SURGICALLife
NOVEMBER/DECEMBER 2010
health...wealth...lifestyle...
Marketing Surgeon, heal thyself
Depression,drug abuse and suicide amongst doctors
7
your surgical
practice to potential referrers
mistakes made by surgical
TOP
practice owners
How you can avoid them
$12.95
Crossing the Boundary An insight into why some doctors form sexual relationships with patients
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SURGICALLife health...wealth...lifestyle...
Highlights
16 18 22 44
Departments
Medicare Audits
07 Features
The Surgeon’s Guide to Understanding the PSR
30 Medical Legends
Surgeon, heal thyself Depression, drug abuse and suicide amongst doctors
Crossing the Boundary An insight into why some doctors form sexual relationships with patients
Marketing Your Surgical Practice to Potential Referrers Why do GPs refer their patients to certain Surgeons and not others?
32 Business & Finance 53 Risk Management 56 Careers 59 Alpha: Technology & Reviews 62 Boutique 64 Travel 69 Lifestyle
26
contents FEATURES
07
50
Creating Oversupply The impact of the so-called ‘Medical Tsunami’?
12
Green Doctors
16
Medicare Audits and the Surgeon The Surgeon’s Guide to Understanding the PSR
18
Surgeon, heal thyself Depression, drug abuse and suicide amongst doctors
22
Crossing the Boundary An insight into why some doctors form sexual relationships with patients
26
Specialists Without Borders
MEDICAL LEGEND
30
Conrad Ramstedt
BUSINESS & FINANCE
32
Express Your Individuality in the World of Investment Choice “What should I do with my money?”
36
Top 7 Mistakes Made by Surgical Practice Owners How you can avoid them
69 64
07 41
Income Protection Insurance
44
Marketing Your Surgical Practice to Potential Referrers Why do GPs refer their patients to certain Surgeons and not others?
50
Taking on Risk for your Children Inter vivos estate planning
RISK MANAGEMENT
53
CAREERS
56
Surgeon Sued for Failing to Warn the Risks of Spinal Surgery Neurapraxia caused by a six hour operation
Dare to Dream How to set meaningful goals and achieve them
ALPHA
59
The Paperless Practice: Is It Time?
BOUTIQUE
62
Boutique
TRAVEL
64
Five Star Gazing
LIFESTYLE
69
Tropical Discovery: the Wines of Bali
71
Soft-roof Drop-top with Panache Mercedes E-class cabriolet oozes quality, style and comfort
SURGICALLife health...wealth...lifestyle...
editor’s note
W
ELCOME to the Summer Edition of Surgical Life. This issue presents some fascinating feature articles, some ground breaking business and finance content, as well as some light hearted lifestyle pieces that you can enjoy over the holiday period. In this edition we touch on some sensitive topics which we hope you will appreciate. We uncover some of the psychosocial problems associated with our professional choices by looking at the disturbing topics of depression, drug abuse & suicide. From our interviews with Mr Jeff Kennett, chairman of beyondblue and Dr Mukesh Haikerwal, former President of the AMA and current chairman of the Doctors’ Mental Health Program Advisory Committee we talk about some of the challenges we face that can lead to poor mental health and self destruction. We have also covered a topic on the fine line between doctors and their patients and talked about the complications associated with crossing this relationship boundary. Our business section would like to welcome Mediq – a Medical Financial Services company who present the finance section cover story. They share with us some business and financial mistakes that could be costing us the success of our practice. Since the last edition, we have been overwhelmed with your feedback and are delighted to continue receiving submissions from our readers. I would encourage you to submit any editorials you feel would be of interest to your peers, both personally and professionally. Please submit feedback, compliments, complaints and letters to the editor at: editorial@medicallife.com.au Seasons greetings.
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 magazines or espresso media. No part of this magazine can be reproduced or copied without the express prior consent of the publisher.
NOVEMBER/DECEMBER 2010
Selina Vasdev
Editor selina@medical-life.com.au
Ravi Agarwal
Business Editor Marketing ravi@medical-life.com.au Contributing Sources
Dr. Richard Cavell Dr. Paul Anderson Dr. Eugenie Kayak Prof. Paddy Dewan
The Surgical Life magazine is published bi-monthly by Medical Life Publishing Pty Ltd. Surgical Life & Medical Life Publishing is proud to be independent of any academic institution or professional association. Suggestions, content ideas or complete articles written by readers are welcome and will be reviewed by the Editorial Committee. Please direct all inquiries and submissions to: Medical Life Publishing PO Box 2471 Mount Waverley VIC 3149 Phone: +61 (03) 9001 6373 Fax: +61 (03) 8677 9554 Email: mail@medical-life.com.au
FEATURES
Creating
Oversupply
by Selina Vasdev
The impact of the so-called ‘Medical Tsunami’? When speaking to medical students these days, their biggest concern is no longer passing exams, chatting up partners or even where to go for their next holiday. The biggest fear looming over their minds, is now the reality that they may not get an internship position in Australia upon graduation. Gone are the days when you could complete your medical degree as an Australian medical student and be guaranteed internship and resident/registrar jobs to follow.
B
ETWEEN 2007 and 2012 the number of new doctors being generated by medical schools will rise by 86 per cent - from 1586 to 2945 per year. The harsh reality is that ten new medical schools have
opened up since 2000 and many of the older medical schools have increased their intakes. Spurred by the prospects of increased funding, more money from overseas students and scoring significant vote-winning SURGICALLife
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FEATURES points with the public, there has been an unprecedented growth in medical training places. Sadly, it appears that no-one has done their sums when it comes to a single cold truth: There is a massive disparity between medical student places and intern positions. To date, the number of intern positions has managed to keep up with the number of medical graduates, but the sustainability of this over the next 5 years is looking highly unlikely. A 50% increase in intern numbers will be required to keep pace with the new numbers of domestic student graduates. There are numerous initiatives being explored by a variety of stakeholders (e.g. Postgraduate Medical Councils, AMA subcommittees, Governmental bodies, Department of Health and Ageing) looking at ways and places to create new internship jobs to meet the demands. Professor James Angus of the Medical Deans of Australia and New Zealand has predicted a potential 20% shortfall of intern placements
“Gone are the days when you could complete your medical degree as an Australian medical student and be guaranteed internship and resident/registrar jobs to follow.�
The latest Medical Training Review Panel published by the Department of Health and Ageing in April 2010, demonstrates the ballooning number of medical graduates. UNIVERSITY Adelaide ANU Bond Deakin Flinders Griffith James Cook Melbourne PG Melbourne UG Monash PG Monash UG Newcastle/UNE Notre Dame Sydney Notre Dame WA UNSW Queensland Sydney Tasmania UWA PG UWA UG UWS Wollongong Total
2009
2010
2011
2012
2013
2014
85 72 55 0 74 117 82 68 132 0 159 85 0 80 169 272 206 75 15 168 0 0
97 85 73 0 106 149 100 69 143 0 182 104 0 90 162 328 228 88 33 159 0 68
98 78 84 112 114 142 88 88 148 52 221 80 107 106 200 300 222 81 60 126 90 70
125 86 80 132 125 156 96 72 150 67 228 166 113 109 206 306 251 109 58 105 98 74
145 85 93 128 120 150 162 79 172 65 247 172 112 104 209 305 228 99 64 115 118 73
155 95 80 128 132 150 162 280 0 65 240 169 112 104 210 305 228 100 65 145 110 73
1,914
2,264
2,667
2,912
3,045
3,108
* (this table does not include international students, only domestic students enrolled at Australian universities). Source: 2010 MTRP report from the Medical Deans of Australia and New Zealand (MDANZ)
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even with all the suggested measures being implemented. All the State Governments have guaranteed intern positions for all Commonwealth Supported Place and domestic full-fee paying medical students. Therefore, it appears that International students, Interstate applicants, New Zealand and AMC graduates will be the ones who will likely be affected by the shortfall. In addition, there will likely be a lack of accredited training positions in specialist training and general practice training programs to absorb all the new graduates who have completed internships. Currently, the total number of first year accredited trainee positions across all the specialties roughly matches the number of doctors completing intern positions. Rising graduate and intern numbers could lead to the following additional problems: 1. Inadequate numbers of supervisors for interns and other junior postgraduate trainees. In most settings, trainee supervision is largely driven by the enthusiasm and goodwill of senior clinicians. This is seldom remunerated directly (although some employment contracts stipulate teaching and supervisory duties) and often incurs a substantial opportunity cost for consultants. With the estimated growth in trainee numbers, this pro-bono system is unlikely to be sufficient. There is a real risk of supervisor disengagement and burnout, which could ultimately influence clinical outcomes. 2. Bottlenecks in accessing Training Positions. Increasing numbers of graduates will lead to an increase in demand for training positions, especially in the more popular specialties. This phenomenon occurred very recently in the UK where some popular specialties had doctors completing up to five unaccredited years and securing a whole array of postgraduate qualifications to try to be shortlisted.
FEATURES
“ There is a real risk of supervisor disengagement and burnout, which could ultimately influence clinical outcomes.”
3. A lack of Consultant positions after completion of specialist training. This happened in the UK where fully qualified obstetricians were working as registrars for many years after completion of all requirements for admission to fellowship. The expansion in trainee numbers has been huge for certain specialties as demonstrated by the table. There has been an overall 51% increase in trainee numbers over the last 5 years, a significant proportion of this being in Psychiatry, Surgery, ICU and Emergency Medicine. The question that arises is, will there be the consultant posts available to accommodate this vast jump in trainees? Predicting future workforce numbers has always been difficult to estimate and previously, the healthcare system has always erred on the side of
Growth in Advanced Training Positions across all medical specialties between 2005 and 2009
Medical specialty
2005
2006
2007
2008
2009
Adult medicine Anaesthesia Pain medicine Dermatology Emergency medicine General practice Intensive care Medical administration Obstetrics and gyneacology Educational and environmental Ophthalmology Paediatrics Pathology Pathology and RACP (jointly) Psychiatry Public health medicine Radiation oncology Radiology
672 477 N/A 60 458 1,905 187 81 299 72 53 234 282 N/A 87 71 77 263
690 477 36 64 489 2,003 180 84 325 74 50 284 194 107 178 80 57 288
9948 416 49 31 462 2,003 285 86 338 59 47 286 176 95 177 75 96 299
1,043 463 45 33 480 2,162 326 80 109 61 70 395 211 124 278 75 104 314
1,157 485 53 39 811 2,309 375 92 131 55 77 453 224 137 322 61 101 328
% Increase 72.62 1.7 N/A -35 77.1 21.2 100.5 13.6 -56.2 -23.6 45.3 93.6 -20.6 N/A 270.1 -14.1 31.2 24.7
Source: Medical Training Review Panel 13th annual report – with figures quoted as being from GPET and the specialist Colleges
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FEATURES
“...some popular specialties had doctors completing up to five unaccredited years and securing a whole array of postgraduate qualifications to try to be shortlisted.”
References: 1. GJ Fox and SJ Arnold. The rising tide of medical graduates: how will postgraduate training be affected? MJA 2008; 189 (9): 515-518 2. Medical Training Review Panel. Department of Health and Ageing, July 2010 3. www.mmc.nhs.uk Images: Page 7, “School of Medicine” by rhennau http:// www.flickr.com/photos/rhennau/2932237513/ Page 9, “Sydney University - Medical School” by State Records NSW http://www.flickr.com/photos/state -records-nsw/4057365850/ Page 10, “Medical School Mural 1” by Sam Blackman http://www.flickr.com/photos/samblackman/141643386/. Images licensed under Creative Commons Attribution 2.0 Generic license, http://creativecommons.org/licenses/by/2.0
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a mild shortage of doctors knowing that any shortfall could be easily accommodated with international medical graduates. However, erring on the side of having too many doctors at an undifferentiated junior doctor level or a specialist level could have devastating consequences on the profession. We only have to follow the example of countries around the world with surpluses of doctors. The situation occurring in Australia at the moment mirrors what happened in the UK over the last 4 years very closely. The debacle occurred between 2006 until now in the UK due to a combination of events. Firstly, there was political impetus to build new medical schools and expand the older ones. In addition, there was a significant growth in overseas trained doctors (mainly from European Union Countries) entering under new EU regulations. Finally, there was a knee-jerk response to increased numbers of junior trainees by creating a ‘fast-track’ system to specialist training where a medical graduate becomes a specialist within 7 years of graduation. This project came
under the auspices of the Modernising Medical Careers group of the NHS with disastrous consequences. Those graduates unable to secure training posts in the MMC-managed selection process were now unable to take up positions and were forced to wait until the following year to apply again. Medical graduates had to face the prospect of being unemployed and finding work outside of the medical profession. In 2007, there were approximately 10,000 unemployed doctors. Many emigrated overseas, principally to Australia and New Zealand. Some left to find jobs outside of the medical profession. Others registered for the dole. The NHS to this day has not lived down the shame of mishandling medical postgraduate training and the damage that it did to the goodwill of doctors of all specialties. Whether there will be an Australian version of this situation, in the near future, is hard to say. What appears definite is that medical workforce demographics are changing, and the ‘Medical Tsunami’ at junior doctor level is almost unavoidable.
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FEATURES
GreenDoctors As doctors we have a duty to firstly do no harm and to provide leadership in advocating for action to protect health and humanity, although for many of us our workplaces significantly contribute to an adverse ecological footprint.
E
VIDENCE strongly suggests that human activity is significantly contributing to an alarming rate of climate change, which is predicted to present increasing challenges to the maintenance of human health and the effective delivery of local and global healthcare. Within Australia, it is likely that there will be more extreme heatwaves, fires and floods as well as changes in the distribution of certain vector-borne diseases such as dengue fever and Ross River viruses. These changes will lead to further demands on our increasingly strained health and emergency services. Globally as the Lancet publishes ‘climate change is the biggest global health threat of the 21st century’1.
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We are a profession that prides ourselves on evidence-based practices yet we remain relatively quiet as scientific evidence continues to accumulate on the need to reduce carbon emissions to prevent an impending devastating situation for humanity. All whilst plausible answers and solutions are published daily. Even if the evidence for anthropogenic involvement is not absolutely 100% we should be reminded of the precautionary principle, written by Bradford Hill in 1965 ‘…all scientific work is incomplete…and is liable to be upset or modified by advancing knowledge. This does not confer upon us a freedom to ignore the knowledge that we already have, or to postpone that action that it appears to demand
FEATURES at a given time’2. the same as Physician Life so starts with ‘climate change...is predicted etc’ The healthcare sector’s contribution to greenhouse gas emissions, landfill and environmental degradation is not insignificant. Although there is no equivalent Australian data we know the United Kingdom’s National Health System (NHS) produces 3.2% of that country’s total carbon footprint3. Hospitals are high energy and water consuming, waste producing organisations. Embracing sustainable practices can lead to significant environmental advantages as well as having the potential to deliver financial gains. A recent joint publication by the World Health Organization and Health Care Without Harm ‘Healthy Hospitals, Healthy Planet, Healthy People’ describes numerous cost saving examples associated with environmentally sustainable hospital modifications4. As practising doctors we can instigate actions within our everyday practice that have thepotential to lead to significant reductions in carbon emissions. Audits investigating the sources of CO2 emissions generated by the NHS have shown that addressing the procurement practices of medical equipment and drugs as well as those of goods and services (procurement accounting for a staggering 60% of total NHS CO2 emissions) is just as, if not more important, than decreasing the emissions accrued from powering healthcare buildings (22%) or through staff and patient travel (18%)5. Within hospitals, operating suites are a significant contributor to energy resource consumption and waste production, generating approximately 20% of hospital waste6. Anaesthetists and surgeons are a constant presence in operating suites and are well placed to improve the environmental effect of their workplaces. By following the waste hierarchy ethos of ‘Reduce, Reuse, Recycle’ in our everyday practice and even taking further steps to ‘Rethink and Research’ our daily
environmental impact, we can make a difference and hopefully encourage those around us as well.
REDUCE Address adverse environmental impacts, waste and costs by using less of everything (power, equipment, products, medications etc.) Reduce landfill and clinical waste streams by ensuring correct waste segregation and the implementation of recycling options. Clinical waste generally has a higher fossil fuel carbon content compared with general waste, requires either high temperature incineration or chemical treatment before deposition into landfill, and is usually 10 fold the expense of general waste to dispose of. Consider the environmental impact of the medical gases (N2O, sevoflurane, isosflurane, desflurane) we may use and how this can be reduced. Their overall contribution to greenhouse gas emissions can be thought of as low, however when their emission amounts are related to daily activities their effects can be considered significant. For example, each minute of N2O usages at 0.5 litre / minute is equivalent in global warming potential to driving an average car 1 km7. Therefore using N2O for a day can be contributing as much to the ‘greenhouse effect’ as
driving an average car 500-1000 km. Although sevoflurane, isoflurane and desflurane are generally used in far lower concentrations than N2O, Ryan et al in Anaesthesia and Analgesia have recently published that 1-2 litres FGF (fresh gas flow) at 1 MAC (minimum alveolar concentration) of desflurane, using European Union data, equates to driving a car 375-750 km per hour of anaesthetic use, whereas sevoflurane or isoflurane equate with driving 28 km (2 litres FGF) or 31-62 km (1-2 litres FGF) per hour of use, respectively8.
REUSE Assess the validity of reusing medical equipment were appropriate. The replacement of reusable medical items with disposable (single-use) items is ubiquitous, often due to perceived lower costs and infection risks. Yet little evidence supports this practice, in fact evidence exists to the contrary. Life cycle analysis studies that have been done on anaesthetic trays and laproscopic surgical equipment have shown environmental and financial advantages of reusable items compared with disposable ones9-11.
RECYCLE Promote recycling options at work. Co-mingled (collecting paper,
“Climate change... is predicted to present increasing challenges to the maintenance of human health and the effective delivery of local and global healthcare.” SURGICALLife
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FEATURES cardboard, glass, plastic and metal in the one receptacle) recycling programs exist for local government curb-side collections. It is incongruous that co-mingled recycling does not occur within the controlled setting of all our hospitals. Almost 60% of anaesthetic general waste is potentially recyclable12. Manufacturing recycled plastics uses approximately 25% of the energy compared to equivalent plastic products produced from raw products. Hospitals are beginning to recycle noncontaminated plastic products. Not all plastics within hospitals can be recycled together with up to 30% of medical plastics comprising PVC (polyvinyl chlorine). PVC requires separation from other plastics and undergoes a different recycling process. However preliminary PVC recycling programs converting hospital waste into PVC pipes have been set up. Minimising the volume of batteries, electronic items and medical equipment that ends up in landfill is also important. Food waste has
been diverted from landfill to compost deposits or warm farms in several hospitals. Deposition into landfill comes at both an environmental and financial cost. Recycling can lead to significant advantages in both these areas. Water is increasingly scarce in many parts of Australia. Reverseosmosis renal dialysis units ‘reject’ or discard water (30-50% of the original mains water used) that is formed by predialysis water filtration before exposure to blood products. This ‘reject’ water falls within potable limits in most parts of Australia and has been used in hospital gardens and toilets13.
RETHINK
environmental impacts with 99% of the raw materials used in their manufacturing ending up as landfill3. Each patient in French and German hospitals accounts for 1.9 kg and 0.4 kg of waste per day respectively, whereas a patient in a UK hospital accounts for 5.5 kg, with Australian estimates reflecting UK amounts14. Attention to the procurement policies and processes by which medical drugs, equipment and paper (accounting for 22%, 9% and 5% respectively of total NHS CO2 emissions)5 are sourced could result in significant environmental, financial and ethical benefits.
RESEARCH
Analyse the latest evidence and clinical recommendations to ensure appropriate use, prescription and administration habits are preventing unnecessary consumption, waste and cost. Production of most medical drugs can have significant adverse
“Within hospitals, operating suites are a significant contributor to energy resource consumption and waste production, generating approximately 20% of hospital waste6.”
Further research surrounding the entire life cycle analyses of the equipment, products and medications used in our health care system is needed. Enabling practitioners to make truly informed decisions about environmental and financial impacts. Health care professionals as community leaders, educators, providers and contributors to environmental degradation and greenhouse gas emissions need to look towards embracing environmentally sustainable practices within their homes, their workplaces, and the wider community16.
Dr Eugenie Kayak MBBS, FANZCA, MSc Member of the National Management Committee of Doctors for the Environment Australia (DEA) www.dea.org.au
References: Costello A, Abbas M, Allen A et al. Managing the health effects of climate change. Lancet 2009; 373: 1693-1733. 2 Hill AB. The environment and disease: association or causation? Proc R Soc Med 1965; 58: 295-300. 3 Cole A. Saving the Planet as Well As Lives. BMJ. 2009;338:742-744. 4 Healthy Hospitals, Healthy Planet, Healthy People. World Health Organization and health Care Without Harm. www.noharm.org/lib/downloads/energy/Healthy_Hosp_Planet_Peop.pdf (accessed August 2010). 5 Saving Carbon, Improving Health: NHS Carbon Reduction Strategy for England. www.sdu.nhs.uk/ page.php?page_id=94 (accessed August 2010). 6 Lee BK, Ellenbecker MJ, Moure-Eraso R. Analyses of the recycling potential of medical plastic wastes. Waste Management 2002; 22: 461-470. 7 McGain F. Why anaesthetists should no longer use nitrous oxide. Anaesth Intens Care 2007; 35:808-9. 8 McGain F, McAlister S, McGavin A, Story D. The financial and environmental costs of reusable and single-use plastic anaesthetic drug trays. Anaes Intens Care 2010; 38:538-544. 1
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9 Adler S, Scherrer M, Ruckauer KD, Daschner FD. Comparison of economic and environmental impacts between disposable and reusable instruments used for laparoscopic cholecystectomy. Surg Endosc 2005; 19: 268-272. 10 Schaer GN, Ossi RK, Haller U. Single-use versus reusable laparoscopic surgical instruments: A comparative cost analysis. Am J Obs Gyn 1995; 173 (6): 1812-1815. 11 McGain F, Hendel S, Story D. An audit of recyclable waste from anaesthetic practice. Anaes Intens Care 2009; 820-823. 12 Agar JWM. Reusing renal Diálisis Wastewater: The Elephant in the Room. Am J Kidney Dis 2008; 52 (1):10-12. 13 Tudor TL, Marsh CK, Butler S et al. Realising resource efficiency in the management of healthcare waste from the Cornwall National Health Service (NHS) in the UK. Waste Manag 2008; 28: 1209-1218 14 www.acfonline.org.au/greenclinic (accessed August 2010) 15 www.greenpractice.org.au (accessed August 2010)
contributing
WANTED riters
Feel you have something you would like to share with all other Surgeons?
We are currently looking for articles and submissions for SURGICALLife . Please email: editor@medical-life.com.au
FEATURES
Medicare Audits and the Surgeon
The Surgeon’s Guide to Understanding the PSR A Professional Services Review (PSR) involves an assessment of Medicare claims to determine whether there has been “inappropriate practice” by a medical practitioner.
A
PSR investigation can be triggered by a number of items flagged as being outside the normal range of behaviour for a particular specialty group. That is to say, your billing patterns are always compared to your peers. If your billing methodology is two standard deviations away from the mean for your craft group, you could trigger a Red Flag. Typical Red Flags for Surgeons would include: Billing for Postoperative Consultations – when this has already been accounted for in the surgical item fee
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Upcoding of consultations – it would be normal practice for surgeons’ outpatients consultations to be of varying lengths. Surgeons whose consults were heavily coded to be of longer durations, would potentially open them up to triggering an audit due to their billing behaviour being vastly different to that of their peers. Billing for Multiple Operations in One Surgical Episode – Where this practice differs significantly from your peers and could be construed as being unnecessary or not actually being performed. High Volume Billing for Any Single Item Number –
FEATURES where this practice differs significantly from your peers. Billing for services when the surgeon is not present – billing for services performed by others who are unable to access Medicare. e.g. trainees. In addition to the above, behaviour which could also be referable to the PSR would be where allegations have been made, or anonymous sources have reported that one of the following activities is occurring: • Billing for goods and services not rendered • Billing for phantom patients • Upcoding or billing for more time than the duration of the actual service • Paying kickbacks in exchange for referrals (income splitting) • Billing for medically unnecessary interventions • Misrepresenting the quality of care provided • Double billing After receiving a warning either from claims data or from an anonymous report, the PSR would normally review a random sample of the surgeon’s records. Following examination of the medical records, a report to the surgeon and consideration of any submission received from the practitioner, the Director of the PSR must select one of the following three outcomes: • Decide to take no further action (all charges are dropped) • Enter into a confidential agreement with the surgeon including an acknowledgement of inappropriate practice and sometimes an agreement to repay certain Medicare benefits and / or a partial or complete disqualification from claiming benefits for a certain period. Other outcomes may include a requirement for counselling, disqualification from Medicare for up to 3 years, referral to the relevant Medical Board and / or publishing details of the investigative findings. • Establish and make a referral to a peer review Committee. Where the Director considers the conduct of the person under review needs further investigation, a Committee is established. The Committee comprises members drawn from the panel appointed by the Minister for Health and Ageing. The Committee may conduct a hearing where the person under review can provide both oral and written evidence in support of their case. After considering all the evidence and taking into account any submissions received, the Committee produces a draft report containing findings on the conduct of the person under review. Where the findings are that the person under review has not practiced inappropriately, the matter concludes. Where the findings are of inappropriate practice, the person under review is given time to make submissions on the draft report. After considering those further submissions
a final report of any inappropriate practice is then forwarded to the Determining Authority. At any stage in the process the person under review may seek judicial review in the Federal Court. The PSR has produced an annual report on its activities since 2007 and over this time, PSR investigations have increased over seven-fold. The majority of investigations involve GPs, but there are a growing proportion of specialist referrals. Key ways to minimise the risk of Medicare concerns leading to a PSR referral include:
“At any stage in the process the person under review may seek judicial review in the Federal Court.” • Ensuring you have a clear clinical justification for management decisions, including referrals and prescriptions, which accords with generally accepted peer professional practice. • Ensuring your notes are legible and contain sufficient detail of history taken, examination / testing / investigation results, diagnosis and management plan – a common test is whether the notes contain sufficient information to allow another practitioner to take over the patient’s care. • When claims are made for less common Medicare items, i.e. longer consultations, there is sufficient reason and notes to justify later why the claim was appropriate. • Ensuring complete compliance with all Medicare requirements for certain. • items, i.e. liaising with other care providers and completing certain forms / plans. If you are contacted by Medicare or the PSR about your practice, we recommend you notify one of the solicitors in the Medico-legal Department of your Medical Defence Organisation immediately for advice before responding.
Charles Gordon is a Medical Indemnity Specialist Insurance Adviser and is also the director of Medselect, Australia’s leading medical defence advisory service.
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features
Surgeon,
heal thyself
Depression, drug abuse and suicide amongst doctors We are known for being healers and carers of our patients. But the dark side of our profession is relatively understated. Although our position ensures that we take good care of those we treat, we massively neglect the issues causing hurt in our own lives.
D
“Female doctors have a suicide rate more than twice as high as lay females.�
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epression is a relatively undiscussed problem, yet common among medical students and doctors, and can occur at any stage of our careers. Australian doctors have a suicide rate that is higher than that of the general population, and female doctors have a suicide rate more than twice as high as lay females1. We have to admit, we are notoriously bad at seeking help or treatment for our personal illnesses, a stereotype which is not only based on anecdotal evidence but confirmed by research. A study into preventative health behaviour among General Practitioners in Victoria found that 57% of GPs did not have their own GP, while 12% of them
nominated themselves as their own GP and 30% assigned a professional partner2. More interestingly, recent research carried out by the national depression initiative beyondblue found that many doctors and medical students who suffered depression and anxiety ignored their condition1. So why is it that doctors who suffer from mental illnesses are so reluctant to seek help? Studies have found that doctors are more concerned with the aftermath of admitting such vulnerabilities3. Of course, as a doctor you have a duty to maintain a happy persona and healthy outlook. It is usually this fear of appearing vulnerable and the reluctance to seek advice that can lead to devastating outcomes. The unsettling truth is that doctors have the highest rate of suicide of any profession4. This year, beyondblue reported that male doctors are 26% more likely to commit suicide than other males, and female doctors are 146% more likely to commit suicide than other females1. It is believed that General Practitioners who suffer from depression are concerned about the potential implications for their practice and that admitting the need
FEATURES for help could trigger uproar amongst the medical community, perhaps even causing a stir with the medical board. Doctors of all specialties are understandably worried about the implications for career development5 and the risk of backlash. There is real concern about; stigma6, confidentiality and embarrassment1. It is the fear that disclosing a mental illness will stifle our careers and that our colleagues will question our professional integrity1. So instead... many doctors choose to suffer in silence. But when this isolation and pain becomes unbearable, who better to be able to prescribe the drugs needed to end such misery? Which is why we are more likely to take addictive prescription drugs than the general population. With the most commonly abused prescription drugs being, benzodiazepines and opioids1. Self prescription is popular7, even though it is frowned upon and illegal in some places. Not only do we know how the drugs will react with our bodies but we know exactly what amount to use to cause the body to shut down and bring the heart to a grinding halt! Dr Mukesh Haikerwal, former President of the AMA and current chairman of the Doctors’ Mental Health Program Advisory Committee, was beaten and robbed in September 2008. He underwent a craniotomy during which part of his brain was removed, and was in hospital for two months. He claims that whilst recovering from an illness “which included psychological problems...I made a point of seeking help. I see it as a professional responsibility to make sure that I am well and fit for work before I went back to work.” Dr Haikerwal says, “Nobody would think twice about taking insulin if they needed it when they had diabetes, or a puffer if they had asthma. And it’s much the same for mental illness including depression and anxiety.” From an outsider’s perspective, a doctor’s life seems rich and rewarding and of course for most of us, it is. But Mr Jeff Kennett, chairman
of beyondblue, has an alternative opinion. He says, “With due respect to the profession, who’d want to be a doctor? ...You’re seeing sick people, you don’t have a break, you’ve got to somehow present yourself in a way that looks enthusiastic and fresh the whole time, and you’re dealing with people who are depressed, with other forms of injury, snotty noses. It’s a hell of a bloody lifestyle. Endless. And the demand never ceases.” With this in mind, we can confirm that there are numerous factors that can contribute to the downward spiral of a doctor’s health and well being. The stresses of a medical career are widely acknowledged. We are continually exposed to pain, disease, death and suffering; a morbid routine for anyone to get used to. Our working environment is intense to say the least8 and yet it is stretched, not only by having to remain alert under such pressures, but having to do so whilst upholding high professional responsibility. Some of us more than others fear the risk of complaints and legal action based on the decisions we make and the actions we take whilst helping our patients and it
is this fear of scrutiny that causes doctors to keep their problems hidden. Some causes of our ill-health may actually be attributed to our own personalities including the tendency for perfectionism. Some of us suffer from incredible inflexibility and a gross over-commitment to work, which inevitably causes conflicting demands on our time. Self- criticism and an inability to relax are also quite common and perhaps are linked to the early stages of one’s medical career which during the studying phase and training years re-affirmed such qualities and associated them with the success of becoming a doctor. Long working hours is perhaps the most complained about factor9, clearly detrimental to the health of any individual let alone a doctor responsible for the care of others. It seems that doctors who are geographically isolated or feel marginalised may also experience particular stress which can develop into something far more problematic. Being single9 or even spending considerable lengths of time working exclusively in private practise or as a locum may also be detrimental.
“It is usually this fear of appearing vulnerable and the reluctance to seek advice that can lead to devastating outcomes.” SURGICALLife
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FEATURES Inevitably this isolation, with a lack of peer support can be a major source of job dissatisfaction. Although most doctors adopt effective strategies and copying mechanisms, others find it hard to juggle the responsibilities and expectations put on them. Personality traits such as conscientiousness, commitment and obsessionality are also to blame for high levels of stress and burnout10. But what if this is the personality profile of the kind of people who become doctors in the first place? There are several interventions that are believed to reduce the risk of mental illness and in turn suicide. Doctors are less likely to become depressed if they sleep more, have greater job satisfaction, have a higher income and have less stress at work. beyondblue also advocates a number
of interventions as effective in the treatment of depression including; cognitive-behavioural therapy, interpersonal therapy and medication. The feelings associated with depression, coupled with drug taking behaviour have resulted in numerous documented suicide cases amongst medical professionals. Suicide of a doctor is shocking to society. The damage that is left behind, among family and friends, and the workplace, is enormous. During an interview Psychiatrist Professor David Clarke said, “Suicide is an uncommon event, but it’s so tragic and has such ramifications that it’s a marker for something. The suicide rate in doctors is a little bit higher than the general population, but the good news of course is the suicide rate in Australia has been dropping for the last ten years, and
“It is usually this fear of appearing vulnerable and the reluctance to seek advice that can lead to devastating outcomes.” References 1 beyondblue. The Mental Health of Doctors: A Systematic Literature Review, a meta‐analysis of mental illness in doctors and medical students. 2010 2 McCall L, Maher T, Piterman L. Preventive health behaviour among general practitioners in Victoria. Aust Fam Physician 1999; 28: 854‐857 3 Anonymous. View from the bottom. Psychiatric Bulletin 1990;14 452-4. 4 Rosenberg HM, Burnett C, Maurer J, et al: Mortality by occupation, industry, and cause of death: 12 reporting states, 1984. Monthly Vital Statistics Report, Centers for Disease Control and Prevention 1993; 42:1‐64 5 North CS, Ryall JM: Psychiatric illness in female physicians:are high rates of depression an occupational hazard? Postgrad Med 1997;101:233–236,239–240,242. 6 http://www.abc.net.au/pm/content/2010/s2986807.htm 7 Selly P. Self-prescribing by doctors. HealthTrends. 1988;20:128-129. 8 Arnetz BB. Psychosocial challenges facing physicians of today. Soc Sci Med 2001;52(2):203‐13 9 Sullivan P, Buske L. Results from CMA’s huge 1998 physician survey point to a dispirited profession. CMAJ 1998;159(5):525‐8
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we should feel very good about that.” The most common method of suicide among doctors is the use of drugs and poisons. Anaesthetists and Emergency Doctors are especially likely to kill themselves, implying that drug abuse is related to medical speciality, usually emphasised by the availability of drugs11. Doctors are by no means immune to psychosocial problems and the associated traps of depression, drug abuse and suicide. Yet self-care and well being are not exactly subjects covered as part of professional training, nor are they topics that receive immediate attention in professional practice. More importantly, medical training seems to put a premium on physical stamina and emotional resilience12 making it almost impossible for us to fight back. With huge stresses based around our personal and professional lives, doctors can develop serious issues that often go undetected and untreated. It is therefore crucial for interventions to be made readily available for doctors to allow them to seek help and treatment without fear of repercussions. According to Mr Kennett, beyondblue aims to increase awareness of the symptoms of mood disorders, identify risk factors, reduce barriers to seeking help, and promote existing services with “The objective to ensure that we have a healthy medical profession.” Doctors in trouble should be able to seek help without stigmatisation and with confidence that our profession will support their rehabilitation13.
Dr. Richard Cavell & Selina Vasdev
Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. 2003;289 (23): 3161–3166 11 McManus IC, Keeling A, Paice E. Stress, burnout and doctors’ attitudes to work are determined by personality and learning style: a twelve year longitudinal study of UK medical graduates. BMC Med 2004;2:29 12 http://scienceweek.com/2005/sw050826‐4.htm 13 http://www.nytimes.com/2003/07/08/health/doctors‐toughest‐diagnosis‐own‐mentalhealth. html?pagewanted=1 10
Images Page 15, “Conditional Suicide - How Long?” by Kazi Tahsin Agaz (Apurbo) www.flickr.com/photos/elomelosnapshots/512396611/ Page 16, “Despair” by fakelvis www.flickr.com/photos/lloydm/2305701220/. Images licensed under Creative Commons Attribution 2.0 Generic license
‘Depression is
‘Depression is
more than thanstress. stress. more doesn’tgo goaway.’ away.’ ItIt doesn’t
You can’t leave depression at home. It goes to work with you. You can’t think straight. You don’t tell anyone because you fear what others will think – but hiding it is exhausting. Find out more about how to deal with depression and where to get help. For more information visit our website or contact the beyondblue info line.
1300 22 4636 infoline@beyondblue.org.au
Crossing theBoundary An insight into why some doctors form sexual relationships with patients
Hardly a month goes by without news of a doctor somewhere in Australia confessing to partaking in a sexual relationship with a current or former patient. The purpose of this article is not to discuss the ethics and wrongs of this, as these are widely documented elsewhere.
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his article has been written to give doctors an insight and understanding of how a lapse in personal behaviour can escalate to serious criminal actions. Firstly, it is important to realise that this problem is not unique to doctors; teachers, nurses and priests have had similar complaints to their registration boards. It is hard to estimate the prevalence of inappropriate doctorpatient relationships, because the vast majority go unreported1 as many patients are often reluctant to complain, because of feelings of guilt and shame, fear they will not be believed, and bizarrely continuing concern for their doctor2. Surveys from overseas indicate that about 3-10% of doctors have formed sexual relationships with a patient3-5. Local experience is limited to an anonymous postal survey of psychiatrists which found that almost 8% of psychiatrists reported some form of erotic contact with a patient during or after termination of treatment6. Another local survey, this time with General Practitioners as the studied population, reported 6% of GP’s had dated a patient and 4% had engaged in sexual contact with a patient 7. The underlying principle upon which this prohibition of sexual intimacy with a patient is based on is the fiduciary duty arising from this relationship. If a lawyer is going to handle a doctor/patient sexual misconduct case, he must have a solid understanding of the fiduciary relationship that exists between the patient and the patient’s doctor. The nature of the relationship is significant not only to elements of negligence or other causes of action, but also underpins the injuries and damages those patients and their families suffer8. A fiduciary relationship is defined as a relationship where a person (patient) justifiably relies upon another person (doctor) to protect their personal interests and/or act in their best interests. The doctor/patient
relationship is a clear example of a fiduciary relationship. Often, service professionals are legally construed to be fiduciaries for those people that seek and obtain their professional’s services9. Within the doctor/patient relationship is the element of power. The doctor has the knowledge, the training, the education, and the ability to treat the patient. This knowledge and training, places the doctor in a position of power. The patient, not having this knowledge, justifiably relies upon the doctor to act in the patients’ best interests. Vulnerability in the patient is also present in the doctor/patient relationship. This vulnerability arises from the fact that most patients seek medical service because of physical or mental problems or conditions. The patient then is expected within this fiduciary relationship to disclose confidential and sometimes embarrassing information, thereby further increasing the patient’s vulnerability10. One key concept in ascertaining how premeditated the boundary violations are is the concept of grooming. Grooming is the term used to describe the escalation and the positioning of a patient by the doctor, making the patient more vulnerable to being used by the doctor for his own needs, instead of dealing with the patient’s needs. One scenario of grooming a patient is where the doctor begins by complementing the patient on her looks, beauty, dress, etc. Later the doctor begins to touch the patient’s hand as the doctor delivers his advice and treatment. Even later, the doctor starts hugging the patient during or at the end of a visit. At the same time or shortly following this physical contact the doctor will often engage in sexual innuendo or some form of sexual talk. The doctor will often begin disclosing his own personal information (making the patient an equal, and no longer just a patient); this information can often include disclosure of lack of satisfaction and pleasure with his sex-life and with
“Surveys from overseas indicate that about 3-10% of doctors have formed sexual relationships with a patient.” his sexual partner. This step-by-step grooming of a patient usually suggests the behaviour is more calculated, sinister and more premeditated. Earlier, we established that this problem is not confined to a miniscule minority. Now let us explore what leads to doctors to transgress professional boundaries and partake in this reprehensible behaviour. When we analyse the profiles of the doctors concerned, they tend to fit two major groups: A small number of the perpetrators are predatory serial offenders who sexually exploit multiple patients for their own sexual gratification11. The second group consists of doctors who committed a single offence where the usual reason given is usually the culmination of a series of boundary crossings (non exploitative departures from usual practice). The distinction between boundary crossings and boundary violations is important. Crossings are departures from usual practice that are not exploitative, and can sometimes be helpful to the patient (e.g. embracing a patient), while boundary violations (e.g. kissing a patient) are crossings that are harmful to the patient. The failure to recognise SURGICALLife
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FEATURES when this behaviour is escalating and the loss of insight into when the succession of boundary crossings has culminated into a violation are the key steps leading to the transgression12. Risk factors for doctor/patient relationships which cross the boundary: Doctors who practice an informal style of medicine where they use first names to refer to each other. The overly patient-centric consulting style is divorced from the historical paternalistic doctor patient relationship. e.g. Treating patients without clear management goals, therapy exceeding a normal length of time, therapy outside of your normal areas of competence, special fee arrangements, personal telephone calls between sessions, treating the patient as a friend, adoption of unwise techniques such as routine hugs, excessive touching, out-ofcontext socializing with patients and excessive self disclosures. These actions can be misinterpreted by patients and may make it more difficult for doctors to simultaneously maintain clear professional and personal boundaries13. 1. Patients who have previously been victims of sexual abuse are prone to recreating patterns where they expose themselves to sexual abuse. The so-called “sitting duck” syndrome. A survey of 40 Australian women who had experienced sexual abuse from a healthcare provider found that twothirds had a history of childhood abuse14. • Emotional stress, mental illness or substance abuse in the doctor • Disclosure of personal information or stressful circumstances in the doctor’s life (role reversal and abandonment of the traditional doctor/patient relationship) 2. Patients with dependent and borderline personality disorders are also risk factors. They have considerable difficulty with interpersonal relationships and maintaining consistent and
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appropriate boundaries15. 3. Specialties where repeated and long term contact is maintained. Also specialties where patients make disclosures about their emotional wellbeing have a higher propensity to lead to boundary crossing. Specialties identified as being of higher risk are Psychiatry, General Practice and Gynaecology16. What happens when the transgressors are caught? Well until recently, medical boards were different State based entities with different regulations, and so the punishments served were of a particularly diverse nature. In general, most doctors were deregistered for 6 months to 2 years for professional misconduct, received some form of psychotherapy/ counselling and some were forced to have chaperones if their crimes were thought to be more opportunistic or predatory. One can only assume that a high percentage of these cases would be pursued in the civil courts for medical negligence including the tort of outrage, the intentional torts of assault and battery, and one might also include an allegation of
lack of informed consent. If a breach of fiduciary duty (duties) is proven, the patient/victim is entitled to all physical and psychological damages that are directly and proximately caused by the doctor’s breach. Currently, there is no official program to rehabilitate offenders back into the medical workforce as the consequence. A treatment program for Australian clergy who have breached sexual boundaries has been in existence for several years now. The program uses a multidisciplinary team approach and includes individual and group therapy, from both psychodynamic and cognitive perspectives. Clergy who have responded well to treatment can then negotiate a graded return to restricted ministry. 17 A similar program may well be beneficial to doctors who have violated patient boundaries and have expressed remorse. The whole area of sexual boundary violations by doctors with their patients is a cloudy area with many medical authorities very unwilling to commit any formal policies on how to prevent this happening. The
“Grooming is the term used to describe the escalation and the positioning of a patient by the doctor, making the patient more vulnerable to being used by the doctor for his own needs.”
best advisory position statement guiding doctors on managing boundary violations in clinical practice has been issued by the Royal College of Psychiatrists (UK) which offers the following sound advice:18 • Physical touch beyond normal social exchange should be used with caution. A ‘no touch’ policy is unworkable and may be anti‑therapeutic, but the inherent power imbalance between professionals and patients means that touch of any kind may be misinterpreted. • Inappropriate self‑disclosure (the
commonest form of boundary violation) or disclosure of confidential personal material without consent should be avoided. • Treatment or therapy should generally not take place in a practitioner’s home. If the practitioner is in private practice and works from home, the work should take place in a designated area, kept apart from the practitioner’s ordinary domiciliary arrangements. • Treatment or therapy should not generally take place outside the workplace (e.g. in restaurants or places of entertainment).
References 1 Quadrio C. Sexual abuse in therapy: gender issues. Aust N Z J Psychiatry 1996; 30: 124-131. 2 Galletly CA. Psychiatrist-patient sexual relationships — the ethical dilemmas. Aust N Z J Psychiatry 1993; 27: 133-139. 3 Kardener SH. Sex and the physician-patient relationship. Am J Psychiatry 1974; 131: 1134-1136 4 Gartrell N, Herman J, Olarte S, et al. Psychiatrist-patient sexual contact: results of a national survey. I: Prevalence. Am J Psychiatry 1986; 143: 1126-1131. 5 Wilbers D, Veenstra G, van de Wiel HB, Weijmar Schultz WC. Sexual contact in the doctor-patient relationship in The Netherlands. BMJ 1992; 304: 1531-1534. 6 Leggett A. A survey of Australian psychiatrists’ attitudes and practices regarding physical contact with patients. Aust N Z J Psychiatry 1994; 28: 488-497. 7 Coverdale JH, Thomson, AN and White GE. Social and sexual contact between general practitioners and patients in New Zealand: attitudes and prevalence. Br J Gen Pract. 1995 May; 45(394): 245–247. 8 http://en.wikipedia.org/wiki/Fiduciary 9 http://definitions.uslegal.com/b/breach-of-fiduciary-duty 10 Robert A. Zielke, et. al. Secrets In the Exam Room: Sexual Misconduct by Doctors. 11 Crow SM, Hartman SJ, Nolan TE, Zembo M. A prescription for the rogue doctor: part I — begin with diagnosis. Clin Orthop 2003; 411: 334-339 12 Gutheil TG, Gabbard GO. The concept of boundaries in clinical practice; theoretical and risk management dimensions. Am J Psychiatry 1993; 150: 188-196. 13 Nadelson C, Notman M. Boundaries in the doctor-patient relationship. Theor Med Bioeth 2002;
FEATURES • Treatment, therapy or clinical assessment in the patient’s home is justified only on clinical grounds, and clinicians should be prepared to justify how and why such work has taken place. • Treatment or therapy outside inpatient settings should generally take place within working hours of the service (which may vary). If such work is to take place at unusual hours, this should be agreed with a mentor, supervisor or senior colleague and the reasons recorded. • Doctors should avoid being in dual roles with patients, for example doctors should avoid treating family members, friends, family of friends, colleagues or family of colleagues. This is particularly true in cases where the patient is a doctor. • Other role conflicts include issues relating to money and dual relationships. • Doctors should not appear as expert or professional witnesses in cases where they know the patient in a clinical relationship. They may act as professional witnesses but will be bound by their duty of confidentiality in the ordinary way.
Selina Vasdev
23: 191-201. 14 Kluft RP. Treating the patient who has been sexually exploited by a previous therapist. Psychiatr Clin North Am 1989; 12: 483-500. 15 Cherrie A Galletly. Crossing professional boundaries in medicine: the slippery slope to patient sexual exploitation. MJA 2004; 181 (7): 380-383 16 Randy A. Sansone, MD, and Lori A. Sansone, MD. Crossing the Line: Sexual Boundary Violations by Physicians. Psychiatry (Edgemont) 2009;6(6):45–48 17 Canaris C. The ‘out of house’ solution to boundary violations. Aust Psychiatry 2003; 11: 406-409. 18 Royal College of Psychiatrists. Vulnerable patients, safe doctors; College Report CR146, London UK 2007; pp 1-30. 19 Epstein RS, Simon RI. The Exploitation Index: an early warning indicator of boundary violations in psychotherapy. Bull Menninger Clin 1990; 54: 450-65. 20 Vamos M. The concept of appropriate professional boundaries in psychiatric practice: a pilot training course. Aust NZ J Psych 2001; 35: 613-18. Images: Page 18, “Crossing the Line” by CarbonNYC www.flickr.com/photos/carbonnyc/35399751/ Page 20/21, “Crossed fingers 1” by Katie Tegtmeyer www. flickr.com/photos/katietegtmeyer/124315323/ Images licensed under Creative Commons Attribution 2.0 Generic license, http://creativecommons.org/licenses/by/2.0
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Image above: "MEDCAP - Natural Fire 10 - Palabek Kal Health Clinic - US Army Africa - AFRICOM - 091018-F-8314S-108" by US Army Africa www.flickr.com/ photos/usarmyafrica/4036889678/ Images licensed under Creative Commons Attribution 2.0 Generic license, http://creativecommons.org/licenses/by/2.0
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imagine that most people at some stage in their life have had someone persist and influence a decision that turns out to be not only positive but life shaping. Russell Lee is one of those people. He has been responsible for coordinating operation “open heart” which takes both cardiac surgical and intensive care teams into developing countries to operate on paediatric cases deemed beyond the capabilities of the medical teams in that developing country. It is through his persistence that I lead a medical team into Rwanda and down onto the Congolese border as part of a worldwide response to the 10 year anniversary of the genocide, which has also caused me to adjust my medical/ surgical focus. That didn’t happen overnight and there were several specific things that his persistence needed to overcome. A successful private practice, which doesn’t easily release its primary practitioner, was one. Then there was the wilful replacement of personal goals to go where the need is greatest, something that is also often difficult to fit in with being a single parent. The third aspect, and not the least
important in changing lanes in your fifties, centred around a return to Africa, which would mean for me confronting the ghosts of having been involved in a terrorist attack. While a young consultant surgeon in South Africa, I had been quietly attending a church when it was attacked by five terrorists. They entered the church with AK-47s shooting and throwing grenades into the congregation. This killed 11 and seriously injured 50 of us. One of the bullets grazed my temple, another passed subcutaneously through my left flank, the grenade which exploded in the aisle near to me caused a comminuted 14 part fracture of my left radius and ulna. The only thing really left intact was the neurovascular bundle. I was fortunate that a great friend of mine, spent five hours putting together my forearm so that I could operate again. Getting out of Africa at that point was a primary aim. Going back, was not as you might imagine even a consideration. It was 10 years almost since that incident and I had often reflected on that part of my training which was in Africa and the great need that there is
FEATURES there for doctors/nurses. But the desire to go back and contribute had been held in check by the past trauma which had provided a convenient excuse to deny the challenge. Australia has a fantastic health system, founded on an equally impressive medical education structure. The thought remained that with motivation there is a lot we can contribute from that to developing countries. In addition, the fact that a little also goes such a long way continued to provoke one’s thinking and question whether one could overcome ghosts of the past. I think that you go into surgery partly enjoying the challenge of dealing with difficult situations. There was definitely a part of me that was challenged to go back and also be part of a global response which had been so lacking at the time of the genocide. But there was also the challenge to deny those ghosts any further licence. Part of me needed to know that I could do that. Gisenyi is a small town right on the Rwandan Congolese border. It has a 300 bed hospital which has not been repaired since the genocide. It was, and is in a serious state of disrepair. It serves a catchment area of over a million people on both sides of the border. It is seriously understaffed both with doctors and nurses. The team of 13 from Australia/New Zealand/ England/America and South Africa that I led was mostly nurses, although we had a physiotherapist, pharmacist and hospital administrator. Having worked in Africa previously I had some insight into what to expect. To say that the rest of the team were shell-shocked on the first day would be an understatement. However, the camaraderie and the desire to make a difference made that one of the most memorable two weeks for all the team and myself. And out of that experience came the realisation that more should and could be done. Although it would be fair to say no one was quite certain how. What then was needed was a calculated assessment of where there
was maximum benefit. The following year a small group went back to the same hospital for two weeks. While working in the hospital a truck lost its brakes coming down the hill and went through the hospital fence overturning and trapping eight people underneath it, including five children who all died. Coming out of the theatre all that we could do was to organise the townspeople to get the truck off the dead and place them in the morgue. Given the injuries that they sustained the facilities would not have been adequate to have treated them had they survived. We quickly realised that ours was far from an ideal contribution in addition to which,
surgical education. It was proposed therefore that a seminar/conference be arranged to be held in Kigali to cover at a postgraduate level, medical and surgical emergencies. After discussions with the Dean at Flinders University in South Australia a memorandum of understanding was struck and the task of finding a group of specialists in medicine/anaesthetics/surgery to teach began. My initial feeling was that with a group of seven specialists we could successfully stage a twoday seminar. When we began our search through various contacts, we secured a Professor of Medicine from Arizona, a Canadian Anaesthetist, an
“Then there was the wilful replacement of personal goals to go where the need is greatest, something that is also often difficult to fit in with being a single parent.� there were no theatre lights, hygiene was nonexistent, the steriliser was broken and the power frequently went out. Everyone you had to treat as being HIV positive. One also had the feeling that any changes that were initiated in terms of surgical technique needed ongoing supervision to become accepted practice. We needed to find a more effective way of helping. From this humble beginning Specialists without Borders grew. Initially we had no idea whether there would be any like-minded people who were at that point in their lives where they wanted to and could give up some of their time to help those who are less fortunate. After discussions with the Dean of the medical school in Rwanda, it was decided that one of the areas where there was most need was postgraduate medical and
Italian Immunologist, a Tasmanian Dentist, and seven surgical specialists from Australasia covering ENT/ Orthopaedics / Neurosurgery and General Surgery. We also had five nurses who were going to conduct a separate nursing seminar. In the end we were oversubscribed and had to say no to seven of our colleagues/ specialists. The response of so many who wanted to help was in itself an endorsement of what we were trying to achieve. Trying to coordinate a conference from so far away has its challenges. Asking 13 of your more esteemed colleagues to attend and lecture when you have no idea of what the turnout is going to be like or the conference facilities is daunting to say the least. But it was clear that they had great faith in the concept SURGICALLife
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FEATURES and were prepared to pay their own travel and accommodation. This provided great encouragement in spite of the organisational difficulties. The conference was attended by 100 African doctors, and the nurse’s conference by 90 nurses. Our evaluation carried out at the end of the seminar indicated an overwhelmingly positive response. The doctors and nurses/specialists who participated also felt that they were meeting a significant need in terms of education and that this was a concept which should be developed and sustained into the future. The team that had formed by that stage was then invited down to the medical school at Butare. This is about a 3 ½ hour trip from the capital Kigali. Both doctors and nurses
“Then there was the wilful replacement of personal goals to go where the need is greatest, something that is also often difficult to fit in with being a single parent.”
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then involved themselves with Ward rounds and teaching over two days before returning to Kigali. The experience of sharing with a group of consultants, who are all likeminded in wanting to improve medical education by giving of their time and effort should not be undervalued and is perhaps best summarized by Kate Drummond an Australasian neurosurgeon who participated in the last seminar in Kigali."What a joy it was to interact with colleagues who work in such a different place but with whom we had so much in common in terms of clinical, personal and training challenges. We could all have so much to offer each other in the future.” The success of the seminar has led to a request to return and with the development of the organisation Specialists without Borders and a request for further medical/ surgical education seminars in Cambodia/Honduras/ Mongolia and the Pacific. SWB as the organisation is now known has evolved to have a National Australasian executive and the growing international database of specialists and all aspects of medicine and surgery as well in nursing and Allied health. SWB is a not-for-profit organisation registered with the Australian Securities Commission with a request lodged for Australian Aid status. An educational baseline has been now developed, from which the current consultants are able to input the level of medical education required in the future and contribute to an evolving curriculum. Professional and personal relationships have developed which will allow the ongoing exchange of medical information, and the exchange of African/Asian/Pacific doctors in specialty training. It is hopeful therefore that the current format will be able to be developed into an even more effective model in the future given the significant input of both consultants/specialists and the
feedback from participating doctors. Having input from those specialists who have participated has been invaluable in developing Specialists without Borders. I think it would be fair to say that all are keen on seeing a return on their investment of time and money. There is a need to see that what is being done has an impact, and what is being offered is of the highest standard. The appointment of an educator from Flinders University to oversee the quality of teaching has been one of the innovations. Ongoing assessment of knowledge at the completion of seminars to test the development of those doctors attending is another. The establishment of relationships with colleagues in developing countries has opened up the opportunity for assisted exchange of young doctors. The request for our faculty to provide personnel to assist in examination and assessment of medical students in developing countries has also been a commendation of the level of teaching provided. Perhaps the most surprising aspect of this to me, was the number of people who are prepared to offer something back and who are prepared to endure the personal and financial challenges to do that. What was also surprising was not only that there was a growing number who on learning about what we do want to join us, but that one hundred percent of the original team want to go back and contribute more. But then again I suppose it should not be too surprising. For many this is the motivation in doing medicine and we as an organisation are merely facilitating an effective way of dealing with the original desire to help people.
Dr Paul Anderson is a director/ founder of Specialists without Borders and is a consultant upper gastrointestinal surgeon in Adelaide. MBChB, FRACS, FRCS (Edin), PhD, MA www.specialistswithoutborders.org
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Conrad Ramstedt
MEDICAL LEGENDS
Conrad
Ramstedt
been relieved. I still tried, however, Monday 23rd to accomplish the plastic procedure August 2010 was a by transverse suture of the muscle warm winter’s day edges. However, the tension on the in Melbourne. Ninetysutures was so very strong that the nine years ago the 23rd first one cut through immediately. August was a Wednesday. Then the thought shot through my In Münster, a surgeon was head, "A plastic alteration of the cut performing an operation on a baby edges is completely unnecessary; who had Congenital Hypertrophic the stenosis seems to be already Pyloric Stenosis, The boy would have relieved by a simple splitting of the been less well than the resuscitated pyloric muscle and coincidently infants we see in the 21st century; he would have been severely dehydrated st 2010 was warm winter’s day in Melbourne. Ninety-nine years ago the thespasm as well, which is the characteristic basis of the disease." and malnourished. Conrad Ramstedt, Wednesday. In Münster, a surgeon waswhoperforming on a baby I did not complete the plastic had changed an the operation spelling of his operation on the muscle which had l Hypertrophic Pyloric Stenosis, The surname boy would been back less towell than from have Rammstedt st been originally planned, but left that of his grandfather, was probably ants we see in the 21 century; he would have been severely dehydrated the cut gaping, covering it with a more focussed on the infant under his Conrad Ramstedt, who had changedcarethethanspelling of his surname from tab of omentum for safety's sake family history, particularly and ended the operation. The little that of his grand-father, was probably focussed infant under as more he was strugglingon to the complete one vomited a few times for the first what was then accepted procedure of history, particularly as he was struggling to complete what was the then few days which I attributed to the pyloroplasty. In his own words: of pyloroplasty. In his own words: sutures placed at the beginning, but he recovered promptly and 'At the laparotomy on August completely to the great joy of his 23, 1911, I was astonished at otomy on August 23, 1911, I was astonished at the pyloric tumour as parents.’ the pyloric tumour as thick as humb. After I had split the tumour down tomythethumb. mucosa for a distance of After I had split the I had the impression that the stenosis had beendown relieved. I still for tried, Professor Ramstedt performed this tumour to the mucosa a accomplish the plastic procedure by transverse muscle operation for the second time on 18th distance ofsuture about 2 of cm.,the I had the impression that the the stenosis ver, the tension on the sutures was so very strong that first onehadcut June, 1912, and in September of that
“Conrad Ramstedt, who had changed the spelling of his surname from Rammstedt back to that of his grandfather, was probably more focussed on the infant under his care than family history.”
Conrad R
diately. Then the thought shot through my head, "A plastic alteration of is completely unnecessary; the stenosis seems to be already relieved by ting of the pyloric muscle and coincidently the spasm as well, which is istic basis of the disease." I did not complete the plastic operation on hich had been originally planned, but left the cut gaping, covering it f omentum for safety's sake and ended the operation. The little one w times for the first few days which I attributed to the sutures placed at g, but he recovered promptly and completely to the great joy of his 30
SURGICALLife
MEDICAL LEGENDS
year reported these two cases to the Natural Science Assembly at Münster. In the first decade of the 20th Century many advances were made and likewise in the second decade. In January 1911 the Northern Territory separated from South Australia, June saw the coronation of King George V in England, July the rediscovery of Machu Pichu in Peru, and on 22nd August the Mona Lisa was stolen from the Louvre. Ramstedt would have been aware of the rising tensions that led to the First World War and, on 23rd August may have read of the Norwegian Roald Amundsen’s impending arrival at the South pole on 14th December. In 1911 Pyloric Stenosis was a condition that was only just starting to be understood. Yet Ramstedt managed to develop a solution that is largely unchanged to this day. Others had made a contribution that Ramstedt was aware of. Four years earlier, Fredet, in France on October 12, 1907, performed an extra-mucosal splitting of the pyloric muscle, similar to the operation undertaken by his German counterpart
Weber on December 3, 1908. Fredet had recognised the advantage of not incising the mucosa as Weber had recommended, but failed to realise that the muscle splitting was curative, only abandoning the gastroenterostomy ten years after Ramstedt’s insight. Ramstedt was born on 1st February 1867 in the central Prussian village of Hamersleben, Germany, as the son of a physician. He studied medicine in Heidelberg, Berlin and Halle, from where he graduated in 1894. He worked in Halle from 1995 to 1901 before joining the German army in which he served with distinction during the First World War. Following discharge in 1919, he became chief surgeon to the Rafael Klinik in Münster.
contributed to medicine in other ways, he will be remembered as a hero for the realisation that pyloric stenosis can be treated by splitting the muscle. Ramstedt died on 7th February 1963, in Münster, having been immortalised by a bust made by his daughter, Tessa.
Professor Paddy Dewan,
MBBS PhD MD MS BMedSc MMedSc MRACMA MAICD FRCS FRACS Paediatric Surgeon/ Urologist
Apart from the five articles he wrote on Pyloric Stenosis, Ramstedt's main contributions to the medical literature are chapters on the male genito-urinary organs which he wrote for Handbuch der praktischen chirurgie edited by Bergmann, Bruns and Mikulicz in 1927. Although he
Ramstedt SURGICALLife
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BUSINESS & FINANCE
Express your individuality in the world of investment choice “What should I do with my money?” Most financial advisers, when asked this question by a client, adopt the traditional approach of investment in managed funds, typically accessed through what is termed a master trust or wrap platform.
T
his recognises that the financial adviser, in implementing wealth creation structures and strategies for you, requires the services of a professional investment manager (accessed through a managed fund) in the day-to-day management of your money. Managed funds involve the pooling of assets for a large number of investors into a single fund that is then invested on their behalf, with returns allocated based on the number of units held. Such an approach undoubtedly is of advantage for smaller investors
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given the benefit of professional management and access to investment opportunities they would otherwise miss. “But I don’t think managed funds are for me?” The managed fund approach has its shortcomings, the most common of which are tax and transparency related. If an investor buys units in a managed fund just before the fund sells a stock which, for example, has doubled in value, the new investor is hit with a capital gains tax liability immediately. And, in
BUSINESS & FINANCE the ongoing management of the fund, the investment manager at no time makes decisions having regard to each investor’s tax position. It is often said tax is an investor’s greatest expense. Yet you are paying a fee to the fund without this being considered. As a consequence, larger investors take a different approach, that is, to invest directly. This is typically done either: • on a do-it-yourself (DIY) basis (e.g. buying and selling shares over the internet), • through a stockbroker (what is termed an advisory relationship – the stockbroker will make a recommendation to you and you agree or not to go-ahead with that decision); or • via a financial adviser (again on an advisory basis with the financial adviser, acting as an intermediary and/ or sounding board, usually transacting on your behalf through an on-line broker or stockbroker). Whilst this comes with the benefits of direct ownership i.e. clear entitlement to franking credits attaching to shares, flexibility of making buy and sell decisions according to your tax position etc., it does not come with the benefits of professional investment management afforded by managed funds. These encompass skills in constructing portfolios, day-to-day active management of portfolios, the applied research in terms of stock selection and access to macro-economic data which can play a part in decisionmaking. These direct approaches are the domain of DIYers who are willing to take an active interest in their investment affairs and accept overall responsibility for performance of their portfolio, as at no stage do any of the other parties take on this responsibility. “I like the direct investment approach but am a doctor, not an
investment manager – and just don’t have the time or experience “ If having a professional investment manager to take responsibility for the management and performance of your very own portfolio has appeal, don’t despair. There is another option -a Managed Account. A Managed Account, initially developed in the US, is an account whose key feature is that the underlying assets are held personally by the investor. It does not involve pooling of assets or you being a unit holder. You have your own portfolio, with holdings in your own name. Managed accounts come in various forms, the two most common of which are a Separately Managed Account (SMA) and an Individually Managed Account (IMA). The essential difference between the two is the legislative framework which governs the operation of each. A SMA is accessible much like a traditional managed fund through a Product Disclosure Statement (PDS). A SMA is thus a “ununitised managed fund”, whereby you have a portfolio of directly held investments managed by a professional investment manager who uses a model portfolio approach, implementing the same investment decisions across all accounts generally without taking into account your personal circumstances. A SMA is viewed as an alternative to the traditional managed fund. It is typically seen as being at the lower end of the value scale given it is a managed fund replacement. “OK, I am interested but I want something with a fuller service offering allowing for my own circumstances now and in the future” This is where an IMA fits in. An IMA is a portfolio management service for high worth clients, whereby the professional investment manager implements decisions across your portfolio, based on the mandate you have agreed with them and with full consideration of your personal circumstances. Some of these relate not only to your tax position but also to
“Such an approach undoubtedly is of advantage for smaller investors given the benefit of professional management and access to investment opportunities they would otherwise miss.”
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BUSINESS & FINANCE
“An IMA is not for everyone. It suits an investor who has or is coming into some wealth but does not have the time, inclination or experience to run their money – yet wants a couple of professionals to run it, as they would like it run.”
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your investment preferences (e.g. as a doctor, you may not want to invest in a tobacco company from an ethical perspective). With an IMA provider, you will also not only have access to an investment management capability customized to your unique situation but also to a financial advisory offering. This means any financial advice around structuring and strategies is closely aligned with the mandate attached to managing your money. It all happens under the one roof. These roles are separate with SMAs, as exemplified by the fact that financial planners use SMAs in place of traditional managed funds i.e. as a product replacement, not a change in service offering. The overall relationship with an IMA provider is more akin to a “family office” style arrangement, where any issue attaching to the client’s financial affairs can be coordinated at this level, given the knowledge of the client. An IMA is not for everyone. It suits an investor who has or is coming into some wealth but does not have the time, inclination or experience to run
their money – yet wants a couple of professionals to run it, as they would like it run. Essentially it is a Do It For Me offering as opposed to Do It Yourself. “I like the sound of this IMA . But what are the negatives? ” Hard to find once you accept the fact that entrusting an IMA provider to manage your money is not dissimilar to giving over your money to a managed fund-just that with an IMA provider you can actually see what you own ! One of the disadvantages floated within the industry is that, for the IMA provider, the individualised nature of the service can mean IMAs are labour-intensive. It is said IMA providers don’t possess the economies of scale in transacting on your behalf that more mass market SMAs and managed funds have. Whilst perhaps justifiable in certain circumstances in the past, technology has served to level the playing field in recent times – as is the case with technology in general. And will only continue to reduce the cost of delivering this offering as the popularity of IMAs grows. • So, if you tick yes to the following: • an individually tailored portfolio; • the benefits of direct share ownership; • attention to and consideration of your tax position; • a transparent fee structure; • all paperwork attended to by someone else; • easy accessible on-line reporting; • access to your own portfolio manager as well as financial adviser under the one roof; and • no tax impact if you wish to change service providers, given stocks are in your name an IMA is hard to beat.
Geoff Greetham, BEc , CFP, CPA Geoff is a co-Executive Director of Accordius, a privately-owned personal funds management business, based in Melbourne.
Nurturing your medical
wealth How personal are your investments? Are your investments tailored to your needs? Do you always know what you are invested in? Are your investments structured to allow for effective tax management? Are you aware of all the fees being charged against all your investments? Is the person making investment decisions on your behalf a full time fund manager or just a relationship manager? Do they do their own research or just follow the recommendations of others? AT ACCORDIUS we know that you have worked hard to create your wealth. We work one-to-one with our clients providing them with Individually Managed Accounts that are tailored to maximise returns. We have the flexibility to either work with your own financial advisor or, if required, provide high quality, unaligned advice. We believe in complete investment transparency. You can see every transaction made on your behalf.
Dr Paul Kasian
Fiona Hinrichsen
Hamish Moore
Geoff Greetham
If answering yes to the above questions is important to you then you should
CALL us at 03 8623 3368, EMAIL us at pkasian@accordius.com.au or ggreetham@accordius.com.au or VISIT www.accordius.com.au.
7 TOP
mistakes made by
surgical practice owners
How you can avoid them
“We all get so obsessed with ‘productivity’, we fail to take time for business growth, staff training, business development, cost reduction, marketing, process optimisation etc.”
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he title of this article is not new. In fact, there have been a few ‘common mistakes’ articles written for doctors in the past. Almost without exception, these articles highlight deficiencies in medical practices with the intention of upselling items such as insurance coverage, practice loans, equipment finance and other financial products. This is not my intention. I am simply listing the most
BUSINESS & FINANCE common business mistakes I have identified when I have consulted with practice owners. The reasons why most medical businesses of all specialties make the same set of mistakes even though they provide different services are: 1. The Principal Medical Specialist is the chief service provider as well as the business owner and is responsible for many of the important business functions. 2. The business consists of core functions (provision of medical services) and non-core functions (administration, marketing, IT, book-keeping, accounts, telecommunications, business development, billing etc) which are mostly performed in-house or sometimes outsourced. 3. There are usually both revenue-earning (medical) and non-revenue earning staff (non-medical). The ratio of these is critical in determining the scalability of the whole business operation.
1
Trading Under the Incorrect Corporate Structure
Choosing the correct structure for your medical practice is vital from day one. The two main reasons are asset protection and tax efficiency. The corporate structure of your practice is the financial foundation that will govern how much wealth you are able to generate and retain from your business. It is extremely important to “begin with the end in mind”. We find it gut-wrenching to see medical specialists who take huge tax-hits after all those years of gruelling study and hard work, simply because they did not take the time upfront to ensure their corporate structure suited their business operation and growth plans. In general, the options will involve some combination of trusts and companies but the exact tree and arrangement of these should be determined by a good accountant prior to even starting your business. If you are already operating under one structure and find out that this is not the best structure for you, rolling over to another business structure may have Capital Gains Tax implications. You should source an accountant with experience in structuring medical practices.
2
Working ‘in’ the Business rather than ‘on’ the Business
Most business owners are guilty of this. It’s a classic case of missing the wood for the trees. We all get so obsessed with ‘productivity’, we fail to take time for business growth, staff training, business development, cost reduction, marketing, process optimisation etc. What is the solution? Aim to spend at least one half day a week on
developing your business. This will pay greater dividends in the long run, reduce the amount of time you spend putting out fires and also help reduce your business-related stress.
3
Poor Internal Reporting & Business Measurement Systems
One of the key differences between a ‘mum and dad business’ and a professional practice is the implementation of systems and processes that capture vital data about the business, and the use of internal reporting to measure profitability, efficiency, and client satisfaction.
“One of the key differences between a ‘mum and dad business’ and a real business is the use of internal reporting and financial statements.” Very few medical practice owners realise the importance and utility of producing regular internal reports. Making this mistake, not only prevents your medical practice from reaching its full potential but it could potentially lead to unforeseen catastrophic consequences. At a minimum, medical practices should be publishing the following reports for dissemination across all business stakeholders on (at least) a monthly basis: 1. Numbers of New Patients categorised by Source/ Referrer. 2. Gross Revenue (total billings invoiced) and Cost of Sales - For Medical Practices, Cost of Sales are usually the cost of equipment/ consumables. In addition to the above, the following reports should be monthly: 1. Percentage accounts remaining unpaid at 30 days, 60 days, 90 days 2. Revenue brought in per doctor (If a multi-doctor practice) 3. Previous Financial Year Income vs Current Financial Year Income (for the same quarter) 4. Previous Financial Year Expenses vs Current Financial Year Expenses (for the same quarter) 5. Cash Flow Statement – Incoming Cash versus Outgoing Cash – a critical statement to avoid short term cash crises Also highly recommended on a quarterly basis are:
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BUSINESS & FINANCE 6. Referrer Satisfaction Survey 7. Patient Satisfaction Survey 8. Website Analytics 9. Competitor Pricing analysis 10. Benchmarking against other specialists with similar patient demographics and case mix comparing income and expenses. Once you have engaged a good medical accountant they should be able to help you implement systems to efficiently capture and review this vital business information.
4
Employee Mismanagement
Most doctors employ staff for the first time when they run their own medical practice. Up until this point they have been used to working with colleagues in hospitals where the working relationship was very different. Upon first becoming an employer, many
“Not preparing an adequate succession plan in the event of the departure, intentional or otherwise, of that employee is setting yourself up for potential disaster.”
practice owners make the mistake of either trying to be ‘best friends’ with their rooms staff or becoming tyrants to them. Both of these are maladaptive and can result in early resignation. It is all too common to see medical practice owners who believe they have something unique and that their employees are totally devoted and loyal to them; it’s a myth. Every employee has a flight risk. Failing to document the core processes of the business and failing to implement an adequate succession plan in the event of the departure of that employee, equates to setting yourself up for potential disaster. There are three things that every practice owner should do immediately, unless they already have something of this nature in place: • Document core business processes for all staff – From client enquiry to receipt of payment, the core processes and tasks of your business should be documented. Ideally this will be in a flow-chart or matrix format where each task/ step is noted and responsible staff member identified. Key suppliers and other third-parties should also be identified. One way of achieving this is to ask your employees to document the key processes they perform as this will re-enforce their understanding of the operations of the practice and will often highlight inefficiencies that can then be addressed. • Succession Planning – create a contingency plan in the unlikely event of the departure of every critical employee. This may consist of having the employee teach another staff member all the critical operations of the business and more importantly everything they do, all the protocols they follow, all the important contacts and contact details and all usernames and passwords. It sounds like an enormous chore, but it will potentially reap dividends in the unexpected sickness, departure, absence of the critical employee. It is hard to emphasise the importance of the above steps in such a small section and we could easily devote a whole article to these topics alone. • Create career progression for every staff member – make them feel that they are not doing a repetitive, mindless task but a valuable job with training and career progression opportunities: - I would recommend holding a performance review for each staff member once a year where they can self-assess their progress and write their goals for the year to come. - Be generous when paying including training sessions
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BUSINESS & FINANCE for computer software training, business training, and management training for your staff members. The benefits go beyond what is immediately obvious in their newly acquired skills as their morale and sense of loyalty is often massively boosted.
5
Lack of Business Planning
If you fail to plan, you plan to fail. A commonly used cliché but very applicable to the medical profession. The vast majority of doctors never write a business plan and so have never committed any goals to paper. The lack of planning is not necessarily the problem, it is the failure to set, and adhere to goals. At a minimum of at least once annually, all specialists should review and contemplate: • Pricing Strategy - Prices sufficient to allow an ongoing, sustainable profit but not excessive as to be uncompetitive • Patient satisfaction • Other stakeholder satisfaction • Growth of their practice – taking on additional staff (medical or administrative) or marketing to improve the quality and quantity of their leads • Operational Processes review – is there an opportunity for cost reduction? e.g. telecommunications. Is there an opportunity for process optimisation?
6
Poor Billing and Debt Control
Medical practices are one of the worst offenders in chasing their debts. Some practices even have default rates of over 30%! There are many reasons for this: • Doctors and their practice staff are uncomfortable talking to patients about money • Patients are often unable to pay because they are genuinely hospitalised and have no access to bank facilities • If there has been a less than perfect outcome, many doctors ‘forget’ to chase the debt as they believe this will reduce the chance of complaints or litigation • Doctors feel compassion and sympathy for their patients and don’t want to pursue legal action or use debt collection agencies if the patients default • Fears of litigation, complaints or bad blogs on the internet are also likely to play a part in reducing the zeal with which medical practices chase up bad debts.
However, what I would suggest is that a ‘Debt Collection Strategy’ is documented, agreed upon by all stakeholders, including a set of defined reasons when debt collection will be waived, and that this is adhered to at all times.
7
Failure to Leverage the Business Doctors in Australia are taught their craft to an exceptional level ensuring excellence as practicing clinicians. However, there is paucity of
“Medical practices are one of the worst offenders in chasing their debts. Some practices even have default rates of over 30%!”
business education in most specialist training programmes and this creates a knowledge gap which is hard to plug. Medical practices which provide outstanding services, have excellent patient satisfaction and have long lists of patients waiting to access their services suggests that there is significant opportunity for leverage. Without taking on additional clinical staff, the business operation has reached capacity and so the earning potential is now at its maximum. Many medical practices feel contented they have reached this point and are fearful of scaling their practice to capitalise on their high patient flow. Leveraging is recognising that demand outstrips the capability to supply and that this presents to take on associates with the potential for cost sharing and even revenue sharing.
Simon Lucas CA, AFP is a Medical Wealth Strategist at MEDIQ Medical Financial Services and advises medical practices and individuals on structures, accounting, taxation & finance. Visit www.MEDIQfinancial.com.au to learn more tax and finance strategies for Surgeons and access three additional financial mistakes made by medical practice owners at www.MEDIQfinancial.com.au/surgeons
It is hard to suggest a single strategy which is applicable to all practices as this will heavily depend on the type of patients encountered, the range of services performed and the individual philosophies of the doctors involved. SURGICALLife
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Income Protection Insurance Learn how to save 10s of $1,000s and even over $100,000 in income protection insurance payments with strategies to keep you covered your whole working life and keep your money in your pocket.
Y
OUR income is worth protecting and in your profession seeing illness and injury first hand the importance of income protection is highlighted every day. As a medical professional, it’s incredibly important to obtain the best income protection policy for you. A good policy covers you for blood borne diseases, allows you to keep an eye on your business for up to 10 hours each week without penalty and covers you for total or partial disability. Let’s look at how you can save on your income protection policy without compromising on benefits and features by firstly concentrating on payment structure and then on a two policy tailored strategy.
Payment Structure – Cost Reduction Strategy Stepped premiums are great in the short term, though will end up costing you a lot more in the longer term than level premiums.
Stepped Premiums
Sometimes you are only told about stepped premiums as these are the cheaper option, at least initially. However, over time as you receive your renewal notice in the mail, you start notice that the policy premium increases more than CPI. This is an age based increase and is only a few percent in your thirties, a little more in your early forties. In your late forties and beyond, the cost of your insurance
will become so high that you may be forced to either reduce your benefit or cancel the cover all together. This potentially leaves you without the required cover at a time when you need it most.
Level Premiums
Level premiums are designed to remove the age based increases and therefore do not have the dramatic increases in cost over time. Level Premiums usually cost 50% more than stepped premiums however as you will see, Level premiums give you the certainty of knowing what you will pay for your insurance up to age 65 or 70.
CASE STUDY Dr Joseph Smith is 40 years old and is married with 2 children aged 4 and 2. His family has one income. He plans to send his children to private school and possibly to assist them through university. He is a physician and works as a sole trader and his business shows a profit after uninsurable expenses of approximately $250,000 per annum. Joseph wishes to insure his income.
OPTION A – ONE POLICY As an industry standard, Joseph can only insure 75% of his income which is $18,750 per month. He has been quoted for a policy that after waiting 30 days, pays a benefit until SURGICALLife
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BUSINESS & FINANCE
age 70 with CPI on claim. Policy 1 - $18,750 per month, 30 day waiting period, benefit period until age 70, CPI on claim. The stepped premium cost of this policy is around $4,900pa. Please refer to the red line on the chart to note the increase to income protection insurance premiums over time. As you can see by the time Joseph is 50 his policy will cost him around $11,100pa
differing waiting and benefit periods can reduce cost and allow you to meet your insurance needs. Let’s explain these terms before we proceed with the example. The waiting period is the time that needs to pass after the commencement of your accident or illness before you start to receive a benefit from the insurance company. This can range from 2 weeks to 2 years. This may reflect the period of time that you can manage because of leave, annual leave, savings etc. that you have without needing an income protection benefit stream. The longer the waiting period, generally the less expensive the insurance premium will be. The benefit period is the period you will continue to receive an income protection benefit in the event that Joseph was then provided a quote for level premiums for the same policy for $7700. The level premium you are unable to work due structure works out to be HALF the cost of the stepped premium structure if the policy is held for the and at 54, it will cost $14,800pa. to illness or accident. This can be for duration. In fact using the graph as an example, although a stepped premium is cheaper initially, its evident These costs concerned Joseph as at a set period (i.e. 2 or 5 years) or until that in your late 40’s you could be paying the same amount for your insurance premiums than you would for the level premium policy. If you hold your income protection policy into your 50’s, the cost of a stepped 54, his children will be aged 18 and a set age (i.e. to age 55, 60, 65 or 70). premium policy grows above and beyond the level premium. 16 and will still be fully dependent on The choice of which benefit period is SAVINGS TIP him. He is concerned he may be forced suitable to you reflects your income to cancel the cover due to cost. protection goals and objectives. The If when asked “how long you see yourself needing income protection?” and the answer is 10 years or more, then you should consider a level premium structure for your policy as it will more than Joseph was then provided a quote longer the benefit period, generally likely be cheaper in the long term. for level premiums for the same the more expensive the premiums will policy for $7700. The level premium be. Waiting Period and Benefit Period – Cost Reduction Strategy structure works out to be HALF the A TWO POLICY option that has differing waiting and benefit periods can reduce cost and allow you to meet your insurance needs. Let’s explain these terms before we proceed with the example. cost of the stepped premium structure OPTION B - TWO POLICIES TAILORED if the policy is held for the duration. TO YOUR NEEDS The waiting period is the time that needs to pass after the commencement of your accident or illness before you start to receive a benefit from the insurance company. This can range from 2 weeks to 2 years. This may In fact using the graph as an example, reflect the period of time that you can manage because of leave, annual leave, savings etc. that you have without needing an income protection benefit stream. The longer the waiting period, generally the less although a stepped premium is Joseph thinks that he can survive expensive the insurance premium will be. cheaper initially, it’s evident that in on savings and his LOC and $10,000 The benefit period is the period you will continue to receive an income protection benefit in the event that your late 40’s you could be paying per month in the short term. He you are unable to work due to illness or accident. This can be for a set period (i.e. 2 or 5 years) or until a set age (i.e. to age 55, 60, 65 or 70). The choice of which benefit period is suitable to you reflects your income the same amount for your insurance wishes to consider a waiting period premiums than you would for the of 30 days for $10,000 per month and level premium policy. If you hold your a staggered 90 days for the balance income protection policy into your of $8,750. That way, if he has a long 50’s, the cost of a stepped premium term disability, he will receive the full policy grows above and beyond the benefit after 90 days as the policies level premium. run in tandem. Considering he plans to send his children to private school Waiting Period and Benefit Period and possibly to assist them through – Cost Reduction Strategy university Joseph needs the full cover until this time. After the age of 60 he A TWO POLICY option that has and his wife may be empty nesters
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and he believes they need only $10,000 per month until age 70. Let’s see how this two policy option can save you. Policy 1 - $10,000 per month, 30 day waiting period, pays this benefit until age 70. Policy 2 - $8,750 per month, 90 day waiting period, pays this benefit until age 60. Both with CPI on claim. The stepped premium price for both of these in total is $4,165 pa and increases each year. Alternatively, the level premium here is $6,335pa. As you can see in the tables comparing Option A and B, Joseph has a cheaper option that covers his needs using this two policy strategy combined with level premiums. By tailoring your income protection policies to your needs and considering level premiums, you can afford to be comprehensively covered over your working life and save over half the possible premium cost based on the standard stepped one policy option. Carolyn Wright, Partner, Insurance Advisor at Life Shield Pty Ltd. Carolyn has had experience across a broad range of financial services and now concentrates on advising professionals how to have a complete and cost effective insurance strategy that meets their needs now and over the longer term.
This material is not intended to constitute personal advice and must not be relied upon as such. This material is of a general nature only and has been prepared without taking into account your individual objectives, financial situation or needs. The example provided is an indication only and these are not personal quotations or firm market pricing. You should consider the appropriateness of this material having regard to your objectives; financial situation and needs, before making a decision based on this material, and consider obtaining independent advice from a licensed financial adviser. You should read the relevant Product Disclosure Statement before making a decision about whether to acquire a product. Life Shield Pty Ltd ATF Life Shield Trust is a Corporate Authorised Representative of Millennium3 Pty Ltd FS ABN 61 094 529 987 (AFSL No. 244252)
Surgeons visit visit Surgeons
Health Professionals Professionalsgo go to to Health www.lifeshield.com.au www.lifeshield.com.au www.lifeshield.com.au Surgeons visit www.lifeshield.com.au
Health Professionals go to44 or call call 1300 1300 44 77 77 10 10 or www.lifeshield.com.au www.lifeshield.com.au or call 1300
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We understand Surgeons. WeWe understand Surgeons. have the experience and knowledge required to provide Wean have the experience and knowledge required to provide efficient and professional service.
an efficient and professional service.
on.
Markergticinalg your su
practtiailce
to poten referrers
Why do GPs refer their patients to certain Surgeons and not others? New referrals are the lifeblood of all surgical practices. No matter what surgical subspecialty you perform, you can not rely solely on your existing patient base. You will always lose patients by attrition and you will need to bring in new referrals to maintain your income. Your ability to generate new referrals from referrers depends on relatively few factors and is very malleable. In fact, a Surgeon with a little marketing insight can perform a couple of minor tweaks which can profoundly alter the number of referrals they receive.
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“A Surgeon with a little marketing insight can perform a couple of minor tweaks which can profoundly alter the number of referrals they receive.”
B
efore we discuss how to perform those tweaks, let us look at which factors influence the number of referrals you receive: The honest truth is, there are relatively few variables at play here. From the most influential to the least influential factors in how referrers decide where to send their patients: • Financial Incentives (Highly Illegal) • Nepotism (Highly Unethical) • Your professional reputation with the local referrer population (usually GPs but could also be specialist physicians depending on the area of practice) • Whether your Practice Name/ Brand Name is ‘Top-Of-Mind Awareness’ for the referrer • How simple the referral process has been made for the GP As you can see, apart from financial kickbacks which are highly illegal and nepotism where referrers send patients to their own relatives/ friends, the science to generating referrals is quite transparent. There are only three real factors dictating to whom the GP (or other doctor) will make the referral. Let us deal with these individually. Most Surgeons have the naïve (almost idealistic) viewpoint that doctors make referrals to them because
of their professional reputation. This is the “perceived wisdom”which has been passed down from Surgeon to Surgeon, when in reality, very few referring doctors truly know which Surgeons obtain better results or have better clinical outcomes for their patients. The only exceptions to this rule are Surgeons who are so notorious because their reputation is outstanding or abhorrent. The next important point to make is that GPs/ Physicians would not know the names of all or even half of the specialists covering their catchment area. Believing that GPs will make a referral to you based on eminence and reputation is perhaps one of the biggest untruths peddled in medical history. GPs will only know the name of a limited number of specialists in each specialty and the one they choose to refer to is usually the one that is ‘Top-of-Mind’. ‘Top-of-Mind Awareness’ or TOMA, is a marketing term used to depict how most people make purchasing decisions in a state of equilibrium or near equilibrium. For example, if you were choosing which brand of fridge to buy and all factors such as cost, utility, convenience were equal, the you will probably choose the brand you are most familiar with (i.e. was the ‘Top-of-Mind’ brand for you). The referrer is put in a similar situation when making their referral decision. SURGICALLife
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BUSINESS & FINANCE They will usually know the names of a handful of specialists of any particular subspecialty and as long as they haven’t had a bad experience with them, they will probably believe that all of them would make suitable choices to send their patients to. However, the Surgeon that he actually sends the patient is usually the one which is ‘Top-of-Mind’ because it is more familiar to him. The final reason that a GP may
“Believing that GPs will make a referral to you based on eminence and reputation is perhaps one of the biggest untruths peddled in medical history.”
refer to one specialist over another is because the referral pathway to that specialist is easier than the others. Most humans when confronted with making a decision will often take the path of least resistance if all other factors are equal. Radiology and Pathology companies have used this strategy to create a path of least resistance for GPs to refer, usually by providing a pad of forms where the GP now just has to fill in a few basic patient details, symptoms and simply tick the tests requested. By providing an immediately available form with a few tick box options to request the appropriate specialist service, they have instantly presented themselves as the path of least resistance. In addition, by having their pad within close reach of the referring doctor with their brand continuously displayed, they have probably also created ‘Top-of-Mind’ recall of their brand. Similarly, specialist practices colocated with large group-practice GPs, (or even very close to them) will also enjoy referrals based on the same principal. The path of least resistance has this time been created by geographic proximity. In summary, the goal of every specialist should be to: 1. Ensure their brand is ‘Top-of-Mind’ for all GP/ Referrer’s in their catchmen area 2. Ensure the referral process to themselves is the Path of Least Resistance for any given referrer 3. Ensure their professional reputation is beyond reproach
How Surgeons become ‘Top-ofMind’ 1. Ensure they have a strong brand 2. Ensure their brand is well known to their referral base 3. Ensure the referral process to them is as simple and painless as possible. If this is a pre-printed pad of re-
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BUSINESS & FINANCE ferral slips, their should be a clear fax number to send them If it is a business card with the name of the Surgeon and the name of the conditions he operates on, then this should have a clear referral mechanism stated e.g. Referral letter to be sent to …. fax/ email/ phone number. Another exercise worth mentioning, that every Surgeon should perform, is to find someone to call their rooms posing as a referrer and discover how smooth (or otherwise) your administration staff handles a referral and how pleasant the experience is for the referrer. 4. Ensure they ‘add value’ to the GP practice/ referrer. This can be by providing education seminars for GP Group Practices or by providing excellent letters to the GP advising them of what has been done. Acknowledgement goes a long way too and there are a whole host of ethical and legitimate mechanisms (which are beyond the scope of this article) used by successful Surgeons to acknowledge their appreciation to the referrer.
How Surgeons Kill their Referral Source There are thousands of ways to bite the hand that feeds you, but in my experience, these are the most common ways:
Failing to keep the Referring Doctor (usually the GP) informed. Let the referring practice or business know that the patient has been scheduled, that you appreciate the referral and that you will continue to communicate about what follows. Let them know often with regular progress reports.
Not seeing referred patients promptly. Referring doctors hate their patients’ care delayed the patient can’t get in to in a timely way. The time
to have because see you between
referral and consulting should be at an absolute minimum and the referring doctor should be kept updated. Any unforeseen delays should be discussed with the referring doctor to make sure (e.g. upcoming holidays), with the reasons explained.
Telling the patient (or the doctor) that the primary care diagnosis was wrong. Nobody likes to be wrong, especially doctors. And absolutely nobody likes to be told they were wrong. If your specialist treatment plan is different from what the patient or GP may be expecting, find a diplomatic way to communicate this to both. Talking in a condescending manner to the referrer (even if you believe you are helping him by supposedly educating him) is an absolute faux pas. A general practitioner will obviously not know your specialty as well as you does, so take care to communicate peerto-peer, as professional colleagues, in the care of the patient.
Giving the referring doctor the impression that you are stealing their patient. (The key word is impression.) Simple neglect, oversight or omission can create the feeling that their generous referral has made them lose a patient. So always send the patient back to the referring doctor and make it clear that they still remain in control of the patient (unless for some reason they no longer want to be). Referring the patient on to another specialist without consulting the original referring physician. When the best course for the patient is to see a different or second specialist or subspecialist, consult the primary doctor. It can be quite upsetting to some GPs to find out retrospectively that their patient has been seen by a second specialist with a belated letter from you stating, ‘I took the liberty of referring patient X to a surgeon….’
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BUSINESS & FINANCE Good diplomacy has many benefits.
Being unavailable when treatment is unsuccessful. The specialist who quietly fades away after a complication without recommendations for the next level of management leaves a bad impression and closes the door on future recommendations. If your operation or treatment plan has complications, make sure you keep the GP updated and make sure you don’t leave the GP to field the patient’s questions and phone calls. When doctors stop referring, there is no announcement. You will not get a telegram or fireworks ending a referral relationship. They just quietly stop referring. You may not even know what happened (or failed to happen). And worse, if a practice stops referring, they probably won’t tell you, but they may tell their professional colleagues. Your professional reputation may become damaged and you may quietly lose other referral sources.
“When doctors stop referring, there is no announcement. You will not get a telegram or fireworks ending a referral relationship. They just quietly stop referring.”
It can be very difficult to rebuild a relationship once trust or goodwill has been damaged. Sadly, it usually goes undetected when a doctor stops referring. Following a few simple but vital rules can help make sure your referral stream never dries out.
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
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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
Taking on risk for your
children
Inter vivos estate planning - The pros and cons of going guarantor and giving your adult children a ‘heads up’ in life.
W
e describe inter vivos estate planning as giving your family part of their inheritance while you’re alive to see them enjoy it. With the affordability of housing continuing to be out of reach, parents are increasingly offering financial assistance to children and their spouses, particularly to purchase residential property. Those of us who have children would all agree that helping them make the most of life’s opportunities is a great motivator to give, but sadly, many of us lack a body of objective experience against which to temper the nature and extent of our giving. People usually only have one case study to work from: their own experience. Occasionally, they will share the experience of other family members or close personal friends, but that too provides only a narrow view of the issues that need to be considered. The fine line that everyone seeks to identify is where constructive assistance ceases and where indulgence or waste begins. When it comes to providing financial assistance to our children we would recommend taking some of the emotion and personal bias out of the decision making process by seeking professional advice and employing an objective framework to find where that fine line is.
Some Ground Rules
There is no fashion in either inter vivos or testamentary estate planning solutions because the dynamics of each family are unique. There are, however, some ground rules that can help define how you should approach giving to your children.
Gifting or lending?
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There is a difference. Gifting places no responsibility on the donor and experience has shown us that frequently the donor’s expectations are not met. The X and Y generations have a reputation for being blasé, which often time leads their parents to believe they are being taken for granted. Experience in working with clients has shown us that gifting any more than modest amounts is counterproductive. In fact, we generally advise clients not to gift money to their adult children unless those children are parents themselves.
Children under 30? Only a lender be
It is strongly recommended that if your child is less than 30 years of age, you be a lender. The lending should be used not just to assist, but also to educate. The objective of the education is to leave adult children financially competent and with a healthy respect for their financial affairs. As a lender, you can choose to charge interest or not; to secure or not; or to demand repayment of capital or not. It is healthy to dis-intermediate within a family, in other words to cut out the bank wherever possible. If the parent has to borrow to provide the loan, they should not seek to profit by it, but only to be fully reimbursed for their expense. Parents can generally borrow at cheaper rates than adult children. For example, you can lend to adult children the funds to buy a car under the same terms and conditions as a bank loan, but take advantage of cheaper mortgage lending rates. If the parents are not borrowing to provide the loan,
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BUSINESS & FINANCE then the charge should be the interest they were receiving plus 50% of the difference between that rate and the rate the adult child could secure using their own resources. Where there is substantial assistance being provided for housing and there is an external lender, we advise that where it is affordable for the parent, that the loan be conditional to the extent that interest foregone be applied as voluntary additional payments to accelerate repayment of the non-deductible bank debt.
Documentation? Always put it in writing
Whether you are considering lending or gifting to your children, it is vital that it be properly and formally documented. The primary reasons are control, risk management and asset protection. It would be negligent of both parent and child to assume that there will never be any conflict that may create discord. Additionally, the fluid nature of relationships today means that others may become unintended beneficiaries in the event of divorce or relationship breakdown. Control triggers should be clearly outlined in documentation. For example, if a child accepts assistance from a parent to purchase a real asset and decides six months later to dispose of the asset, it is important that the parent’s interest in the property to the extent of the loan be documented formally to guarantee return of that capital.
Should the loan be stamped or registered against the asset?
There is no prescriptive answer to this question and it depends entirely on the circumstances. Generally though, if the loan is being made to purchase a real asset, such as a property, it makes good sense for the lender to register a first mortgage over that asset. The case study below examines what can go wrong if a child defaults on the mortgage and parents have not registered their interest.
Divorce and relationship breakdown
The Family Court hears most property disputes involving de facto spouses. With binding financial agreements becoming a favoured tool of high-income earners to mitigate the costs associated with divorce and relationship breakdown, such agreements may now have greater implications for parents who provide financial assistance to children in de facto relationships. Having amounts lent to your children properly documented and secured will help protect this capital and ensure it remains within the family in cases of relationship breakdown.
A final word
If your financial position truly allows you to be unconstrained in your capacity to enhance the quality of your life, then it makes sense to extend that same privilege to other family members. But, for both the giver’s and receiver’s peace of mind, it’s important to apply commercial principles when setting the ground rules.
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Case Study : Failure to register a mortgage Angus is 25 years old and single. He is in the process of starting an IT business so savings are scarce. However Angus, like many of his friends, has a dream of owning his own home and soon. He has found a property for sale at $450,000 and his parents, John and Christine have offered financial assistance to Angus to purchase the property. Given Angus’s current financial position, he gratefully accepts the offer. John and Christine are able to fully fund the purchase price on Angus’s behalf. Under the loan agreement, the newly purchased home is offered as security for repayment of the debt to John and Christine. John and Christine see this as a way of protecting their capital in the event Angus’s new business does not perform as well as expected. However, due to their unfailing confidence in his ability to succeed in business, John and Christine fail to register their security on title. Angus, not wanting to borrow further money from his parents, obtained a loan of $200,000 from the bank to help develop his business. He didn’t tell John and Christine because he wanted to prove to them he could manage on his own. The bank, with Angus’s consent, immediately registered an all monies mortgage over Angus’s home. John and Christine now find themselves in a dangerous predicament. Although they have security over Angus’s home, it is not registered. As a start-up business, statistics show that it is more likely to fail than succeed. If that happens, then the bank, having a registered mortgage, will be able to exercise its security over the home in priority to John and Christine, whose security is unregistered. Even if they register their security now, they will only have a second registered mortgage since priority is based on the date of registration, not on the date of the loan. If the home is sold to repay Angus’s loan, then the bank will be paid its $200,000 first and John and Christine will be second in line. Assuming the house is still worth $450,000, John and Christine will be able to recover $250,000 but in order to recover the balance of their loan ($200,000) they will rank equally with all of Angus’s other unsecured creditors e.g. employees, suppliers, etc. This could have been avoided if they registered a first mortgage over the property when they entered into the loan agreement with Angus principles when setting the ground rules. LACHLAN PARTNERS is a Private Advisory Firm focused on client needs and financial goals with offices in Melbourne, Sydney and Brisbane www.lachlanpartners.com.au. The following can assist you with your Estate Planning needs; Roger Wilson (Partner); Eric Maillard (Partner)
RISK MANAGEMENT
Surgeon
sued for failing
to warn the risks
of spinal surgery
Neurapraxia caused by a six hour operation
Mr IW was a 57 year old man who was married with two children. He immigrated to Australia in 1980, from India. He was employed as an insurance assessor.
I
n the course of this employment, he engaged in heavy lifting that resulted in a lumbar intervertebral disc prolapse. He was in pain and somewhat immobile after development of the hernia, which is one reason why his weight ballooned to 124 kilograms. The patient tried many methods of reducing his pain, including opioids and TENS. The pain was so severe that he had suicidal thoughts. He saw a neurosurgeon, Dr AK, in 2004, who told him to lose weight. Mr IW lost 14 kilograms, but was still in significant pain. Dr AK advised Mr IW to have spinal surgery – specifically, a posterior lumbar interbody fusion and pedicle screw fixation of L4-5 and L5S1. Dr AK advised him that the surgery would have a 70% to 75% chance of significantly relieving his pain. He also advised that without the procedure, the prolapse could progress to affect Mr IW’s spinal nerve roots, which could leave him in a wheelchair, with loss of bladder and bowel control. He advised Mr IW that of all the patients he has done a similar procedure on, there were two patients whose symptoms did not improve.
Mr IW remembers Dr AK telling him of the risk of infection and bleeding. But he says that Dr AK never advised him of the risk of damage to nerves or nerve roots from the operation. He states specifically that Dr AK never advised him of the risk of incontinence or weakness of his lower limbs. Mr IW was nevertheless aware that spinal surgery was “serious business”, and that operations do not always result in success. In fact, Mr IW had earlier had a lipoma operation that went very badly. Dr AK did not make notes of the warnings that he gave to Mr IW and was, in the words of the judge, “forced to resort to what in his professional practice he considered or believed he would have said, rather than to an actual recollection about it.” Two expert witnesses testified that they would not warn an ordinary patient of the risk of neurapraxia, but that Mr IW’s weight increased the chance that he would develop neurapraxia from the operation. Dr AK eventually conceded that he did not warn Mr IW of the risks of neurapraxia, but that he should have. Mr IW underwent the operation,
during which he was immobile in a prone position for six hours. The operation was performed diligently, and the hardware was successfully inserted. The operation took two hours longer than normal, mainly due to the patient’s obesity. Mr IW woke up after the operation in severe pain and complained that both his lower limbs were paralysed. Dr AK was unable to correlate the patient’s symptoms with his clinical signs, and so he performed further surgery the next day to “confine and explain” the patient’s condition. After the second operation, a neurologist diagnosed Mr IW with ‘typical bilateral femoral neurapraxia’, and thought it likely to improve over the next few weeks. Neurapraxia is usually transitory. It involves no loss of continuity of axons, but rather temporary disruption to their function. One of the expert witnesses said that he had seen it once in about a thousand fusion procedures. Mr IW was in hospital for 10 days post-operatively, and was then transferred to a rehabilitation unit for 2 months. He received intensive
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RISK MANAGEMENT physiotherapy, but complained that he could not move his legs properly and was in constant pain. Eventually he was able to mobilise with a walking frame. He had nerve conduction studies that demonstrated no permanent or ongoing loss of lower limb nerve function. Examining him months later, the neurologist said “His current neurophysiological finding is out of proportion to his physical manifestation”. No easy explanation could be found for the patient’s stated limb weakness. Mr IW sued Dr AK, alleging that Dr AK failed to warn of the risk of
in the proposed treatment; a risk is material if, in the circumstances of the particular case, a reasonable person in the patient’s position, if warned of the risk, would be likely to attach significance to it or if the medical practitioner is or should reasonably be aware that the particular patient, if warned of the risk, would be likely to attach significance to it. Both experts in this case said that they would not warn of the risk of neurapraxia in this type of case. However, that does not exonerate Dr AK. In New South Wales, if a responsible body of m e d i c a l professionals would not do something say, during an operation, then that can be relied on to say that not doing that thing is not negligence. However, this does not apply to the duty to warn a patient of a material risk of a procedure. The legal duty to warn of material risks and the legal duty to perform the operation diligently are separated on this point. The judge found that Dr AK should have warned of the risk of neurapraxia, as Dr AK later conceded. The surgeon claimed that in the context of severe and chronic pain, paralysis or potential paralysis, and the obvious risks of such a long and invasive operation, neurapraxia was a relatively trivial thing. However, the judge considered that bilateral femoral neurapraxia following the surgery was a sufficiently serious condition that it could be the foundation of a negligence claim. It was not a trivial or minimal condition. The judge considered that the fact that a second operation was performed in view of the neurapraxia “puts the matter beyond doubt.” So the idea that neurapraxia is a relatively minor complication does not exonerate the doctor.
“Mr IW underwent the operation, during which he was immobile in a prone position for six hours.” neurapraxia. Mr IW said that if he had known of the risk of neurapraxia, he would never have agreed to undergo the operation. He claimed $350,000. The patient’s symptoms were vague and out of keeping with his clinical signs. But that was not enough to exonerate the doctor. The judge found that the patient did suffer a complication of surgery: “I consider on the balance of probabilities that the plaintiff sustained bilateral femoral neurapraxia following the first operation. It may not have been life threatening, it did not persist for very long and it was certainly not permanent, but whatever may have ailed the plaintiff before the operation, he certainly did not suffer from this condition.” The judge found that neurapraxia is an inherent and unavoidable risk of this type of surgery, and that obese patients are more likely to suffer from it. But that is still not enough to exonerate the doctor. Australian law recognizes that: A doctor has a duty to warn a patient of a material risk inherent
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The judge found that the patient was no worse off following the surgery, from a legal point of view. He had bilateral femoral neurapraxia, but that resolved. He was immobile and in pain after the operation, but he was immobile and in pain before it as well. Since the patient was not made permanently worse overall, he has suffered no overall permanent harm. The patient claimed that he would not have undergone the surgery if told of the risk of neurapraxia. Australian law asks whether the patient – not any patient, or the average patient, but this patient would have undertaken the surgery if he had known of the risk. The judge said: “having regard to his desperate preoperative plight, the plaintiff would not have declined the proposed surgery upon the basis of a possible risk of the condition that he suffered in fact… The prospect for this plaintiff of some mild and temporary interference with power and sensation in his lower limbs is out of all proportion to the disabling and distressing condition from which he hoped Dr AK’s surgery would provide a cure or at least some relief.” Consequently, the judge found that Mr IW would have undergone the surgery even if he had been told of the risk of neurapraxia. In the final analysis: • Mr IW would have undergone the operation even if he knew of the risk of neurapraxia, and • The neurapraxia did not adequately explain his ongoing immobility and pain, and • The patient was no worse off after the operation than before it Therefore, even though Dr AK was negligent in failing to warn of the risk of neurapraxia, Mr IW was unable to prove that Dr AK’s failure to warn of that risk did him any harm. Dr AK won the case. Dr. Richard Cavell
Dare toDream
How to set meaningful goals and achieve them
This edition focuses on something that many doctors neglect. Because of the prescribed course that a medical career can take many doctors don’t set defined goals and often just go with the flow. While it can seem like the easiest option it leaves a lot to chance. This article shares a new way of setting meaningful goals that has the ability to put your goals on anabolic steroids.
A
Image above: "dream on" by TheAlienness GiselaGiardino www. flickr.com/photos/gi/2953550/. Images licensed under Creative Commons Attribution 2.0 Generic license, http://creativecommons. org/licenses/by/2.0
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s humans we steer towards what we focus on. This is the reason that goal setting is so important. Goals send commands to our subconscious minds that cause us to move towards those goals. Studies have shown the subconscious mind to be at least 30,000 times more powerful than our conscious mind so
it’s important to get the subconscious mind moving in the direction we want. But while it’s incredibly powerful, the subconscious mind does not have the ability to choose or to make value judgements; it merely obeys your dominant thoughts - what you are focussing on most of the time. It’s therefore important that our
CAREERS dominant thoughts are what we want in our lives, because regardless of whether you want it or not, if you’re focussing on it your subconscious will make sure you’re moving towards it. States/emotions like anxiety are in effect negative goal setting, because by worrying about what you don’t want you are actually setting this up as your dominant thought and your subconscious moves you towards it, even though you don’t want it. For example, if you’re worried about not having enough money and you’re focussing on your lack of money, chances are you’re going to end up in worse financial difficulties. Have you ever thought something like “don’t stub my toe, don’t stub my toe”, then you’ve done exactly that, stubbed your toe? That is exactly what negative goal setting is. The purpose of goals is not just to achieve that goal, the purpose of goals is to create dominant thoughts that moves you and your life in the direction you want. But I noticed that just setting goals wasn’t enough; I noticed there were a lot of people who had goals but who never seemed to achieve them, and I also noticed that this happened to me sometimes. So I searched for an answer as to why this was the case, and I think I’ve found it.
The benefits of positive thinking While some people think positive thinking is merely the ‘woo woo’ practice of naive simpletons who just want to feel good, science has demonstrated the undeniable benefits of it. Positive thinking causes the brain to release serotonin. Not only does serotonin cause you to feel happiness and a sense of wellbeing, but it has now been demonstrated to form a bridge to more effectively connect brain cells and to connect the left and right brains. On the other hand, negative thinking causes the release of cortisol which causes feelings of stress, sadness and depression. And if this isn’t enough, it has also now been demonstrated to reduce communication between brain cells and also the left and right brains. So, by combining positive thinking with a practice of goal setting that
search for an answer led me to a man called Brian Mayne. Brian teaches a process that is fun and easy to do and results in both your left and right brain being activated; it’s called Goal Mapping which can be summarised by the following process: 1. Dream – create a vision for your ultimate life and set goals 2. Order – determine your key goal that will make the other goals happen too 3. Draw – activate your right brain and your subconscious through images 4. Why – activate your subconscious through emotions – why is this goal so important to you? 5. When – set a deadline, a goal without a deadline is just a wish! 6. How – what are the actions you need to take? 7. Who – choose the people or organisations that can support you
“The purpose of goals is not just to achieve that goal, the purpose of goals is to create dominant thoughts that moves you and your life in the direction you want.”
Activating the whole mind The old wives’ tale is that the left brain is based on logic, while the right brain is based on creativity. We have already established that our goals are there to move us, and for goals to be truly effective they need to register in both our left and right brains. Most people set goals by writing them down. This is great because the written word communicates with our logical left brain. But the problem with this is that our creative right brain is not activated by simply writing goals; the right brain speaks in images and emotions and therefore these need to be used to harness our full potential.
activates both the left and right brains, we give ourselves the best chance at not only a happy life, but also a life where we achieve the things that are meaningful to us.
The answer… You might be thinking “this is all well and good, but what specifically can I do to set goals that activate my left and right brain so that I get them aligned and on target so that my life flows exactly where I want it to?” I had the same thoughts and my
“If you think you can do a thing or think you can't do a thing, you're right.” Henry Ford Dr Sam Hazeldine is the Director of Medrecruit who recently did a presentation of Goal Mapping and how to apply it to get results. http://goals.medrecruit.com
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When It Comes To Working As A Specialist Surgeon, 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 surgeons to get you the perfect placement, a placement that meets all your unique needs. Your personal Solutions Specialist is trained to negotiate the very best deal possible for you so you can be secure and comfortable in the knowledge that you’re getting the best package, personalised for you. When you register with MedRecruit you will also receive valuable and
much sort after resources related to locuming to ensure you maximise the benefits to you. You will also receive membership only access to our specialist partners, such as Deloitte, who are industry leaders at working with doctors to ensure they get the most out of their careers. With offices in both Australia and New Zealand, and relationships with more hospitals across Australasia than any other agency in our field, you will gain access to the largest database of vacancies which will ensure you get the best solution tailored specifically to you; we have far too many vacancies in your speciality to list on this page! Due to our long standing and strong relationships with many hospitals you will have choices of positions that are not advertised anywhere else. When you register with MedRecruit you will immediately receive:
Passport to Lifestyle & Career
Webinar
eBook
•
This online webinar is potentially worth many thousands of dollars to you and you will receive access to it at no charge.
This eBook was created using 3 years of validated research and testing. It reveals: • The secrets to setting meaningful goals • The keys to achieving those goals • The 7 habits that highly successful doctors utilise to create their desired lifestyle in medicine, whatever that is for them
This is a much sought after eBook for doctors that you will get as soon as you register with MedRecruit. In this eBook you will find:
• • •
Video interviews with NZ Prime Minister John Key and top sportspeople about peak performance The 7 myths of locuming revealed Rewards for you! Videos of sucessful, real locum doctors sharing their feelings and experience using the renowned MedRecruit system
The 7 Secrets to Explode Your Income as a Locum
It reveals: • The 7 things that any senior doctor can apply immediately to maximise their income • The key ways to become tax efficient to keep even more of that increased income in your pocket!
What should you do now?
Creating a Lifestyle in Medicine – The 7 Habits of Highly Successful Doctors
Either register at www.medrecruit.com or call 1800 MEDRECRUIT (633 732) and you will receive these three resources absolutely free and we will schedule a call for you with the exact Solutions Specialist who can best serve you.
If you need to recruit a doctor for your practice then please register in the same way and we will find you the right doctor to meet your needs.
Welcome to a whole new way of locuming where you are the priority and you have your own personal specialist team to assist you to get you the best outcome.
ALPHA
The
Paperless Practice:
?
is it time
When talking paperless practices, they generally fall into one of three categories.
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he first being a long term practice where filing space has become an issue for many thousands of patient records. Secondly is the modern thinking practice that appreciates and understands the cost benefit and efficiencies to be gained by moving to a ‘less paper’ environment. And thirdly is the young guns that have never entertained the idea of being anything else but paper free. Often, however, there are many different thoughts and misconceptions as to what a “Paperless Practice” is. Whenever talking paperless we must first consider what the term paperless or paper free means. Whether you are looking to implement a paperless environment on a clinical level or for your entire business, there are many solutions that can be applied. Regardless, this is an important decision and when deciding you must ensure that you are looking well into the future so as not to be trapped into a system that may cost
you a lot of time and money to migrate forward from should you require further expansion from your initial approach. In a medical practice, as opposed to general business, patient records and their ongoing storage are a critical factor and therefore the combination of a number of integrated systems can play a vital role in what can be achieved. The philosophy should always be to start your practice with a solid database system. The system, if it is well designed, can provide the flexibility to integrate from your core database (your Practice Management software) as it becomes the hub of all activity within your practice. Keeping the above in mind, these days there certainly are a huge range of integrated solutions available. Most practices now use a computerised Appointment Book; this is integrated with the Practice Management system which in turn is
“The philosophy should always be to start your practice with a solid database system.” SURGICALLife
ALPHA integrated with an expanded range of options. This software allows integration with several different Medical Records systems, some being leading products for GP’s and others for a variety of Specialist needs. The servicing provider then may refer to Integrated MIMS or even send an eScript. The possibilities are endless. For example there are Pathology Labs that can integrate with the software and in other cases specialist devices and machines (Imaging) all
“The next level is Secure Messaging which incorporates referrals, hospital discharge summaries, pathology reports etc. This adds a new dimension to your practice when you can receive your referrals directly into your practice management software with NO human intervention being involved.” integrating and reducing the amount of duplication and paper. The servicing provider can now also raise a Referral or a respond to a Referral Letter securely online. Numerous software vendors have agreed to adopt the government agency NEHTA standards for this purpose. Online referrals save money, time and improve practice efficiencies. Typically the Patient workflow from the practitioner’s consultation then moves back to reception for the billing stage where again a number of paperless (less paper) scenarios can be on offer. There is a choice of
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any combination of the following integrated Medicare solutions:Medicare Online for Patient Claims and Bulk Billing, DVA Paperless Streamline, ECLIPSE for health Fund In-Hospital claims and now a choice of major banks’ EFTPOS terminals for Medicare Integrated Easyclaim or HICAPS eConnect for Medicare and Allied Health Fund claims. Whilst the latter EFTPOS systems all use a minor amount of paper, practices will save both time, money and improve cash flow. As well, automatically they will be helping their patients by submitting their claims electronically and better still, with the use of our Easyclaim solution, Patients can receive the Medicare Rebate monies immediately into their bank account of choice. This is confirmed from a small piece of paper from the EFTPOS terminal. However the real point is these billing systems all save considerably on paper use. Your chosen software must have available a scanning module option where you can import, attach, append, export or simply scan a document to a patients profile. Document Management and Scanning Systems are often invaluable for filing, storage and retrieval paperless purposes. For example, if the patient’s referral letter needs to be stored or any other paper or in fact “soft copy” computer files / documents can also be filed within these systems against the Patient Administrative documents and softcopy files be appropriately filed and managed similarly saving ahuge amount of space, costs and time. Practices also have a choice for Offsite Transcriptions services where you simply talk into a digital recorder and upload the recording to a typing pool where your letter is typed onto your letterhead and sent back to you with 24 hours but more often than not within 12 hours ready for editing. Again, integration is the key; this service is available as a stand alone process but creates greater value when the completed letters are saved to your patients profile in
your software. These services can complement your existing typist(s) and help out at anytime when needed. The next level is Secure Messaging which incorporates referrals, hospital discharge summaries, pathology reports etc. This adds a new dimension to your practice when you can receive your referrals directly into your practice management software with NO human intervention being involved. NEHTA (www.nehta.gov.au) have been set the task of working towards and developing a recognised National Standard for secure messaging, this area includes the following: e-referrals, e-Discharge Summaries, e-pathology and e-Medical Management. These solutions will significantly reduce the amount of paper on your desk, support your reception staff in their duties and improve the seamless exchange of patient information from one practitioner to another. Government policy on e-Health is certainly hotting up, although the new wave did start years ago, nearly eight, when in fact my own practice was the first to go with the full functionality of what was then HIC Online, since renamed and now known as Medicare Online. Some believe the Government should further support their existing initiatives and have a better understanding and appreciation for what software developers can do for practices, servicing providers and their patients, as technologies continue to move rapidly forward. We together, with the take up of these excellent online paperless systems, will continue to help benefit our community at large.
Geoff Neill started his own General Practice on the Gold Coast that operated with five GP’s. He is now working for Medilink, a Practice Management Software Company.
EASY practice management has just become easier ! MEDILINK esi now incorporates all the benefits of HICAPS together with all the benefits of Online Claiming to . MEDICARE for Practices and their Patients.
MEDILINK esi integrated solutions offers Practices all the benefits of 21 years of development and experience with . its leading Practice Management software. Integrated all-in-one solutions provide:
MEDILINK software is well reputed to be the easiest and most intuitive with its best of breed Appointments module included with its most comprehensive range of features for, the smallest to the largest of practices, Practice Management. Whilst easy is very much a key word that our clients continue to praise us for – equally so is Medilink’s unbeatable value for money. Other features include:‐ All facets and types of billing for medical and allied health needs. Extensive Management Reporting, makes management very easy and very accountable at the same time. MEDILINK was the first to receive the HIC’s NOI (Notice Of Integration for complete Online Claiming in 2002) then Medicare ECLIPSE certification for Health Fund Online Claiming, and now Medicare Integrated EASYCLAIM Note: It does NOT MATTER who your Providers bank with. All EFTPOS transactions are IMMEDIATELY processed and claims paid into their Bank account(s). As are Patient Medicare Rebates into their Bank accounts. MEDILINK esi Other Integrated Paperless Options include: 9 SMS Appointment Reminders with Confirmation and helpful reporting for easy management. 9 Scanning and document management helps further achieve a “paperless practice”. 9 DVA Streamlined Paperless Online Claiming. 9 MS Word, MS Excel and Crystal Reports integrated for complete flexibility. 9 eMESSAGING to conform to NEHTA’s (government agency for eHealth) secure messaging for Referral Letter transmissions, sending and receiving. 9 Clinical Notes, a variety of options are available including custom templates. 9 Free remote access with free Updates is standard with Medilink’s VIPS support membership. MEDILINK offers the greatest range of choices with best of breed solutions for your complete Practice needs.
BOUTIQUE
Clear Skies Ahead Does your practice need a little more light or perhaps you have a wall at home in need of a new aspect? Sky Factory Luminous SkyCeilings are virtual skylights offering photographic illusions of real sky with amazing results. www.theskyfactory.com
Designer Sounds Stand In Case Treat your iPad to its very own leather case that protects it securely and becomes a stand for easily delivered presentations or movie watching. Truss Case for iPad RRP $69.95. www.targus.com.au
Red Letter Days Stand out in your street and ensure the postman never misses a delivery with this eye catching Project Letter Box RRP $570. www.robertplumb.com.au
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This feature piece docking station comes with a fully active 5-speaker system and is guaranteed to fill any room with deep, clear, quality sound. Edifier Breathe RRP $499 www.edifier-international.com
Pool Toy Cool Down Celebrate summer in style with the 1 litre fridge carafe $102 and stylish covers $30. www.top3.com.au
Your Serve Delight at the table with the appetizer 4x4 serving set comprises of4 sets of ‘spoon and fork’ in a stunning presentation gift box, 8 piece set RRP $110. www.top3.com.au
Set your Zodiac pool cleaning robot to work and enjoy a long summer of a spotless pool. Set the Polaris 9300 Sport to work and in an average of 90 minutes, your pool will be sparkling again. RRP $2,000 www.zodiac.com.au
It’s Time Arrive on time with the Rolex white gold Daytona available at LK Jewellery RRP $40,860 www.lkjewellery.com
Turn Styles Show off your cooking style with the Boomerang Wok. It lets your food come back with a simple flick of the wrist – the no effort push action simply turns and then returns your food to the same place it started. RRP$174.95 www.milkandsugar.com.au
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ďƒš
Igloo Village, Finnish Lapland, Scandinavia
Igloo Village, Finnish Lapland, Scandinavia Lapland is the magnificent country of fells, reindeer and Northern Lights. From December until April, in close proximity to Hotel Kakslauttanen is the famous Igloo Village. The Igloo Village boasts 20 amazing Snow Igloos as lodgings, an Ice Gallery, a bar made of ice and the world's largest snow restaurant. The star attractions in the village are the five Glass Igloos, which provide a unique opportunity to sleep under the Lapp sky admiring the northern lights in a warmer environment. They tell us that the experience is also unforgettable when there is a snowstorm! For those brave enough, you can take a morning dip in a nearby ice hole, but we think we’ll stick to the sauna. www.kakslauttanen.fi
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TRAVEL
Five Star GAZING If camping out isn’t your idea of a holiday, Sarah Harvey has discovered some spots that might change your mind. No need for the sleeping bag at these five star camping destinations, all you need is an adventurous spirit and a desire for the unique. SURGICALLife
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TRAVEL
Nxabega Okavango Safari Camp, Botswana, Africa
Nxabega Okavango Safari Camp, Botswana, Africa Africa’s Nxabega Okavango Safari Camp is located on the edge of the Okavango Delta on more than 17,000 acres bordering the Moremi Game Reserve in Botswana. Meaning ‘Place of the Giraffe’, Nxabega is ideally positioned to explore the magnificence of the Okavango. Twice a day, you can jump in an open 4WD safari vehicle or take a powerboat excursion and experience the majesty of the wildlife up close. Nxabega is an intimate camp for a maximum of 18 guests. This means you have the opportunity to meet fellow travellers but the site is private enough for you to feel as
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if you are the only campers on the Delta. Luxury camping is in one of the nine classic safari tents on raised wooden platforms. Each tent has a private game-viewing deck and ensuite bathroom. The heart of Nxabega consists of sophisticated living and dining areas made from local timber and thatch overlooking the flood plain. You can indulge in bush picnics in surprise settings, breakfast in bed, lamplit cocktails on a river island, or a walking safari with delectable picnic. www.ccafrica.com
TRAVEL
ďƒš
Tented Camp, Golden Triangle, Thailand
Tented Camp, Golden Triangle, Thailand Located near Chang Rai your experience at the Four Seasons Tented Camp in Thailand begins on your trip to the campsite as it is accessible only by riverboat. Every detail in the 15 luxury tents has been attended to, right down to the hand hammered oversized copper bathtub. Each tent has two massage beds on its private sundeck, a reminder that you are well and truly in the midst of Thai luxury. Spend your days learning to care for the elephants, in cooking classes, taking riverbank picnics or simply enjoying the spa treatments on offer. The finest details are attended to
Dinner is an elegant affair with white linen and beautifully simple porcelain and glassware. extending to mealtimes as well. During breakfast and lunch, tables are decorated with local hill tribe artifacts, with indigenous stoneware and silver cutlery used for serving. Dinner is an elegant affair with white linen and beautifully simple porcelain and glassware. www.fourseasons.com/ goldentriangle SURGICALLife
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TRAVEL
Spend your days in spa treatments, or for the more adventurous, perhaps an elephant trek.
The Oberoi Vanyavilas, Rajasthan, India
The Oberoi Vanyavilas, Rajasthan, India The Oberoi Vanyavilas is India’s first luxury jungle resort. It offers a unique opportunity to experience the natural peace and beauty of the jungle in private and luxurious accommodation that needs to be experienced to be believed. Like the hunting parties of old, guests at the resort stay in tents. However, these tents are nothing like any you have seen before, offering the utmost luxury. With only 25 in total, each air-conditioned with marble bathroom, freestanding bathtub, private walled garden and sun deck offering total privacy. Tents are scattered within the 20acre jungle estate, allowing you to marvel at the stunning scenery including the Ranthambhore Tiger Reserve next door. Spend your days in spa treatments, or for the more adventurous, perhaps an elephant trek. The Vanyavilas make a perfect base to recharge before exploring the palaces of Rajasthan. www.slh.com/vanyavilas
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Voyages Longitude 131°
WHY NOT TRY … Masai experience Two nine-suite tented camps in the Masai Mara Plains immerse you in nature, but without sacrificing luxury – butler included. Bateleur Camp at Kichwa Tembo offers an abundance of game throughout the year, but from June to October the area witnesses an awe-inspiring sight – the great migration. www.slh.com/bateleur
Star gazing at the Rock Situated overlooking the World Heritage–listed wilderness of Uluru-Kata Tjuta National Park, Longitude 131° offers complete five-star luxury and private views of the sun rising and setting over Uluru. Enjoy dining out under the spectacular desert night sky. www.longitude131.com. au L
the wines of Bali In my previous career as an actor (yes, it’s a loose definition), holidays didn’t feature much. Jobbing actors tend to lurch from one scantily paid contract to another. The period in between shows, once charmingly referred to as “resting”, is now better known as telemarketing. Holidays are thin on the ground. Of course there is a multitude of wonderful things about being a jobbing actor, but none of them is holidays.
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his year marks my tenth anniversary as an ex–thespian, and it still gives me a thrill to be able to take a holiday from time to time. Nothing quite as luxurious as one every year, but just every so often... We all need holidays. But of course, it’s all relative. I was reading recently about a 3–day arts and music festival. It’s a camping event – or glamping they call it now since they’ve installed a hairdressing tent. In the article a sweet young twenty–something was quoted as saying “This is my first holiday since November, so I’m really going to go all out”. Poor kid – all those months without a holiday. My heart just bled. I’ve just had my first holiday since November too. 2007. Our destination was Bali. (Hardly an exotic destination I know, but we’ve been regulars for years, and
we really didn’t have the energy to break in a new country: sightseeing... photo opportunities... scary toileting arrangements...) We’ve been to Bali so many times now, that a beautiful decaying temple is just another temple. The gorgeous terraced rice fields truly are gorgeous, and very ricey, but we don’t need to go for a day trip and take snaps. What we desperately needed was a fly and flop, and that’s precisely what we had. After a reassuringly uneventful six–hour flight, and a steamy one hour queue at immigration with genial fellow travellers, we drove just far enough to take us beyond the reach of the tourist traps. And there, in the undeveloped west of the island, we hunkered down. Of course, we could have simply gone to the Gold Coast but the exchange rates were prohibitive.
“This year marks my tenth anniversary as an ex–thespian, and it still gives me a thrill to be able to take a holiday from time to time.”
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LIFESTYLE Our room had no television, no phone, no radio. Just an enormous and stupidly comfortable bed with a vast, billowing mosquito net and a huge picture window opening onto to the tropical garden, and beach beyond. It wasn’t possible to abandon all decision making responsibility: the first decision of the day centred on shorts or sarongs. Then there were decisions involving papaya, pineapple pancakes and Nasi Goreng. But with those breakfast obstacles cleared, we would waddle to the pool area. As midday approached, the choices become more complex: massage or walk or beer?
our modest resort featured Jacob’s Creek Chardonnay at a shade under AUD$100 per bottle. Meaning absolutely no disrespect to the good people at Jacob’s Creek – or their very fine wines – the words over my dead body sprang from my lips faster than you can say Bintang. The only remotely affordable alternative is the range of locally made Balinese wines, and I confess to having approached them with extreme caution. This isn’t just wine–wanker prejudice. It’s fair to wonder how a fruit which can thrive on near vertical slopes in chilly Europe handles life
“The wines of Bali are clean, simple styles which are climatically, culturally, and gastronomically apt.” It was my avowed intention to banish all thoughts of work for fourteen days. And I almost did. But working in the wine industry does have its drawbacks. To approach lunch without a beer was unthinkable; and a gin and tonic at sunset was mandatory. But at dinner time, my thoughts would fly to a zesty off–dry Riesling or a lightly chilled Pinot Noir... maybe a Verdelho or a Grenache – yum. Then the beaming young Balinese waiter would present the wine list and my heart would sink. While it offers tropical delights in abundance, it would be fair to say that Bali is not a wine–lover’s paradise. The extraordinarily high price of imported wine is an effective disincentive. The restaurant at
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in the tropics. Grapes are prone to a range of fungal infections. How do the Balinese winemakers manage the vicissitudes of producing wine in humid, tropical conditions? The answer is with ingenuity, creativity, and skill. The 100% Balinese–owned family winery has 14.5 hectares under vine in the north–east of the island, and a state of the art winery in the south. They produce a range of fruit– driven, light to medium bodied wines that reflect the tropical climate, and complement the spicy flavours of the local cuisine. It’s an impressive undertaking, particularly when you consider the unique challenges of producing wines barely 8 degrees from the Equator.
Vines are trained onto very high trellises, supported by small trees. The height maximises exposure to cooling breezes and discourages pests. The shade from the trees protects the berries from the sun, and affords a degree of comfort for the vine workers. It’s an ingenious solution, although seeing grapes being picked from overhead takes some getting used to! The lush climate results in year– round fruit. While the vines we know in Australia have a dormant cycle, Bali’s vines are evergreen, producing grapes which can be harvested continually throughout the year – turning our traditional notion of “vintage” on its head. In the 14 years that they have been making their popular Rosé, over 200 vintages have been produced! Are the wines any good? Of course they are, and that’s not just Holiday Taste talking! (Holiday Taste is that oxymoronic phenomenon, which leads us to make surprising choices that we would certainly repudiate back home. It can, for instance, lead grown women who should know better, to allow themselves to be photographed performing the traditional dance of the indigenes. But that’s another story.) The wines of Bali are clean, simple styles which are climatically, culturally, and gastronomically apt. And, while a gin and tonic will always be my first choice for watching a tropical sunset, you could do a lot worse than a lightly chilled glass of Aga Red with your Sate Ayam.
Gillian Hyde After a 35 year career as a “Jobbing Actor”, Gillian transferred her attention to the wine industry. Today she holds the position of Head of Membership at The Wine Society (www.winesociety.com.au) – which she juggles with the increasing demands on her as a wine writer.
LIFESTYLE
p o t p o r d f o o r t f e o h S c a n a with p ss
la c E s e d e c Mer ty, i l a u q s e z o cabriolet eoand comfort. styl
Mercedes-Benz E250 CGI Avantgarde cabriolet in metallic palladium silver paint,with AMG Sports Package, Entertainment Package and Dynamic Handling option. Real world drive-away price: $135, 500.
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leek and elegant. This car is beautiful. It’s the MercedesBenz E250 CGI cabriolet. It has an imposing, angular front end, a swept-back windscreen, two doors and four seats. Its external appearance is stylish, strong and elegant. Feedback from casual observers on the exterior is uniformly positive. Inside, the car radiates quality and style. It’s automatic-electroniceverything. When you get in and out of the back seat, the front seats scoot forward and back automatically. Buttons on the steering wheel can control your mobile phone and most of the car’s other functions. The sound system is superb, and when cranked loud is good enough to wake up the carpark of my local hospital. When parked, you can watch television on the centre display. The satellite navigation system knows every hospital in Australia, including private hospitals
and day care centres. It is bright and clear, even in direct sunlight. But this car is all about the roof. When the weather allows it, you can direct the soft black fabric roof to fold itself into the boot in a matter of seconds, leaving you exposed to the sun and the stares of admiring pedestrians. The system is quick and neat, and invokes an elaborate choreograph of machinery and material. It is entirely automatic. When the roof deploys itself, it snicks itself into position neatly. With the roof on, it’s remarkably quiet inside. The roof mechanism consumes a considerable amount of boot space. You could stow several surgical kits and a doctor’s bag in the boot comfortably, but don’t expect to cram several large suitcases in if you want to put the roof down. The red-brown leather seats are perfect for boy racers. The front
“The satellite navigation system knows every hospital in Australia.” seats are slightly uncomfortable for lipophilic passengers, but the shape is modifiable by controlling the inflation of several air bladders. The rear seats look cramped. They are of the “plus two”-style – this is not a car intended to routinely carry four adults – but they are surprisingly comfortable for those of modest stature. While sitting in the rear, my fivefeet-ten-inch frame missed the roof comfortably, but my engineer friend who is six feet tall complained that his head scraped the roof while he sat in the back. High-BMI doctors will definitely prefer the front seats. I had a chance to compare the vehicle with an E-class saloon, and the cabriolet sure feels cramped by comparison. For example, a $1 coin left behind by a previous passenger of the cabriolet SURGICALLife
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LIFESTYLE had fallen between the passenger seat and the centre console and could only be retrieved using surgical tools. The air conditioner is impressively cool, and the heater equally impressive in its warmth. Each gets to the target temperature rapidly after being switched on. The efficient seat warmers kept my gluteal region nice and warm. Mercedes offers the Airscarf system, which blows warm air posterior to your neck independent of what the air conditioner is doing. The badge at the front of the car is of the inlaid type, rather than the trophy type that invites jealous hooligans to rip it off. Much attention has been paid to lighting in this car. The headlights and indicators are bright enough to make the car stand out at night among ordinary vehicles. When reversing, visibility is poor even with the roof down. The car comes with reversing proximity sensors and a reversing camera is an option. The rear headrests may be lowered if no one is in the back seats. The car has a few quirks. The
steering wheel tends to block the driver’s view of the instrument cluster when placed in its most natural position, but it can be moved. The gearstick must be moved “around corners” rather than in a straight line. There’s a quaint foot-operated parking brake with a manual release. The chassis is solidly built, and the doors close with a satisfying clunk. There is an overriding feeling of safety. Front seat passenger leg room is extraordinary given the car’s modest length. Now to the engine. It’s a 4 cylinder 1.8 litre job that revs to 5500 rpm. It is so quiet that several times I attempted to start the engine, having failed to realise that it was already running. Under hard acceleration you get a faint side-to-side shake, but otherwise it exudes refinement. For performance enthusiasts the 1.8 litre will definitely feel anaemic. It is mated to a 5-speed “flappy paddle” semi-automatic gearbox. Merely $3000 more will upgrade you to a 2.2 litre diesel with way more torque and 25%
more fuel efficiency than the petrol 1.8, so this upgrade is an absolute nobrainer if you don’t mind filling your car with diesel. Higher-displacement petrol engines are available, at additional cost of course - a 3.5L 6-cylinder and a 5.5L 8-cylinder. They come with a seven-speed auto. Final opinion: Exciting, luxurious and comfortable. I’d buy one. I would prefer the 3.5L 6-cylinder version, with the Entertainment package (better sound system, keyless entry and TV tuner) and Dynamic Handling option (steering wheel mounted shift paddles and electronic damping system). It comes with reversing camera, 7-speed gearbox, and metallic paint as standard. Real world drive-away price: $168,010.
Dr A. Babinski. Dr Babinski is a medical practitioner who has worked in motoring journalism as a hobby for 13 years. Mercedes-Benz loaned us the vehicle for 4 days. Our reviewers have no other relationship with Mercedes-Benz.
Second opinion
On an aesthetic level, I love the red leather. It’s muted and elegant. The driver’s seat is very comfortable and well supported. This felt like I was driving around in a brochure. Everyone looked at me and said, “Who’s that rich, classy lady?” The roof is quick enough to go up or down while stopped at a traffic light. When I put my foot down, the engine hesitated. You need more power. I loved the fact that the car offered me my seatbelt. I quite liked the voice of the satnav. When I had the radio on, I liked the feeling of an old-fashioned wireless, but the tuner changes were too slow. The coffee cup holders are deep, so your drink won’t topple over. The steering wheel obscured the indicator lights. There’s not enough room in the boot with the top down. I would prefer two seats and a bigger boot. The heating was very efficient. It kept me warm when it was pretty icy outside. If you were a guy, you’d say it was a chick’s car. I saw it in the Sex and the City movie. Chicks with a disposable income would buy this car. Final verdict: Yes, I’d buy one, if I could get a good deal. I would get it in black. By CC, collaborative legal practitioner
Third opinion
Above photograph by S. Kayman
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With the roof up, it’s quite dark. The saloon has a sunroof that lets more light in. The cabriolet’s perfect for a summer drive. I’d stick with the sedan, though. This car’s not as practical. Also, it’s not high-powered enough for me. Final verdict: It’s a reasonably-featured, well-priced coupe, but I want the torque and the horsepower to fully enjoy the experience. I’d get the V8. By Gregorius, Mercedes owner and IT consultant
advertiser index Investec................................................................................................................................2 Locum Bank .....................................................................................................................11 Accordius...........................................................................................................................35 Maddern Financial Advisers ......................................................................................40 Life Shield Insurance.....................................................................................................43 Marketing Doctors.........................................................................................................49 Lachlan Partners.............................................................................................................51 Integra................................................................................................................................55 MedRecruit.......................................................................................................................58 When It Comes To Working As A Specialist Physician, Your Needs Are Different WORK AND TRAVEL MediLink. From...........................................................................................................................61 Junior Doctors
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much sort after resources related to locuming At MedRecruit we understand that to ensure you maximise the benefits to you. finding the right positions in a locum You will also receive membership only access capacity and in a permanent capacity to our specialist partners, such as Deloitte, who as a specialist have its own specific are industry leaders at working with doctors to ensure they get the most out of their careers. needs and requirements. Your needs are as unique as your speciality and With offices in both Australia and New Zealand, your career and you don’t want to and relationships with more hospitals across be lumped in with the junior doctors Australasia than any other agency in our field, is shaping up to be a challenging year for investors who have very different needs and you will gain access to the largest database2011 of International Medical Recruitment (IMR) is Australasia’s largest Recognised throughout Australia and New Zealand as a premium medical recruitmentvacancies company, specialising in filling and shortyou emerging locum best service, LocumBank will negotiate the best possible which willlong ensure get the requirements. getting term medical vacancies throughout Australia and New Zealand. locum rate and benefits for every placement, everythe time. right advice will make all the difference.
Clear Billing.......................................................................................................................75 When it comes to
Mediq Medical Financial Services............................................................................76 we believe in the value Lachlan Partners is bringing together some of Australia’s foremost experts at key seminars to be held in March 2011 across the Eastern Seaboard. of a their close relationship. Our eminent speaking panel includes solution tailored specifically to you; we have far LocumBank, a subsidiary of IMR, has access to hundreds of LocumBank offers a FREE service to all locum doctors and specialises in tooallowing many vacancies in your speciality to list on As you decide to work with MedRecruit you will vacancies, unadvertised our dedicated locum team to closely organising mutual recognition medical registration, health service match available employment opportunities desired documentation, for doctors working under an ABN, flights and this page! Due to toouryour long standing and invoicing strong be matched with your own personal Solutions requirements. accommodation, plus regular updates on available shifts. relationships with many hospitals you will have Specialist who specialises in working with If you are interestedchoices in travelling or you have some leave coming up, Listed below is a small selection of positions currently available. If you are of positions that are not advertised physicians to get you the perfect placement, a why not consider a locum in Australia or New Zealand? Amazing interested in a vacancy or would like further information on other available anywhere scenery and unique career experiences else. are available, ranging from an opportunities, please contact us on 1300 4 LOCUM or email placement that meets all your unique needs. info@LocumBank.com.au urban city centre hospital to retrieval work in an outback community. Chris Caton John Marasco Your personal Solutions Specialist is trained to LocumBank we have a shift toyou suit everyone! Alternatively you can visit our website at www.LocumBank.com.au for When register with MedRecruit Chief Economist CEO negotiate the very best deal possible forAtyou further information or to sign up to receive a weekly shift list. you will immediately receive: BT Financial Group so you can be secure and comfortable in the Colliers knowledge that you’re getting the best package, General Medicine Consultant General Medicine Consultant General Medicine Consultant ‘Global Economic ‘Investing in Commercial Regional NSW 09 12 July 2010 Regional NSW 14 18 June 2010 Regional NSW 13 26 Sept 2010 personalised for you. When you register with and Market Outlook’ and Residential Properties $2000 per day $2000 per day $2000 per day MedRecruit you will also receive valuable and Industry co-operation are Mixed the hallmarks Mixed elective lists & on call elective lists &of onthe call beehive. Wealth management Mixed elective lists &and on call Flights, accommodation & vehicle provided Ref #: 454/09
Flights, accommodation & vehicle provided Ref #: 112/43
ICU Consultant
Accordius is a privately Cardiology Consultant
Seminars are being held in the following locations
Regional QLD 07 - 13 July 2010
Regional QLD 12 - 14 Nov 2010
$1950 per day Mixed elective lists & on call
$1950 per day Mixed elective lists & on call Flights, accommodation & vehicle provided Tuesday March Ref #: 100/98
$1950 per day
Mixed elective lists & on call Flights, accommodation & vehicle provided Ref #: 989/23
Mixed elective lists & on call Flights, accommodation & vehicle provided Ref #: 345/09
Cardiology Consultant Regional QLD 06 - 12 Sept 2010 $1950 per day Mixed elective lists & on call Flights, accommodation & vehicle provided Ref #: 344/90
Gastroenterology Consultant Regional NSW 16 - 18 July 2010
Mixed elective lists & on call Brisbane Flights, accommodation & vehicle provided
$1950 per day
Mixed elective lists & on call
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Flights and accommodation provided Ref #: 432/12
Flights, accommodation & vehicle provided Ref #: 451/09
Flights, accommodation & vehicle provided Ref #: 455/18
Webinar
Melbourne
Thursday March 31st 2011 4.30 - 6.30pm Level 1, Crown Towers, 8 Whiteman Steet, Southbank VIC (Free Parking Available)
Lachlan Partners is a Private Client Advisory Firm client needs and financial goals with offices in Melbourne, Sydney and Brisbane.
If maintaining and growing your wealth in a transparent relationship is important to focused on ICU Consultant ICU Consultant you, visit2010 www.accordius.com.au on 03 8623 3378 to arrange a Regional QLDor 28call - 29us July 2010 Regional VIC please 20 - 22 Aug $2000 per day
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:
Sydney
Wednesday March 16th 2011 8th 2011 Ref #: 678/00 7.30 - 9.30am 2 - 4pm The Portside Centre, The Novotel Brisbane individually managed discretionary directConsultant investment services. Respiratory Consultant Respiratory Level 5, Symantec House, Creek St, Brisbane QLD Regional NSW 26 - 30 200 July 2010 Regional VIC 21- 25 June 2010 $2000 per day 207 Kent Street, Sydney NSW $1800 per day
$2000 per day Mixed elective lists & on call
Passport to Lifestyle & Career
•
what is happening in Australia and Globally’
Flights, accommodation & vehicle provided Ref #: 199/67
ownedCardiology personal funds management business that offers a Consultant
Regional QLD 19 - 25 July 2010
Flights, accommodation & vehicle provided Ref #: 778/43
• • •
requires a similar approach.
Paul Saliba Chief Investment Officer Lachlan Partners ‘Dynamic Approach to Asset Allocation - Applying the new Zone System’
The 7 Secrets to Explode Your Income as a Locum
eBook
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Creating a Lifestyle in Medicine – The 7 Habits of Highly Successful Doctors
This online webinar is potentially worth many thousands of dollars to you and you will receive access to it at no charge.
To attend OR obtain a Seminar DVD and receive a
month This eBook was created using 3 3 years of complimentary subscription to validated research and testing. ItInvesting reveals: Times email your details to Video interviews with NZ Prime Minister • The secrets to setting meaningful goals update@lachlanpartners.com.au Tel:1300 4 LOCUM Fax: 03 8648 6846 info@LocumBank.com.au• www.LocumBank.com.au John Key and top sportspeople about The keys to achieving those goals peak performance It reveals: • The 7 habits that highly successful doctors Investing Times, Australia’s foremost independent Paul Kasian Fiona Hinrichsenutilise toHamish Moore Geoff lifestyle Greetham in The 7 myths of locuming revealed • The 7 things that anyDrsenior doctor create their desired newsletter providing financial and investment wealth Rewards for you! can apply immediately to maximise medicine, whatever that is forcreation them account Accordius holds AFS Licence No. 321955, specifically allowing us to provide an individually-managed service suitable high net worth investors strategies sincefor1971. Videos of sucessful, real locum doctors their income sharing their feelings and experience • The key ways to become tax efficient www.lachlanpartners.com.au using the renowned MedRecruit system to keep even more of that increased Telephone 1800 643 631 (Freecall) income in your pocket! 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.
What should you do now?
Either register at www.medrecruit.com or call 1800 MEDRECRUIT (633 732)
and you will receive these three resources Welcome to a whole new way of locuming absolutely free and we will schedule a call for where you are the priority and you have you with the exact Solutions Specialist who can your own personal specialist team to assist best serve you. you to get you the best outcome. EASY practice management has just become easier !
MEDIQ Medical Financial Services
MEDILINK esi now incorporates all the benefits of HICAPS together with all the benefits of Online Claiming to . MEDICARE for Practices and their Patients.
MEDILINK esi integrated solutions offers Practices all the benefits of 21 years of development and experience with
MedRecruit Ad_August2010_FINAL_phys&physc.indd 1
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23/08/10 1:19 PM
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MEDILINK software is well reputed to be the easiest and most intuitive with its best of breed Appointments module included with its most comprehensive range of features for, the smallest to the largest of practices, Practice Management. Whilst easy is very much a key word that our clients continue to praise us for – equally so is Medilink’s unbeatable value for money. Other features include:‐ All facets and types of billing for medical and allied health needs. Extensive Management Reporting, makes management very easy and very accountable at the same time. MEDILINK was the first to receive the HIC’s NOI (Notice Of Integration for complete Online Claiming in 2002) then Medicare ECLIPSE certification for Health Fund Online Claiming, and now Medicare Integrated EASYCLAIM
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