen other doctors having a great lifestyle and career, I think I can do that too!” This causes them to feel hopeful and excited, which causes them to take action to change their present conditions, like locuming or changing their work conditions to work four days a week, which causes them to have the time off they desire and to create the lifestyle they want for themselves and their family. We’ve determined that paradigms are affecting our lives and that there are two cycles through which you can live; one which starts with current results and is the formula for losing, and the other, which starts with thoughts and goals and is the formula for winning. So let’s take another shift sideways and look at how we can set quality goals and thus have quality thoughts to feed the cycle of success. Quality Goals There are three levels of goals. Level one goals are goals that you ‘know’
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usually want you to succeed, but they don’t want to feel inferior to you, so they pull you back in line to keep you where you are. You get sick of trying to balance this, so you go back to level one goals that you know will be simple and that you can achieve. But again as soon as you get bored here you have to step up to level two goals, and the cycle continues. However, there’s another level. Level three goals! With level three goals you have to ask yourself the very important question ‘what would excite me?’ This is the realm of fantasy; this is where it gets stimulating, and fun. A great level three goal for a doctor might be “I want to work 40 hours a week, to have eight weeks holiday each year with my family and to still make over $400,000 per year.” To transform a fantasy into a goal you must ask yourself two questions: ‘Can I achieve this?’ (For which the answer is almost always yes because in this universe the realms of possibility are limitless) and ‘will I achieve this?’ This second question is the important one.
Will I do whatever it takes to make this my reality? This is important because if the answer is ‘no’ then you don’t deserve it. But if the answer is ‘yes’ then that fantasy becomes a goal that has real meaning and you’re well on your way. So to succeed you need to determine your own paradigms by combining level three goals that excite you, with the cycle of success, and let those exciting goals determine how you feel, which determines how you act, which determines the results you get. This is the formula for a fulfilling life, a fun life. In the next magazine we’ll discuss how you can specifically integrate this information into your medical career to create the lifestyle you deserve. Dr Sam Hazledine is the Director of Medrecruit - www.medrecruit.com
When It Comes To Working As A Specialist Psychiatrist, Your Needs Are Different From Junior Doctors At MedRecruit we understand that finding the right positions in a locum capacity and in a permanent capacity as a specialist have its own specific needs and requirements. Your needs are as unique as your speciality and your career and you don’t want to be lumped in with the junior doctors who have very different needs and requirements. As you decide to work with MedRecruit you will be matched with your own personal Solutions Specialist who specialises in working with psychiatrists to get you the perfect placement, a placement that meets all your unique needs. Your personal Solutions Specialist is trained to negotiate the very best deal possible for you so you can be secure and comfortable in the knowledge that you’re getting the best package, personalised for you. When you register with MedRecruit you will also receive valuable and
much sort after resources related to locuming to ensure you maximise the benefits to you. You will also receive membership only access to our specialist partners, such as Deloitte, who are industry leaders at working with doctors to ensure they get the most out of their careers. With offices in both Australia and New Zealand, and relationships with more hospitals across Australasia than any other agency in our field, you will gain access to the largest database of vacancies which will ensure you get the best solution tailored specifically to you; we have far too many vacancies in your speciality to list on this page! Due to our long standing and strong relationships with many hospitals you will have choices of positions that are not advertised anywhere else. When you register with MedRecruit you will immediately receive:
Passport to Lifestyle & Career
Webinar
eBook
•
This online webinar is potentially worth many thousands of dollars to you and you will receive access to it at no charge.
This eBook was created using 3 years of validated research and testing. It reveals: • The secrets to setting meaningful goals • The keys to achieving those goals • The 7 habits that highly successful doctors utilise to create their desired lifestyle in medicine, whatever that is for them
This is a much sought after eBook for doctors that you will get as soon as you register with MedRecruit. In this eBook you will find:
• • •
Video interviews with NZ Prime Minister John Key and top sportspeople about peak performance The 7 myths of locuming revealed Rewards for you! Videos of sucessful, real locum doctors sharing their feelings and experience using the renowned MedRecruit system
The 7 Secrets to Explode Your Income as a Locum
It reveals: • The 7 things that any senior doctor can apply immediately to maximise their income • The key ways to become tax efficient to keep even more of that increased income in your pocket!
What should you do now?
Creating a Lifestyle in Medicine – The 7 Habits of Highly Successful Doctors
Either register at www.medrecruit.com or call 1800 MEDRECRUIT (633 732) and you will receive these three resources absolutely free and we will schedule a call for you with the exact Solutions Specialist who can best serve you.
If you need to recruit a doctor for your practice then please register in the same way and we will find you the right doctor to meet your needs.
Welcome to a whole new way of locuming where you are the priority and you have your own personal specialist team to assist you to get you the best outcome.
contributing
WANTED riters
Feel you have something you would like to share with all other Psychiatrists?
We are currently looking for articles and submissions for PSycHiATRYlife . Please email: editor@medical-life.com.au
M EDIC A L LEGEND S
EmilKraepelin
(1856-1926)
One of the Most influential Psychiatrists of his Time
German Psychiatrist, born February 15, 1856, Neustrelitz, Mecklenburg; died October 7, 1926, Munich. His classification system for mental illness influenced subsequent classifications, and his distinctions between schizophrenia and manic-depressive psychosis remain valid today. PSYCHIATRYlife
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Emil Kraepelin The concepts embodied in Kraepelin’s classification system did not originate with him, but he was the first to synthesize them into a workable model that could be used to diagnose and treat mental patients.
K
raepelin studied medicine in Würzburg and Leipzig, where he made the personal acquaintance of Wilhelm Max Wundt (18321920). Whilst still a student he decided to become a Psychiatrist - Irrenarzt – and was awarded a prize for a work on Psychiatry from the University of Würzburg, where he was called upon as assistant to Franz von Rinecker (1811-1883) at the age of 21 years. After passing the Examina at the University of Würzburg in 1878 he succeeded Aguste-Henri Forel (18481931) as assistant to Johann Bernhard Aloys von Gudden (1824-1886) in the Oberbayerische Kreisirrenanstalt in Munich, and worked there for four years. Here he used Wundt’s experimental techniques to study the effects of drugs, alcohol, and fatigue on psychological function, and in 1881 published a study of the influence of infectious diseases on the onset of mental illness.
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In 1882 he moved to the newly opened clinic in Leipzig, headed by Paul Emil Flechsig (1847-1929). At the same time he began experimental work in Wundt’s laboratory. This angered Flechsig to such a degree that he was thrown out of Flechsig’s clinic. He was admitted to the Policlinic headed by Wilhelm Erb (18401921), however, and thus was able to be habilitated as a Dozent, receiving the venia legendi, in 1883. In 1883 Kraepelin wrote his Compendium der Psychiatrie in order to improve his financial condition. In this work he first presented his nosology, or classification of disorders. Kraepelin divided mental illnesses into exogenous disorders, which he felt were caused by external conditions and were treatable, and endogenous disorders, which had such biological causes as organic brain damage, metabolic dysfunctions, or hereditary factors, and were thus regarded as incurable. As
Wundt
advised
him
against
committing himself fully to psychology, he returned to Gudden, who gave him a position as an assistant in the München Kreisirrenanstalt. In order to be able to marry his seven years older fiancée, Ina Schwabe, with whom he had been engaged since he was fifteen, Kraepelin accepted a position as Physician-in-chief at the Irrenanstalt Leubus. This institution is housed in a celebrated ancient Cistercian abbey, situated on the Oder, northwest of Breslau, in the Prussian Province of Silesia. It is still used as a mental asylum. The couple had four daughters. After marrying, in 1885 Kraepelin changed this for a position with the Heilund Pflegeanstalt in Dresden, and the following year was appointed professor of Psychiatry at the University of Dorpat, now Tartu, Estonia, succeeding Hermann Emminghaus (1845-1904). In 1891 he came to the Grossherzoglich Badische Universitäts-Irrenklinik in Heidelberg, succeeding Carl Fürstner (1848-1906), who went as ordinarius to Strassburg. In Heidelberg he established a physiological laboratory in order to attract students to scientific work, and from July 6 was supported in this work by the new assistant physician, Gustav Aschaffenburg (1866-). He collaborated with Franz Nissl (1860-1919) and from 1902 with Alois
M EDIC A L LEGEND S
Kraepelin divided mental illnesses into exogenous disorders, which he felt were caused by external conditions and were treatable, and endogenous disorders, which had such biological causes as organic brain damage, metabolic dysfunctions, or hereditary factors, and were thus regarded as incurable. Alzheimer (1864-1915). Alzheimer moved with him when Kraepelin in 1904 became professor of clinical Psychiatry and head of the Psychiatric clinic at the Ludwig-MaximiliansUniversität München, succeeding Anton Bumm (1849-1903). Kraepelin remained in Munich until his retirement in 1922, when he became director of the Deutsche Forschungsanstalt für Psychiatrie, which he had founded in Munich in 1917. He made Munich a world centre of Psychiatric research. Kraepelin went travelling as far as India, Java, the United States of America and Mexico, in order to work in comparative psychiatry. He was planning a sustained journey to Ceylon and India with his pupil Johannes Lange (1891-1938) when he died in 1926. In a letter to his brother Karl, dated January 27, 1905, he wrote: “At the present time I have only one main goal in sight, to make so much money that I will have no problem travelling wherever I want.” Initially Krapelin was reluctant to undertake histological studies in psychoses, but the studies of Oskar Vogt (1870-1959) and Korbinian Brodmann (1868-1918) on cortical structure and function convinced him to commence in 1905. In 1911 he attached the eponym Alzheimer’s disease to presenile dementia. Among his outstanding students were Alfons Maria Jakob (1884-1931), Hugo Spatz (1888-1969)
and Robert Bérány (1876-1936). All through his career Kraepelin continued to refine his classification. In the sixth edition (1899) he first made the distinction between manic-depressive psychosis and dementia praecox, now called schizophrenia. Dementia praecox was Kraepelin’s Latin translation (1896) of the Belgian Psychiatrist Francois Morel’s earlier term (1857) demence precoce, “early deterioration of the mind.” He believed that manic-depressive disorders and melancholia (depression) were exogenous and thus treatable, while dementia praecox fell among the endogenous, incurable illnesses, as he believed it to be caused by organic changes in the brain.
the Psychiatric effects of alcohol. He published 19 works on the topic. In the Psychiatric clinic in Munich alcohol was banned. Instead the patients were offered lemonade, the so-called Kraepelinsekt. He advocated the establishment of curative institutions for alcoholics, which was not supported by Innenministerium.
Kraepelin also distinguished at least three clinical varieties of dementia praecox: catatonia, in which motor activities are disrupted either excessively active or inhibited; hebephrenia, characterized by inappropriate emotional reactions and behaviour; and paranoia, characterized by delusions of grandeur and persecution.
Kraepelin had a ten year older brother, Karl (born 1847) with whom he was very close. Karl became a renowned professor of botany.
The concepts embodied in Kraepelin’s classification system did not originate with him, but he was the first to synthesize them into a workable model that could be used to diagnose and treat mental patients. Throughout his career he continued to refine his classification, and was working on the ninth edition of his Psychiatrie: Ein Lehrbuch fur Studierende und Ärtze, now grown into several volumes, when he died.
The principles of the Kraepelin system are still important to the classification of mental illnesses. After a period with dwindling interest in psychiatric diagnostics, particularly in the U.S., the systematics again has come into focus through a new American system of diagnosis, DSM-III. This has been called a form of neo-Kraepelianism.
Outside Psychiatry Kraepelin’s interests were in the creative arts, such as music, theatre, and painting. He was never a very social person and in his later years had even less time to devote to these interests. In his leisure time he wrote romantic poetry, many of them describing experiences during overseas travel. Ole Daniel Enersen, editor and publisher of whonamedit.com
Kraepelin was a fierce campaigner against smoking and alcohol and investigated
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B O U T I Q UE
J
VALENTINE'S DAY GIFT IDEAS
ust as you’re beginning to recover from an angst-filled season of holiday shopping, Cupid reminds you that it’s time to bring out the credit card yet again. This Valentine’s Day, don’t get bogged down worrying about finding the perfect gift for your other half. Here are some suggestions for that special someone.
Him
Leatherman Super Tool 300
If he is one for tackling the great outdoors, then he will need to have his Leatherman on standby. The Super Tool 300 is the tough little workhorse you want on your side when it comes down to the line. It’s made from really tough stainless steel, and it’s packed with fantastic tools that will come in handy no matter what task is at hand. Just think of it as the superhero of Multi-Tools! RRP $169
HER iPod nano
If your sweetheart is tech-savvy and cause conscious, go for Apple’s (RED) iPod nano. This nano is the triple treat - its festive Valentine’s colours, looks techno-chic and a portion of the proceeds go to help fight AIDS in Africa. If you want to make it really personal, you can have your Valentine’s name engraved on the back. Trust me, you can never go wrong with an iPod. RRP from $199
BOTH Espresso Machine
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T R A V EL
Where in the world can you find the most extravagant spas? ‘YTL Hotels’ in Malaysia was the first hotel group to take the concept of the ‘stand-alone spa’ to its ultimate incarnation and create whole ‘villages’ of pampering. Hilary Doling throws herself on the massage table to road-test three of the world’s most indulgent spas. Tanjong Jara Resort, Kuala Terengganu
W
rapped in a sarong, followed by a procession of women carrying brass trays heaped with flowers and men with water pots I walk in the footsteps of ancient Malaysian royalty. A drum bangs rhythmically at every step and the early morning sun makes the sea sparkle. I confess when I received my invite to participate in the Mandi Bunga bathing
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ritual the night before I had been less than thrilled. It is an invitation given to selected guests (often honeymooners) at Tanjong Jara Resort where each morning a procession marks the official opening of the spa for the day. Sitting at Nelayan beach restaurant, several chardonnays into dinner when the note is delivered, my companion and I giggle ungratefully at the thought of being singled out. We are both female and patently not lovestruck
honeymooners, having left husbands and children behind for a spot of ‘R’ n ‘Spa’, and we consider ourselves unsuitable and quite possibly (given our giggles) unworthy too. But this morning after a spot of embarrassment at breakfast, when we were hijacked over our Bircher muesli and publically robed up, the beauty of this traditional royal cleansing ritual
and its ancient significance begins to seep into our ungrateful souls. And that is the essence of Tanjong Jara Resort. Here, away from the KL crowds, amid the curling jungle of peninsular Malaysia in the isolated far north-east, what you get is an unadulterated taste of Malay culture. When our procession reaches the Spa Village (yes this resort has a whole spa ‘village’ not just a room or two) I am
The resort buildings too take inspiration from the local culture, all modelled on royal palaces from the days of the old Malacca Sultanate, with dark wood interiors and curtain-draped day beds.
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taken to one of the private pavilions with outdoor bathing benches on which I sit as a therapist gently pours flowered water over me, and quietly wishes me health, happiness…all the good things in life. The blossoms stick to my sarong, water droplets hang on my eye lashes and I feel, well, like a queen. Now I have a confession to make, this isn’t the first time I have been pampered in a spa. In the course of my lucky life I have been face down on a massage table more often than Bill Gates has made another billion. And I can honestly say that the special Asam Roselle massage at Tanjong Jara was one of the best spa treatments I have ever had. In part because of the beauty of the surrounds and but mainly because of the gentle expertise of my therapist. The Malay treatments at Tanjong Jara have been handed down from generation to generation (all be it with a large dose of creative adaptation for five-star spa use). The ingredients used come from indigenous herbs and plants, not a large cosmetics company, which is why you’ll find leaves in your bath and crushed husks in your skin scrub.
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The resort buildings too take inspiration from the local culture, all modelled on royal palaces from the days of the old Malacca Sultanate, with dark wood interiors and curtain-draped day beds. I particularly like the Anjung Rooms (choose 302 or 402 for beachside isolation) with their private outdoor plunge pools.
Pangkor Laut Resort, Perak
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hen Sting’s helicopter landed on the island of Pangkor Laut on the west coast of Malaysia the waiting staff member wasn’t sure how to greet him. ‘Sting’ seemed somehow too casual, ‘Mr Sumner’ a little strange. Nevertheless, whatever his decision, ‘Sting’ and his family will have been greeted by a level of private luxury at Pangkor Laut that few other Malaysian resorts offer, which is why he isn’t the only star to touch down on this island. Pavarotti loved the place, so much so that they named a suite after him. Sting’s private vehicle would have whisked him straight to a secluded cove, a bay away from the main resort, to one of eight elaborate private estates. Now normally once ensconced in a villa like this, or in one of Pangkor Laut’s over-water bungalows in the main part of the resort, there would be few reasons to leave. However, no-one can resist the
T R A V EL
resort’s Spa Village for long. The Village is so impressive that even your average spoilt superstar might want to sling on a sarong and slip in unobtrusively. One of the first of its kind anywhere in the world when it opened in 2002, the Spa Village took indulgence to a new level. Since then its creators YTL Hotels have used the concept successfully in their other resorts such as Tanjong Jara Resort on Malaysia’s east coast and Cameron Highlands Resort . This really is a whole separate ‘village’
of indulgence with its own 50-metre swimming pool, its own spa-cuisine restaurant, a small library and its own private massage pavilions. Scattered through its landscaped gardens are healing huts where experts from a variety of disciplines from Indian Ayurvedic to Chinese herbal wait to advise you. Whatever treatment you opt for we recommend you book a Bath House Ritual first. The staff will tie you into a sarong (see ‘dress code’ below) and lead you through two separate bath houses and a series of watery indulgences from waterfall-style showers to a Japanese
goshi-goshi wash and steaming hot pools. Then if you follow this with a signature Malay Lapis Lapis wrap, we guarantee you’ll be so mellow you’ll want to do almost nothing for the next 24 hours at least. Which is why, if you are not staying in the exclusive private estates, I recommend the over-water Spa villas as the next best thing. These 22 villas are within the confines of the Spa Village so really, you never have to leave at all.
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Away from the KL crowds, amid the curling jungle of peninsular Malaysia in the isolated far north-east, what you get is an unadulterated taste of Malay culture.
Cameron Highlands Resort, Cameron Highlands
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ndulating green tea plantations cover the hills around the Cameron Highlands Resort.
Up here in the cool crisp mountain air the English in Malaysia escaped the heat of the lowlands and transplanted their European life to the tropics. They built bungalows like English cottages, played rounds of golf, and took invigorating country walks, all accompanied by copious cups of tea brewed from the leaves from the tea plantations that they planted all over the rolling green hills. Tea. I say, what a jolly spiffing idea. How fortunate that one arrives at Cameron Highlands Resort just in time
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for traditional afternoon tea. There are also scones and strawberry jam, tiered plates stacked high with sugary cakes and of course the ubiquitous cucumber sandwiches. Lady Bracknell would have been proud. Since the theme of our stay is clearly tea I can’t resist the spa’s signature tea bath followed by a massage. My private Spa Village room has a deep claw-footed bath and white shutters. It also has a small flat-screen TV and head phone, which frankly I could do without. I prefer my spas without the technology. Nevertheless as I sink back into my tea and chrysanthemum bath, having scrubbed my face with loose leafed tea
and put tea bags on my eyes, I reflect that really tea is wasted on the drinkers; this is much more refreshing than a cup of Twinings. I’d recommend an indulgent spa safari like this to anyone, after all the “M” in Malaysia stands for “massage” doesn’t it? At the end of my trip I was on cloud nine and that’s before I got on the plane and climbed to 30,000 feet. Hilary Doling is Editor in Chief of www. Luxurytravelbible.com, the world’s ultimate on-line destination guide. For further information please contact YTL Hotels & Resorts on toll free 1800 667731, email globalhotels@bigpond.com or visit www. ytlhotels.com.
TRAVEL LI F E S T YLE
Just what the
Doctor
ordered… September 25 may seem like an awfully long time ago now, but the wounds are still raw for many: The first 2010 AFL grand final - and its inconceivable draw – certainly provoked some emotional outbursts. It all started out happily enough. There was Julia Gillard at her amusing best, invoking the gods of football not to permit a draw because the Australian public wouldn’t be able to bear it. At the time, I thought it a fairly witty comment for someone who’d had approximately seven hours sleep since August. Who knew how prophetic those words would be?
I
’m a relative newcomer to AFL – not your long term, dyedin-the-wool supporter – but I sat down to watch with a cold beer and high expectations. When the end came, not with a bang but a whimper, I was shocked. I called my Melbournian brother, who is overseeing my induction to AFL, to voice my displeasure. ‘At least’, he said with infuriating equanimity, ‘You got to see an historic draw’. PSYCHIATRYlife
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LI F E S T YLE Historic? The Industrial Revolution was historic; the invention of the Printing Press was historic! History is lofty, edifying, important... isn’t it?
Greek roots, spelling and grammar. I could even parse then. Mind you, it was 1965: I could also do handstands and the splits.) The Australian Medical Profession
We all have our own personal histories, and they’re mostly not earth-shattering, but they’re important to us.
There’s an awful lot of history out there to be claimed, but it’s easy to overlook if you haven’t made a personal connection with it. Like my internet historian who rated Online Dating but not teabags. We all have our own personal histories, and they’re mostly not earth-shattering, but they’re important to us. (When I recall my education in the Queensland public school system back in the sixties – I feel very close to history. We used slates, practiced copy-book writing, and learned the times table by rote. We were taught Latin &
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I have no quibble with the expression. Certainly if Max had referred to him as a Ladies’ Man there would have been hell to pay. And in any case, he was by all accounts, a Family Man. In between practicing neurosurgery; lecturing in applied neurophysiology; serving in WW2, and publishing over 40 articles for a range of medical journals, the dashing (literally, I imagine) young Dr Gilbert Phillips somehow also found time to serve as president of the Wine and Food Society. While on his travels in London, Gilbert was impressed with the activities of a co-operative wine-buying society he saw there. On his return to Australia he established, in 1946, The Australian Wine Consumers’ Co-operative Society Ltd.
To test my contention, I visited a number of websites - one of which provided a list of Events that Changed the World. It started, impressively, with the Use of Fire and the Invention of the Wheel; Written Language, and both World Wars (see… lofty, edifying!); then ended – to my surprise – with Internet Dating. I don’t have a problem with internet dating, I just hadn’t realised that it has actually changed the world. Not in the way that, say, the invention of the teabag has. Then it started to dawn on me: history isn’t a collection of causalities or chronological absolutes: it’s personal. The same brother who is coaching me to say Carn the Pies (and unprintable things about the ump) is a political history nut. The depth and breadth of his knowledge is astounding. Did he study it? No. It’s just an interest. It speaks to him. It’s personal.
- who studied under him, and became Gilbert’s junior neurosurgical resident - referred to Gilbert (even while apologising for the term) as a Man’s Man.
rightly lays claim to a wonderful history (if a short one, in global terms). So too, does the Australian Wine Industry. And when the two collide, magnificent things happen. Think Dr Henry Lindeman… Dr Christopher Penfold… Dr William Angove… Dr Max Lake… Dr Gilbert Phillips. Hang on - who??? Dr Gilbert Phillips was born in Sydney in 1904, and died at the age of just 49, from secondary melanoma. A neurosurgeon, an athlete (rowing, swimming and boxing), a great cook and a wine lover, Dr Gilbert Philips was also famous for his wit & erudition. Damn it, the man could even sing. Australian wine pioneer Dr Max Lake
Astoundingly, Gilbert’s co-op continues to operate to this very day – although wine lovers know it better as The Wine Society. And while the Australian Wine Industry of 2010 would be unrecognisable to Gilbert, I think he’d be pretty pleased with some of the changes. His outrage at the application of European regional wine names to Australian products may have seemed quaint to many at the time: it is now, not simply accepted, but required. History is in the heart of the beholder. That’s why, when someone mentions 1946, you may think: the mass production of juke boxes; atomic testing & the invention of the bikini… I think of a dashing young Aussie doctor, and a great bottle of Australian wine. Ten years ago, Gillian Hyde made a mid-life career change from Show Business to the Wine industry, and today holds the position of Head of Membership at The Wine Society. www.winesociety.com.au
LI F E S T YLE
Australia’s Passion for Coffee Explained With over one billion cups of coffee brewed in restaurants and cafés right across the country each year, it’s fair to say that Australians know a thing or two about this popular beverage. What most people don’t know is that European style cafés first arrived in Sydney thanks to a Russian man named George Repin. Repin came to Australia in 1925 after fleeing Soviet Russia with his family, and by 1930 he had opened several ‘coffee inns’. His shops soon became favourites for city dwellers and workers looking for that ‘extra kick’ to get them through the day. In the late 1930s Repin took several trips to America, where he learned the virtues of roasting his own beans – an indispensable craft that is central to producing a great cup of coffee. From these humble beginnings, the coffee craze spiralled and became a culture,
as important to the daily ritual of doing your hair or brushing your teeth. Yet, when Global chains like Starbucks attempted to crack the market here, they failed to consider this rich history of bean-ology and in 2008 - after eight years of making terrible coffee – they announced the closure of more than half of their existing outlets. Small café owners and coffee enthusiasts alike quietly raised their espressos to this subtle victory.
LI F E S T YLE So what makes a great coffee, and where did Starbucks go wrong? It begins with the coffee beans themselves which, oddly enough, aren’t beans at all. They are actually seeds, found within the ripe red and purple berries of the plant. There are two types of plant, Arabica and Robusta. Arabica is considered to be the superior coffee plant and is by far the most popular. The beans are harvested, usually by hand, and then roasted in a coffee roaster. Coffee beans are a highly traded commodity and form the backbone of economy in regions like Latin America, Southeast Asia and Africa. Here in Australia we now have
hundreds of thriving family-run coffee roasting houses, and it is not unusual for the best cafés to roast and sell their own beans on the premises. But preparing a great coffee is like preparing a great meal - having the best ingredients is useless if you don’t know how to put them together. Coffee beans need to be ground to the correct consistency just before they are used. An espresso machine requires a very fine grind to ensure all the flavour and acidity of the bean can be extracted in the short time the steam is pushed through it. Plunger and percolator coffee machines need a coarser grind, because the coffee grounds sit in hot water for longer. While electronic blade grinders are faster, and certainly cheaper than the traditional models, a coffee purist will avoid them regardless of the cost. It’s not worth the extra convenience to end up with smashed and bruised beans.
another integral part of the barista’s job. Milk can be challenging – it’s got to be hot, but not burnt, and the density and amount of foam on top need to be just right. A cappuccino should have one centimetre of creamy and finely textured foam floating on top of the coffee, while a flat white requires just two millimetres. If that all sounds a bit daunting, consider the fact that a good barista needs to be able to quickly and consistently repeat this process hundreds of times a day, without fail. Thankfully, there are now companies that offer speciality training courses where you can learn and practise these skills. It makes the average 17 year old Starbucks employee look ill equipped and poorly trained, to say the least. And while it’s easy to have a go at the corporate giants, they aren’t the only ones guilty of serving up mediocre coffee. Finding that master barista can take some time. In recent years Melbourne and Perth have surpassed
Melbourne and Perth have surpassed Sydney to become Australia’s most mature coffee cultures, offering a wide range of tastes and experiences. If an espresso machine is used, it’s important for the coffee to be correctly loaded into the espresso machine. The barista needs to use the right amount of grounds and ensure that they are tamped correctly. Use too much or tamp too hard and your coffee will be bitter and way too strong. Use too little and you’ll end up with weak and dirty looking hot water. If all of these variables are spot on, you end up with 30-50 millilitres of excellent espresso. A perfect espresso shot will have a golden cream-like foam top called a crèma, which is where the aroma and flavour live. Your espresso should have a creamy texture, complex flavour, and should never taste bitter. In Australia we love our milk based coffees, such as the cappuccino or flat white, and this penchant adds another important element to the craft of killer coffee. Correctly heating and foaming the milk is
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Sydney to become Australia’s most mature coffee cultures, offering a wide range of tastes and experiences. The way we find our favourite coffee is changing too. The Internet has transformed the way people find information of all sorts, and there are now numerous coffee-centric blogs and websites to help people find the best cup of coffee in their area. Of course, at the end of the day, you’re the best judge because you know what you like. Try new places, try new drinks, and remember - if you think something tastes fantastic, share it with the other coffee enthusiasts! Alan Byrne is the founder of BestAussieCoffee.com, a website where lovers of coffee can rate their local café and contribute to the communal quest to find the best coffee in Australia.
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You wouldn’t trust just anyone to treat you or your family? So why trust just anyone with your finances?
Specialist Medical Accountants and Financial Planners for Doctors You will never need to explain ‘salary packaging’, ‘Medicare Safety Net’ or “out-of-pocket” fees to us because we speak the same language as you. We think we know just about every tax deduction and financial planning secret for doctors and their medical practices because that’s what we have chosen to specialise in.
MEDIQ Medical Financial Services
1300 589 527
www.MediqFinancial.com.au Accounting & Taxation Commercial Loans
Life Insurance
Equipment Finance
Investments
Melbourne
Sydney
Financial Planning Home Loans
Medical Indemnity
Fit-out Finance
Medical Practice Strategic Consulting
MEDIQ Financial Planning is a Corporate Authorised Representative of Synchron AFSL 243313
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