First Steps as a new anaesthetist
What to do Immediately after you get your Letters
To Gap or Not To Gap Out-of-pocket Costs and the Anaesthetist
Bullying in Medicine Is it Endemic in Australian Hospitals?
Altruism in Medicine... Is it declining?
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Altruism in Medicine Is it Declining? - Part 1: The History of Altruism
Bullying in Hospitals Is it Endemic in Australian Hospitals?
To Gap or Not to Gap Out-of-pocket Costs and the Anaesthetist
First Steps as a New Anaesthetist What to do Immediately after you get your Letters
Departments 07 Features 30 Business & Finance 46 Risk Management 50 Careers 54 Medical Legends 59 Alpha 62 Boutique 63 Humour 64 Travel 69 Lifestyle
Great Minds Think Alike... Or Do They? Different Types of Intelligence and Medical Specialty Choice
Altruism in Medicine... Is it Declining? - Part 1: The History of Altruism
Bullying in Medicine Is it Endemic in Australian Hospitals?
To Gap or Not To Gap Out-of-pocket Costs and the Anaesthetist
07 14 20 24
BUSINESS & FINANCE
QE2 vs. Austerity What are the Ongoing Implications for Your Portfolio?
Self Managed Supers’ Clean Bill of Health What’s Holding You Back?
First Steps as a New Anaesthetist What to do Immediately after you get your Letters
What's New in Risk Insurance A Market Update
Do Specialty Colleges Owe a Duty of Care to Examination Candidates?
Queensland Anaesthetic Nurse Jailed and Deregistered Male Nurse Stabs his ex-Lover with Suxamethonium
The Secret to Creating a Lifestyle in Medicine Part One
Wireless Technology in Anaesthesia Where are we now and where we will be in 10 Years?
Valentine's Day Gift Ideas
The Hazards of an Old Anaesthetist in the Changing Room of the Operating Theatre
Where in the World Can You Find the Most Extravagant Spas?
Just What the Doctor Ordered… Dr Gilbert Phillips, Neurosurgeon and Wine Lover
Espresso Nation Australia’s Passion for Coffee Explained
appy New Year and welcome to the first edition of 2011.
Looking back, 2010 was the launch year of Anaesthetic Life. Our team have worked tirelessly to ensure that every edition discusses topics that push the boundaries of traditional medical journalism. Since our first edition, we have continued to improve our editorial, design and quality by taking your comments and suggestions on board. To continue this improvement, we are currently undertaking the Anaesthetic Life Survey 2011 and would be grateful to all our readers who can take a few moments to fill this out. (Details on Page 12 & 13). It’s a short, simple survey which provides us with valuable information on how to improve what the magazine has to offer and is the best way to voice your concerns, share your compliments and promote your suggestions. One entrant will win a years worth of free anaesthetic billing (worth up to $15,000) courtesy of ClearBilling.com.au. In keeping with tradition, the Anaesthetic Life team have also made a New Year’s resolution. But unlike many others which are usually broken within the first 4 days, this is one we intend to keep. We will keep on providing a publication that is relevant to your medical specialty, educates you on the nuances of medical business/finance and entertains you with information about recreational interests and luxury items. As always, we aim to be the publication that reflects issues of health, wealth and lifestyle for Anaesthetists in Australia. We are continually expanding our editorial committee and are keen to welcome other medical specialists who wish to voice their opinions to their peers. Regards,
Business Editor Marketing firstname.lastname@example.org Contributing Sources
Dr. Sud Agarwal Dr. Tony Atkinson Dr. Tony Blinde Dr. Richard Cavell Dr. James Nguyen Karen Tonks The Anaesthetic Life magazine is published bi-monthly by Medical Life Publishing Pty Ltd. Anaesthetic Life & Medical Life Publishing are proud to be independent of any academic institution or professional association. Suggestions, content ideas or complete articles written by readers are welcome and will be reviewed by the Editorial Committee. Please direct all inquiries and submissions to: Medical Life Publishing PO Box 2471, Mount Waverley VIC 3149
Selina Vasdev Editor
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Great Minds Think Alike... OR DO they? Different types of intelligence and medical specialty choice. Within the medical profession, it is a commonly accepted belief that there are differences between doctors from different medical specialties. But how real are these differences? And could different forms of intelligence be differentially used within the different specialties?
or years it was generally accepted that there was just one measure of intelligence, IQ (Intelligence Quotient) - that which can be measured by standardised intelligence tests. The term was devised by the German psychologist William Stern in 1912 and was based on the notion that we all have a set level of general cognitive ability, our level of capability to understand logic, solve problems and reason. However, what happens when we have individuals who excel at one type of reasoning but perform poorly in other areas? Einstein famously failed his university entrance exams and performed poorly in high school tests. Yet he is regarded as one of the greatest thinkers of the 20th Century. Obviously the tests he was sitting didnâ€™t measure his â€˜typeâ€™ of intelligence.
F E AT U R E S
Einstein famously failed his university entrance exams and performed poorly in high school tests. Yet he is regarded as one of the greatest thinkers of the 20th Century.
In 1983 Harvard professor Howard Gardner proposed his Theory of Multiple Intelligences. This theory stated that there were at least 7 different types of intelligence, and that an individual could have high levels of any one or more of these types of intelligence, sometimes to the detriment of the others. So which of these intelligences would lead one to a choice of a certain medical specialty? And which forms of intelligence are most useful to those in say, Surgery as opposed to say Anaesthetics? The first, and perhaps most obvious observation is that a high level of visualspatial intelligence will be especially useful to those working in or wanting to work in surgery. Durkin (2010) states:
“In order to understand anatomical relationships thoroughly, a doctor must be able to think structurally, to visualise in three dimensions. Before making the initial incision, the surgeon will have a mental blueprint of that part of the patient’s body in which the operation will occur.” Doctors who have a special strength in this area may well be drawn to Surgery as a career choice, and may make very good surgeons as a result. Surgeons may also tend by be high on the bodily-kinaesthetic form of intelligence as they have to be very aware of their hand’s movements and be very precise in making these movements. Good motor control and motor-memory may well be a valuable tool to a budding surgeon. However, in contrast to specialties that demand more patient contact, those working in the surgical subspecialty may have less need for Gardner’s “Interpersonal intelligence”. This form of intelligence describes those who are especially sensitive to others’ feelings and emotions, and who are able to use this information to facilitate good relationships with others. Whilst many surgeons may well also have these abilities, these are not as important as other skills to becoming an excellent surgeon. Gardner’s idea of ‘Interpersonal intelligence’ is very closely related to the concept of Emotional Intelligence (EI),
The EIGHT types of intelligence 1
Verbal-linguistic Intelligence This is the ability to work well with language. Those with this form of intelligence could easily learn a new language and are good at reading and writing. They will be able to write eloquently, will enjoy debates and arguments, and will usually have a large vocabulary and enjoy learning new words and their origins. Logical-mathematical Intelligence This is the ability to apply logic to systems and numbers. People who have this type of intelligence are natural problem solvers. They usually perform well on traditional IQ tests. Engineers, scientists, economists and mathematicians have this type of intelligence.
Visual-spatial Intelligence This is the ability to perceive the world visually and re-create it without physical stimuli. This type of intelligence allows you to think in terms of visual space. People with this form of intelligence are usually very good at picturing shapes or objects as they would look from different angles in their mind’s eye, without needing to see the object in front of them. Bodily-kinaesthetic Intelligence People with this type of intelligence learn best through bodily movement. They usually excel in physical activities such as dancing and sports. A person high on this form of intelligence will have excellent motor skills and memory for motor movements.
F E AT U R E S a paradigm that is becoming ever more commonly considered in the medical world. Emotional Intelligence is the ability to monitor one’s own and others’ feelings and emotions in order to guide one’s thinking and actions. EI involves skills that are important for many medical disciplines, such as communication skills and interpersonal awareness. Borges (2009) found that medical students’ EI was typically slightly above that of the general population of college age adults, demonstrating that this form of intelligence is a quality that most doctors probably possess in some measure. It makes sense that Emotional Intelligence would be an important trait for many medical specialists to possess. Doctors with good communication and interpersonal skills are less likely to receive patient complaints and more likely to play a major role in reducing medical errors (Weng et al., 2008). Levinson et al. (1997) demonstrated an empirical link between doctors’ communication behaviours and subsequent malpractice litigation in the US. Emotional Intelligence could be extremely useful to doctors who have a substantial amount of patient contact, such as Psychiatrists, GPs and all patientfacing doctors. Stratton & Elam (2005) state that EI could enhance a Physician’s performance through building the rapport and trust necessary to establish a solid patient-doctor relationship. In a recent study, researchers found that doctors’ Emotional Intelligence were positively associated with higher patient trust as well as better patientdoctor relationships (Weng et al, 2008).
This is important as the patient-doctor relationship was also found to mediate a patient’s overall satisfaction with the physician. Stratton & Elam (2005) further put forward the argument that EI may moderate Physicians’ abilities to understand patients’ responses to treatment regimes, thus improving patient adherence. So EI or Gardner’s Interpersonal intelligence could be of great importance to doctors who work extensively and closely with patients,
Doctors with good communication and interpersonal skills are less likely to receive patient complaints and more likely to play a major role in reducing medical errors. as high levels of this form of intelligence should significantly enhance their patient relationships and may even influence clinical outcomes. So what types of intelligence would be useful to Anaesthetists? An interesting anomaly in the Emotional Intelligence literature is a study by Talarico et al. (2008) which found that Emotional Intelligence was not significantly related to performance in Anaesthetics residents. This may of course have a lot to do with the fact
Interpersonal (or Emotional) Intelligence This is the ability to empathise with people—the skill of understanding the moods and motivations of others. People with this intelligence work best in fields where they interact with others on a daily basis. The concept of Emotional Intelligence (EI) is related to this type of intelligence and will be discussed later.
Intrapersonal Intelligence This is the ability for self-analysis and reflection. People with this form of intelligence have good self-understanding and tend to be deep thinkers, often being introspective. They like to spend time pondering on deep issues.
Musical Intelligence Those with this form of intelligence are good at making or composing music, or have the ability to understand and appreciate music. People with this intelligence typically have good pitch, can sing and can play several different musical instruments. Recently Gardner added an eighth intelligence:
Naturalistic Intelligence This is the ability to appreciate nature and the outdoors. Those with this form of intelligence will have a good understanding of how environmental cycles work, a natural instinct for direction and the ability to understand their natural surroundings.
F E AT U R E S of this intelligence, which could explain why Talarico et al (2008) found no link in their study of EI and Anaesthetists. So it is apparent that different medical subspecialties may require very different types of intelligence. Emotional or Interpersonal intelligence may be of particular importance for Physicians who have a lot of interpersonal contact with patients, whilst surgeons may benefit most from visual-spatial intelligence and anaesthetists may require high levels of logical-mathematical intelligence.
As doctors we need to exhibit high enough levels of all these types of intelligence... that performance for Anaesthetics residents may be more heavily related to clinical outcomes, as well as patient satisfaction outcomes. Therefore success as an Anaesthetist may depend on other forms of intelligence, such as logicalmathematical intelligence. This form of intelligence enables an Anaesthetist to have the skills needed to make rational judgements about the risk vs. safety of a patient, as well as making quick mathematical calculations regarding drug levels. Other valuable qualities for an Anaesthetist are the ability to remain calm under pressure and level-headedness, both skills which could be linked to a form of Emotional Intelligence, the ability to keep one’s own emotions under control. This is a form of EI not often measured in typical studies
Clearly, as doctors, we need to exhibit high enough levels of all these types of intelligence to firstly, be accepted to medical school, then to acquire and retain the expected amount of knowledge and to problem-solve throughout the course of this demanding job. But perhaps in medicine the most important qualities are commitment and a drive for hard work. A recent study by the British Medical Association showed that when it came to predicting performance and career outcomes across a range of medical careers, academic achievement measures (Year 12 exam results) predicted performance and career outcomes far better than an intelligence test measure (McManus et al, 2003). Career outcomes such as performance in undergraduate training, performance in post-registration house officer posts and time to achieve membership qualifications were all predicted by doctors’ Year 12 results whereas intelligence did not independently predict any of these career outcomes. This demonstrates that in the world of medicine, motivation, determination, and capacity for hard work may prove more important than innate levels of any type of intelligence. Karen Tonks, Psychologist
References: Borges, N., Stratton, T., Wagner, P., & Elam, C. (2009). Emotional intelligence and medical specialty choice: findings from three empirical studies. Medical Education, 43 (6), 565-572 Durkin, J. (2010). What Attributes do doctors typically have? http://www.jocrf.org/resources/AptitudesofPhysicians.html Levinson, W., Roter, D.L., Mullooly, J.P., Dull, V.T., Frankel, R.M. (1997). Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA, 277: 553559. McManus, I. C., Smithers, E., Partridge, P., Keeling, A., Fleming, P. (2003). A levels and intelligence as predictors of medical careers in UK doctors: 20 year prospective study. BMJ 2003; 327 : 139 doi: 10.1136/ bmj.327.7407.139 (Published 17 July 2003) Stratton, T.D, Elam CL, Murphy-Spencer AE, Quinlivan SL. (2005). Emotional intelligence and clinical skills: preliminary results from a comprehensive clinical performance examination. Acad Med. 80(10 Suppl): S34-S37. Talarico, J., Metro, D., Patel, R., Carney, P., Wetmore, A. (2008). Emotional intelligence and its correlation to performance as a resident: a preliminary study. Journal of Clinical Anaesthesia, 20 (2), 84-89. Weng, H., Chen, H., Chen, H., Lu, K., Hung, S. (2008). Doctors’ emotional intelligence and the patient-doctor relationship. Medical Education, 42(7), 703-711. Pictures: Page 4 & 8, "Albert Einstein" by manfrys http://www.flickr.com/photos/manfrys/2134586133/ Page 9, "ANGER!" by Amy McTigue http://www.flickr.com/photos/amymctigue/3543454897/ Page 10, "Hard work can hurt" by normalityrelief http://www.flickr.com/photos/normalityrelief/3075723695/ Images licensed under a Creative Commons Attribution 2.0 Generic Licence http: / / creativecommons.org/ licenses/ by/ 2.0
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in Medicine... Is it declining? Part 1: The history of altruism
‘Altruism: unselfish concern for the welfare of others.’ ‘Selfish: chiefly concerned with one’s own interest, advantage, to the exclusion of the interests of others.’1
F E AT U R E S
ow did ‘altruistic behaviour’ develop? Why has it endured? Is it in danger of dying out?2 Does it even matter if it does? More importantly, what does all this have to do with Medical Practice in the 21st Century?
The following is Part 1 of a short 2 part review of an enormous topic. These are probably not the sort of philosophical ruminations that most people have every day. After all, the considerations of running a busy practice and keeping everybody happy so that the work continues to come in so that the family has a roof over their head, food in their stomachs and iPads in their school bags are somewhat more pressing and preoccupying. However, ‘altruism’ is what gives the great majority of us the drive and determination to succeed in our personal lives, by fostering lasting relationships with our friends and family and as Medical Professionals, ensuring we give the best we know how to our patients. So it is worth spending a little time to review the topic.
The Origins of being nice. There are a number of theories that variously invoke genetics3 4, evolution5, social biology, different schools of belief and winning Stone Age conflicts6. A possible mechanism for the evolution of the very first altruistic gene/cell (represented by present day Volvox carteril) makes absorbing, if somewhat heavy reading7. But putting that to the side, the overall gist of all proposed theories suggests that it was only because ancestral Homo sapiens developed ‘the trait’ and helped each other with the hunting, fishing and fighting that we had any chance of survival and growth. An interesting and recent theory, carefully researched and presented, would suggest just how close we previously came to
...‘altruism’ is what gives the great majority of us the drive and determination to succeed in our personal lives...
F E AT U R E S
The trait works in many people, as evidenced by the hundreds of thousands of people who perform unsung acts of generosity and bravery on a daily basis. that was remotely ‘not like Us, but like Them’. Unfortunately, with no more Homo neanderthalensis to take on, this previously practical propensity was (likely) turned against fellow CroMagnons who, unhappily for ‘Them’, talked, walked or looked different to ‘Us’.
extinction, before learning together, for each other.
In his book, ‘Them + Us’8 Danny Vendramini presents persuasive evidence that from about 100,000 years ago until only fairly recently, Homo sapiens were the primary food and sexual prey for Homo neanderthalensis, the ‘peak predator’ of the era. So attractive were they that around about 50,000 years ago, there were very few of our ancestors left. Then… something changed. That something could well have been the development of the ability to work and fight together in a way which gave the struggling proto-Humans the tactical advantage over their now surprised former predators. The slow, dim ones already having been eaten, left the faster clever ones to breed, thereby passing on the ability to run faster... and together. By becoming co-operative, Cro-Magnon man was born and over the next 25,000 years or so, co-operatively wiped out Homo neanderthalensis, the last of whom died about 25,000 years ago, in Gorham’s Cave, near Gibraltar.
It is only because the development and survival of constraining and socialising behaviour that such violence and aggression has not (yet) caused the extinction of Homo sapiens through uncontrolled in-fighting. Altruistic behaviour (the trait) was one aspect of this social behaviour and its persistence can be traced to the advantages that it gave to the individual, clan or tribe that exhibited it. For some ‘do unto others as you would be done by’ is the mother and father of all commandments. It is after all THE core value of all successful civilised societies. The concept of ‘I’ll scratch your nits and you scratch mine, in a few moon’s time’, deferred gratification or saving goodwill (not in such words) would have acted to bind individuals together, make one individual more reliable as a cave companion, hunter, fighter or potential mate, thereby ensuring the trait carried on.
The direct consequences of being nice. (A very very short history of the human race...)
It was the invention of agriculture about 10,000 years ago in the Fertile Crescent of Mesopotamia and the Levant that freed man from the need for and dangers of forever foraging. In turn it required that he give up wide roaming and hunting and settle down.
Vendramini makes the case that our violent and aggressive ‘modern human nature’ is a result of those approximately 25,000 years of predation. Our ancestors had only survived by developing a serious and deadly dislike of anything
Settling down was the stimulus for buildings as durable as caves but more readily available, for protection from danger and the elements and safe storage of excess produce for lean times. Food security led to an increasing population
which in turn led to an increasing size of settlements. Shacks turned to hamlets, that grew into villages which developed into cities. The strong leader of the tribe became the strong village leader who became the king of the city and then with conquests, king of the land that became the nation. Surpluses allowed humans the luxury to start asking questions like ‘Why?’ ‘What?’ and ‘When?’ Such questions gave rise to Religious, Philosophical and Scientific specialists (Astronomy being amongst the first) who sought to understand but very quickly realised the potential to control. Production of excess and increasing specialisation led to the need for exchange of goods and labour and this led to barter and hence monetary systems. The increasing size (See ‘The Dunbar Number’ later) and complexity of human settlements required increasing civil administration and ‘laws’. The inevitable friction between adjacent settlements often led to competition for resources and increasingly deadly wars. None of these changes would have occurred had the Homo sapiens not developed the ability to co-operate with his immediate fellow and of course, as populations grew and coalesced, with his newer neighbours. Because of the success that came from the trait, it was carried forward. Homo sapiens survived and multiplied to become the dominant animal on the planet today.
Are only humans nice? The answer to the question is ‘No’. Homo sapiens are not the only species to display such behaviour. It is commonly seen in many colony animals such as termites and ants where a particular caste will be sacrificed to protect the colony and queen against invasion and attack.
F E AT U R E S
Moving to higher animals, there are many well recorded accounts of dolphins protecting humans from sharks or rescuing them from drowning. Elephants not only experience a prolonged period of mourning for their dead but demonstrate extraordinary concern for the safety and welfare of other species, including man. Many of the higher primates display behaviour that can only be described as altruistic. A quick Google on ‘altruism in animals’ records approximately 440,000 results. Clearly there exists a spectrum of sentience, self-awareness and the potential for intra and inter species cooperation throughout the animal kingdom, including many, but sadly not all, humans! In fact, there are really strong indications that other animals are quite capable of taking revenge for human cruelty9. The trait works in many people, as evidenced by the hundreds of thousands of people who perform unsung acts of generosity and bravery on a daily basis. For instance, there are many volunteer organisations here in Australia, who, with minimal government funding, willingly perform vitally necessary functions. The SES being a case par excellence. It is easy to dismiss such action as due to the (sub)conscious anticipation of
later reward, perhaps money from a will, acknowledgement of their humanity, and glowing praise from adoringly thankful onlookers. That does not explain the dangers that some people put themselves in. Sometimes altruistic impulses can end in tragedy, as when a person drowns trying to save an animal (which survives). This would sadly suggest that sometimes the trait overrides common sense which certainly is not a good thing because we want altruistic people to survive, not die in the act.
Being nice and Medicine. (Medicine: The ART of healing). If altruism did not exist within the animal kingdom it would have needed to be invented for our professional ancestors to achieve the remarkable successes they had. Where would the many great and brave pioneers responsible for early Medical developments have gained the inspiration and courage to do the things they did? Even if not the entire reason it must contribute significantly. We can imagine the sweating shaman prancing around the comatose chief of the tribe with great vigour, blowing smoke and shaking boney things, to cure his rapidly expanding subdural. Whatever the outcome for the hapless chief and the
• 1796 Jenner ‘vaccinates’, his son based upon the clinical observations of milkmaids... • 1898 Bier experiences the first intrathecal anaesthetic and the first ‘low pressure headache’! • 1929 Forssman catheterised his own right atrium. He is sacked but shares a Nobel Prize. To this day there are many Medical Practitioners who regularly do far more than is expected of them. The large numbers of Health Professionals who work for medical benefits and charities, in underprivileged areas both at home and abroad, humanitarian aid workers etc. would suggest that, in the absence of ulterior motive, these people possess a more ‘expressive’ altruistic trait. Whatever it is and whatever the actual motives, in simple terms it can be described as doing the best one knows for others. It may be a little hard for some to understand or even describe but the world in general and the profession in particular would be very different if such drives were absent. (It is obviously of critical importance that the pathologically driven and dangerously overworked are not mistaken for ‘eager altruists’ and receive help accordingly.)
Whatever it is and whatever the actual motives, in simple terms it can be described as doing the best one knows for others. unhappy shaman, this was perhaps the origin of medical altruism.
But what is it?
Since that early anxious moment there have been any number of Great Moments in Medicine, some of which were in fact ‘altruism by proxy’ and most of which would not pass a Modern Ethics Committee!
It is a satisfaction that is shared by the patient/recipient who recognises that this is somebody who respects them as worthy of that extra attention and consideration and does not look for any tangible reward for what they do. The reward is the satisfaction that comes from knowing that a difference has been made and that it has been because of a personal decision to do what is known to be right.
Just a very few examples:
Unfortunately such activity rarely receives
The principles were codified in Greece, about 500 BC, by Hippocrates.
F E AT U R E S
Many people in Westernised societies are becoming more alone and self-absorbed in the midst of crowds.
the attention it should which is a shame because it is attending to the seemingly simple act by doing that little bit extra; giving more of one’s time, thinking what small but critical changes and comforts can be provided or doing something in a different way. It is these activities that make Medicine an Art and not just ‘a job’.
Are some of us less altruistic? It is hard to measure precisely but the answer to this would seem to be ‘Yes’. Various surveys and studies indicate that job satisfaction is decreasing in medical personnel around the globe, overseas10 11 12 in Europe13 14 and Australasia15 16 . It appears that altruism decreases when people are dissatisfied with their own circumstances.17 This is not really hard to understand. Whilst some may distract themselves being busy, others will not be able to do so. This decline in altruism is not limited to Medical Practitioners and would seem, worryingly, to be a fairly widespread problem. Altruism requires empathy, and this seems to be on the decline18. For a species that survives through cooperation this is not a good thing.
ways that the Human being can be ground down and demoralised and these are just some of the ways. This will be expanded upon later. Many people in Westernised societies are becoming more alone and selfabsorbed in the midst of crowds. This trend is encouraged by the technology that we have that allows a great deal of ‘socialisation’ to occur ‘on-line’ or cocooned from those around. This may be a useful survival tactic but carried to extreme, it is disastrous. Individually this can lead to people walking under cars or even buses, active ear phones in-situ. Collectively it can lead to an inability to work co-operatively for the benefit of all. Personal and social political apathy is a sign of pathology... Norwegian rats are often used as a good model for some higher, human behaviour. Studies of crowding in these animals shows very clearly that behavioural and social norms break down in ways that mirror human societies today.19
The Dunbar Number. There are simply far too many of us crammed together in too small a space for the trait to have full expression. It is quite
clear from a number of studies that the optimum size for a community to really properly function with cooperation is 150 - 200 individuals20 (The Dunbar Number) and anything much above this becomes socially ineffective. Smaller groups will form that will adopt their own standards which may conflict with those of the parent group. It is easy to see how conflict and conflicting ideas, attitudes, moral codes and action can result. Hence, the need for ‘social constraints’, laws, police and unfortunately, Lawyers. It appears the Dunbar Number is a simple way of quantifying the number of social connections and hence the co-operative capacity our cerebral cortices are ‘hard neuroned’ to handle. In the event that we cannot quickly increase it, we have a problem that will have to be solved by other means... Altruism in Medicine... Is it Declining? Part 2: 'The reasons why' - a further discussion in to the reasons behind the decline is to be continued in the next edition. Dr. Tony Blinde, Melbourne
Why? Unfortunately, it would seem that we are actually being encouraged to lose what empathic capability we had. ‘Popular’ TV shows providing prizes for portrayals of people suffering unpleasant and painful misfortune can only encourage this decline, even if they are more a symptom than the cause. Self-interest is promoted blatantly and subtly in advertisement for anything from cars to crackers. The ‘Me oh My, I want it NOW’ generation is growing at the expense of concern for others and the broader cost to society of unsustainable greed. There are many
References : 1 Collins Concise Dictionary. 2 10.3949/ccjm.75.Suppl_6.S33 Cleveland Clinic Journal of Medicine November 2008 vol. 75 Suppl 6 S33-S36. 3 Numerous but see British Psychological Society (BPS) (2010, October 14). “Selfless’ genes attract mates.” 4 University of Nottingham (2008, October 15). “‘Being Altruistic May Make You Attractive.” 5 The Independent/UK January 10 2008. “Evolutionists At War Over Altruism’s Origins.” 6 By Samuel Bowles. Science, Vol. 324 Issue 5932, May 5, 2009. “Did Warfare Among Ancestral Hunter-Gatherers ..” 7 Mol Biol Evol (August 2006) 23 (8): 1460-1464. “Evolutionary Origin of the Altrustic Gene.” 8 kardoorair Press, Danny Vendramini ‘‘Them + Us.” 9 Jason Hribal .. Fear of the Animal Planet - The Hidden History of Animal Resistance. Counterpunch. 10 Job satisfaction .. in Turkey S Bodur, Dept Public Health, Uni Konya, Turkey. OccMed Vol 52, No. 6, pp 353-355, 2002. 11 Leigh. Arch Intern Med, Vol 162, July 22, 2002, p 1580-1. 12 Human Resources for Health 2010, 8:26doi:10.1186/1478-4491-8-26. 13 Psychological morbidity.. BMJ 1998; 317 : 511. 14 J Health Polit Policy Law. 2008 Dec;33(6):1133-67. 15 Anaesth Intensive Care. 2008 Mar;36(2):214-21. 16 Anaesthesia. 2003 Apr;58(4):339-45. 17 www.businessperspectives.org/journals.../PPM_EN_2005_04_Arciniega.pdf 18 The Empathy Deficit, Keith O’Brien, Boston Globe, Oct 17 2010. 19 Calhoun, John B. Various … Google ‘calhoun rat studies’. 20 R.I.M Dunbar, “Neocortex size as a constraint on group size in primates,” Journal of Human Evolution (1992), vol. 20. Pictures: Page 16, "e la chiamano estate" by nettaphoto http://www.flickr.com/photos/nettaphoto/215109874/ Page 17, "Mercedes Bends and Altruism Rules." by Newtown grafitti http://www.flickr.com/photos/pinkcotton/3736850281/ Page 18, "200/365: Lonely in the crowd" by Janine http://www.flickr.com/photos/normalityrelief/3075723695/ Images licensed under a Creative Commons Attribution 2.0 Generic Licence http: / / creativecommons.org/ licenses/ by/ 2.0
“The tears ran down my face, hidden by my surgical mask. My consultant continued relentlessly, 'Why can't you do this? It really isn't hard. Are you stupid? Can't you see how to help me?'” ANAESTHeTicLife
Bullying in Medicine
Is it endemiC in Australian Hospitals?
his quote is taken from an account of one Junior Doctor’s experience of bullying in a surgical training post, published in the British Medical Journal. The Junior Doctor goes on to say, “The atmosphere in the operating theatre was tense. The criticism continued, if not with words, then with sighs and angry tutting. The staff had all seen this happen many times before—hard working, pleasant trainees reduced to nonfunctioning wrecks in the space of an operation. ... I didn’t know what to do. I felt uncomfortable continuing in such distress. Either my consultant didn’t notice or she didn’t care. I wondered what would happen if I asked to leave and decided that it would probably just make things worse for me. I stayed. Three hours of hostility and criticism. At the end I ripped off my mask and gloves and turned, only to find her standing behind me. She registered my swollen eyes and tear stained face in complete silence. I have never seen such a cold, emotionless stare, and I hope never to again.”1
This case documents a phenomenon that we most likely have all seen happening around us in hospitals and practices where we work – workplace bullying. Workplace bullying is surprisingly common, and is becoming more so. In recent surveys carried out in the UK, the US, Australia, and European Union, the percentage of people who had been bullied in their workplace ranged from 8 to 20 per cent2. In medicine this figure is even higher. A recent study in an NHS trust in the UK found that one third of medical staff reported having been bullied in the previous year3. This proportion
was replicated two years later with a similar study finding that 37% of Junior Doctors in the UK reported experiencing bullying in the preceding year 4. Tim Field, founder of a national workplace bullying advice line in the UK, states that healthcare sector staff comprise about 12% of the over 5000 calls his service receives yearly, ahead of social services (10%) and the voluntary sector (68%). According to Field, experiences such as the one described here are common. It’s not just in the UK that this worrying state of affairs is the case. In the United States, several studies report a culture of mistreatment or bullying of medical students throughout their medical school years, with this pattern often continuing well into the early training years5, 6. In Australia the situation was regarded as so serious that the Queensland Government set up a Workplace Bullying Taskforce. This Taskforce was commissioned with producing a thorough report on the extent of bullying in workplaces across Australia, and devising a strategy on addressing this problem. One Specialist Registrar in Forensic Psychiatry writing in response to the account of bullying outlined above says “My medical experience spanning four countries in the last 20 years is sufficient for me to declare that the kind of bullying described here is not unique to the United Kingdom.”7 So what causes bullying and why do some people bully? Firstly, let’s take a look at the kinds of behaviours that constitute bullying – you may well recognise some of these from observations of your colleagues or peers. Lyn Quine, in her study of bullying amongst
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Junior Doctors, asked participants to fill in a questionnaire which listed bullying behaviours and asked doctors whether they had experienced these in the preceding year. Some of the items listed included; “Persistent attempts to humiliate you in front of colleagues”, “Persistent attempts to belittle and undermine your work”, “Withholding necessary information from you”, “Shifting goalposts without telling you” and “Persistent unjustified criticism and monitoring of your work” (for the full list of bullying behaviours see Quine, 2002). Alarmingly, 84% of the Junior Doctors surveyed reported having experienced at least one of these bullying behaviours (although most would not consider themselves as having been “bullied” in the past year). A general definition of workplace bullying is “a form of physical or psychological harassment”. The Queensland Government Workplace Bullying Taskforce defined bullying as: “repeated behaviour directed at one particular individual which is offensive, intimidating, humiliating or threatening, and which is unwelcome and unsolicited”.
bullies often pick high-performing, ‘threatening’ individuals as their targets speak volumes of the bully’s motivation to intimidate and therefore eradicate the ‘threat’. In this way, bullies can be motivated by jealousy, lack of knowledge, fear or insecurity. In clarifying the common targets of bullying, Tim Field comments “The stereotype of a “victim” as a weak inadequate person who somehow deserves to be bullied is giving way to the realisation that bullies, who are driven by jealousy and envy, pick on the highest performing and most skilled staff, whose mere presence is sufficient to make the bully feel insecure. Threats (of exposure of inadequacy) must be ruthlessly controlled and subjugated. Those who can, do. Those who can’t, bully.”8 Although many have observed that medical bullies often pick high-performing individuals as their targets, there is another side to the coin in that some observers have highlighted another ‘type’ of victim. Kristin Becker, a consultant in Clinical Genetics observes “Bullies often seek out easy targets: people with a passive nature who do not have much self confidence.”8 So it may be that, just like the very nature of the bullies themselves, different types of person could become targets of bullying for very different reasons.
In Australia the situation was regarded as so serious that the Queensland Government set up a Workplace Bullying Taskforce.
So what causes some people to become bullies and not others? Within the medical sphere, bullies most often come from the higher ranks of medicine and bullying is almost always perpetrated against those in lower or training grades. However, this is not always the case and doctors may be bullied by their peers or even their juniors7. Bullying by same-level colleagues often takes the form of victimisation and undermining of one particular individual – embarrassing them in front of colleagues or juniors, undermining their decisions and generally making life more difficult for this person. Daphne Austin, a Consultant in Public Health comments “I have observed quite unacceptable behaviours which at best can be considered unprofessional and at worst abusive.”7 Sadly, many doctors within senior positions may not even realise that they are ‘bullying’ their peers or juniors. Graeme Mackenzie, a GP from the UK remarks “Unfortunately, many senior doctors are unaware that they have a problem. Only psychopaths are horrible and enjoy it. Most people are rude and horrible because they feel anxious, stressed, and put upon, and these emotions drive chronic bullying and rudeness. Elevated rank leads to years of this behaviour being unchallenged, which removes any chance of insight developing.”8 Many also argue though that bullying is the result of personality disorders – that doctors who bully do so out of a deep-seated sense of inadequacy and insecurity7. They use bullying as a way of making themselves feel more powerful. Observations that
Whoever the victim, the targets of bullying often have little recourse to complain or address the problem, as they fear for the consequences on their career. Many medical job applications rely on good references from previous job posts and doctors fear being labelled a “trouble maker”. Dr. Agell, a Consultant Psychiatrist, points out, “The imbalance of power is the most important factor in determining inaction. ... If a bullied person was capable of ending the incident they would do so.”7 Junior Doctors being bullied often assume (perhaps correctly) that the more senior doctor perpetrating the bullying will have more powerful connections than they do, and therefore the consequences for the Junior Doctor’s career will be more farreaching than those for the “bully”. For senior doctors suffering at the hands of bullies, the situation can be even more complex. Consultants or Registrars being bullied by colleagues or juniors may feel inadequate at not being able to ‘handle’ the bullying situation themselves, despite research showing that bullies often deliberately choose individuals they see as competition. Doctors in the senior levels of their careers also suffer from the pressure of the repercussions on their career of reporting an incident of bullying. So what can we do to address the problem of bullying in
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hospitals? On an individual level, if you are being bullied it is important to keep a note of incidents, to record times and dates, and to enlist witnesses who will corroborate your experiences. Go to your Clinical Supervisor or a similar individual who you respect and get along with. Even if the bully is never formally disciplined, a paper trail will have been laid such that if similar incidents occur in the future, greater notice will be paid and the bully will be more likely to be picked up. At an organisational level, John Boulton, a professor of medical practice in Australia, suggests that further training in doctordoctor communication skills may be the way forward7. Although medical students are now routinely taught doctor-patient communication skills, if they were given situations to role-play designed to mimic common medic-medic interactions maybe they would be better equipped to deal pro-actively with dysfunctional situations in the workplace when they arise. He comments “If the traumatised young doctor whose story we heard had had the opportunity to role-model a communication strategy based on a solid theoretical understanding of dysfunctional power play, then perhaps she could have been able to look the surgeon in the eye at the end of the operation and say, “Your behaviour was unacceptable; I am seeking advice from the Human Resources department on the avenues available to lodge a formal complaint, and I intend to lobby for your removal as a supervisor”.”
Within the medical sphere, bullies most often come from the higher ranks of medicine and bullying is almost always perpetrated against those in lower or training grades.
The symptoms and signs of the presence of a bully often stare us in the face. We need to learn to pick up on these signs and provide more support for those in our workplaces who may be on the receiving end of bullying. The Queensland Government Workplace Bullying Taskforce provides guidelines on dealing with bullying. We must, as a profession, clamp down on the idea that ‘tough’ management is somehow beneficial to our doctors. If we can do this, we minimize the risk of losing potential good doctors who will, if treated right, lead our profession into the future. Karen Tonks, Psychologist
References 1. Personal Views: Bullying in medicine. BMJ 2001; 323:1314. 2. Graves, L. (2003). The Big Fight. Personnel Today, Jan 2003. http://www.personneltoday.com/ articles/2003/01/21/17061/the-big-fight.html 3. Quine, L. (1999). Workplace bullying in NHS community trust: staff questionnaire survey. BMJ 1999; 318:22832. 4. Quine, L. (2002). Workplace bullying in junior doctors: questionnaire survey. BMJ 2002;324:878–9. 5. Daugherty, S.R., Baldwin, D.C. Jr., Rowley, B.D. (1998). Learning, satisfaction, and mistreatment during medical internship. JAMA 1998;279:11949. 6. Kassebaum, D.G., Cutler, E.R. (1998). On the culture of student abuse in medical school. Acad Med 1998;73:114958. 7. Responses to ‘Personal Views: Bullying in medicine.’ BMJ 2001;323:1314 doi:10.1136/bmj.323.7324.1314 8. Bullying in medicine. Editor’s Choice – Letters Page. BMJ 2002; 324:786 doi: 10.1136/bmj.324.7340.786/a
Out-of-pocket Costs and the Anaesthetist
othing seems to provoke the anger of patients, politicians and surgeons more than when anaesthetists charge out-ofpocket costs or gaps. However, as with every controversial subject there are two sides to the story....
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rebates from Medicare are effectively being devalued. In fact, with each additional year (and inadequate increase in MBS rebates), the real earnings of doctors are decreasing incrementally. Therefore, to neutralise the difference between the ever escalating CPI (used to represent the cost of living) and the modest increase in Medicare rebates, doctors would need to charge an everincreasing gap fee. This was the rationale used by the AMA in their “Why is there a Gap?” campaign and has been used by numerous private medical practitioners on their websites to justify their charging of AMA rates. A personal analogy that I would like to introduce is when I hired a photographer for a family event and tried to negotiate his rather lofty price. His rebuttal was that he has placed a fixed dollar value on his time. If his services were to be
engaged, then the cost was to be a fixed cost based on the amount of time he devotes to the task. What I would like to pay for it is immaterial. He simply wants to meet the dollar value he has attributed to one unit of his time. This concept has been paralleled in clinical practice where doctors have costed out their time and decided what each unit of time should be worth. If a case brings in remuneration below that, then a gap is added to make up the difference and bring it up to the value assigned to one’s time. However, it isn’t always that simple… there is a substantial body of people who wholeheartedly believe that charging above the MBS scheduled fee, or even above the full health fund rebate, is greedy opportunism. How did this dichotomous understanding of out-ofpocket costs originate?
The patients totally fail to see that these grandiose names actually reflect the co-payment they make to the health fund when they claim, rather than the rebate paid to doctors.
There is the free-market, economic theory which dictates that all doctors are independent contractors who value their time at different rates and so can determine their prices at whatever rate they choose. If the patient’s health fund is not willing to pay that price, then the gap is borne by the patient. When explained to an accountant, banker or lawyer, this argument makes perfect sense and would typically be greeted by a nonchalant ‘of course’. If we examine the failure of Medicare rebates to be indexed to the Average Weekly Earnings (AWE) index or even the Consumer Price Index (CPI) since the advent of Medicare, we find that today’s
cheaper option, then some patients will choose to exercise their consumer choice and seek an alternative option.
“Consumers will be willing to buy a given service, at a given price, if the marginal utility of additional consumption choices is equal to the opportunity cost determined by the price.”
These dichotomous views have a lot to do with the potent marketing employed by private health funds. With frequent usage of euphemistic terms such as “Top-Hospital cover” [HBA], “Gold Plus cover” [GMHBA], “Blue Ribbon cover” [Medibank], patients are easily misled into believing that because they have paid larger health fund premiums, they are less likely to receive out-of-pocket costs. The patients totally fail to see that these grandiose names actually reflect the reduced co-payment they make to the health fund when they claim, rather than the rebate paid to doctors. Additionally, patients utilising these so called top-level cover schemes firmly believe that the health fund pays doctor a higher rebate because they have chosen a higher level of cover than the bargainbasement variety. All this contributes to the common misconception that doctors are feathering their own nest at the expense of ‘helpless’ patients. With the advent of informed financial consent and the glitzy, political propaganda behind it, voters too were easily fooled into thinking that their outof-pocket costs would be diminished when they could easily walk away and ‘shop around’. This clearly does not apply to anaesthetists as their patients
typically meet them for the first time on the day of surgery and rarely have any opportunity to exercise any consumer choice. Having said this, there are a large number of anaesthetists who choose to diligently no-gap all their patients. Some of these choose to take it one step further by casting aspersions on their lessaltruistic colleagues who are charging gaps. It is perhaps this internal group of perennial no-gappers who have voiced their discontent with their gap charging colleagues, that makes the remaining anaesthetists wince with a small sense of shame. After a substantial discussion with an economist, I was enlightened to hear the application of a micro-economics model to the costing of healthcare and the sensibilities of prospective informed financial consent: “Consumers will be willing to buy a given service, at a given price, if the marginal utility of additional consumption choices is equal to the opportunity cost determined by the price.” In plain English: If the overall costs incurred in cancelling the operation on the day of surgery and rescheduling with a lower cost service provider provides a
If we make the basic assumption that a patient will have had to take a day off work to attend for surgery, it becomes even more unfeasible that he or she will decide to cancel for monetary reasons alone. So according to my economist friend, anaesthetists have free reign to charge whatever fee they decide is justifiable. It appears to be a situation in which the consumer has limited supply choice whilst the anaesthetist has uncontested demand. However, few anaesthetists would be swayed by an economic model alone. There are many other social, political and logical reasons why anaesthetists would not simply charge the highest fee they possibly could. These include: • Genuine altruistic concern for the patient, especially pensioners and lowincome earners • Apprehension about upsetting a patient who is already unwell, in pain or distressed • Concern over potential loss of work, if they offend the surgeons who referred the patient to them • Concern over “discovery” by peers who express disdain / disapproval for out-of-pocket costs • Fear of a complaint from the patient regarding excessive fees to the Medical Board or other official body. In closing, it is clear that the supply and demand of anaesthetic services does not follow a typical, elastic supplydemand curve and that informed financial consent may not be the panacea promised. More realistically, a complex interplay of altruism, fear, sycophantism and humanistic concern prevail when deciding how to charge patients. Dr. James Nguyen
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B U S I N E S S & F inance
QE2 vs. Austerity What are the ongoing implications for your portfolio?
You would be forgiven for thinking QE2 is an acronym for Queen Elizabeth II, however in the world of finance this term has utmost importance for global growth. In the US, Ben Bernanke and his team at the Federal Reserve unveiled on November 3rd a second round of â€œquantitative easingâ€? to the tune of US $600 billion over the coming 8 months. This is equivalent to about 4% of the US economyâ€™s annual output, which is a staggering number, but far less than the original $1.75 trillion of QE throughout early 2009 to early 2010.
QE2 is a strategy based on pushing people out of safe-havens and into riskier investments.
Quantitative Easing Defined
he reality is that QE and now QE2 is a relatively new term for an age old method of stimulating the economy. With US interest rates near to 0%, the best available method to stimulate the economy is to hit the printing press; or technically the US government buying back Treasury Bonds. In its simplest form, the methodology involves the US Government buying Treasury bonds to loosen monetary policy and cause Treasury yields to fall. This will push investors away from safe-haven investments and into riskier assets with a higher expected return. Banks are likely to be beneficiaries and they will in turn loosen their stance on lending, creating liquidity in the market and reducing the cost of funding for other corporates. A lower cost of capital and greater
liquidity will drive profits, investment opportunities and greater employment; ultimately creating shareholder value and GDP growth. While great in theory, whether investors will bite is a key issue. Behavioural finance shows that investors like to be pulled into investment opportunities but resist being pushed. QE2 is a strategy based on pushing people out of safehavens and into riskier investments. Economic data from the US has produced mixed results since the initial QE in early 2009. The initial QE package did little to restore confidence as growth and employment remained subdued. However, many would argue it saved a likely “Great Depression” event. Since the announcement of QE2, economic data has been generally improving with consumer confidence up and share markets have rallied in
Europe’s two biggest economies, the United Kingdom and Germany, are now taking the “austerity” approach, which can loosely be defined as belt-tightening or cutting of public spending to reduce fiscal deficits. anticipation of further upside. We have welcomed the positive data; however GDP growth remains relatively subdued and unemployment bucked its recovery and unexpectedly rose to 9.8% - hardly positive. Europe in the Opposite Direction Across the North Atlantic Ocean, parts of Europe are actually doing the opposite. After years of debt-fuelled growth, both publicly and privately, concerns regarding public finances are
at an all-time high. Europe’s two biggest economies, the United Kingdom and Germany, are now taking the “austerity” approach, which can loosely be defined as belt-tightening or cutting of public spending to reduce fiscal deficits. This is very different to Ireland, Greece, and other troubled European nations who are clearly in crisis management. Germany, led by Chancellor Angela Merkel, has announced their most ambitious austerity plan since World War 2. The aim is to save $80 billion by
B U S I N E S S & F inance So what does this all mean? In the shortterm, you can expect to see an uptick in American GDP growth; however belt tightening and structural change is inevitable in the long-term, which will impact on enduring growth. The US is already on the borderline of surpassing its debt ceiling of US$14.294 trillion and forecasts suggest this will be breached in March/April 2011. Congress is likely to extend the debt limit, but any political conflict could cause significant volatility on global markets. Our Views
Even the world’s most influential economist, John Maynard Keynes, supported QE over Austerity during a large-scale downturn. 2015 but large-scale public job losses are expected including 40,000 job cuts in the armed forces and 10,000 federal ministry civil servants. The United Kingdom plans to save £81 billion by 2015 including welfare payment cuts to the tune of £7 billion and a whopping 490,000 public-sector jobs cuts. Theoretically, implementing austerity during a contractionary phase will create large-scale unemployment, put downward pressure on inflation (potentially deflation) and exacerbate the negative effects on GDP.
comfort from the fact that Governments are finally acting responsibly and paving the way for a better future, which may create confidence and therefore increase their risk appetite. Impact and Likely Effects The UK and Germany are arguably taking the higher risk stance – belt tightening may appear to improve the public finances, however, the Great Depression is a practical example of the risk associated with this strategy. The shortterm result is largely unpredictable and the longer-term impact will be dependent on the success of the austerity plans. Only time will tell.
This was the effect during the Great Depression from 1929-1933, where Governments desperately tightened belts to ensure sovereign debt defaults were kept to a minimum. It wasn’t called “austerity” at the time, but the overall result was disastrous.
The US is also taking a risky stance, however the risks appear to be longerterm in nature. Should the Fed’s QE2 efforts fail, do they continue to QE3? And if so, what if that fails? The hole in the public coffers could get deeper.
Even the world’s most influential economist, John Maynard Keynes, supported QE over Austerity during a large-scale downturn. However, supporters of austerity claim that this time is different. Mums and Dads in the United Kingdom and Germany may take
On the contrary, there is also the risk QE2 will work too well and drive inflation to dangerous levels – but this risk appears small. Regardless of the outcome, US public debt will be dangerously high, leaving the next generation to pay the bill.
As an investor, we still see the best opportunities in the Emerging Markets in the medium term; but even emerging markets are not without risks. On face value, this is an obvious portfolio allocation with outstanding growth and comparative public balance sheet strength. To our minds, the main concern is valuation and potential bubbles like that seen in Japan during the 1980s. A key risk that is often overlooked when investing in emerging markets is the “transfer of wealth effect” caused by foreign speculative flows. If QE2 or austerity works and the developed economies turn the corner encountering a period of outstanding growth, foreign investors are likely to quickly rebalance their portfolios, causing a flow of funds out of emerging markets and back into the developed economies. This could be a catalyst for a downturn in emerging markets investments. All in all, uncertainty creates opportunity. A close eye may identify an undervalued Dow Jones, DAX or FTSE as a more attractive investment proposition than an overvalued emerging market. However, based on current circumstances, our stance is that investors should remain overweight to emerging markets for the foreseeable future. Lachlan Partners is a Private Advisory Firm focused on client needs and financial goals with offices in Melbourne, Sydney and Brisbane. Roger Wilson (Partner) and Scott Dixon (Advisor) can assist you with your portfolio needs. T: (03) 9605 9200. www.lachlanpartners.com.au
Protect your investments in 2011 2011 is shaping up to be a challenging year for investors - getting the right advice will make all the difference. Lachlan Partners is bringing together some of Australia’s foremost experts at their key seminars to be held in March 2011 across the Eastern Seaboard. Our eminent speaking panel includes Chris Caton
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Chief Investment Officer Lachlan Partners ‘Dynamic Approach to Asset Allocation - Applying the new Zone System’
Seminars are being held in the following locations Brisbane
Tuesday March 8th 2011 2 - 4pm The Novotel Brisbane 200 Creek Street, Brisbane QLD
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Lachlan Partners is a Private Client Advisory Firm focused on client needs and financial goals with offices in Melbourne, Sydney and Brisbane. REGISTER NOW AS SEATS ARE LIMITED To attend OR obtain a Seminar DVD and receive a 3 month complimentary subscription to Investing Times email your details to firstname.lastname@example.org Investing Times, Australia’s foremost independent newsletter providing financial and investment wealth creation strategies since 1971. www.lachlanpartners.com.au Telephone 1800 643 631 (Freecall)
Self Managed Supers’ Clean Bill of Health What’s Holding You Back? In February of this year, Jeremy Cooper, chairman of the Super System Review (entitled “the Cooper Review”) addressed a conference of superannuation professionals in Melbourne at which he made the observation that “self managed superannuation funds (SMSFs) may be the way of the future as more people seek more information and control over their retirement savings”.
t was particularly interesting to hear this from the man charged with undertaking a comprehensive review of Australia’s superannuation system, focussing on its governance, efficiency, structure and operation.
...the Review Panel concluded that the SMSF sector was largely successful and well-functioning.
Jeremy Cooper’s view was reinforced in the final report into Australia’s Super System, submitted midyear to the government, in which the Review Panel concluded that the SMSF sector was largely successful and well-functioning. The Review Panel focussed on some issues, which, for the most part, did not directly relate to trustees and members,
B U S I N E S S & F inance
Given their increasing popularity and Cooper’s strong endorsement, it is wise to ask the question that if the head of the Super System Review thinks a SMSF is the way of the future, what would be the factors holding one back from establishing such a fund?
regular statistics which show: • SMSF numbers have increased approximately 50% in the past 5 years (from 290,000 to 430,000) • some 90% of these SMSFs are either 1 or 2 member funds • based on the latest quarterly data, the fastest growing segment are those in the 35-44 age bracket and • the average SMSF balance is now some $900,000 (and still growing) Given their increasing popularity and Cooper’s strong endorsement, it is wise to ask the question that if the head of the Super System Review thinks a SMSF is the way of the future, what would be the factors holding one back from establishing such a fund? Why a SMSF may not be for you ? The most common reasons put forward for not pursuing this path include the following:
but instead to service providers to SMSFs and the wider regulatory framework. Some SMSF Facts for Starters As at June 30th, 2010, SMSFs already held the largest proportion of superannuation assets accounting for 31.9% of assets, according to APRA (the Australian Prudential Regulation Authority) followed by retail funds with 27.7% and next, industry funds with 18.4%. In terms of the composition of these funds, the ATO (Australian Taxation Office) which regulates SMSFs, provides
• cost (to take advantage of a SMSF, the combined members’ super needs to be of a reasonable size to defray the costs. Most service providers in this space suggest a minimum of $200,000 to begin with, which the ATO confirms on its website) • time (allocated to not only manage the fund investments but also to keep the necessary records/documentation) and • responsibility (as the ”controller” or specifically trustee of your own fund, you are responsible for the decisions and operation of the fund with the need to comply with superannuation regulation) There is no doubt the balance consideration is very important and the
easiest to assess. Many an adviser would have difficulty in justifying establishment of a SMSF for anyone with less than $200,000. As to other reasons, it is a matter of degree and goes to one’s preparedness to delegate responsibilities to other service providers. eg. investment advisers. A self managed super fund is like your own “self managed” practice. You retain responsibility for the day to day operations of your own practice but involve others in its management and administration. The same concept can apply to a SMSF. You can self manage as much of it as you want to. But this doesn’t preclude you from engaging other service providers at any time, the role of which the Cooper Review clearly acknowledged. The trick is obviously to find those people with the requisite competence and who can provide value over and above any fee they charge. Many people see this as the most daunting aspect with the term “self managed” being too strictly interpreted. This is not to make light of the responsibilities associated with it but to point out there is a lot of help at hand. And engaging experts in chosen specialities can not only provide you with the opportunity to enjoy the advantages of such a structure but also to maximise it. But why a SMSF should be considered ? As you can gather a SMSF is not for everyone. For someone to embark down this path, they should only consider this if they
B U S I N E S S & F inance have a desire for greater control over their: • investment choice • overall investment costs; and after tax performance, remembering • tax is by far the greatest investment expense. The first point goes to the heart of Jeremy Cooper’s earlier assertion of “more people seek(ing) more information and control over their retirement savings”. For those in the medical profession, a SMSF provides a compelling reason for putting practice rooms into a SMSF (the subject of our June/July 2010 article) along with other sundry investments. Invariably though, benefits aside, the decision can boil down to the cost and performance of current arrangements versus the potential cost and possible performance that could be generated through a SMSF. In accessing the features of a SMSF, logically one would expect a premium be paid for this. Interestingly, what appears on the surface to be a premium, when analysed, can be quite the contrary. Essentially the costs for a SMSF are clear and controllable. At every stage accounting, trading and administration - you know what you are up for. As you determine the level of involvement, you have greater control over the costs incurred in operating your SMSF. Whereas the costs for say a retail fund can be difficult to calculate even for those who operate in the industry. Part of this derives from the typical fund of fund structure employed whereby the retail fund charges a fee at one level for access to the underlying investment options (can be up to 0.50%) and the individual fund managers, which it engages to manage money, charge their own fees at another level (up to 0.80% for equity options), with this reflected in their unit price. Research house, Chant West, commented in March 2008, that because the majority of investment managers failed to disclose underlying fees, it was almost impossible to compare super offerings. It conservatively estimated that quoted
Research house, Chant West, commented in March 2008, that because the majority of investment managers failed to disclose underlying fees, it was almost impossible to compare super offerings. It conservatively estimated that quoted fees understated true costs by as much as 0.30 to 0.60%. This fees within fees was dubbed the “Russian Doll syndrome”.
fees understated true costs by as much as 0.30 to 0.60%. This fees within fees was dubbed the “Russian Doll syndrome”. And then even if you feel you have a grasp on costs, the real rub comes when looking at performance, suffice to say a 10% return in a SMSF is likely to mean more to you than a 10% return in a retail fund. This stems not only from the flexibility to manage tax in a SMSF eg. by deferring contributions tax until the end of the financial year but also from the clear entitlement a SMSF provides, with the following three examples, the first of which was raised in the recent Cooper review, demonstrating the point: • for life insurance premiums paid by a retail fund, Cooper quoted “members do not always get an appropriate allocation of the tax deduction for their share of the premium paid by the fund”; • with franking credits attaching to Australian share investments, such franking credits are typically applied by a fund against all tax liabilities of the fund such that a member may not obtain full advantage of their proportion of those franking credits; and
• where a member moves into pension phase in a fund, any accumulated deferred tax liabilities in respect of unrealised capital gains become no longer applicable, but the release of this “burden” is often reflected in all member accounts not just those who have moved into pension phase. So, as long as the investments “work” to a comparable level, costs can be regulated and tax managed to your benefit, the responsibility and the paperwork associated with a SMSF become worth the effort – and that is only if you don’t want someone else to handle this ! Why sell yourself short by not exploring the SMSF option, if you desire control ? Mr Cooper clearly thinks you should. Geoff Greetham, BEc , CFP, CPA Geoff is a co-Executive Director of Accordius, a privately-owned personal funds management business, based in Melbourne, specialising in SMSFs . Accordius can assist you in providing advice on and managing investments for SMSFs.
Nurturing Nurturing your your medical medical
wealth wealth How personal are your investments? How personal are your investments? Are your investments tailored to your needs? Are your investments tailored to your needs? Do you always know what you are invested in? Do you always know what you are invested in? Are your investments structured to allow for Are yourtax investments structured to allow for effective management? effective tax management? Are you aware of all the fees being charged against Are youinvestments? aware of all the fees being charged against all your all your investments? Is the person making investment decisions on your Is the person making on your behalf a full time fund investment manager or decisions just a behalf a fullmanager? time fund Do manager ortheir just own a relationship they do relationship manager? Do they do their ownof research or just follow the recommendations research or just follow the recommendations of others? others?
AT ACCORDIUS we know that you have worked hard to create your wealth. We work one-to-one providing them with your AT ACCORDIUS we know with that our you clients have worked hard to create Individually Accounts that areclients tailored to maximise wealth. We Managed work one-to-one with our providing themreturns. with Individually Managed Accounts that are tailored to maximise returns. We have the flexibility to either work with your own financial advisor or, required, provide high quality, unaligned advice. believeadvisor in Weif have the flexibility to either work with your ownWe financial complete investment transparency. You can see every transaction made or, if required, provide high quality, unaligned advice. We believe in on your behalf. complete investment transparency. You can see every transaction made on your behalf.
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F Rst Steps AS A NEW
ANAESTHetist This full article with web links to all the documents mentioned is available at: www.Anaesthetic-Life.com.au
Approval of all Training Requirements by ANZCA
The first step is obtaining recognition as a specialist anaesthetist by ANZCA. This will involve submitting all your paperwork to prove completion of:
Well, here is the anaesthetist’s guide to cutting through the red tape as you transition from registrar to specialist.
You should have probably completed most of this along the course of your training, and so hopefully, you should not have to hunt around too much to source
here you’ve done it… Finally crossed the line…. Driven past the chequered flag. That goal that you set yourself 1215 years ago when you were 18 years old about becoming a specialist…. You’ve now achieved it. So first of all congratulations! Then the excitement slowly turns into fear as you think about the mountain of paperwork and red tape that lies before you.
1. 24 months Basic training 2. Primary Examination 3. 36 Months Advanced Training 4. Final Examination 5. Modules 1-12 (includes the formal project) 6. Either the EMAC or EMST course
proof of the above. The main form you need to complete is the ‘Application for Admission to Fellowship by Examination and Training’ form available on the ANZCA website. Now a useful tip is that this can be completed up to 4 weeks prior to the anticipated completion date for all training requirements, provided there is a formal statement from your Supervisor of Training. This will usually allow you to meet one of the earlier application closing dates for earlier approval. There is approximately a three week delay in approval of fellowship after the application closing date. After approval from the college, you will receive a letter and a provisional certificate confirming your acceptance for fellowship. You will
B U S I N E S S & F inance
Summary of Steps
1 2 3 4 5 6 7 8 9 10 11
Complete all training requirements for ANZCA
Register as a specialist with AHPRA (The new national medical board) Register with Medicare Australia as a specialist anaesthetist
Obtain Medical Indemnity cover to work as a specialist and cover your estimated private earnings Register with all the Private Health Funds as a Provider Decide on who is going to do your Billing for you
What to do Immediately after you get your Letters need copies of this for almost all the other applications, so guard it well. Register as a specialist with AHPRA (The new national medical board) Until recently you would have held General Registration (or some form of Limited Registration for international graduates). Now, officially AHPRA want new specialist anaesthetists to complete form ASPC-03 ‘Application for specialist registration for a medical practitioner (currently holding general registration)’ which costs nothing but importantly allows you to use the term ‘Specialist’ to describe yourself. This is a new process that has only come into effect this year due to the merger of all the state medical boards. You will need
Obtain accreditation with all the Private Hospitals you want to work at Speak to an Accountant to make sure you are structured correctly to earn money in the most tax-effective way Open a Bank Account Create a Business Card
Tell people you are open for business and start networking with surgeons/ procedural physicians
a certified copy of the ANZCA fellowship acceptance letter or fellowship certificate to send with this application. Register with Medicare Australia (formerly the Health Insurance Commission) This is a process which will be completely foreign to most new anaesthetic consultants. You would have had very little contact with Medicare Australia in the past. However, in the very near future, the Medicare Provider Liaison phone number will probably be on speed dial on your phone. Registration as a specialist anaesthetist is what will give you Medicare billing rights – ‘Access to Medicare’. There are
three (and potentially more) forms to fill in here: 1. Application for recognition as a Specialist or Consultant Physician Allowing you access to rebates that are marked as anaesthetist only 2. Application for an Initial Provider Number for a Medical Practitioner- Which will issue you with your first provider number so you can commence accessing Medicare benefits and private health fund rebates 3. Provider Registration for EFT payments – So you can speed up all payments from Medicare and to save trees by receiving all your payments electronically rather than by cheque Now the official stance from Medicare
B U S I N E S S & F inance Australia is that you are supposed to have a different provider number for each location you work at. So for anaesthetists that do fractional work across a variety of private hospitals, this could mean having 20 or more provider numbers. Well, most anaesthetists cheat a little and just apply for a single provider number to their home address, rooms address or billing agent’s address. They then bill all locations from this single provider number. There is one exception to this rule. If you are International Medical Graduate or were not a permanent resident of Australia when you enrolled in medical school here, you are restricted to accessing Medicare benefits in designated ‘Districts of Workforce Shortage’. This is also known as section 19AB of the Health Insurance Act. This will mean you have to obtain a 19AB exemption for each location you want to work and then obtain a unique provider number for each of these locations after obtaining a 19AB exemption.
• MIGA (www.miga.com.au) • InVivo (www.invivo.com.au)
Medical Indemnity Cover as a Specialist Anaesthetist
The major health funds in Australia:
Up until now, whilst working as a registrar, you have enjoyed the luxury of having Medical Defence Organisation (MDO) cover for little over a hundred dollars. That is about to change. Shortly, this will change significantly. Your premium is mainly dependent on what you declare as your ‘Gross Billings’ which basically means your total private practice earnings pre-tax. If you are a public hospital staff specialist and do no private practice, you can expect to pay around $1000 to $2000. After that, the premium goes up almost proportionally with your gross billings. It is not uncommon for anaesthetists with gross billings above $500,000 to pay $25,000+ in medical indemnity premiums. Expect to pay around 5% of your private practice earnings to the MDO’s. There are currently five Medical Defence Organisations which offer medical indemnity cover for specialist anaesthetists in Australia. These are: • AVANT (www.avant.org.au) • MIPS (www.mips.com.au) • MDA National (www.mdanational.com. au)
In addition, there is a medical indemnity broker, Medselect (www.medselect. com.au), which obtains quotes from multiple organisations and then presents you with the range. There is no fee to you for their service but they do receive a commission from the insurance company. Register with all the Private Health Funds By this stage, I am assuming you now have completed all the above steps and have received written documentation back from each organisation. There are around 40 major private health funds in Australia. Registering with each of them can be very time consuming so most people register with the largest ones initially and then the smaller ones only if they encounter patients who are insured by those funds.
• Medibank Private • BUPA (formed by the merger of HBA, MBF, NRMA, SGIO, Mutual Community) • Australian Health Services Alliance (which consists of around 30 of the other health funds) • NIB • HBF • HCF • GMHBA • Australian Regional Health Group (consisting of St Luke’s, Cessnock & District, Mildura Health and Latrobe Health) • Your State Work Cover Authority • Your State Road Accident 3rd Party Insurer (e.g. TAC in Victoria) The registration documents for all these funds are downloadable from the electronic version of this document available at the URL given in this article. BUPA, HBF, HCF and NIB are the major ‘No-Gap’ funds, which means that they pay you an extra sum of money (above the Medicare rebate) BUT ONLY if you agree to not charge the patient any additional gap. This has upset anaesthetists in the past as the funds have effectively set a price on what anaesthetists should be paid. If an anaesthetist wants to charge more than this amount, then the health
fund clawback their extra sum above the MBS fee, potentially leaving the patient with a huge gap. Therefore, many anaesthetists begrudgingly accept this fee as the fee for their services and the patient ends up thinking BUPA have done a great job as they received no gap.
Decide who is going to do your Invoicing and Billing The options available to you are: 1. 2. 3. 4.
Yourself A trusted relative A billing agent Private Anaesthetic Group
Realistically, each unit of your time is better spent earning income as an anaesthetist rather than chasing bills and spending hours on the phone whilst on hold to the health funds. So the selfbilling method although it sounds good, can also be a false economy. There is a number of anaesthetic billing software packages available which all cost around $2500 upfront with $500-$800 annual licensing fee: • Access Anaesthetics (www.healthbase. com.au) • Cutting Edge (www.cesoft.com.au) • Medical Business Systems (www.medbussys.com.au) All have their pros and cons but in general, I would suggest a unit of your time is
B U S I N E S S & F inance
A medical accountant will be able to advise you on which structure to operate through. Whoever you choose as a referee is likely to be bombarded with lots of paperwork so you should warn them about this in advance. The full list of private hospitals and links to them is provided on the electronic version of this article available at the URL listed in this article. Speak to your Medical Accountant
better spent performing anaesthesia than doing administrative work. Alternatively, you can outsource your administration to a billing agent who you fax all the patient details to including details of the procedures performed for a fixed percentage of the value of the invoice. Their rates should include debt collection, follow up and they should also provide you with good monthly accounts statements. The anaesthetic billing agencies operating Australia-wide that provide these services are listed below. The fees for all of them are 5% of earnings: • Clear Billing(www.clearbilling.com.au) • MedicalBilling(www.medicalbillingservices.com.au) • MedProBilling(www.medprobilling.com. au) Register for accreditation with all the Private Hospitals This can be particularly frustrating as there are so many forms to fill in and each hospital usually requires a separate form to be filled in. First decide which hospitals you want to work at and would like to apply for accreditation for and then print them out and fill them in. Make sure you allocate at least half a day to do this as it can be a very laborious process. In addition, most private hospitals will ask you for the names of two or three referees who they contact.
Depending on how much you are likely to earn in private income and also your individual financial situation, the recommended structure you should use to earn this private income may vary. The most common structures used for anaesthetists are some form of trust based structures, but there are some anaesthetists who earn their income through companies or in their own name. A medical accountant will be able to advise you on which structure to operate through. Apply for an Australian Business Number Whatever trading entity you end up using, remember it needs to be registered for an Australian Business Number (ABN), a Tax File Number (TFN) and possibly GST Registration. This can all be done online at www.abr.gov.au or via your medical accountant. Open a Bank Account You will need to open a bank account in the name of the business entity that is earning income. If you are planning on doing your own billing and invoicing, you may choose to obtain BPAY and/or Merchant Facilities to accept EFT and credit cards from patients for out-of-pocket fees. These facilities are both available from all the big banks so it may be worth shopping around for a good quote. BPAY costs around $500 for a once-off establishment fee and then usually approximately $1 per transaction. Merchant Services (to accept credit cards) varies on the number of transactions but expect to pay between 1.2 and 2.5% of the
transaction amount in bank fees. Create a Business Card This is an important step in becoming well known amongst surgeons and other proceduralists. You should make this as professional looking as possible and make sure you provide a contact number (usually your mobile) so that you are accessible at any time. There should be a postal address where patients can send cheques or remittance notices and a web address if you plan to accept payments online via credit card. Never put your home address on the business card. Always use either your group’s rooms or your billing agency’s address or a PO Box (obtainable from any post office for around $70 per year). The reverse side of the business card can be designed so that it has a section where you declare the patient’s out-of-pocket fees so that you meet the informed financial consent requirements. Conclusion Best wishes on the journey that lies ahead. Income generation is only half the game, investing it wisely is just as important. This article was written with the intention of guiding new anaesthetists on the administrative burden they first have to navigate when they qualify. Please visit the Anaesthetic Life website (www. anaesthetist-life.com.au) to download this article and all the Medicare, AHPRA and Health Fund and Private Hospital documents mentioned. Adam Faulkner is a Medical Wealth Strategist at Mediq Financial Services and advises Anaesthetists on structuring, investments and finance. Please visit www.mediqfinancial.com.au or call 1300 589 527
What’s New in
Insurance A M ar k et U p date
Managing financial risk remains a major consideration regardless of one’s income level or stage in life. This article provides an update on some innovative and customer-friendly initiatives now available across the Australian Life and Disability insurance market. Of course, “new” does not unilaterally mean “better”. Your circumstances may benefit from some, or possibly many of these new offerings. But starting with a heightened awareness of ‘what’s out there’ helps you know when you’re getting up-to-date and pro-active risk management advice.
B U S I N E S S & F inance
Loyalty programs and credit card payments
ne leading Australian insurer has recently announced an exclusive partnership with Qantas which provides one frequent flyer point for each dollar spent on premiums (with a maximum of $20,000 per policy per annum). Additional points can be earned simply by paying premiums by credit card. Fortunately, most insurers do not apply a surcharge for credit card payment and there are even a number of insurers who take American Express and Diners Club. Critical illness events now covered The most dynamic area of product innovation has been Critical Illness cover (also known as Trauma). This cover pays out a lump-sum amount on diagnosis of a serious medical event such as cancer, heart attack or stroke. Importantly, payout events do not require the individual to be ‘disabled’ before, during or after the event. The big news here is that the criteria of medical events have generally become easier to satisfy. The other major advancement has been the introduction of partial payments for events such as low grade melanomas, prostate cancers at T1, carcinoma in situ, partial blindness and partial deafness. Bear in mind that a lot of older Critical Illness policies do not even include now ‘standard’ events such as cardiomyopathy, kidney failure and benign brain tumours.
Work up to 10 hours per week whilst on claim for total disability Under most income protection policies, disability is defined in terms of one’s inability to perform their work duties. While this is an intuitive way to define disability, it can be restrictive for selfemployed medical specialists. The inherent problem with the standard ‘duties-based’ definition is that working even one hour per week jeopardises the payment of a benefit under ‘total disability’. If you are able to put aside a sickness or injury to consult with patients or meet with staff, suppliers or business partners, you put your benefits at risk. As an example, an anaesthetist who is physically unable to keep up his/her regular lists but could still perform a lighter work load, would be faced with the dilemma of either forgoing income protection benefits or forgoing income from patient care. In the last 12 months, the majority of leading insurers have added clauses to their professional income protection policies providing a second means of assessing ‘total disability’: namely, the inability to work 10 or more hours per week. Under the market-leading policies, you can return to work for up to 10 hours per week with no reduction in benefits paid, regardless of the earnings you generate during these 10 hours. Increased levels of cover now available – great news for medical specialists
Be rewarded for being healthy While insurers customarily charge more to new applicants with ‘sub-standard’ health, they have not previously offered a discount for being healthy. This has recently changed, with the introduction by one insurer of a 20% premium discount for policy holders who demonstrate a healthy lifestyle. To be eligible for the discount you must be between 30 and 50 and have been a non-smoker for more than 5 years, with a favourable family history and driving record.
High income levels and financial commitments necessitate substantial levels of cover. Insurers have historically curtailed the maximum levels of cover available to new applicants. Only recently, income protection benefits were limited to a maximum of $20,000 pm ($240,000 pa). This is simply inadequate for most high earning medical specialists (especially considering that benefits are still tax-payable). Fortunately, maximum levels have recently been increased to $40,000 pm with most insurers and even $60,000 pm with
While insurers customarily charge more to new applicants with ‘sub-standard’ health, they have not previously offered a discount for being healthy. ANAESTHeTicLife
B U S I N E S S & F inance certain providers. As a guide, an income (after business expenses) of roughly $1,160,000 is required before cover can reach $40,000 pm. Increased maximum levels for other product types can be seen in the table. Ownership via super Determining the most appropriate owner of your policies is a technically complex question which will be discussed in future articles. As far as product innovations go, it is worth noting that many insurers now permit the ownership of Life, TPD, Trauma and Income Protection in a
Pays out in the event of:
Previous Maximum Levels Today's Maximum Levels
No limit (although levels must be justified financially).
Permanent disability and inability to work again
Critical Illness / Trauma
Medical events such as cancer, heart attack and stroke
Business Expense Cover
Temporary disability whilst paying for business expenses
Occupationally acquired HIV, Hepatitis B or C
Your child suffers a critical illness or death
superannuation environment. Again, the suitability of this will vary greatly from person to person, depending on factors such as their current age, years till retirement and cash-flow situation and changing legislation. A policy feature so valuable that insurers no longer offer it This article has introduced you to the most newsworthy recent initiatives in Life and Disability Insurance. But not all changes are improvements. There are a number of features on older policies which have been discontinued by insurers, as they were simply too ‘good’ (meaning expensive to the insurer) to continue offering to new customers. The prime example of this is a feature on some income protection policies called a ‘Lifetime Benefit’. This feature generally
means that a claim will continue to be paid to a claimant for the rest of their life – even after the policy would have otherwise expired (typically at age 65). An ongoing payout of $20,000 pm continued for an additional 20 years equates to roughly $5m of additional benefits. Clearly, you can see why insurers have discontinued offering this policy feature. Is what’s new right for YOU? While many of these product innovations
are exciting, they must be evaluated in context. Adjustments to your current policies may well be justified, but only after careful and impartial consideration. For time poor professionals, working with an advisory firm with expertise and integrity can provide tremendous value to ensure you and those who depend on you are optimally protected. Aaron Zelman, is a partner of specialist risk advisory firm, Priority Life. He can be contacted at email@example.com, 1300 12 24 36 or after hours at 0412 366643.
Disclaimer: This advice may not be suitable to you because it contains general advice that has not been tailored to your personal circumstances. Please seek personal financial and tax advice prior to acting on this information. Before acquiring a financial product a person should obtain a Product Disclosure Statement (PDS) relating to that product and consider the contents of the PDS before making a decision about whether to acquire the product. The material contained in this document is based on information received in good faith from sources within the market, and on our understanding of legislation and Government press releases at the date of publication, which are believed to be reliable and accurate. Opinions constitute our judgement at the time of issue and are subject to change. Neither, the Licensee or any of the National Australia group of companies, nor their employees or directors give any warranty of accuracy, nor accept any responsibility for errors or omissions in this document. David Davidson Financial Services Pty. Ltd. trading as Priority Life is an Authorised Representative(s) of Apogee Financial Planning Limited ABN 28 056 426 932, an Australian Financial Services Licensee, Registered office at 105 –153 Miller St North Sydney NSW 2060 and a member of the National Australia group of companies.
R I S K M A N A GE M EN T Dr SY obtained an MD from Sarajevo in 1964, and a radiology diploma from Zagreb in 1973. He then practised radiology for 20 years in Croatia and Yugoslavia.
e later emigrated to New Zealand, where he was provisionally registered to practise medicine in 1994. For several months he worked in radiology, and received some further training in radiology. From 1994 to 1999, he attempted the examinations to become a Fellow of the Royal Australian and New Zealand College of Radiologists. Unfortunately, he failed the radiology component, not once but four times in a row, but managed to pass the pathology component on his third attempt. In 1999, he sought a review of his papers. He claimed that the appointed reviewer had only spent 15 minutes with him, and that this short interaction was not enough to satisfy him as to why he had failed. He immigrated to Australia during these attempts, and in 2002, he became an Australian citizen. Since arriving in Australia, he has never been registered as a medical practitioner, and has altogether failed to find work as a doctor in this country.
Do specialty Colleges owe a duty of care to examination candidates?
The College is alleged to have breached its duty of care Dr SY initiated legal action in 1999 in the New South Wales Supreme Court. He claimed that the College had a duty of care towards him in respect of the conduct of its examinations, and a duty of care to undertake a proper review at his request. He claimed that these duties had been breached, and that he had suffered economic loss as a result. He claimed compensation from the Supreme Court. He also initiated action in the Federal Court, asking for a court order to have him registered as a Fellow of the College. Dr SY stated in court documents that the â€œexam has no professional or ethical meritsâ€?, that the â€œoral part is practically impossible, cogently revealing farcical
The existence of a duty of care is a cornerstone of the law of negligence. If the College owed him no duty of care, then it could not be held liable for negligence.
R I S K M A N A GE M EN T
nature of the process”, and that his experience at the review “clearly exposed heavy manipulation barely different from open fraud.” The existence of a duty of care is a cornerstone of the law of negligence. If the College owed him no duty of care, then it could not be held liable for negligence. Problems with the doctor’s presentation of his case Since Dr SY had little money, he was unable to hire legal expertise and so represented himself. His problems with the English language were obvious to the judges who heard his case, and at one time he spoke to a judge through his son. His court documents were hand-written. In order to present his case he called upon a number of laws , from the Trade Practices Act to the Corporations Act, the Australian Securities and Investments Commission Act, to the Freedom of Information Act and the Privacy Act. However, the judges were unable to fully follow the legal arguments that Dr SY was trying to make. One judge found his court documents difficult to understand, and said that the way he put his case was “inherently confused”. However, the judge gave him credit for his efforts, stating “It is readily apparent that the applicant has been untiring in his endeavours to secure qualification to practice radiology earlier in New Zealand and now in Australia. He has undertaken a study of legal authorities with a view to pursuing [court action] in that regard. The extent of his persistent legal research as a legally unqualified litigant has been somewhat remarkable for a person having the handicaps of language, an absence of local secondary and tertiary qualification and of course an absence of any Australian academic qualification and experience.” Do the Specialty Colleges owe a duty of care? The judges valiantly attempted to make sense of the case regardless. One question that immediately arose was: Does a College owe a duty of care towards examination candidates? This College claimed “no” - that it has no duty of care to candidates.
However, one judge of the NSW Supreme Court thought that it was arguable that, if the College was the doorkeeper for granting persons with appropriate professional competence the right to practise in a particular medical specialty, then there might be a duty to conduct the examinations and the review of the examinations with due care. Another judge also pointed out arguments that favour the view that a duty of care should exist: • the College of Radiologists is a nationally recognised body for setting the standards and administering the exams required to allow recognition and registration as a specialist in radio-diagnosis, and • the College also effectively determines whether a candidate will be able to practise as a specialist radiologist Dr SY’s case was thrown out – but not because there was no duty of care However, owing to the doctor’s lack of legal training, the courts were not able to proceed with the case. Dr SY had four opportunities to properly put his case to the courts, and each time the judges decided that the legal documents that he had drafted were defective. In 2009, on his fourth attempt, the Supreme Court threw out his claim once and for all. The judge pointed out that by that stage, the legal proceedings had been going on for 9 years at “considerable expense”. So the College won the case, but not because it proved that it had no duty of care. The question has yet to be answered The question of whether the College of Radiology, or even any of the Specialty Colleges, owe a duty of care to examination candidates has still not been answered. If the answer is “no”, then candidates would be unable to sue for negligence. But, if the answer is “yes”, then there is a possibility that the Colleges will see litigation in future from failed candidates who are unhappy with the result. Dr Richard Cavell
R I S K M A N A GE M EN T
Queensland Anaesthetic nurse jailed and deregistered Male nurse stabs his ex-lover with suxamethonium
RD was a 47-year old male nurse who was registered in the state of Queensland. He practised mainly as an anaesthetic nurse and one of his tasks was to restock the anaesthetic trolley at the private hospital where he worked. He also was a keen bird fancier and had a collection of parrots and other birds at home.
e was married until 1996, when his first wife died. He had a relationship with another woman from 1997 to 1998, which resulted in a son being born. Soon after that relationship, he got married to a third woman. However, during this marriage he paid child support to the mother of his son and maintained contact with her and his son.
By 2005 he was in a casual sexual relationship with the mother of his child, as a result of which she became pregnant again. He was frustrated by this and wanted her to have a termination, but she refused.
R I S K M A N A GE M EN T
Nurse RD said that he intended to use the suxamethonium as a “truth serum” to determine whether or not she really was pregnant with his child. In November 2005, he took an ampoule of suxamethonium home from work. His story as to how he ended up taking it home was inconsistent. At one stage, he said that he laundered his own scrubs and simply took an ampoule home in the pocket of his scrubs by oversight, and found it in his laundry after a wash. When he found it, instead of returning it to his workplace, he says he kept it with the idea that he could use it to euthanize sick birds. A judge later said that the ideas that he washed his own scrubs, and that a glass ampoule could survive going through the wash, “strain credulity”. However he came to be in possession of the suxamethonium, once he was in possession of it and intended not to give it back, it constituted an act of theft from his employer. He drew up some of the suxamethonium into an ordinary syringe and placed it in the glove box of his car. He then arranged to meet the mother of his child beside a park. After she parked her car, he took the syringe, removed the cap from the needle, and walked with it to her car. When she opened the door of her car, he averted her attention by stating that there was “a mark or something” on her neck and then inserted the needle. She pushed him away. A struggle ensued in which he stabbed her several times with the needle. Eventually she managed to pull the plunger out of the syringe, and he stopped attacking her. Nurse RD later said that he intended to use the suxamethonium as a “truth serum” to determine whether or not she really was pregnant with his child. He stated that he intended to cause her fear so as to have her confess her actions:
pregnancy and that she’d done it wholly and solely for her own benefit.” A judge hearing the case accepted that suxamethonium should only be administered under the supervision of an anaesthetist, or when facilities are available for endotracheal intubation and artificial ventilation. Nurse RD knew this. The judge described it as an “irrational, crazy plan”. He said that it was likely that Nurse RD simply could not accept the reality that the woman was refusing to terminate the pregnancy. He described RD’s plan as motivated by an “extraordinary degree of selfishness” and said it was “suggestive of a seriously deficient moral framework which must give rise to a concern about whether, if at some point in the future a conflict arose between the interests of the respondent and the interests of his patients, he could be trusted to put the interests of his patients first.” The Nursing Tribunal found that that RD’s conduct was “totally unacceptable behaviour for any registered nurse to engage in, however extenuating the stressors in the professional’s life.” Nurse RD was found guilty by a jury of unlawful wounding, and stealing from his employer. As punishment, Judge Robertson of the District Court of Queensland jailed him for 6 months. RD’s registration as a nurse was cancelled by the Queensland Civil and Administrative Tribunal. He appealed that decision to the District Court, where Judge McGill confirmed that he be deregistered for 7 years. He was also ordered to pay $13,500 to cover the Queensland Nursing Council’s costs in prosecuting him. Dr Richard Cavell
“I want to hear the truth… I wanted to know that she had tricked me into this
The Secret to Creating A Life or career? So many doctors struggle with sacrificing one to have the other believing that a successful career in medicine doesn’t fit in with an incredible lifestyle. There is a way you can have both.
happy balance of life and a successful medical career is something everyone wants, but sadly very few have. Yet it is totally achievable, but not by using outof-date thinking that worked in a medical system 50 years ago. There are certain things you must address to be able to create a lifestyle that supports your choice to enter the medical profession, and it starts with your beliefs and mindset about medicine. In this two-part article (the second part will feature in the next edition) we will delve into what you need to master to achieve a career and a life. Part One will uncover the knowledge you need and Part Two will reveal how to integrate that knowledge to create the lifestyle you deserve. So what is this thing that determines whether you can create a lifestyle as a practicing doctor? Although a bit of a buzz word these days, it’s not a word that is used much in the medical world, although it does control how we look at and how we practice medicine, I’m talking about...Paradigms.
CAREERS C A R EE R S
the list goes on. Growing up your mind is completely open and usually other people’s rules and paradigms are forced upon you, and because you strive to fit in you adopt their paradigms and these end up creating controlling beliefs that determine how you live. One common paradigm in medicine, that has been created and perpetuated by a medical system that is out of date in today’s world, is that doctors must make huge sacrifices in their personal lives to practice medicine. While you might read this and say “well that’s true” are you open to the fact that there might be another way? That doctors can have really fulfilling personal lives and also great careers, that it’s possible that a great personal life can actually complement a doctor’s career? That’s a shift in the paradigm. The bottom line is that you’ve got these things that you didn’t even know existed and you never created, but they still control your life and everything you do!
want and the lifestyle you deserve than just paradigms. Let’s now take a shift sideways to talk about two cycles; the cycle of ignorance (or the formula for losing) and the cycle of success (or the formula for winning). These cycles are in fact a shift in your paradigm, they are a new way of looking at success or failure. Both these cycles are very similar, with subtle differences. But it is these subtle differences that will transform the quality of your life. Cycle of Ignorance – Formula for Losing Let’s cover the cycle of ignorance first, or the formula for losing. This is the way most people live, which is why most people aren’t living the lives they want. The starting point for this cycle is your present results. Your present results are the result of the past; they’re not your future. But most people use their present results as the starting point for how they look at the world and how they live. The cycle maintains that
lifestyle in Medicine ONE Paradigms A paradigm is an organised set of beliefs that controls how you think, feel and act in a certain situation. Paradigms act as a filter through which you interpret and process the world. Nothing in your life escapes their influence. Paradigms are incredibly powerful. But who created the paradigms that you are living with and that control your life? Did you? Or did someone else? The bad news is that generally, others have created the paradigms that you live with. Sometimes consciously, sometimes unconsciously, your paradigms have been created by parents, teachers, peers, the establishment, society...and
Time to panic? Not exactly! The good news is that once you are aware of your paradigms and know how to use some simple yet powerful tools, you can create your own paradigms that work to serve you. There is no point or value in suggesting to you what paradigms you should adopt, that’s for you to decide. What is healthy is to question your paradigms and to ask if they really work for you, because if they are limiting you in some way then maybe it’s time to look for a better alternative. By changing your paradigms you can change the quality of your life forever. So we’ve established that paradigms are controlling how you think, feel and act. But there’s more to success or failure in creating the medical career that you
their present results determine their thoughts, which determine how they feel, which determine their actions, which in turn cause more results. So if people are starting with poor results, this will dictate poor thoughts, which will result in poor feelings, causing them to take poor actions, which will inevitably lead to even more poor results. It’s a vicious cycle, and it doesn’t get any better. For example, a doctor might be continually working 70 hours a week. As a result they may start to think negatively about their colleagues and their patients, which makes them feel overwhelmed and depressed, which causes them to be critical and angry with all the people around them, even those at home, which feeds back in to this downwards spiral.
C A CAREERS R EE R S Cycle of Success – Formula for Winning Even if most people fall into this negative trap, thankfully there is a way out of it. That is the cycle of success, or the formula for winning. For this cycle, we don’t start with our current results; we shift it around and start with quality thoughts, with quality ideas, with defined goals. We let our quality thoughts determine how we feel, which then determines quality actions, which ultimately brings quality results. Then we’re in a position to look at those results and to produce more quality thoughts or goals. This is the cycle of success; it’s a cycle that grows upon itself causing an ever increasing quality of life. A doctor who is living with the cycle of
you can achieve. The point of a goal is to stretch yourself and it’s not just about achieving the goal but about the person you become while striving for that goal. These goals are inherently boring, such as having the goal of just making it through each week until your next holiday. People get fed up of these goals so quickly, we need to move on to level two goals. Level two goals are goals that you ‘think’ you can achieve. They’re not emotionally charged but they do stretch you that little bit more, such as having the goal of cutting down from 70 to 60 hours a week. The problem here, like with any goal that you move towards, is that you move away from something else. For example, this might be your colleagues who say that you should be doing more. Your colleagues
Doctors can have really fulfilling personal lives and also great careers, that it’s possible that a great personal life can actually complement a doctor’s career. success might start with the thought “I’ve seen other doctors having a great lifestyle and career, I think I can do that too!” This causes them to feel hopeful and excited, which causes them to take action to change their present conditions, like locuming or changing their work conditions to work four days a week, which causes them to have the time off they desire and to create the lifestyle they want for themselves and their family. We’ve determined that paradigms are affecting our lives and that there are two cycles through which you can live; one which starts with current results and is the formula for losing, and the other, which starts with thoughts and goals and is the formula for winning. So let’s take another shift sideways and look at how we can set quality goals and thus have quality thoughts to feed the cycle of success. Quality Goals There are three levels of goals. Level one goals are goals that you ‘know’
usually want you to succeed, but they don’t want to feel inferior to you, so they pull you back in line to keep you where you are. You get sick of trying to balance this, so you go back to level one goals that you know will be simple and that you can achieve. But again as soon as you get bored here you have to step up to level two goals, and the cycle continues. However, there’s another level. Level three goals! With level three goals you have to ask yourself the very important question ‘what would excite me?’ This is the realm of fantasy; this is where it gets stimulating, and fun. A great level three goal for a doctor might be “I want to work 40 hours a week, to have eight weeks holiday each year with my family and to still make over $400,000 per year.” To transform a fantasy into a goal you must ask yourself two questions: ‘Can I achieve this?’ (For which the answer is almost always yes because in this universe the realms of possibility are limitless) and ‘will I achieve this?’ This second question is the important one.
Will I do whatever it takes to make this my reality? This is important because if the answer is ‘no’ then you don’t deserve it. But if the answer is ‘yes’ then that fantasy becomes a goal that has real meaning and you’re well on your way. So to succeed you need to determine your own paradigms by combining level three goals that excite you, with the cycle of success, and let those exciting goals determine how you feel, which determines how you act, which determines the results you get. This is the formula for a fulfilling life, a fun life. In the next magazine we’ll discuss how you can specifically integrate this information into your medical career to create the lifestyle you deserve. Dr Sam Hazledine is the Director of Medrecruit - www.medrecruit.com
When It Comes To Working As A Specialist Anaesthesiologist, Your Needs Are Different From Junior Doctors At MedRecruit we understand that finding the right positions in a locum capacity and in a permanent capacity as a specialist have its own specific needs and requirements. Your needs are as unique as your speciality and your career and you don’t want to be lumped in with the junior doctors who have very different needs and requirements. As you decide to work with MedRecruit you will be matched with your own personal Solutions Specialist who specialises in working with anaesthesiologists to get you the perfect placement, a placement that meets all your unique needs. Your personal Solutions Specialist is trained to negotiate the very best deal possible for you so you can be secure and comfortable in the knowledge that you’re getting the best package, personalised for you. When you register with MedRecruit you will also
receive valuable and much sort after resources related to locuming to ensure you maximise the benefits to you. You will also receive membership only access to our specialist partners, such as Deloitte, who are industry leaders at working with doctors to ensure they get the most out of their careers. With offices in both Australia and New Zealand, and relationships with more hospitals across Australasia than any other agency in our field, you will gain access to the largest database of vacancies which will ensure you get the best solution tailored specifically to you; we have far too many vacancies in your speciality to list on this page! Due to our long standing and strong relationships with many hospitals you will have choices of positions that are not advertised anywhere else. When you register with MedRecruit you will immediately receive:
Passport to Lifestyle & Career
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.
B U S I N E S S & F inance
ViRGINIAAPGAR Virginia Apgar was born in New Jersey, USA in 1909, the daughter of Helen Clarke Apgar and Charles Emory Apgar. She entered Mount Holyoke College in 1925, majored in zoology, and was active in the college community. She received her Bachelor of Arts at the Mount Holyoke College in 1929. Her scant economy forced her to support herself on extra work; one of her jobs was catching cats for the physiological laboratory. A dedicated musician since childhood, she found time to play her cello and violin.
t a time when few women even attended college, Apgar was determined to make medicine her life’s work. Following her BA she studied medicine in New York, graduating M.D. from the Columbia University’s College of Physicians and Surgeons, in 1933. From 1933 to 1936 she was surgical intern and resident under Alan (Allen Oldfather) Whipple (18811963) at the Columbia Presbyterian Hospital. Her superior, who had seen former female surgeons educated by him encounter problems in commencing their own practice and supporting
themselves, advised her instead to switch to anaesthesiology, which needed reinforcement at the Columbia P & S. Into anaesthesiology After two frustrating years of practice, Apgar, convinced that as a woman she could not support herself in the predominantly male field of surgery, followed Whipple’s advice and turned to the newly emerging field of anaesthesiology, which had long been relegated to the domain of nursing. During the years of 1936 and 1937 she
learned the basics of anaesthesiology by the nurse anaesthetists at the Columbia Presbyterian; at this time there were no anaesthesiologists at the hospital. During the years 1937–1938 she was a resident for six months each with two of the fathers of American anaesthesiology, Ralph Waters at the University of Wisconsin in Madison, and Emory Rovenstine at the Bellevue Hospital in New York. Thus prepared, in 1938 Apgar returned to the Columbia Presbyterian Hospital/ Columbia-Presbyterian Medical Center, division of anaesthesia. In 1939 she
M EDIC A L LEGEND S received her Board Certification from the American Society of Anesthesiologists, the second woman to get this diploma. The same year she was appointed anaesthesiologist-in-chief at the division of anaesthesia under the department of surgery at the Columbia Presbyterian Hospital, becoming the first woman to head a department there. Among other things, she developed programs for residents in anaesthesiology and student’s courses. From the beginning there were major problems in the cooperation with the surgeons, who were previously used to working only with nurse anaesthetists. It was also a toil to get paid for narcoses given, as this at first depended on what the surgeons were prepared to let their patients pay. The war years were characterized by an increasing clinical and administrative workload, as many of her colleagues had been drafted for war service. This workload may have contributed to her giving up her administrative duties, when in 1948 an independent Department of Anesthesia was established at the hospital. Instead it was her friend, the scientifically trained Emmanuel Papper from the Bellevue Hospital who assumed the position of professor at the newly established clinic of anaesthesia. Dr. Apgar, however, in 1949 was appointed simultaneously professor of
terms of hypoxia and acidosis, and also on the effects of maternal anaesthesia on the neonate. She also introduced the anterior approach to the stellate ganglion in 1948. Virginia marches on During a sabbatical year in 1959 Virginia Apgar read in a master of public health examination at the Johns Hopkins University in Baltimore, receiving a master’s degree in public health. This and her increasing interest in following up children in a broader perspective after birth led her to various tasks with The National Foundation for Infantile Paralysis. This foundation, originally the heart child of Franklin D. Roosevelt, was founded in 1938 to fight polio and promote medical research through large nationwide collections under the name of March of Dimes. The foundation today presents itself thus on the Internet: We’re the March of Dimes Birth Defect Foundation. Our mission is to improve the health of babies by preventing birth defects, infant mortality and low birth weight. When Apgar joined the foundation in 1959 as director for the division of congenital malformations, research programs mobilized and funded by the foundation had virtually eliminated polio
Dimes was spent working to generate public support and funds for research on birth defects. A spectacular fundraiser, Apgar is credited with the foundation’s dramatic financial growth. As an educator of the public she greatly increased both visibility and attention to the problems of birth defects. Honours Virginia Apgar received many honorary assignments and titles, among them, in 1959, Lecturer in Medicine at Johns Hopkins, and the same year clinical professor of paediatrics at the Cornell University, New York. In 1961 she received the Distinguished Service Award from the American Society of Anesthesiologists. She was appointed Honorary Associate Fellow of the American Academy of Pediatrics, and Associate Fellow of the American College of Obstetricians & Gynecologists. In 1973 she enjoyed the attention of the general public as Woman of the Year on national television. That year she was appointed lecturer in the Department of genetics at the Johns Hopkins School of Public Health. She served as an alumna trustee at Mount Holyoke College from 1966 until 1971. She served the American Society of Anesthesiologists as Treasurer from
Much of Apgar’s time with the National FoundationMarch of Dimes was spent working to generate public support and funds for research on birth defects. anaesthesiology - the first woman with a professorship at the College of Physicians & Surgeons at the Columbia University. Relieved of the burdens as chief of clinic Virginia Apgar now moved into obstetric anaesthesia and became Attending Anesthesiologist at the Sloane Hospital for Women, where for ten years she was to devote herself to the evaluation of the newborn child in the period immediately after delivery. After introducing her score, Virginia Apgar went on to do further important research in neonatal acid-base status, especially in
disease in the U.S.A., and were therefore reoriented towards congenital malformations. She headed programs in research in the causes, prevention and treatment of birth defects. She was director for the division of congenital malformations (195967), vice president and director of basic research (1967-72) and senior vice president in charge of medical affairs (1973-74). Much of Apgar’s time with the National Foundation-March of
B MUEDIC S I N EA S LS & LEGEND F inance S
1941 to 1945 and was awarded the ASA Distinguished Service Award in 1961. She was the first woman officer of ASA. In 1973 she was the first woman to receive the Gold Medal for Distinguished Achievement in Medicine from the College of Physicians and Surgeons, Columbia University. In 1994, Apgar was pictured on a U.S. postage stamp, as part of the Great Americans series. A lady of many facets Virginia Apgar enjoyed a contentful and fascinating life with a wide scope of interests beyond medicine. An eminent lecturer - though at a machine gun-like pace – she was in high demand and a widely travelled person. This gave her the opportunity to pursue one of her great hobbies, angling, frequently in exotic places like the salmon rivers of Scotland and on the Great Barrier Reef. She was also an avid stamp collector, who herself was to be portrayed on a stamp. Her greatest, life-long interest, however, was music, no doubt influenced by her father who was an amateur musician and held family living-room concerts during her childhood. During her working years she played in three orchestras: The Teaneck Symphony of New York, The Amateur Music Players, and the Catgut Acoustical Society. Dr. Apgar usually carried the cello or viola with her on her frequent travels and often joined chamber music groups in cities she visited for a night of playing. The instrument builder An accomplished cellist and violinist, Dr. Apgar built her own stringed instruments. It was a visit to a preoperative patient in 1956 that led to Dr. Apgar’s interest in
In 1994, Apgar was pictured on a U.S. postage stamp, as part of the Great Americans series. constructing stringed instruments. This patient was Carleen Hutchings, a high school science teacher and musician. Her interest in how stringed instruments produce sound prompted Mrs. Hutchings to do studies in a home laboratory and, eventually, to construct fine stringed instruments based on her scientific studies. She had one of her self-made violins with her when she was in the hospital for surgery, and she invited Dr. Apgar to play it during her preoperative visit. Enchanted by the excellent sound quality of the instrument, Apgar joined Mrs. Hutchings in her studies and later learned instrument construction from her. Working from 12:00 midnight to 2:00 a.m. (much to the chagrin of her neighbours who were trying to sleep), she produced four stringed instruments – a violin, mezzo violin, cello and viola – in her small apartments bedroom filled with woodworking tools and a workbench. The “phone booth caper.” A legend illustrating her commitment
to musical excellence was reported in a New York Times article published a year after Dr. Apgar’s death. The episode is known as the “phone booth caper.” In 1957, the article reported, Dr. Apgar and Carleen Hutchings, “liberated” the curly maple shelf from a pay telephone booth in the lobby of the Harkness Pavilion of Columbia-Presbyterian Medical Center, to make the back of a viola. Because Dr. Apgar had been unsuccessful in getting the wood through proper channels, the two women devised a plot to steal it. When they found the piece of wood they brought to replace the shelf was too long, they had to use a women’s lounge to shorten the piece with a saw, Dr. Apgar standing guard in the hall, dressed in her hospital uniform, told a nurse who heard the sounds coming from the lounge, “It’s the only time repairmen can work in there.” The stuff that legends are made of In remarks at Dr. Apgar’s memorial service in September 1974, Dr. L. Stanley James, professor emeritus of paediatrics and of obstetrics and gynaecology, called
M EDIC A L LEGEND S
Virginia Apgar enjoyed a contentful and fascinating life with a wide scope of interests beyond medicine. An eminent lecturer - though at a machine gun-like pace – she was in high demand and a widely travelled person.
Dr. Apgar a student until the day she died. “Learning was the focal point of her life. Her curiosity was insatiable . . . she never became rigid. This rare quality enabled her to progress through life without becoming walled in by tradition or custom. It kept her young and vital. She started flying lessons a few years ago and even wanted to fly under the George Washington Bridge.” David Little, a longstanding friend and for periods a close associate of Virginia Apgar, began his memorial speech occasioned by a reprint of Apgar’s first publication from 1963 with the following words: “The speciality of anaesthesiology lost one of its most distinguished ladies last year when Ginny Apgar died on August 9. She was a physician in every sense of the word, a true scientist, everybody’s friend - but above all, a lady.” In her obituary in the Winter issue of P & S Quarterly, predecessor of P & S Journal, Dr. Leonard Brand, professor emeritus of clinical anae sthesiology, wrote: “Anybody who met her had a ‘Ginny’ story to tell, whether it had to with her interest in music, playing the violin and cello, or building her own string instruments. Or whether it had to do with her love of fishing . . . There were stories about her stamp collecting and her love of baseball and golf. There were stories about her driving her automobile as if it were an airplane. These stories could fill several pages, and they have filled several pages of publications, books, eulogy notes, speeches, and other materials. Whether they reflect the sense of humour she showed as a teacher or as a guest on the Johnny Carson show or whether they recount the numerous times she saved lives by carrying a small surgical knife
and tubing for emergencies, the stories collectively portray the kind of person Virginia Apgar was. Virginia Apgar is one of only two anaesthesiologists to be honoured on a U.S. stamp, the other being Crawford Long. The stamp, 20-cent, part of the Great Americans series, was released on October 24, 1994, during the annual meeting of the American Academy of Pediatrics in Dallas, Texas. The meeting featured string quartet musicians playing a cello Dr. Apgar made and two violins and a viola she helped make.
Apgar Award in Perinatal Pediatrics. On October 14, 1995 Virginia Apgar was inducted into the National Women’s Hall of Fame in Seneca Falls, New York. Ole Daniel Enersen, editor and publisher of whonamedit.com Eponyms: Apgar's score The Apgar score is a system for point score evaluation of the physical condition of a newborn one minute after birth.
The American Academy of Pediatrics gives an annual award called the Virginia Time was precious to her and her mind and hands were never still. I remember once watching a World Series baseball game on television with my children when the game was interrupted by rain and simultaneously our phone rang. My daughter said, “That must be Ginny. She only calls during rain delays. -Dr. Leonard Brand, P & S Quarterly obituary. One of the few things she could not do was talk slowly. Some people believed she had another hole for breathing. After a talk to several hundred physicians at an international meeting, it was later apparent that many had not understood a word she said, but they were enraptured and loved her. Somehow they got the message. -Eulogy delivered by Dr. L. Stanley James. Whenever Virginia was expected to our house, my teenage son and his friends would spend half a day in the library, concocting difficult questions to spring on her. She never failed to get the answers right. -Columnist Joan Beck, co-author with Dr. Apgar of “Is My Baby Alright?” in 1973. One of her favourite anaesthetic agents for delivery was cyclopropane, which she firmly believed to be completely safe and harmless to the infant. When her research fellows found out that infants born under cyclopropane were slightly but significantly more depressed compared to other infants, she was horrified. After looking at the data, she accepted the verdict without question and immediately announced at luncheon in a loud voice: “There goes my favourite gas.” -Eulogy by Dr. James
Feel you have something you would like to share with all other Anaesthetists?
We are currently looking for articles and submissions for Anaestheticlife . Please email: firstname.lastname@example.org
Wireless Technology in Anaesthesia Where are we now and where we will be in 10 years? By Dr. Sud Agarwal Medical Technology Columnist
A LP H A
he rate of progress and advancement in wireless technology over the last decade has been truly astounding. Nowhere is this more visible than in the field of consumer electronics. Over the last 10 years, our lives have been changed by using Bluetooth earpieces for mobile phones, wireless tablet computers to check our email, RFID proximity cards to enter buildings and E-tag devices to pay for our freeway usage. Similarly, within medicine there is an array of wireless and (tubeless) devices which have just hit the market and that are about to impact our profession in the most unbelievable way:
portable, targeted delivery of volatile via pocketsized in-line vaporizer Transporting the critically unwell patient or even transporting postoperative intubated patients has previously always meant using an infusion of an intravenous anaesthetic agent. This is no longer necessary with the advent of AnaConDaTM portable volatile delivery device with it's own sevoflurane (or isoflurane) single-use delivery device which is placed in-line between the endotracheal tube and the Y-piece. The desired end-tidal volatile concentration can be dialled up and will be administered in such a manner as to recycle over 90% of the administered volatile keeping costs to a minimum. The device also acts as a heat/ moisture exchanger and
a microbe filter cutting down on the total circuit dead space. Each device can hold up to 50ml of volatile and is refillable with proprietary AnaConDaTM pre-filled syringes. The main benefits to the anaesthetist include: • removing the need for scavenging or replacing the anaesthetic circuit tubing • the ability to deliver volatile anaesthesia without an anaesthetic machine – useful in the non-operating room setting with asthmatic patients or for ‘in-the-field’ military usage • the ability to deliver volatile anaesthesia whilst transporting patients (may be particularly useful for cardiac patients being transported postoperatively to ICU where the treating anaesthetist does not want to give propofol which may affect ischaemic preconditioning) Source: http://www.sedanamedical.com/
Real-time wireless patient monitoring via anaesthetist’s iphone Airstrip Technologies recently obtained FDA approval in the US for their Remote Patient Monitoring (RPM) system which will undoubtedly revolutionise the operating theatre environment. Available as a free download for iPhone, iPad, BlackBerry, Android and Windows Mobile devices, Airstrip effectively converts the ubiquitous smartphone into a portable patient monitoring system. With continuous realtime ECG, invasive or non-invasive arterial pressure, plethysmography, capnography and patient temperature streaming, this will surely lead to the death of the bulky
transport monitor and the cable-spaghetti that we take for granted. Compatible with both wifi and 3G cellular networks, the cost savings associated with using a device that is cheap and widely available are potentially massive. The question is no longer: will this App revolutionise transport medicine, but when? Source: http://www.airstriptech.com/
true pocket sized ultrasound machine with good images arrives While not strictly wireless, the days of pushing a large cart-based ‘portable’ ultrasound machine are well and truly over. GE have unveiled their Vscan device which is a palmsized, portable ultrasound which will comfortably fit in to the top pocket of your theatre scrubs. Measuring a mere 13cm long and 7cm wide, it is similar in size to an iPhone and only weighs about three times as much. Boasting a one hour
battery life and 3.5 inch screen, this could possibly become the ubiquitous gadget (following the iPhone and iPad) that every anaesthetist has to have. The current model is limited to B mode ultrasound with colour flow Doppler and a 4 GB memory (expandable to 32 GB) for recording loops. Another limitation is the fact, that to-date, it has only been created with a phased array probe (1.7 to 3.8 MHz). A high-frequency linear probe (beloved by anaesthetists) is in the production pipeline. The price, while not prohibitive, will still dent the wallet at USD$7,900. Source: http:// www.gehealthcare.com/ vscan/
With the rate of technological development ever increasing, who knows what the next few years will bring for further advances in anaesthetic technology. ANAESTHeTicLife
B O U T I Q UE
VALENTINE'S DAY GIFT IDEAS
ust as you’re beginning to recover from an angst-filled season of holiday shopping, Cupid reminds you that it’s time to bring out the credit card yet again. This Valentine’s Day, don’t get bogged down worrying about finding the perfect gift for your other half. Here are some suggestions for that special someone.
Leatherman Super Tool 300
If he is one for tackling the great outdoors, then he will need to have his Leatherman on standby. The Super Tool 300 is the tough little workhorse you want on your side when it comes down to the line. It’s made from really tough stainless steel, and it’s packed with fantastic tools that will come in handy no matter what task is at hand. Just think of it as the superhero of Multi-Tools! RRP $169
HER iPod nano
If your sweetheart is tech-savvy and cause conscious, go for Apple’s (RED) iPod nano. This nano is the triple treat - its festive Valentine’s colours, looks techno-chic and a portion of the proceeds go to help fight AIDS in Africa. If you want to make it really personal, you can have your Valentine’s name engraved on the back. Trust me, you can never go wrong with an iPod. RRP from $199
BOTH Espresso Machine
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The Hazards of an old Anaesthetist in the Changing room of the Operating Theatre
am bending down to peer at the security panel whose numbers, if correctly keyed will allow me to enter the changing room. From behind, a voice says, ‘Come and see me Tuesday. I can improve that vision and introduce you to my new laser machine.’ I nod. Later I am removing my coat and shirt when a surgeon, who also is undressing, spots a large lump on my back. The lump and I have lived together happily for years. He presses, prods, pinches and pummels, and diagnoses a lipoma. “Does it hurt?” “It does now.” Present is a cosmetic surgeon with whom I also work. He too suggests that my appearance could be improved – by the removal of the bags under my eyes. I don’t tell him that I have been up half of the night giving anaesthetics.
By Dr Tony Atkinson, Anaesthetist, Melbourne
An orthopaedic surgeon, not well known for his communication skills, sees me limping. He merely draws an indelible cross on my left hip. It is in fact the right hip that hurts. I bolt to the safety of the toilet. Pause, tinkling, tinkle, pause ... when I emerge I find myself sharing a washbasin with a friendly urologist “T U R, T U R” he sings. “How many times do you get up at night?” “Three” I say, “but two of those are to let the dog out”. He seems disappointed. Back in the changing room I am removing my trousers when a vascular surgeon, fitting in a smoke between cases, spots a bulging saphenous vein. “That needs stripping” he says. “Come in on Tuesday.” I hurriedly pull my trousers up as a colorectal surgeon puts his head around the door. I avoid bending down. “I need an anaesthetist next week.” “How about Tuesday?” I am quick to reply.
T R A V EL
Where in the world can you find the most extravagant spas? ‘YTL Hotels’ in Malaysia was the first hotel group to take the concept of the ‘stand-alone spa’ to its ultimate incarnation and create whole ‘villages’ of pampering. Hilary Doling throws herself on the massage table to road-test three of the world’s most indulgent spas. Tanjong Jara Resort, Kuala Terengganu
rapped in a sarong, followed by a procession of women carrying brass trays heaped with flowers and men with water pots I walk in the footsteps of ancient Malaysian royalty. A drum bangs rhythmically at every step and the early morning sun makes the sea sparkle. I confess when I received my invite to participate in the Mandi Bunga bathing
ritual the night before I had been less than thrilled. It is an invitation given to selected guests (often honeymooners) at Tanjong Jara Resort where each morning a procession marks the official opening of the spa for the day. Sitting at Nelayan beach restaurant, several chardonnays into dinner when the note is delivered, my companion and I giggle ungratefully at the thought of being singled out. We are both female and patently not lovestruck
honeymooners, having left husbands and children behind for a spot of ‘R’ n ‘Spa’, and we consider ourselves unsuitable and quite possibly (given our giggles) unworthy too. But this morning after a spot of embarrassment at breakfast, when we were hijacked over our Bircher muesli and publically robed up, the beauty of this traditional royal cleansing ritual
and its ancient significance begins to seep into our ungrateful souls. And that is the essence of Tanjong Jara Resort. Here, away from the KL crowds, amid the curling jungle of peninsular Malaysia in the isolated far north-east, what you get is an unadulterated taste of Malay culture. When our procession reaches the Spa Village (yes this resort has a whole spa â€˜villageâ€™ not just a room or two) I am
The resort buildings too take inspiration from the local culture, all modelled on royal palaces from the days of the old Malacca Sultanate, with dark wood interiors and curtain-draped day beds.
T R A V EL
taken to one of the private pavilions with outdoor bathing benches on which I sit as a therapist gently pours flowered water over me, and quietly wishes me health, happiness…all the good things in life. The blossoms stick to my sarong, water droplets hang on my eye lashes and I feel, well, like a queen. Now I have a confession to make, this isn’t the first time I have been pampered in a spa. In the course of my lucky life I have been face down on a massage table more often than Bill Gates has made another billion. And I can honestly say that the special Asam Roselle massage at Tanjong Jara was one of the best spa treatments I have ever had. In part because of the beauty of the surrounds and but mainly because of the gentle expertise of my therapist. The Malay treatments at Tanjong Jara have been handed down from generation to generation (all be it with a large dose of creative adaptation for five-star spa use). The ingredients used come from indigenous herbs and plants, not a large cosmetics company, which is why you’ll find leaves in your bath and crushed
husks in your skin scrub. The resort buildings too take inspiration from the local culture, all modelled on royal palaces from the days of the old Malacca Sultanate, with dark wood interiors and curtain-draped day beds. I particularly like the Anjung Rooms (choose 302 or 402 for beachside isolation) with their private outdoor plunge pools.
Pangkor Laut Resort, Perak
hen Sting’s helicopter landed on the island of Pangkor Laut on the west coast of Malaysia the waiting staff member wasn’t sure how to greet him. ‘Sting’ seemed somehow too casual, ‘Mr Sumner’ a little strange. Nevertheless, whatever his decision, ‘Sting’ and his family will have been greeted by a level of private luxury at Pangkor Laut that few other Malaysian resorts offer, which is why he isn’t the only star to touch down on this island. Pavarotti loved the place, so much so that they named a suite after him. Sting’s private vehicle would have whisked him straight to a secluded cove, a bay away from the main resort, to one of eight elaborate private estates. Now normally once ensconced in a villa like this, or in one of Pangkor Laut’s over-water bungalows in the main part of the resort, there would be few reasons to leave. However, no-one can resist the resort’s Spa Village for long. The Village is so impressive that even your average
T R A V EL
spoilt superstar might want to sling on a sarong and slip in unobtrusively. One of the first of its kind anywhere in the world when it opened in 2002, the Spa Village took indulgence to a new level. Since then its creators YTL Hotels have used the concept successfully in their other resorts such as Tanjong Jara Resort on Malaysia’s east coast and Cameron Highlands Resort . This really is a whole separate ‘village’ of indulgence with its own 50-metre
swimming pool, its own spa-cuisine restaurant, a small library and its own private massage pavilions. Scattered through its landscaped gardens are healing huts where experts from a variety of disciplines from Indian Ayurvedic to Chinese herbal wait to advise you. Whatever treatment you opt for we recommend you book a Bath House Ritual first. The staff will tie you into a sarong (see ‘dress code’ below) and lead you through two separate bath houses and a series of watery indulgences from waterfall-style showers to a Japanese
goshi-goshi wash and steaming hot pools. Then if you follow this with a signature Malay Lapis Lapis wrap, we guarantee you’ll be so mellow you’ll want to do almost nothing for the next 24 hours at least. Which is why, if you are not staying in the exclusive private estates, I recommend the over-water Spa villas as the next best thing. These 22 villas are within the confines of the Spa Village so really, you never have to leave at all.
T R A V EL
Away from the KL crowds, amid the curling jungle of peninsular Malaysia in the isolated far north-east, what you get is an unadulterated taste of Malay culture.
Cameron Highlands Resort, Cameron Highlands
ndulating green tea plantations cover the hills around the Cameron Highlands Resort.
Up here in the cool crisp mountain air the English in Malaysia escaped the heat of the lowlands and transplanted their European life to the tropics. They built bungalows like English cottages, played rounds of golf, and took invigorating country walks, all accompanied by copious cups of tea brewed from the leaves from the tea plantations that they planted all over the rolling green hills. Tea. I say, what a jolly spiffing idea. How fortunate that one arrives at Cameron Highlands Resort just in time for traditional afternoon tea. There are
also scones and strawberry jam, tiered plates stacked high with sugary cakes and of course the ubiquitous cucumber sandwiches. Lady Bracknell would have been proud. Since the theme of our stay is clearly tea I can’t resist the spa’s signature tea bath followed by a massage. My private Spa Village room has a deep claw-footed bath and white shutters. It also has a small flat-screen TV and head phone, which frankly I could do without. I prefer my spas without the technology. Nevertheless as I sink back into my
tea and chrysanthemum bath, having scrubbed my face with loose leafed tea and put tea bags on my eyes, I reflect that really tea is wasted on the drinkers; this is much more refreshing than a cup of Twinings. I’d recommend an indulgent spa safari like this to anyone, after all the “M” in Malaysia stands for “massage” doesn’t it? At the end of my trip I was on cloud nine and that’s before I got on the plane and climbed to 30,000 feet. Hilary Doling is Editor in Chief of www. Luxurytravelbible.com, the world’s ultimate on-line destination guide. For further information please contact YTL Hotels & Resorts on toll free 1800 667731, email email@example.com or visit www. ytlhotels.com.
TRAVEL LI F E S T YLE
Just what the
ordered… September 25 may seem like an awfully long time ago now, but the wounds are still raw for many: The first 2010 AFL grand final - and its inconceivable draw – certainly provoked some emotional outbursts. It all started out happily enough. There was Julia Gillard at her amusing best, invoking the gods of football not to permit a draw because the Australian public wouldn’t be able to bear it. At the time, I thought it a fairly witty comment for someone who’d had approximately seven hours sleep since August. Who knew how prophetic those words would be?
’m a relative newcomer to AFL – not your long term, dyedin-the-wool supporter – but I sat down to watch with a cold beer and high expectations. When the end came, not with a bang but a whimper, I was shocked. I called my Melbournian brother, who is overseeing my induction to AFL, to voice my displeasure. ‘At least’, he said with infuriating equanimity,
LI F E S T YLE ‘You got to see an historic draw’. Historic? The Industrial Revolution was historic; the invention of the Printing Press was historic! History is lofty, edifying, important... isn’t it?
table by rote. We were taught Latin & Greek roots, spelling and grammar. I could even parse then. Mind you, it was 1965: I could also do handstands and the splits.) The Australian Medical Profession
We all have our own personal histories, and they’re mostly not earth-shattering, but they’re important to us.
There’s an awful lot of history out there to be claimed, but it’s easy to overlook if you haven’t made a personal connection with it. Like my internet historian who rated Online Dating but not teabags. We all have our own personal histories, and they’re mostly not earth-shattering, but they’re important to us. (When I recall my education in the Queensland public school system back in the sixties – I feel very close to history. We used slates, practiced copy-book writing, and learned the times
I have no quibble with the expression. Certainly if Max had referred to him as a Ladies’ Man there would have been hell to pay. And in any case, he was by all accounts, a Family Man. In between practicing neurosurgery; lecturing in applied neurophysiology; serving in WW2, and publishing over 40 articles for a range of medical journals, the dashing (literally, I imagine) young Dr Gilbert Phillips somehow also found time to serve as president of the Wine and Food Society. While on his travels in London, Gilbert was impressed with the activities of a co-operative wine-buying society he saw there. On his return to Australia he established, in 1946, The Australian Wine Consumers’ Co-operative Society Ltd.
To test my contention, I visited a number of websites - one of which provided a list of Events that Changed the World. It started, impressively, with the Use of Fire and the Invention of the Wheel; Written Language, and both World Wars (see… lofty, edifying!); then ended – to my surprise – with Internet Dating. I don’t have a problem with internet dating, I just hadn’t realised that it has actually changed the world. Not in the way that, say, the invention of the teabag has. Then it started to dawn on me: history isn’t a collection of causalities or chronological absolutes: it’s personal. The same brother who is coaching me to say Carn the Pies (and unprintable things about the ump) is a political history nut. The depth and breadth of his knowledge is astounding. Did he study it? No. It’s just an interest. It speaks to him. It’s personal.
Australian wine pioneer Dr Max Lake - who studied under him, and became Gilbert’s junior neurosurgical resident - referred to Gilbert (even while apologising for the term) as a Man’s Man.
rightly lays claim to a wonderful history (if a short one, in global terms). So too, does the Australian Wine Industry. And when the two collide, magnificent things happen. Think Dr Henry Lindeman… Dr Christopher Penfold… Dr William Angove… Dr Max Lake… Dr Gilbert Phillips. Hang on - who??? Dr Gilbert Phillips was born in Sydney in 1904, and died at the age of just 49, from secondary melanoma. A neurosurgeon, an athlete (rowing, swimming and boxing), a great cook and a wine lover, Dr Gilbert Philips was also famous for his wit & erudition. Damn it, the man could even sing.
Astoundingly, Gilbert’s co-op continues to operate to this very day – although wine lovers know it better as The Wine Society. And while the Australian Wine Industry of 2010 would be unrecognisable to Gilbert, I think he’d be pretty pleased with some of the changes. His outrage at the application of European regional wine names to Australian products may have seemed quaint to many at the time: it is now, not simply accepted, but required. History is in the heart of the beholder. That’s why, when someone mentions 1946, you may think: the mass production of juke boxes; atomic testing & the invention of the bikini… I think of a dashing young Aussie doctor, and a great bottle of Australian wine. Ten years ago, Gillian Hyde made a mid-life career change from Show Business to the Wine industry, and today holds the position of Head of Membership at The Wine Society. www.winesociety.com.au
LI F E S T YLE
Australia’s Passion for Coffee Explained With over one billion cups of coffee brewed in restaurants and cafés right across the country each year, it’s fair to say that Australians know a thing or two about this popular beverage. What most people don’t know is that European style cafés first arrived in Sydney thanks to a Russian man named George Repin. Repin came to Australia in 1925 after fleeing Soviet Russia with his family, and by 1930 he had opened several ‘coffee inns’. His shops soon became favourites for city dwellers and workers looking for that ‘extra kick’ to get them through the day. In the late 1930s Repin took several trips to America, where he learned the virtues of roasting his own beans – an indispensable craft that is central to producing a great cup of coffee. From these humble beginnings, the coffee craze spiralled and became a culture,
as important to the daily ritual of doing your hair or brushing your teeth. Yet, when Global chains like Starbucks attempted to crack the market here, they failed to consider this rich history of bean-ology and in 2008 - after eight years of making terrible coffee – they announced the closure of more than half of their existing outlets. Small café owners and coffee enthusiasts alike quietly raised their espressos to this subtle victory.
LI F E S T YLE So what makes a great coffee, and where did Starbucks go wrong? It begins with the coffee beans themselves which, oddly enough, aren’t beans at all. They are actually seeds, found within the ripe red and purple berries of the plant. There are two types of plant, Arabica and Robusta. Arabica is considered to be the superior coffee plant and is by far the most popular. The beans are harvested, usually by hand, and then roasted in a coffee roaster. Coffee beans are a highly traded commodity and form the backbone of economy in regions like Latin America, Southeast Asia and Africa. Here in Australia we now have
hundreds of thriving family-run coffee roasting houses, and it is not unusual for the best cafés to roast and sell their own beans on the premises. But preparing a great coffee is like preparing a great meal - having the best ingredients is useless if you don’t know how to put them together. Coffee beans need to be ground to the correct consistency just before they are used. An espresso machine requires a very fine grind to ensure all the flavour and acidity of the bean can be extracted in the short time the steam is pushed through it. Plunger and percolator coffee machines need a coarser grind, because the coffee grounds sit in hot water for longer. While electronic blade grinders are faster, and certainly cheaper than the traditional models, a coffee purist will avoid them regardless of the cost. It’s not worth the extra convenience to end up with smashed and bruised beans.
another integral part of the barista’s job. Milk can be challenging – it’s got to be hot, but not burnt, and the density and amount of foam on top need to be just right. A cappuccino should have one centimetre of creamy and finely textured foam floating on top of the coffee, while a flat white requires just two millimetres. If that all sounds a bit daunting, consider the fact that a good barista needs to be able to quickly and consistently repeat this process hundreds of times a day, without fail. Thankfully, there are now companies that offer speciality training courses where you can learn and practise these skills. It makes the average 17 year old Starbucks employee look ill equipped and poorly trained, to say the least. And while it’s easy to have a go at the corporate giants, they aren’t the only ones guilty of serving up mediocre coffee. Finding that master barista can take some time. In recent years Melbourne and Perth have surpassed
Melbourne and Perth have surpassed Sydney to become Australia’s most mature coffee cultures, offering a wide range of tastes and experiences. If an espresso machine is used, it’s important for the coffee to be correctly loaded into the espresso machine. The barista needs to use the right amount of grounds and ensure that they are tamped correctly. Use too much or tamp too hard and your coffee will be bitter and way too strong. Use too little and you’ll end up with weak and dirty looking hot water. If all of these variables are spot on, you end up with 30-50 millilitres of excellent espresso. A perfect espresso shot will have a golden cream-like foam top called a crèma, which is where the aroma and flavour live. Your espresso should have a creamy texture, complex flavour, and should never taste bitter. In Australia we love our milk based coffees, such as the cappuccino or flat white, and this penchant adds another important element to the craft of killer coffee. Correctly heating and foaming the milk is
Sydney to become Australia’s most mature coffee cultures, offering a wide range of tastes and experiences. The way we find our favourite coffee is changing too. The Internet has transformed the way people find information of all sorts, and there are now numerous coffee-centric blogs and websites to help people find the best cup of coffee in their area. Of course, at the end of the day, you’re the best judge because you know what you like. Try new places, try new drinks, and remember - if you think something tastes fantastic, share it with the other coffee enthusiasts! Alan Byrne is the founder of BestAussieCoffee.com, a website where lovers of coffee can rate their local café and contribute to the communal quest to find the best coffee in Australia.
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To Gap or NoT To Gap First steps as a new anaesthetist health...wealth...lifestyle... What to do Immediately after you get your Letters Is i...