whistleblowing in the australian healthcare system
Ageing in Doctors & Cognitive Decline When is it time to hang up the stethoscope?
fukushima burning Anatomy of a Nuclear Disaster
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14 20 28 58
Fukushima Burning Anatomy of a nuclear disaster
State to Federal Cost-Shifting Billing Medicare for services provided in public hospitals – what’s right and what’s wrong?
Ageing in Doctors and Cognitive Decline
When is it time to hang up the stethoscope?
Ethics, professionalism and healthcare management
Departments 10 Features 34 Business & Finance 56 Risk Management 61 Careers 64 Alpha: Technology & Reviews 66 Lifestyle 68 Travel
Medicine – Still a Calling or Just a Job? How those of you who have lost the passion can re-kindle that old flame
Anatomy of a nuclear disaster
State to Federal Cost-Shifting
Billing Medicare for services provided in public hospitals – what’s right and what’s wrong?
10 14 20
Sexual Dynamics at Work Blunt tool or sharp instrument
Ageing in Doctors and Cognitive Decline
When is it time to hang up the stethoscope?
BUSINESS & FINANCE
Self Managed Super For Young Wealth Accumulators Why it’s becoming so popular
Who Wins While Art Loses? The Government’s assault on art is damaging the entire art industry
Smart Investors Target Carbon Tax Opportunities
How will the proposed carbon tax affect your investments?
Risk Issues Unique to Senior Physicians When age matters
34 38 43 46
End of Year Tax-Planning Checklist Top 5 tax-saving tips for physicians
The Rise and Rise of Natural Medicine
Dilution of the words ‘doctor’ and ‘medicine’
Whistleblowing in The Australian Healthcare System
Ethics, professionalism and healthcare management
So You Want To Build Your First Practice?
The things you need to know and do
The doctor's preferred tablet
The matching game
Having a Whale (shark) of a Time Off the Coast of WA
elcome to the May/June Edition of Physician Life.
This edition marks a very special occasion – our one year celebration. So here is wishing Physician Life a very Happy Birthday! Over the last year we have presented you with six editions of Physician Life and we hope that you have enjoyed reading these as much as we have enjoyed putting them together. Over this time we have learned more about your likes and dislikes and have taken on your feedback for future articles.
I am pleased to have marked our first birthday with the huge success of the Part 3 Course event that was run in Melbourne on 16th April 2011. A special thanks to our speakers and delegates who made this event possible and proved that the ‘Business of Medicine’ really is an area that requires further nurturing. The response from attendees and those who missed the event has reinforced the message that there is a general lack of information provided to doctors on the business and financial aspects of medical practice. Both our magazine and future events aim to fill this void. Regards,
Editor firstname.lastname@example.org Contributing Sources Dr. Stephen Bolsin Dr. Tony Blinde Dr. Lisa Ferrier-Brown Dr. Richard Cavell Dr. Mark Colson Hilary Doling Gillian Hyde Dr. Peter Karamoskos Dr. Michael Levitt Dr. James Nguyen Dev Sharma The Physician Life magazine is published bi-monthly by Medical Life Publishing Pty Ltd. Physician 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. Editorial Please direct all inquiries and submissions to: Medical Life Publishing PO Box 2471, Mount Waverley VIC 3149 Phone: 03 9001 6373 Fax: 03 9923 6662 Email: email@example.com
Selina Vasdev Editor
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Cover Image: "Japan Nuclear Radiation Suits" by ssoosay www.flickr.com/photos/ssoosay/5537572153/ Images licensed under a Creative Commons Attribution 2.0 Generic Licence http://creativecommons.org/licences/by/2.0
The information contained in this magazine, while believed to be correct, is not guaranteed. Medical Life magazine and its directors, employees and consultants do not accept any liability for any error, omission or misrepresentation in relation to the Information. Nor does it accept any loss, damage, cost or expense incurred by any person whatsoever arising out of or referable to the Information displayed within the magazine. The Editor has the right to omit or edit contributions for style, space or legal concerns. Any view expressed in Medical Life magazines are not necessarily the view of the Medical Life Publishing. No part of this magazine can be reproduced or copied without the express prior consent of the publisher.
Phone: 02 9872 7708 Fax: 02 9872 1002 Mobile: 0414 487 199 Email: firstname.lastname@example.org
LETTERS TO THE EDITOR
ur Letters to the Editor section encourages you to submit your comments and suggestions to Physician Life. As always, I would like to hear more about your opinions on our articles as well as your thoughts on the subjects we cover. At the same time, I am always open to hearing your compliments and criticisms about how we handled subjects and where improvements can be made. Please send your comments to email@example.com marked letters to the editor.
Dear Editor, I agree with Dr T Blinde’s contention that “adulation of (medical) administration” could be detrimental to the provision of health care and the morale of clinicians (“Altruism in medicine…is it declining? Physician’s Life March/April 2011). Lauding health care managers for delivering cost savings and improved productivity has not been rigorously evaluated. Administrators are likely to favour self-preservation or enhanced self-importance, being tempted to look anywhere but their own territory for cost savings and to not critically appraise their own meaningful contribution. Has burgeoning and ever more layered senior health management, unlike proven medical treatment, been subjected to the rigour of evidence - based scrutiny for clinical - and cost-effectiveness? There is no direct evidence that senior health management, the often self-perceived fount of organisational strategy and vision, confers a health benefit at all. A Medline search I conducted in March 2011 combining “hospital administration” and “cost-effectiveness” yielded a mere 43 abstracts; when limited to more valid study types (Clinical Trial, Meta - Analysis, Randomized Controlled Trial, Clinical Trial, Phase I, Clinical Trial, Phase II, Clinical Trial, Phase III, Clinical Trial, Phase IV, Comparative Study, Controlled Clinical Trial, Evaluation Studies, Multicentre Study, Validation Studies) only three remained: a cross-sectional study of the complementary health care centre governance, review of the economic aspects of implantable defibrillators and a cost-effectiveness analysis of immunoglobulin use.
Has burgeoning and ever more layered senior health management, unlike proven medical treatment, been subjected to the rigour of evidence - based scrutiny for clinical - and costeffectiveness? Furthermore, a search of the Cochrane Library yielded no citations on the health effects of medical and health care administration. Indeed, it could be argued that scarce health care funds are being diverted from patient care to costly medical administration. Dr. J.T., QLD
Please send your comments to firstname.lastname@example.org marked letters to the editor.
LETTERS TO THE EDITOR
Dear Editor, I would like to pass comment on the article featured in your March/April Edition about research fraud. As a professor I found it of great interest and thank you for exposing this topic. It is a frightening, yet all too common occurrence. Clearly, those involved in misconduct either in the form of plagiarism; falsification and fabrication lack ethics and have no place in research or medicine. The concept of research fraud is cheating; it is misguiding our profession and misleading the public. It undermines the publicâ&#x20AC;&#x2122;s trust in medical research and ultimately doctors. Although there is greater response from journals to detect scientific fraud, this is still a slow process and there are still plenty of cases that are likely to go undetected or even unreported.
Dear Editor, Thank you for sending me bi-monthly copies of your magazine. The articles are well written and you seem to cover topics that are relevant to our profession.
There needs to be a stricter code of good practice and a body of independents to investigate allegations.
You seem to raise issues in a way that clearly fills a gap. For me personally, the ones relevant to starting out in private practice have been especially valuable. They have helped reinforce ideas and strategies for my business, but have also identified areas of complacency and development (marketing).
For this I thank you.
Prof. F.R., VIC
Dr. R.F., VIC
Dear Editor, Itâ&#x20AC;&#x2122;s not difficult to see why some doctors are guilty of research fraud, particularly as the incentives for plagiarism are inadvertently enhanced when career advancement and financial rewards are linked with producing papers â&#x20AC;&#x201C; often with the emphasis on speed and volume rather than quality. Best, Dr. S.T., WA
Please send your comments to email@example.com marked letters to the editor.
Dear Editor, I'd like to pass on some positive feedback to you and your team about the magazine you are producing. Just like every other doctor, I receive a tonne of glossy marketing material dressed up as news and information claiming to be of value to me as a doctor as well as enhancing the efficiency of my practice. Initially I thought your magazine fell into the same category. But I have been very pleasantly surprised to find the articles are actually quite 'meaty' and there are many of them in each edition (rather than just a couple amongst pages of ads). The ones that most stand out are from the business section along with some of the hard hitting subjects you cover in the features. Keep up the good work. Dr. L.C., NSW
Dear Selina, I would like to congratulate both you and your team on a very modern approach to imparting information which may be of interest to the medical community. For me, one article really stood out in the March/ April edition. This was Altruism in Medicine ... Is it Declining? Part 2: The Reasons Why by Dr Tony Blinde. I have to agree that there are now issues between and within all of the competing interests in the health sector. Unfortunately, it has led to administrators in one camp and doctors usually in another. Of course moving forward from this presents an ongoing challenge. I would have also added that strong leadership is now needed in both camps to try and now move the whole health agenda forward, firstly by re-establishing appropriate dialogue.
LETTERS TO THE EDITOR
Dear Editor, I write in relation to an incorrect advertisement that appeared in the January – February issue of Physician Life. This marred what was otherwise a very helpful series of articles in the magazine. On Page 19 there was an advertisement to raise funds for a young Palestinian child, Malak, with a congenital abnormality (very small external ears, and deaf), and who needs to come to Australia for surgery to create new ears and to provide a specific type of hearing aid, because “it cannot be done anywhere in the Middle East”. There is no doubting that the Palestinian healthcare system has extremely high demands on its limited resources and that children in particular are innocent victims. Whilst the aim of the advertisement was humanitarian, it should be noted that both the surgery and provision of these types of bone anchored hearing aids (BAHA) are available in the Middle East. There at least 7 hospitals in Israel which provide these services, including Hadassah & Shaare Zedek Hospitals (Jerusalem), Bnei Zion Hospital (Haifa), Sheba & Ichilov Hospitals (Tel Aviv), Soroka Hospital (Beer Sheva) and Schneider Hospital (Petach Tikva).
Palestinian children do have access to some services in Israel, with the Peres Center for Peace handling such humanitarian aid requests, and, I am advised, usually paying full costs of the procedures and providing the equipment needed. The funds come from humanitarian sources in Italy, Switzerland, the Netherlands and the USA. The “Saving Children” campaign was begun in 2003 and has had > 6500 referrals since, the majority being for neurosurgery, cardiac, and orthopaedic surgery; plastic surgery is also performed. Details can be found at www.peres-center. org/, together with an application form for a physician to complete requesting assistance for children like Malak.
Dr. Deborah J Verran., NSW
I do not know if Dr Tony Blinde plans to write about how to move forward from the current position that he described but I do hope that someone plans to.
Dr. Bernie Tuch, NSW
Please send your comments to firstname.lastname@example.org marked letters to the editor.
F E AT U R E S
Medicine Still a Calling or Just a Job? How those of you who have lost the passion can re-kindle that old flame
F E AT U R E S
Can you honestly say you love being a doctor? Or like many GP’s and specialists who were recently surveyed would you too express an admixture of feelings - a combination of enjoyment, satisfaction and frustration? All mingled in with a constant fear of being sued? Would you encourage your children to seek a medical career or push them to train in finance or some other field which looks to hold a better future financially and that is less likely to suffer government interference? Do you feel like you have lost your medical “mojo”? If so, how do you get it back in the midst of long hours, never ending demands and not to mention the perception that doctors are called to their profession for the needs of their patients first, and themselves, and their families second? Psychiatrist Dr Lisa Ferrier-Brown takes a personal look at the practice of medicine. The always pithy great grand daddy of physicians William Osler wrote: “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” Is this aphorism still true several hundred years ahead or has our evidence-based platform replaced the best of what we do?
The changing medical landscape There is no doubt how much the practice of medicine has changed, even over the short period of the last ten to twenty years. Mid career doctors still remember and bore their younger colleagues with tales of an era when hospital patients stayed as long as there was a clinical need. The option of a “social” admission was still possible - particularly in the Repatriation Hospital and where it was understood that Christmas was a difficult and lonely time for old veterans. As an intern I can still remember when patients other than those suffering with the most extreme forms of psychosis and depression had a similar right to a hospital bed. Nostalgic longings have gone for days when paperwork was clinically and not bureaucratically generated and when negligence claims were rarely made, and even more rarely won, unlikely to best fit us for the remainder of our careers in medicine. A 60 something surgical friend of mine often tells a story of how even a noticeably drunk general surgeon practised for years
without complaint by staff or patients. Thank goodness those days are gone. But if you are hankering for the post-war and pre-Medicare glory days of medicine in Australia it’s worth stopping to think about why we still do what we do and what makes it worthwhile. Although surveys of doctors’ work satisfaction usually confirm the intellectual stimulation of dealing with the human body and its ills, less often do we tell our colleagues about, or even stop to review for ourselves, those little triumphs against illness and injury that must surely make the practice of medicine the most emotionally gratifying of all the professions. In an era of evidence-based medicine, meta-analyses and the decline of case reports as a form of teaching and expression, it’s easy to lose the threads of what binds us together despite our differing sub-specialities. Sharing the “moment” with patients There are for all of us who work in clinically intense evnironments, heartening moments of making a difference to a patient’s suffering. More
William Osler wrote: “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.”
F E AT U R E S often it is an objectively small win over the tidal wave of ills which befall those we care for; sometimes it isn’t an actual “win” but just a consultation moment when we and our patients share a sense of real connection. Influential American psychologist Carl Rogers dominated mid 20th Century thinking about self actualisation, a process whereby we are fully present in the moment and which
is associated with a heightened sense of connection with ourselves and the world. The concept still holds good today; those “moments” of either shared understanding with a patient or their family over efforts rewarded, or at least appreciated, should not be glossed over. As doctors we are sometimes more comfortable with our professional boundaries remaining in place than we are with allowing patients
to thank us and share with them with their triumphs and losses. The intense emotions of these particular “moments” are easily submerged by avoiding eye contact, changing the subject and looking through the notes or at the computer. If we become distracted by the ‘busyness’ of the consultation or feel awkward accepting heartfelt thanks we miss out on being in the moment with our patients. We also miss
If we become distracted by the busyness of the consultation or feel awkward accepting heartfelt thanks we miss out being in the moment with our patients. out on the satisfaction “elixir” we all need to help us bear the inevitable difficulties of medical life. As a psychiatrist I know all too well how confronting even positive emotions expressed by patients can be. Allowing our patients the opportunity to connect with us does not have to lead to a loss of boundaries. Rather, both at the time and later when the working day is over it’s worth stopping just to savour the daily “moments” that make medicine worthwhile. Mostly no one will ever know about these interactions and some of the time even our patients don’t know how good their outcome has been. As well as stopping to appreciate these moments at the time, some of them will be worth sharing in peer review and others might be worth putting pen to paper about. Regardless, their appreciation either in a consultation or privately, is a sure antidote for “burnout”, cynicism and the treadmill of keeping up with the ever growing demands of paperwork and protocol. All of us have our own stories to tell about why our chosen area of medicine is gratifying. Non-psychiatrists, including doctors and the lay population often view psychiatry as being a “depressing” pursuit. There is a stereotype that the conditions psychiatrists treat are “chronic” and incurable. The truth is very different. I am constantly amazed at how well even very disturbed or
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mentally ill patients do over time; there is nothing more satisfying than to watch an individual’s recovery evolve and to sometimes be made redundant in the process! I never learnt in medical school, and I’m assuming you didn’t either, how much I would learn from my patients; seeing their bravery and determination to get better and how they cope with the challenges of being sick, and the ultimate challenge of facing death. All this leaves me feeling privileged to share in their triumphs and losses. By the process of sharing our patient’s experiences, within our professional boundaries, we have an enormous opportunity to undergo personal growth “on the job”.
latter sounds familiar it’s also worth thinking about how to regain passion about what you do and to restart a process of personal growth. Teaching or mentoring a new wave of doctors, whether they are generation Y or beyond is a great way to start. Opportunities exist for those outside the academic paradigm to volunteer for student practice visits which are not too time intensive or to become a more personal mentor to a junior colleague. Each of us underestimates the amount of real, not just textbook knowledge, accumulated even a decade into our careers. Osler recognised this still fresh truth in another of his often quoted pieces of wisdom:
stymie our efforts to get on with the job.
Avoiding “stagnation” by mentoring
“No bubble is so iridescent or floats longer than that blown by a successful teacher.”
Despite the worry about suicidal patients and the increasing demands of paperwork Dr Ferrier-Brown still loves being a psychiatrist - “nothing beats the satisfaction of knowing you have made a positive difference to a patient’s life; it’s a privilege to share the gains after the hard times”.
Another famous psychologist of the 1900’s, Erik Erikson developed a theory of life stages. The challenge of mid adult years (45 to 65) as conceptualised by Erikson was to evolve into a life phase of generativity and creativity versus the potential trap of “stagnation”. If the
Although none of us know what the medical landscape will look like in another twenty or thirty years, each of us needs to respond to the changes with flexibility, particularly when the so-called improvements in the system seem to
In times like this viewing the practice of medicine as more than a minefield to negotiate is increasingly a challenge but one which remains within our grasp. Seize the (medical) moment and savour it, either privately or with colleagues and pass on the wisdom of your experience to the next generation of doctors. They will need to learn the same lessons themselves if medicine is to remain a “calling” rather than just a job. Dr Lisa Ferrier-Brown, forensic and general psychiatrist.
F E AT U R E S
Fukushima Burning Anatomy of a nuclear disaster â&#x20AC;&#x153;the [Fukushima] disaster has enormous implications for nuclear power and confronts all of us with a major challenge. The worries of millions of people throughout the world about whether nuclear energy is safe must be taken seriously" - Yukiya Amano, IAEA Director General, 5th Review meeting on the Convention on Nuclear Safety 4th April, 2011 The Fukushima nuclear disaster ranks as the second worst nuclear reactor accident in history. It also ranks as the worst multiple reactor accident in the world. What happened? How did it happen? And what are the implications for the people of the Fukushima district and the surrounding areas most affected? Why is ionising radiation a public health hazard? What happened? On 11th March, 2011 at 2:46 p.m. local time an earthquake of magnitude 9.0 occurred at a depth of 32km in the Pacific Ocean 130km east of the industrial city of Sendai on Honshu. This earthquake is the most powerful experienced in Japan, and was followed by many aftershocks of
considerable magnitude. The effects of the earthquake in Pacific coastal regions of northeast Japan were greatly exacerbated by the tsunami generated by the earthquake which hit the coast some minutes later at heights of 10 metres or more. The Fukushima I reactor complex comprising of six nuclear reactors was most severely affected. At the time, only three reactors were operating (1, 2 and 3), and the active core fuel rods of reactor 4 had been placed in the spent fuel pond in the ceiling of its building. All reactors at the complex stored up to seven times the amount of fuel rods in their cores with spent fuel ponds in the ceiling of each building with minimal containment structures to protect them.
As far as human health is concerned comparisons therefore between Chernobyl and Fukushima disasters are valid. The earthquake and subsequent tsunami interrupted the AC power to the primary and secondary cooling systems of the complex. The backup diesel generators failed as they were inundated by flooding, having been placed below the level of the sea wall. Backup batteries to power the pumps were eventually depleted. Subsequently, the four active reactors’ cores overheated and sustained partial core melts resulting in explosions which severely damaged the buildings. The spent fuel rods of reactors 3 and 4 were exposed to air also resulting in overheating and a fire in the spent fuel pond of reactor 4. Containment structures of reactors 2 and 3, designed to contain highly radioactive active fuel were also damaged. Reactor 3 is fuelled by MOX (mixed oxide fuel which is a blend of uranium and plutonium). As of early April, there were significant amounts of ongoing radioactive fallout. This was made worse by the large volumes of seawater needed in an attempt to externally cool the reactors and spent fuel ponds. This resulted in extensive offshore and local contamination including the groundwater, exacerbated by the rupture of reactor 2, secondary containment which continues to leak the damaged core contents into the plant precinct.
case scenario and still remains poorly controlled. Any pronouncements as to the eventual conclusion of this disaster are therefore currently speculative. However, the currently known facts are troubling enough. The International Atomic Energy Agency (IAEA) uses a 7 point INES (International Nuclear Event Scale)1, 2 to categorise nuclear incidents (2-3) and accidents (4-7).3 The Chernobyl disaster ranked as a 7/7 accident. The Japanese nuclear regulator (Nuclear and Industrial Safety Agency) initially ranked the Fukushima disaster as a 5/7 accident (comparable to the Sellafield, UK reactor fire in 1957, and Three Mile Island USA core melt in 1979). However, the French nuclear regulator (ASN) and the US Nuclear Regulatory Commission subsequently classified it as a 6/7 accident, representing a “serious accident” resulting in “a significant release of radioactive material likely to require implementation of planned countermeasures.” On 12th April, NISA upgraded its classification of the disaster as a 7/7 (“major release of radioactive material with widespread health and environmental effects requiring implementation of planned and extended countermeasures”),3 and thus on a par with Chernobyl.
What are the consequences?
What happens when a nuclear reactor overheats?
We still don’t know what the full consequences of this disaster are or what they will be. We do know, however, that the nuclear accident has tracked closer to the worst case than the best
When nuclear cores overheat due to a lack of water coolant, they ultimately melt. Remaining water quickly turns to steam preventing replenishment of the
water and endangering the integrity of the pressure vessel. Furthermore, the reactor pressure vessel may also melt leaking the melted fuel which may escape into the environment if the primary and secondary containment structures (concrete) have been damaged. Spent fuel is kept at around 25 degrees in cooling ponds for a few decades. The water must be continually replenished to maintain this temperature. If there is a loss of water or a failure of replenishment, the spent fuel will overheat and catch fire, releasing its radiotoxic contents. Note that the longer fuel is irradiated in the reactor core, the more radioactive it becomes due to the build-up of fission by-products which also contaminate the fuel limiting its usable life. Only about 1-2% of the uranium in fuel rods is actually used up in a reactor. It is these fission by-products that pose the greatest immediate danger if released into the environment. Radioactive fallout and its health effects Radioactive fallout from a nuclear reactor can be considered in two groups: Isotopes of the noble gases (xenon, krypton-133) are radioactive elements with a very low chemical reactivity, relatively short half-lives, are not retained by the body and they remain and become dispersed in the air without ground deposition. Hence they have limited adverse health potential. The second and more dangerous radioactive fallout group is represented by mainly the radioactive isotopes of iodine, cesium, and tellurium.
These elements form fine suspended particles in the air (aerosols), which due to their weight will gradually end up falling on the ground when released in the air, contaminating all vegetation, clothing and any other surfaces including water sources. Those that pose the greatest health threat are Cesium-137 (half-life 30 years) and Iodine-131 (halflife 8 days). Iodine-131 is a beta emitter and is absorbed into the blood stream through inhalation and ingestion and concentrated by the thyroid gland where it is highly carcinogenic, predominantly in young people under 18 years of age. Cesium is a gamma and beta emitter. It is also absorbed by the body through the respiratory and gastrointestinal tracts and subsequently into the bloodstream and deposited throughout the body. Cesium takes between 10 days and 100 days for half of it to be excreted from the body so there is significant hazard once it is absorbed. Unlike I-131 therefore which loses most of its potential for harm in a few months, cesium remains hazardous in the environment for several hundred years.
Furthermore, the prevailing jet stream is towards the United States west coast which is likely to have higher levels of contamination (but still very minimal at that distance) than, say, northern Canada which is closer to Japan. Contamination is likely to spread throughout the northern hemisphere and indeed trace amounts have already been detected from nearly all monitoring sites4 in that hemisphere. There is effectively an 'air curtain' at the equator that prevents contamination from reaching the southern hemisphere. Shortly after the nuclear plant explosions, a 20km exclusion zone was established and residents between 20 and 30km were advised to remain indoors. The IAEA and
US NRC suggested this was inadequate and advised an 80km exclusion zone. Utilising CTBT monitoring data, the Austrian Central Institute for Meteorology and Geodynamics calculated that in the first three days, the activity of I-131 emitted was 20% and Cesium-137 20-60% of the entire Chernobyl emissions of these isotopes. Although Chernobyl emitted vastly more fallout than Fukushima has to date, it was the I-131 and Cs-137 that accounted for most of the terrestrial human and environmental hazard, and these are the main Fukushima fallout components. Also, the Fukushima plant has around 1760 tonnes of fresh and used nuclear fuel
FIGURE 1: Main transfer pathways of radionuclides in the terrestrial environment (UNSCEAR 2011)
So how much radioactivity was emitted and how does it compare to Chernobyl? The spread of airborne contamination is unlikely to be evenly distributed due to many variables including the prevailing winds, the altitude the contamination reaches before dispersion and the time period of release. Thus, although we speak of radial zones from the plant, the shape of the fallout most likely will represent a plume rather than a concentric disc.
F E AT U R E S on site with an unknown amount having been damaged, whereas the Chernobyl reactor had only 180 tonnes. As far as human health is concerned comparisons therefore between Chernobyl and Fukushima disasters are valid. Emissions have continued since then, albeit at a lesser rate than initially was the case. Note, however, that there has also been extensive contamination of the sea off the coast of Fukushima as contaminated seawater runoff from the plant used to cool it continues unabated at a rate of 7,000 tonnes per day. Concentrations of radioactive iodine were measured at over 4,300 times the legal limit. Measures to intentionally dump the contaminated seawater build-up into the sea are being considered. Contamination
“… there is a linear dose-response relationship between exposure to ionizing radiation and the development of solid cancers in humans. It is unlikely that there is a threshold below which cancers are not induced.” – US National Academy of Science, BEIR VII report, 2006 of the seawater will compromise the fish stocks along the local coast for some time and has destroyed any remnants of the fishing industry that were not wiped out by the tsunami. France’s Institute for Radiological Protection and Nuclear Safety (IRSN) has estimated that within 20km of the plant the levels of contamination will exceed that of Chernobyl , and there will be “a strongly contaminated zone”, extending to 60km around Fukushima in which there will be “measurable impacts but not dramatic impacts” although the contamination will be less than the comparable area around Chernobyl. Beyond this zone contamination will be measurable as far as 250km but with health impacts not able to be measured. The more extensive evacuation zone advised by the IAEA (but ignored by the Japanese authorities) was vindicated, as later monitoring showed hot spots of contamination as far as 43km from the plant with levels of activity comparable to those areas which were mandatory evacuation zones at Chernobyl.
What are the health impacts of ionising radiation? Ionising radiation (IR) imparts its deleterious health effects through two mechanisms: transference of its energy to atoms in biological tissue which then becomes electrically charged leading to the formation of free radicals which then damage the cell’s genetic blueprint (DNA) leading to genetic mutations; and direct DNA disruption along the track as ionising radiation traverses through the cell’s nucleus. This then predisposes to the initiation of cancer when the regulatory mechanisms of the cell fail. Cancer may not appear for 1050 (or more) years (latency), although can be as short as 5 years for leukaemia. Ionising radiation is classified as a Class 1 carcinogen by the International Agency for Research in Cancer (IARC) of the World Health Organisation (WHO), the highest classification consistent with certainty of its carcinogenicity. Two types of IR health effects are recognised. The severity of deterministic effects is directly proportional to the
absorbed radiation dose. These include skin damage and blood disorders due to bone marrow effects. The higher the dose, the worse, for example is the skin radiation burn. These have a threshold below which they do not occur, although this may vary between individuals. This threshold is around 100 millisieverts (mSv) at which blood production begins to be impaired.5 Deterministic effects which exceed around 1000mSv induce acute radiation sickness with vomiting, diarrhoea, and shedding of mucosal linings of the gastrointestinal and respiratory tracts, bone marrow suppression and sterility. Once the dose exceeds more than 3000-5000 mSv, death is likely in a matter of days to weeks. Stochastic effects are ‘probabilistic’ in nature. In other words, the higher the dose the greater the chance of them occurring, however, once they occur their severity is the same irrespective of the original dose. The main stochastic effect is cancer. The lower the dose of IR, the lower the chance of contracting cancer, however, the type and eventual outcome of the cancer is independent of
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the dose. The current risk coefficients for the development of cancer are approximately 8% per 1000 mSv (ie 1:12 chance) and 5% for cancer fatality (1:20). The US National Academy of Sciences reviewed the effects of low level ionising radiation (defined as less than 100mSv) in their seminal report and concluded that: “… there is a linear dose-response relationship between exposure to ionizing radiation and the development of solid cancers in humans. It is unlikely that there is a threshold below which cancers are not induced.” – US National Academy of Science, BEIR VII report, 2006 Emergency workers at the plant are likely to have developed deterministic effects as their upper allowable occupational doses have been increased to 250 mSv (from the 100mSv total dose over five years allowable, and the 1mSv per annum allowable dose to the public). One incident induced radiation burns to two emergency workers’ legs from stepping in highly radioactive water in reactor 2, with a calculated total dose of 180mSv from this one incident. In order to limit occupational doses workers have been recruited from a 600 person pool of workers on a rotating basis, and recruitment from overseas has now become necessary to avoid exceeding the revised occupational dose limits. It is highly likely that some of these workers will die of their exposures from the induction of cancer. No cases of acute radiation sickness have been reported to date. The longer term stochastic effects will be much harder to define given the relatively high background incidence of cancer and the long latency period for its appearance. The prompt evacuation of people from the immediate surrounding environment, notwithstanding the insufficient exclusion zone, and offshore wind on the days of maximum fallout, will have minimised these effects. Furthermore, the administration of stable iodine to block thyroid uptake of I-131 in sufficiently exposed young people will also have significantly decreased the development of thyroid cancer. Even though risk models of cancer induction can be used to predict the likely cancers
over the next six decades, it is possible that we will never know the true number of actual excess cancers in the general population due to inherent statistical limitations and large uncertainties, even several decades after the event. This is particularly so at very low doses. The only exception to this will be excess thyroid cancers since this is a rare malignancy and hence is easily statistically detected. How long will it take to resolve the crisis? It all depends on what we mean by “resolve the crisis.” The Japanese government has set a target of “several months” to stop the continuing atmospheric, sea and ground emissions from the plant. Note that this is a desired outcome, not necessarily the likely outcome. It is conceivable that more drastic measures need to be adopted including burying the entire plant under a concrete sarcophagus which alone is estimated will cost upwards of $12bn. Of course, the entire plant will need to be written off as even reactors 5 & 6 which were not damaged are too heavily contaminated. Cleaning up radioactive sites is massively costly, time consuming and dangerous. If the plant is able to be brought under control, it will take more than 30 years to decommission the reactors and decontaminate the site and will cost “more than 12 billion dollars.” Of course, that is not the upper limit of liability for the beleaguered Japanese taxpayer. Bank of America-Merrill Lynch has estimated an upper bound of $130bn for the Fukushima disaster alone in liabilities and economic losses. The decommissioning effort alone will likely bankrupt the operator TEPCO resulting in a knock-on massive liability for Japanese taxpayers. Unlike the case with all nuclear power generated around the world, where operators refuse to generate electricity unless most of their liabilities are capped in the event of a major accident, the 1961 Act on Compensation for Nuclear Damage places no cap on damages. However, if the company is bankrupted, this liability transfers to the taxpayers. After this disaster, the Japanese tax-payers will realise that it is they, not the nuclear power companies, who need protection.
Conclusion The second worst nuclear power disaster has brought tremendous devastation on the Japanese communities affected. The lives that have been, and ultimately will be, lost are difficult to determine at this stage. Although, it is likely that they will not be of the scale of those killed from the earthquake and tsunami. This is due to prompt countermeasures having been implemented. The economic devastation and social dislocation is vast. 200,000 people have been evacuated from the exclusion zone, and 163,000 remain in shelters. If the surrounding 20km of the plant are as contaminated as predicted, most of these people will never return to their homes and the ground will lie fallow for hundreds of years. It is clear that there is no other man-made civilian technology that has the potential for such widespread devastation to public health, the environment or society. Dr Peter Karamoskos is a Nuclear Radiologist in Melbourne. He is the public representative on the Radiation Health Committee of the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA), and Treasurer of the Medical Association for the Prevention of War.
References http://www.iaea.org/Publications/Factsheets/English/ines.pdf http://www-ns.iaea.org/tech-areas/emergency/ines.asp 3 A 1/7 INES event is termed an ‘anomaly’ 4 CTBT (Comprehensive Test Ban Treaty) monitoring sites. These are able to detect minute trace amounts of radioactivity. 5 Compared with a current per capita average of approximately 2mSv from natural background radiation. 1 2
Cover Image: "Japan Nuclear Radiation Suits" by ssoosay http://www.flickr.com/photos/ssoosay/5537572153/ p14 & 15, "Japan Nuclear Explosions" by ssoosay http://www.flickr.com/photos/ssoosay/5529032597/ p16, "image-191637-panoV9free-vflj" by Oldmaison http://www.flickr.com/photos/httpoldmaisonblogspotc om/5528825487/ p16 & 17, "Japan needs our help (Sendai <> Rennes, France)" by leopoSs http://www.flickr.com/photos/leposs/5529917404/ p17, " fukushima inside exploded plant with steam rising from spent fuel rods storage ponds" by daveeza http://www.flickr. com/photos/vizpix/5566184568/ Images licensed under a Creative Commons Attribution 2.0 Generic Licence http://creativecommons.org/licences/by/2.0
State to Federal CostShifting Billing Medicare for services provided in public hospitals what's right and what's wrong?
FEATURES What is Cost-Shifting?
ost-shifting occurs ‘when service delivery is arranged so that responsibility for services can be transferred by one player in the health services sector to programs financed by other players, without the agreement of those other players’.1 Opportunities for cost-shifting exist as a result of complexity in the funding and delivery arrangements in the health system, most particularly, the division of responsibilities between the Commonwealth and State Governments. Cost-shifting often results from ‘perverse incentives’ in the system that make it more financially beneficial to offload costs onto other jurisdictions, rather than work in the interests of the overall health system. How Does Cost-Shifting Occur? Classically, when clinical services which would ordinarily be provided as part of a public hospital’s suite of services are instead rebadged as being ‘co-located’ external entities. This enables these ‘external’ services to be billed through Medicare thereby cost-shifting to the Federal Government. Historically, this has happened most frequently with radiology, pathology, specialist clinics and increasingly perioperative procedural services.
The internet is littered with stories of disgruntled overseas-trained doctors who were employed as public staff specialists in Australian hospitals and paperless Medicare billing was done on their behalf for months or years before they even found out.
The most obvious way is where State-Funded public hospitals don’t offer (or offer very limited) public outpatient services. Instead, they send the patient’s to the specialists’ own rooms which are usually located in close proximity. All consults are then paid for by Medicare (Federally-Funded) with or without the addition of an out-of-pocket fee to the patient. This usually works out better for most specialists as they would mostly receive a higher hourly rate than if they were paid a sessional rate at the corresponding public hospital. The benefit to the public hospital is obvious as they have now avoided the need to fund public outpatient services.
The Australian Health System—a Brief Overview The division of responsibilities for health care between the Commonwealth and States is complex: one commentator has described it as ‘one of the more mixed, disintegrated and confusing systems on earth’.2 There are many types and providers of services, and a range of funding and regulatory mechanisms. Broadly, the Commonwealth Government’s Major Contributions to the Health System Include: • the two national subsidy schemes, Medicare, which subsidises payments for services provided by doctors, and the Pharmaceutical Benefits Scheme (PBS), which subsidises prescription medicines • shared responsibility for funding for public hospital services through the Australian Health Care Agreements with the State and Territory Governments: under these agreements, the Commonwealth provides funding assistance for the operation of public hospitals • subsidisation of private health insurance through the 30 per cent rebate on the cost of private health insurance premiums • funding for a range of other health and health-related services, including public health programs, residential aged care, and programs targeted at specific populations, and • regulation of various aspects of the health system, including the safety and quality of pharmaceuticals and other therapeutic goods, and the private health insurance industry. The State and Territory Governments’ Major Contributions to the Health System Include: • management of and shared responsibility for funding public hospitals • funding for and management of a range of community health services • management of ambulance services.
F E AT U R E S Other examples of cost-shifting are MBS-funded clinics, radiology, pathology services, endoscopy, and perhaps the most sneaky, uninsured private-in-public patients. State Governments have been extremely keen for hospitals to costshift wherever possible, with perhaps the most blatant example of this encouragement has been the Victorian DHS publishing a “Resource Kit for MBS-billed services in Public Hospitals”4 which provides the blueprint for creation, implementation and a detailed description of the ‘legitimate’ billing arrangements to provide Federally-Funded services within a public hospital.
Encouraging patients to choose to opt for treatment as a private patient in a public hospital where the specialist is happy to take the 75% MBS rebate alone as payment is perhaps the sneakiest of all the tricks.
Section 19.2 of the Health Insurance Act explicitly prohibits charging Medicare for services that are fully financed by Statefunded public hospitals3. The grey area is when patients are classified as receiving treatment on an outpatient basis or as a private-in-public patient. In these cases, it may be possible for the specialist providing the medical service, to bill Medicare directly and receive funds even though the services were provided using equipment, staff-time and property fully financed by the State health departments. If the specialist accepts 75% of the Medicare Scheduled Fee as full payment, then it will even appear ‘invisible’ to the patient. An arrangement which was win-win for both Specialists (who can now earn 75% of the MBS rate for procedures/ services rather than a paltry public sessional rate) and Public Hospitals (they have their specialist’s wages funded by Medicare or alternatively, they bill on behalf of the specialist and pool the earnings in a ‘special purpose fund’). MBS-billed clinics and procedural services are growing in popularity Australia-wide, particularly in Victoria, NSW and Queensland. In fact, many public specialists routinely partake in these clinics with the billing for these services performed on their behalf with 100% of all MBS funds being retained by the employing hospital. The internet is littered with stories of disgruntled overseas-trained doctors who were employed as public staff specialists in Australian hospitals and paperless Medicare billing was done on their behalf for months or years before they even found out. Perhaps the most vulgar example of State to Federal Cost shifting has to be the rebadging of public patients as uninsured private-in-public patients. Encouraging patients to choose to opt for treatment as a private patient in a public hospital where the specialist is happy to take the 75% MBS rebate alone as payment is perhaps the sneakiest of all the tricks. The patient jumps the queue, the specialist is better remunerated and the hospital saves money. Win-Win-Win. The only loser is Medicare, therefore, the Federal Government and ultimately the tax payer. With all the examples of cost-shifting seen, the only real risk posed is to the specialist who is accessing Medicare funds whilst on paid public time. He is the only one who would be deemed to be in breach of Section 19.2 of the Health Insurance Act. Any penalties imposed would be on them and them alone. In cases where this action has been brought, the hospital, the State health departments and senior beaurocrats have escaped unscathed.
I advise any specialist who is asked to partake in an arrangement where their provider number is billed on their behalf for MBSfunded services provided within the confines of a public hospital to obtain independent specialist advice.
Dr James Nguyen
References B. Ross, J. Snasdell-Taylor, Y. Cass and S. Azmi, Health financing in Australia: the objectives and players, Occasional Papers: Health Financing Series, Volume 1, 1999, p. 38. 2 S. Leeder, ‘We have come to raise Medicare, not to bury it’, Australian Health Review, vol. 21, no. 2, 1998, p. 30. http://www.austlii.edu.au/au/legis/cth/consol_act/hia1973164/s19. html 3 Specialist Clinics in Public Hospitals www.health.vic.gov.au/ outpatients/specialist-clinics0608.pdf 1
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Dynamics at Work
Blunt tool or sharp instrument
here are broadly two categories of people who might have started to read this article:
1) Those who will have turned to it first, in the hope that it features abundant pictures of svelte, slightly built nymphs wearing nothing more than a come-hither pout and/or strategically arranged limbs and shadows or 2) those who were anticipating an interestingly complex socio-politico-gender based discussion around the ongoing struggle for woman to gain equal status with their mean minded male colleagues. It is not my intention to implicitly cover either of these possible topics, but to open up commentary and refer to the way sexual allure/power are used/misused in the medical workplace and some of the consequences. We have all seen it in action or may even have experienced its effects, good/bad, constructive/ destructive, magnificent/mischievous. So despite its prevalence, why is it not recognised and why is it not taken into account more seriously? Failure to do so, adds to the problems that we face in our daily work. (see the article ‘Altruism in Medicine... Is it Declining? The reasons why’ in the in the last issue)
Consider the following scenarios which are based upon events that have occurred in hospitals around Australia in the last 10 years. The details have of course, been somewhat modified. 1) A young woman makes many attempts, most of which involve sexual relationships with numerous ‘eminent’ (and married) leaders of their specialties, to get into various training programmes. She fails to allure them sufficiently, gives up and goes into an alternative career of pole dancing. 2) A senior surgeon who controls entry to training programmes is well known for serial relationships with attractive (much younger) would-be trainees. The trainees do not always get a post on the training programme but there is no shortage of applicants. 3) A senior surgeon attempts (in an unsurgeon like, ham fisted way) to establish a sexual relationship with an attractive trainee. The trainee encourages the attention until in post then sues for harassment. The trainee wins a large pay-out, but has to continue to train elsewhere. 4) A handsome young (fe)male GP is asked out by a handsome young (fe)male patient. She/he refuses because, being
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young and a little shy, he/she does not want to discuss their personal life with interested lay people at a Medical Board hearing if the relationship ‘goes bad’. 5) A pleasant looking and personable young hospital doctor keeps to himself at work, does not engage in ‘flirty repartee’ and is not considered to be a ‘spunk’. He is in fact subjected to passive aggressive behaviour by nursing staff around him who expect to be seen as professional yet alluring. Under the stress of the bad atmosphere, a significant diagnosis is delayed. The doctor suffers badly from this mistake, but happily the patient survives.
Questions 1) What is the common thread here? 2) Consider the various iterations possible in 4. Are they all the same? 3) In each case, who/what, if anybody/ thing, is ‘wrong’? 4) Why? 5) Who suffers? 6) Why? In my honest opinion, there are no clear answers to question 2 to 6, but the answer to question 1 is of course, sex. It is obvious why sex is so pervasive and persuasive. It is essential to continuation of life and thus has become an activity,
It is generally understood that the female of the species is on the hunt for the most powerful male capable of giving her offspring the best genetic and physical chance of survival. mediated and modulated by all manner of neuro-chemico-psychologic-socioeconomico factors. However, in many animals as well as Homo sapiens, sexual activity can be and is used for a number of ‘purposes’, other than propagation of the species. I will refer to these in turn and talk about the way these purposes can impact upon us in our professional lives and in brief how we can protect ourselves. Re-Creation This well recognised behaviour is seen in most living organisms and of course, also in Homo sapiens. It is generally understood that the female of the species is on the hunt for the most powerful male capable of giving her offspring the best genetic and physical chance of survival i.e The Alpha Male. Once inseminated, the female usually takes on the role of rearing and teaching her young.
worthy of his genes as possible, thus maximising the chance of his offspring dominating the ‘gene pool’. Once his part is played, he will often as not go and lay down and relax until another opportunity presents itself. Interestingly the males of many species are likely to kill the young sired by another male and mate with the female. This of course is in keeping with continuity of their genes. As young doctors (financial alpha people) clearly the field is largely open in the race to find, attract and keep a worthy mate. In-house competition, not just between the unmarried, can be the cause of much workplace tension and activity, professional and otherwise. Once the mate has been attracted, there is always the risk that the actual resources needed by said mate will exceed the ability of the provider. If this failing (and many others) are not met, be it the latest shiny SUV, designer hair clip or ‘trendy togs 4 tots’, then the provider may find themselves sidelined even as they continue providing. Recreation
The male of the species is generally intent on inseminating as many females
Pleasure, be it the taste, smell or feel of
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something, is a strong behavioural driver. It seems clear that Homo sapiens are not the only species to engage in sexual activity for the pleasure of it. All manner of sexual activity has been observed in many other animals species, unrelated to oestrus. Apparently the first squid couple caught “in flagrante delicto” were males. Clearly Homo sapiens are not the only species with sex on the brain much of the time. Normally, of course, this is constrained to appropriate times and venues, but sometimes it spills over into the workplace. In short, if somebody seeking to ‘hook up’ is considered so ‘hot’ they are ‘cool’ then they are also a ‘spunk’ and liable to succeed. If not ‘hot’ they are simply a ‘sleaze’ and liable to a harassment claim. Further, if they are thought ‘hot’ or even ‘tepid’ but do not respond to the infallible charms of some around and just want to work, then they are likely to fall foul
and seemingly increasing human activity of rape as a weapon.
immune to the initial sexual wiles and later legal tactics, of their ‘chosen mate’.
It is not uncommon for the career advancement of any half attractive professional to be dependent upon how many influential staff they can persuade with their alternate knowledge and abilities. There is no doubt in the collective professional mind (of many different professions, as well as ours) that career advancement can be accelerated and assured by sexual favour.
The best way to avoid trouble is, of course, to be aware of the possibility, but explicitly:
If demanded as expected, this is clearly harassment and all that implies. At least, (see the article on Bullying in the last issue) if such favours are offered, it is extremely unwise to accept. Blackmail and extortion can easily follow and that is only the beginning of the troubles. Most of us in medicine for any length of time will be well aware of one or more individuals who, if really scrutinised properly, would not stand up to the
1) As alpha types (at least financially) we are juicy targets and so must watch our backs 2) If you’re planning on getting married, then do get a prenuptial agreement... If you are in any doubt about this one, Give Sir Paul Mcartney a call and ask his opinion 3) Be open to the fact that not everybody who chats you up is enticed by your body or mind. It is wise for all to bear these short, simple comments in mind next time a passing fancy recurs and remember what the wise gorilla never does more than once, in his own nest.
It is not uncommon for the career advancement of any half attractive professional to be dependent upon how many influential staff they can persuade with their alternate knowledge and abilities. of revengeful gossip that can damage their work and thus their professional prospects. This is very common but very hard to do anything about, and especially hard to prove. In a nutshell, all that can be done is to be aware and play the game. Regulation This is where the biologically useful and the universally pleasurable can collide and become of legal interest or worse still, grotesquely corrupted. Sexual activity as a control mechanism, a manifestation of one individual’s power over another, can range from the subservience displays in Baboons, where a submissive non-oestrus female allows a dominant male to mate, to the barbaric
standards of propriety that they might attempt to exude. There are many sexualised skeletons bumping about in many personal and departmental closets. Granting or grabbing sexual favour in exchange for other benefits is not only practised by grunting gorillas.
Dr Tony Blinde Dr Blinde believes science can easily explain all the many wonders we enjoy on this our only planetary home.
Conclusion Sexual stimuli are around us all the time, in the different forms that attract different people. That is the way it has evolved to be. However, we are no longer uninhibited proto humans running about in the skins of others animals, grabbing the nearest female by the hair and running back to our cave with them. Neither are the alpha types amongst us
References p26, "Male and Female Lion Playing" by wwarby http://www. flickr.com/photos/wwarby/3302602311/ Images licensed under a Creative Commons Attribution 2.0 Generic Licence http://creativecommons.org/licences/by/2.0
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Ageing inDoctors Cognitive Decline and
When is it time to hang up the stethoscope?
he Australian medical population is ageing and similarly, so is the medical workforce. Approximately one in six registered medical practitioners are over 60 years of age1 and already experiencing some decline in both physical and mental capabilities. Allowing doctors to work until advanced age can be beneficial in that it preserves highly experienced practitioners, teaching resources and skills in the community. However, the downside is that there is the potential for increased medical errors due to burnout, physical limitations (e.g. tremor, loss of dexterity, reduced tactile sensation, poor fine motor skills and coordination, visual impairment, auditory impairment) and cognitive impairment (poor judgement, impaired ability to make rapid decisions, memory impairment). What is the evidence? Firstly, there is plentiful evidence correlating cognitive decline with increased age. The ageing process significantly targets cognitive speed and
short-term memory as well as ‘fluidity of thinking’ which can be thought of as the ability to solve new problems. However, there have not been any large scale studies correlating impaired ability to practice as a doctor with advanced age. The sparse evidence that may suggest a correlation between advanced age and cognitive decline includes: •
A study of 109 doctors evaluated in the Peer Assessment program in Ontario, Canada found 10% needed significant assistance with their day-to-day medical practice due to impairment. 18% of the doctors needing assistance were aged over 70, while this demographic made up less than 5% of the total population size. A significant overrepresentation
of this 70+ age cohort.2 •
Morrison and Wickersham studied US state licensing boards and disciplinary action in doctors across all specialties over several decades. Their findings were a weakly positive association between age and disciplinary action.3
The dilemma The issue of ageing doctors with cognitive impairment creates a dilemma in that how do we ensure the maximal safety of patient care without infringing on the civil liberties and professional autonomy of elderly doctors? Currently, monitoring by AHPRA (formerly by State medical boards) for signs of cognitive decline in
There is no regular dementia screening for ageing doctors in Australia.
F E AT U R E S senior doctors is only instigated after a complaint or patient injury.4 There is no regular dementia screening for ageing doctors in Australia. In other parts of the developed world, dementia screening has been accepted and integrated into the medical registration and renewal process. The screening itself creates a whole new set of problems revolving around assessing doctors and intervening when it is declared that their cognitive functioning is impaired. Why should we single out doctors for cognitive screening? Doctors are scrutinised for cognitive decline more than any other professional group simply because there are few professions where the welfare of others
that free recall, encoding and retrieval, visuospatial abilities, abstraction, and mental flexibility decline with increasing age.6 Executive functioning deficits often precede memory loss in dementia. Ideally, it would be best to try to detect dementia at the mild cognitive impairment (MCI) stage to initiate closer scrutiny and monitoring for current behaviour which suggest incompetence, because medical errors due to cognitive impairment can occur long before memory lapses become obvious to supervisors and co-workers. Approximately 12% of cases with MCI convert to dementia annually, reaching 80% at six-year follow-up.7 However, the necessity of self-acknowledged memory
doctor's family have noticed subtle cognitive decline, irritability, depression and driving problems. The normal systems in place which one would hope would alert the ageing doctor to his/her cognitive decline are self-awareness, recognition by medical colleagues, family members and other hospital staff (managers, nurses, medical administrators etc). Interestingly, with many senior doctors, it is extremely common for family, colleagues and institutions to inadvertently collude to protect the doctorâ&#x20AC;&#x2122;s feelings at the expense of patients . And so, the doctor unwittingly continues to practice as before without awareness of their newly acquired
Even doctors who retain some insight may minimise or deny functional impairment, fearing social stigma, loss of registration and income, legal liability, and diminished self-esteem.
is so intimately related to the high-level reasoning required of its competent practitioners.
problems for the diagnosis of MCI makes early detection of those less insightful individuals especially problematic.
limitations. Naturally, loss of insight and self-awareness are frequent sequelae of the dementia process.
What happens as the dementia process unfolds?
Before some of the more obvious signs of dementia emerge (i.e. memory problems) clues suggesting the onset of dementia in a doctor may include prescription errors, late payments, irrational business decisions, practice staff concerns, dissatisfied patients, patient injuries, and lawsuits. And very commonly, the
Even doctors who retain some insight may minimise or deny functional impairment, fearing social stigma, loss of registration and income, legal liability, and diminished self-esteem. Also, those who have enjoyed highly distinguished or academic careers, commonly have their sense of identity and self-esteem
Cognitive changes are a normal part of ageing, but the incidence of dementia increases exponentially with age.5 Although professional development and experience may have a positive effect on a doctor's abilities, it is undeniable
F E AT U R E S tied to their ability to practice as a doctor. Quoting a GP transitioning into retirement, “One minute you are a respected member of the community and the next you’re a nobody”. Families may recognise the problem but avoid discussing it for fear of upsetting the doctor, or causing loss of livelihood or community standing. Practice partners may fear financial loss or loss of goodwill value and so perpetuate the myth that the doctor is still ‘safe to practice’. Hospitals may ignore early warning signs and delay reporting of minor age-related dyscompetence because of the revenue the doctor generates. All these factors contribute to the fact, that relying on social and professional systems for recognition of dyscompetence has the potential for serious disaster. What happens overseas? A successful example of a systematic doctor screening programme is the ‘Physician's Achievement Review’ by the College of Physicians and Surgeons in Alberta, Canada.8 Every doctor is screened every five years using a 360-degree pre-screening survey which is completed by peers, patients and non-doctor colleagues where they rate the doctor’s knowledge and skills, communication skills, psychosocial management and office management. The lowest one-third ranked doctors are given an onsite assessment by senior medical staff from the medical board. The purpose behind this methodology is to be able to identify deficiencies including cognitive deficits in doctors before patient injury or errors occur. A novel screening procedure used to identify underperforming doctors is found in Ontario, Canada. The College of Physicians and Surgeons of Ontario, the province's medical licensing authority, sponsors the Physician Review Program (PREP) at McMaster University. The College of Physicians and Surgeons of Ontario quality assurance committees refer approximately 30 of the 26,000 Ontario doctors annually to PREP because of identified competency concerns. 9 The PREP assessment is an intensive oneday evaluation that includes structured oral and written examinations, simulated patient encounters with peer observation, and chart-stimulated recall. Results are
combined into a summary competency score falling into one of six categories:
diagnosis of cognitive impairment and retraining?
I (no deficiencies) II (minor deficiencies) III (moderate deficiencies) IV (major deficiencies) V (unsafe to practice) VI (unsafe to practice in any setting)
18 doctors who performed poorly on PREP initially were reassessed with PREP one to three years later, after remedial education. Of the 12 doctors who remained unsatisfactory at PREP retesting, nine showed moderate to severe dysfunction on the neuropsychological battery. This suggests a strong likelihood of cognitive impairment in underperforming doctors who fail remediation by self-directed CME. There is minimal data available on what happens to doctors after the onset of cognitive decline as screening is performed in so few jurisdictions. However, in Ontario where it has been studied to a small extent, the prognosis appears to be quite poor. 75% of doctors who failed to correct their PREP score after remediation never reached a level of satisfactory cognitive function to rejoin the medical workforce.
Doctors found to have dyscompetence (i.e., Categories III through VI) are offered the opportunity to remediate through self-directed CME and then to be reassessed. This has been extensively studied by Turnbull et al.9-11 to determine the relationship of the PREP competency score to cognitive impairment. 45 PREP participants were interrogated with a neuropsychological battery that evaluated five cognitive domains (verbal problem solving; visual-spatial problem solving; learning and memory; fluency
“One minute you are a respected member of the community and the next you’re a nobody” and attention; and mental tracking) and produced a summary score of cognitive impairment (none, minimal, mild, moderate, or severe). Of the 14 doctors who had satisfactory PREP results (Category I or Category II), 13 (93%) showed no, minimal, or mild cognitive impairment as judged by age-independent norms on the neuropsychological battery. Of the 31 doctors with unsatisfactory PREP results, 17 (55%) showed moderate or severe cognitive impairment on the neuropsychological battery. Therefore, the incidence of moderate or severe cognitive impairment was 7% in the doctors who could be remediated versus 55% in the group who could not be remediated. What is the long term prospect of practicing medicine again after
What should happen if concerns are reported about a doctor’s cognitive functioning? The ageing doctor with dementia must decide how long to continue practicing medicine. Unfortunately, assessment tools cannot yet predict to what extent cognitive impairment translates into dysfunction in professional duties. Doctors may display dyscompetence or underperformance and come to the attention of AHPRA by their patients, peers, or supervisors reporting them. The precipitating event may be a medical error, a malpractice suit or disciplinary action. Once dyscompetence is identified, the state medical board must decide whether the doctor's disability is remediable or permanent. If the doctor's cognitive disability is judged to be significant, then discussing social and financial issues with the
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healthcare team and hospital administration may help the doctor and his family to feel more secure. The doctor will need to undergo assessment and to stop practicing. Hospitals should try to involve the doctor's family to safeguard the doctor's dignity and to respect their long service. Referrals to the Alzheimer's Australia support group may assist families with decisions regarding retirement and long-term care.
Summary It should be remembered that whilst most older doctors in practice are not impaired, the prevalence of cognitive decline that impairs performance is greater amongst those over the age of 65. With such a significant increase in the likelihood of cognitive decline, there may be merit in screening to identify those ageing doctors who do not self-select out of the practice pool when deficits begin to surface. It is recognised that the main criterion that should be used regarding maintenance of registration and treating patients is current level of functioning. There should not be an age cut-off which determines when doctors should reduce their clinical exposure. However, the question that needs to be raised is whether advanced age should be considered a risk factor that merits automatic screening to assess for adequate functioning.
References 1. Robert G Adler and Conn Constantinou: Knowing — or not knowing — when to stop: cognitive decline in ageing doctors. MJA 2008; 189 (11/12): 622-624 2. Norton PG, Faulkner D: A longitudinal study of performance of physician's office practices: data from the Peer Assessment Program in Ontario, Canada. Jt Commiss J Qual Improv 1999; 25: 252-258 3. Morrison J, Wickersham MS: Physicians disciplined by a state medical board. JAMA 1998; 279:18891894 4. Leape LL, Fromson JA: Problem doctors: is there a system level solution? Ann Intern Med 2006; 144:107-115 5. Jorm AF, Jolley D: The incidence of dementia: a meta-analysis. Neurol 1998; 51:728-733 6. Peterson RC: Mild cognitive impairment: prevalence, prognosis, aetiology and treatment. Lancet Neurol 2005; 4:576-579 7. McAuley RG, Paul WM, Morrison GH, et al: Five year results of the peer assessment program of the College of Physicians and Surgeons of Ontario. Can Med Assoc J 1990; 143:1193-1199 8. College of Doctors and Surgeons of Alberta. Doctor Achievement Review (PAR) program. Available at: http://www.cpsa.ab.ca/collegeprograms/par_program.asp. Accessed February 6, 2007 9. Turnbull J, Carbotte R, Hanna E, et al: Cognitive difficulty in doctors. Acad Medicine 2000; 75:177-181 10. Turnbull J, Cunnington J, Unsal A, et al: Competence and cognitive difficulty in doctors: a follow-up study. Acad Medicine 2006;81:915-918 11. Hanna E, Premi J, Turnbull J: Results of remedial continuing medical education in dyscompetent doctors. Acad Med 2000; 75:174-176 p28 & 29, "Rusty mechanics" by daoro http://www.flickr.com/photos/daoro/4380267946/ p30, "090804-20756-LX3" by hopeless128 http://www.flickr.com/photos/hopeless128/3791665221/ p32, "Old hands" by daoro http://www.flickr.com/photos/daoro/4379511801/ Images licensed under a Creative Commons Attribution 2.0 Generic Licence http://creativecommons. org/licences/by/2.0
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Self Managed Super For Young Wealth Accumulators Why itâ&#x20AC;&#x2122;s Becoming So Popular
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Everyone seems to be jumping on the self managed super bandwagon. But is it appropriate for young investors? And if it is, what are the ground rules for building wealth successfully? We explain why self managed super funds are quickly becoming the number one choice of young wealth accumulators. Self Managed Super is on The Rise
elf managed super is the fastest growing sector of the superannuation market, with about 428,000 SMSFs holding $390.9 billion – almost one-third of the total super pool in Australia, according to the Australian Prudential Regulation Authority’s latest super bulletin. Once considered to be the exclusive domain of the over 50s, self managed super funds are slowly gaining popularity among young wealth accumulators. Why Choose an SMSF Over a Traditional Super Fund? Better returns. The average annual return over 10 years for funds with more than four members (in other words, any super fund other than an SMSF) is 3.3%. This dismal return, along with the allure of flexibility, control and the ability to link super assets to estate planning strategies has led to the rise of SMSFs over traditional super funds. But without a doubt, the Government’s back flip on borrowing within SMSFs in 2007 has been the catalyst in bringing SMSFs within the radar of young investors as a smart, long-term wealth-building vehicle. Latest research suggests an additional 40% of SMSF trustees plan to use gearing in the coming 12 months. The Investment Trends 2010 SMSF Borrowing Report found 29,000 SMSFs used a gearing strategy in 2009 compared with 13,500 in 2008. This is a 115% jump in less than two years. And the most favoured assets
are, not surprisingly, property (41%) and shares (30%). So, What Are The Ground Rules? Rule No.1 – Never lose money Rule No.2 – Never forget Rule No.1 Legendary investor Warren Buffet passed on this gem – like many others – and it is as relevant to borrowing within an SMSF as it is to any other form of investment. Why would you borrow in your SMSF if the interest cost of the loan exceeds the return on the investment? For example, if you believe share markets return on average 8% a year, it makes no sense to pay 10% to borrow money to invest in shares. And with the cost of borrowing still relatively high, if you do decide to borrow, it’s vital you choose the right investment that will deliver both income and capital growth. Case Study Building Wealth in Your SMSF Without Sacrificing Your Lifestyle One of the real benefits of gearing within an SMSF is the ability to repay debt more quickly, cheaply and tax effectively, without impacting your cash flow. Take the simple case of Mr and Mrs Smith. Mr Smith is a 32-year-old obstetrician operating in private practice and currently earning $150,000 per annum. Mrs Smith works part-time as a practice manager and earns $50,000 per annum. With a $200,000 super balance, Mr and Mrs Smith set up their own SMSF and borrow to invest in a quality $600,000 property (plus $40,000 stamp duty and legals), returning 4% rental income.
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Case Study Super balance
$13,500 (9% SG contributions)
$ 4,500 (9% SG contributions)
Total super balance
$24,000 (4% rental income)
Add Investment property Less Deposit
Stamp duty & legal costs
Non-recourse borrowing for investment
40,000 -$38,400 (8% interest cost on borrowing of $480,000)
Rental income 4%
Return on remaining $40,000 cash 4%
Super contributions 9%
Less Interest costs
Superannuation tax @ 15%
Net cash flow
They use $160,000 capital from their super balance and borrow $480,000. Outcome Income No effect on lifestyle income Capital Assuming the asset doubles in value every 10 years, by age 60 (28 years later) the asset should be worth $4,178,000 Tax Within super: 10% if sold in accumulation phase OR 0% in pension phase Outside super: assuming asset is held for more than 1 year 23.25%
Statistics show that most self managed funds are owned by married couples, who also act as trustees. As SMSF owners age, the risk posed by the onset of dementia and ultimately death of trustees is another just argument to allow younger family members to join their parent’s SMSF and seamlessly transition wealth over generations. Shifting Goal Posts Self managed super law is continually evolving. Without admitting it had ‘let the genie out of the bottle’, the Government acknowledged the potential dangers of excessive gearing in SMSFs when it announced last December it would review gearing practices in two years’ time to see if ‘leverage posed a risk to superannuation fund assets … in SMSFs’. So, stay tuned for developments in this space. If you are considering setting up a self managed super fund, it makes sense to consult a specialist adviser who can not only help you navigate complex super tax and estate planning laws, but also approach asset selection with financial rigour and independence.
Roger Wilson is a Wealth Management Partner and Eric Maillard is a Business Advisory and Accounting Partner at Lachlan Partners.
The case study does not take account of inflation or salary growth, nor does it consider the positive cash flow / tax impacts of depreciation deductions – all of which would most likely result in no tax being payable. Importantly, in the real world, investing in one asset alone would be considered a high risk strategy. Mr and Mrs Smith should allocate future super savings towards other asset classes to reduce risk and diversify their investment portfolio. SMSFs Are Good For Family Succession Planning
_____________________________________________________ Disclaimer: This document is of a general nature and does not take into account your personal objectives, situation or needs. Before making a decision about setting up a self managed super fund, you should consider your financial requirements. Speaking with a qualified financial adviser may help.
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The Government’s assault on art is damaging the entire art industry
For more than a decade, I have been collecting Australian fine art within my self managed superannuation fund (SMSF). Many people will adhere to the view that this is, at best, unwise. Others, no doubt, dismiss the acquisition of art - whether or not for investment - as nothing more than ‘bourgeoisie’ self-indulgence. But I believe that art can be a valuable asset and my investment in art has always been a serious one and totally within the “law”.
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n May 2009, the then Rudd Government established a panel of experts to review and provide recommendations regarding Australia’s superannuation system. Chaired by Mr Jeremy Cooper, a former Deputy Chairman of ASIC, the Panel’s key preliminary recommendations were released in June 2010 and specifically sought to prohibit investment in collectables and personaluse assets such as artworks within SMSFs. Had the Cooper Review’s recommendations been implemented, no SMSF in this country would have been allowed to invest in art and all art currently held within any SMSF would have to have been sold off within a tight time frame. An outcry from the art industry ensued, followed in July 2010 by a disastrous result for a prominent indigenous art auction conducted in Melbourne. As a result and in the lead-up to the August 2010 Federal election, all major political parties distanced themselves from the Cooper Review’s prohibition of art within SMSFs. More recently, however, the Labor Government, egged on by the Australian Taxation Office (ATO), has done a back-flip on this pre-election commitment and has re-stated its intention to apply “tighter restrictions” to SMSF investments in collectables “to ensure that they are made for retirement income purposes rather than current day benefit”. The detail of these intentions is yet to be made clear and “will be set out in regulations”. As it relates to art, this might yet mean that all works of art currently held in an SMSF will need to be sold within a five year period as advised by the Cooper Review. Even if art is permitted to remain in SMSFs, the Government clearly intends to enforce the so-called “Sole Purpose Test”. The practical impact of this test – an edict of the ATO - is that any art held within an SMSF must not be displayed where the owners, their friends or their family might be able to see it and thereby gain the benefit of seeing it. The Sole Purpose
Test makes it clear that even if art can be owned by an SMSF and even if it is a recognised “masterpiece”, astonishingly, it cannot be viewed in a home or in a workplace. It must be hidden away. Angry ATO punishes art investors Art can appreciate in value just like any other asset. In well-informed hands, it is a sound investment. This might be a systematically accumulated collection (like mine) or it might be an entirely isolated but well-considered acquisition of a masterpiece. Either can offer excellent capital gains. Yet we all know that every investment vehicle – stocks, shares, property and “collectables” - require care and consideration to avoid poor long term returns. Bad judgment and/or bad advice can affect any investment vehicle, not just art. In seeking to exclude art from SMSFs, the Government makes it plain that SMSF investments should be made for the purpose of creating income after retirement rather than to deliver current day benefit. This is all well and good – but art clearly can be acquired for both and it is wrong and unfair to insist that art that has been purchased with the entirely reasonable expectation of long term capital growth is, inherently, unsuitable for inclusion in a SMSF just because it is enjoyable to look at now. The ATO approach is both clumsy and punitive. It is crude, even lazy, to lump all art together and to exclude from SMSFs art that has real potential for future capital growth. The quality of an investment certainly plays no part in the ATO’s thinking when it comes to other investment vehicles. There has never been any suggestion that the ATO intends to apply any restriction whatsoever upon the acquisition of even the most palpably useless stocks and shares. But they are anxious, almost desperate, to exclude all art regardless of investment merit.
In seeking to exclude art from SMSFs, the Government makes it plain that SMSF investments should be made for the purpose of creating income after retirement rather than to deliver current day benefit.
Even insisting that art held in SMSFs not be hung at home or at work (as dictated by the Sole Benefit Test) is both inexplicable and odious. Hanging a valuable work of art, one with reasonable prospects of capital growth, only adds to its value; and it certainly makes it less likely to be damaged without that damage going undetected. The ATO is working very hard to prevent people from adding non-investment artworks to their SMSFs. The ATO resents – deeply – any action that misuses the tax concessions permissible for investments in superannuation funds. But this attitude has resulted in their blinkered implementation of the Sole Benefit Test, another strategy that disadvantages genuine art collectors like me. While it is undeniable that some SMSFs have acquired art entirely for the purpose of making decoration of their home or office less expensive, this cannot be said of me and others like me who have taken the whole art-as-an-investment issue seriously. As it turns out, regrettably, genuine art investors are insufficiently important to
warrant any particular consideration from their Government. The desire to eliminate every possible occasional art buyer from the SMSF scene is so important to the Government that they are ready to sacrifice my hard-earned asset as “collateral damage”. One of the uncomfortable undercurrents emanating from this angry alliance of the ATO and the Labor Government is the ease with which individual liberty and freedom of choice is being discarded. At the end of the day, Australians should retain the right to invest for their future – well or not - as they see fit. The truth is that most Australians will spend most of their investment money genuinely attempting to build for their future; I don’t think that anyone could hope for more than that. Some Australians will, however, spend some of their investment money on less rational options, including an occasional piece of art that might not appreciate in value over time and that is primarily (if not entirely) intended for current benefit and that is very much up to them. It might be a foolish investment
for a particular SMSF but, in the vast majority of cases, it is only a tiny component of the value of that SMSF. And it is that individual who will, in time, bear the fruits of their own investment choice. So, why is the ATO so enraged by this? Who really suffers when an SMSF invests unwisely in a painting? And is that suffering any less when an SMSF invests equally unwisely on the stock market? Whatever else is true, the ATO will not be any better off whichever bad investment the SMSF selects. The tax concession that the ATO is obliged to apply is equal regardless of the category of superannuation investment. And how can it be fair that, in the wake of the ATO’s anger at these non-investment art purchases, my entirely appropriate and carefully constructed acquisitions are considered dispensable? This is an unequivocal infringement upon my rights and upon those of other SMSF directors. If I make a bad investment decision, I will suffer, as I should. But who exactly is suffering when an ill-informed (or illadvised) SMSF acquires a piece of art? By
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will drive art prices (especially the prices of new art) down. Art investors, art galleries and the artists themselves will all suffer. The indigenous art industry will suffer at least as badly as any other, on present evidence probably moreso.
curtailing my SMSF, devaluing it forever, who actually benefits? For me, and for large parts of the art industry, this is not an academic matter but a very real and personal one. The value of my art collection – of my SMSF – is threatened by any decree that forces me to sell within a short time frame (in a fire sale environment as has been proposed by the Cooper Review) or that actively diminishes the pool of potential buyers of art. Without any doubt, if this sustained Government attack on art in SMSFs is maintained, including the shameful Sole Benefit Test, I will lose. But who will gain? And, if someone else does gain at my expense, is that fair? The tax incentives offered for superannuation investments have acted as a great stimulus to a number of industries, including the art industry. Dismantling those incentives for art will damage the value of collections like mine, will discourage potential art buyers, will reduce art sales and
The attack on art in SMSFs is misguided and Government has been misinformed by advisors, like Jeremy Cooper, with skewed agendas or ideological axes to grind. I don’t think any Australian citizen will be better off as a result of the restrictions that have been and that are about to be imposed upon art in SMSFs, but some citizens – me, for one – will be much worse off. For what it is worth, I say: Get rid of the Sole Benefit Test. It is an embarrassing, boorish, culturally ignorant piece of law that reflects very poorly upon its sponsors and casts Australia in a poor light. Where else in the world is it mandated by Government that beautiful and valuable fine art must be stored and hidden precisely so it cannot be seen? Allow art to be included in SMSFs. It is a potentially good investment which supports an important Australian industry. And exclusion of art from SMSFs will damage real people whose livelihoods or whose investments are built upon art.
through education. But, in the name of our open, civilised and egalitarian way of life, let’s not legislate against individual liberty and freedom of choice. The Government and the ATO need to learn to live with the tax concessions they themselves offer through superannuation investments. Tax concessions are just as much a part of Australian life as tax itself. And the Government should embrace the tremendous boost to industries associated with the trade in collectables that has been delivered by having them included in SMSFs; and relish the GST that this delivers. Dr Michael Levitt is a Colorectal Surgeon in Perth who has been collecting art for investment for over 10 years. He has been an invited speaker at art exhibitions and is a passionate advocate of art and the art industry.
References p40 & 41, "Exhibition View 2 - Impressions, The Printed Image El Camino Art Gallery" by Marshall Astor - Food Pornographer http://www.flickr.com/photos/lifeontheedge/1362949699/ p41, "JSOVT(MB): Musei Vaticani chair" by Yaisog Bonegnasher http://www.flickr.com/photos/ghazzog/3735849526/ Images licensed under a Creative Commons Attribution 2.0 Generic Licence http://creativecommons.org/licences/by/2.0
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FinanciaL Smart Investors Target Carbon Tax Opportunities How will the proposed carbon tax affect your investments?
he move is on to implement a carbon scheme in Australia. In late February 2011, the Gillard Government proposed a two-stage plan for a carbon price mechanism, to commence on 1st July 2012, subject to Parliamentary approval this year. It looks likely that the legislation will pass, but many of the most contentious areas remain under discussion - namely the level of the fixed price, phasing in of sectors, and assistance for both households and industry. However, unlike discussions in late 2009, which got bogged down. It is thought that the Green Party may yield more influence this time. Potentially this might result in less assistance to industry (electricity generators and trade exposed sectors). It also means that certain sectors might benefit from increased investment, if Australian households and companies are pushed to move to cleaner practices. Opportunities While carbon tax proposal incentivises
individuals and businesses to be more mindful of their energy use. It is also designed to increase the competitiveness of sustainable energy technologies. Certainly around the world, a global clean energy economy is already mobilising. Our re-insurers, superannuation funds and smart investors are beginning to realise this is the case. In 2010 clean energy investments hit record levels globally at $243 billion.1 The EU and China are leading the charge with renewable energy and energy efficiency investment expected to
grow between $180 -260 billion per annum by 2030 (Bloomberg).1 Australian investment is currently lagging behind the rest of the world. Regional boost from renewable energy The Climate Institute commissioned leading energy and industry specialists to model the opportunities and to talk to regional business and community leaders, to not only see what extra opportunities exist but to see what else is necessary to turn this opportunity into reality. This research is from Sinclair Knight Merz-MMA and Ernst & Young titled Clean Energy Jobs: Regional Australia.2 This recently released research shows the largely untapped energy resources that Australia has in geothermal, large-scale solar, bio-energy, hydro, wind and natural gas. The modelling shows that by 2030, close to 43% of Australiaâ&#x20AC;&#x2122;s electricity could be produced from clean energy, up from around 12% today. Regional analysis shows that greater proportions of renew-
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able electricity are attainable with extra policies and focus. Furthermore, the report commissioned by the Climate Institute, states that reducing greenhouse gas emissions by 25% could boost regional Australian employment by 34,000 jobs.2 Climate Institute Chief Executive, John Connor, said “It shows that clean energy projects could provide an economic foundation to support strong regional populations”. With this potential change in legislation,
tions. They also participate in US NAIC Insurer Climate Risk disclosure each year. Certain smaller companies like Blackmores also take carbon risk seriously. “The company’s headquarters, opened in 2009 has a carbon footprint one eighth of that of a comparable development, along with a range of additional environmental features. In addition they actively reduce product packaging and have an LPG vehicles fleet.
valuations in a low carbon environment. Deutsche Bank analysts recently reported that the hardest hit companies, in terms of net present value, will be Virgin Blue, Caltex and Alumina. BlueScope Steel, Qantas, Origin and OneSteel are also high on the list. A report by Morgan Stanley Smith Barney analysts also believes that the cement, aluminium, oil refining and steel industries would be impacted under the proposed carbon tax.3
It will be increasingly important for all companies to proactively address their
All prudent investors should review their portfolios in light of the changing carbon environment. Smart investors need their portfolios to be future ready. Karen McLeod CFP®, is an Authorised Representative (242000) of Ethical Investment Advisers (AFSL 276544).
smart investors should look at mitigating their investment risk by selecting companies and investments that are actively addressing their carbon use and climate change risks. Investors can benefit from the investment performance of companies that focus on sustainable business practices. Investment opportunities There are many listed companies that are actively reducing their carbon footprint and addressing carbon risk. A few examples of these companies are highlighted below: QBE Insurance is a signatory to ClimateWise in Europe, which provides a framework for insurance companies to build climate change into their business opera-
carbon footprint. As the Responsible Investment Association Australasia (RIAA) states, “… almost every industry will be affected by climate change. Carbon efficiency will become an important component of economic efficiency and productivity. Many ways of making money today won’t be profitable tomorrow. In the automotive and aluminium industries, for instance, up to 65% of their value could be at risk if they fail to find ways to reduce their emissions and energy usage. Just as responsible investors want to be ahead of the curve in investing in clean technology, they want to avoid investing in companies that are not taking sensible, strategic moves toward energy efficiency.” Investment risks There are certainly a number of companies that stand to suffer reduced
1 Mercer - Climate Change Report February 2011 2 http://www.climateinstitute.org.au/clean-energy-jobs 3 “Carbon Scheme Impacts on Heavy Industry: Valuation Scenarios (NPAT, EBITDA & NPV) for Miners & Materials”, 2 March 2011, Analysts Elaine Prior and Felipe Faria. p43, "Power Cables" by woodleywonderworks http://www.flickr. com/photos/wwworks/2651308367/ p44, "Going Green" by ManoharD http://www.flickr.com/photos/ manohard/2857676975/ Images licensed under a Creative Commons Attribution 2.0 Generic Licence http://creativecommons.org/licences/by/2.0 Disclaimer: Ethical Investment Advisers (AFSL 276544) has been certified by RIAA according to the strict disclosure practices required under the Responsible Investment Certification Program. See www.responsibleinvestment. org for details. CFP®, CERTIFIED FINANCIAL PLANNER TM and are certification marks owned outside the U.S. by Financial Planning Standards Board Ltd. Financial Planning Association of Australia Limited is the marks licensing authority for the CFP Marks in Australia, through agreement with FPSB. The contents of this article are intended as general advice only. No specific person’s circumstances, financial situation or objectives have been taken into consideration. You should not act on the information provided without seeking personal advice from an appropriately qualified financial planner. Information included from third parties has been reproduced with their permission. While the source has been verified as reliable, the actual content has not been checked for accuracy. Consequently Ethical Investment Advisers does not warrant the accuracy of the information nor accept liability for any errors in the data.
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Contact Karen McLeod on (07) 3333 2187 or visit www.ethicalinvestment.com.au Karen McLeod is an Authorised Representative of Ethical Investment Advisers Pty Ltd (AFSL 276544). Ethical Investment Advisers (AFSL 276544) has been certified by RIAA according to the strict disclosure practices required under the Responsible Investment Certification Program. See www.responsibleinvestment.org for details.
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Risk Issues Unique to Senior Physicians When Age Matters
n the words of Mark Twain ‘Age is an issue of mind over matter. If you don’t mind, it doesn’t matter’. Unfortunately, your age matters a great deal to the actuaries of insurance companies who determine the sorts of financial protection products that are available to you as well as what you will have to pay to obtain them. Similarly, the Australian Tax Office and government authorities governing superannuation place great importance of your age sometimes to your advantage. This article has been written to inform medical specialists about a number of pertinent risk insurance issues and opportunities unique to those aged 50 and over. Focus Shifts Away from Baby Boomers
Bernard Salt places the Australian baby boom between 1946 and 1961. By his account, the youngest Baby Boomers are turning 50 this year. While pre-retirees tend to be the largest consumers of financial planning advice, risk insurance solutions for this demographic tend to get more restrictive and more expensive. It would seem that insurers welcome those in their 30’s and 40’s with open arms and yet those above 50 are given the cold shoulder. This is seen in the forced expiry of policies, the inability to even apply for new cover above a certain age and the rapid increase of premiums, creating a risk protection maze that is extremely difficult to navigate. Policy Restrictions Insurers lawfully discriminate on the basis of age as seen in the vastly different premiums and options available to say, a 55 year old compared to a 65 year old. Industry data confirms that over 95% of income protection policies in force today are due to expire when the policy holder turns 65 or sooner. And yet, it is increasingly
B U S I N E S S & F inance common for medical specialists to work well beyond this age. This may be due to financial necessity, but even where wealth is sufficient to provide for a comfortable retirement, protecting one’s ability to earn an income remains a high priority for those choosing to work. While certain income protection policies can be continued to age 70, there is little awareness of this and they generally need to be put in place prior to age 60. To their dismay, many specialists over 60 discover this only once they have passed this age. As one medical specialist in his 60’s recently told me ‘I’ll be supporting my children for a long time to come and I can’t possibly afford to stop working just yet’. FindinG SOLutions Aside from forward thinking and taking a pro-active approach, there are still a number of avenues to pursue for those wanting cover beyond age 60 or 65. A handful of insurers will offer new Income Protection policies to those over 60. Age 63 is currently the maximum entry age for Income Protection across the wider Australian market. We have also had success in negotiating for insurers to make special exceptions on a case by case basis. Another approach is to look at Critical Illness cover - also referred to as Trauma - as an alternative to Income Protection. The maximum entry ages for this sort of cover are generally more favourable than Disability cover (including both TPD and Income Protection). Additionally, most
new policies on today’s market now expire at 70 compared to 65 which was the standard expiry age until quite recently. While Critical Illness cover won’t generally pay benefits for short term injuries (such as bone fractures) or disabling sicknesses such as pneumonia, lump sum benefits are payable on events such as cancer, heart attack and stroke. Not only is Critical Illness more accessible for those approaching (or over) 65, it is often a much more sensible way to maximise your benefits. To illustrate, take a medical specialist aged 62 who undergoes by-pass surgery which results in being off work for 2 months post-op. Having an income protection policy of say $20,000 pm and a 30 day waiting period would typically result in a single payment of $20,000 (fully taxable). By comparison, a trauma policy may provide a taxfree payment of $500,000. Importantly, this payment is made regardless of whether the specialist is able to return to work, chooses to take time off or even commences an early retirement. Policy Definitions Can Become More Restrictive With Age Total & Permanent Disability cover (TPD) typically provides a payout when the person insured can never work again. It is a little known fact that policies typically
have an ‘Auto-Conversion’ clause as standard. Consequently, at age 65 (and with some policies, at age 60), the cover becomes much more restrictive as it converts from an ‘occupation- specific’ definition of total and permanent disability to the much harder to claim ‘loss of independence’ definition. Under most policies, a physician who had become blind would be unlikely to claim on TPD after age 65. Thankfully, the Auto-Conversion clause on some policies enables ‘OwnOccupation’ cover to continue till age 70, rather than age 65 or 60. Another area in which cover can become ‘diluted’ pertains to the partial benefits payable under Critical Illness. Payouts for events such as loss of sight in one eye, loss of hearing in one ear as well as early stage prostate or breast cancer are only available for those under age 60. Again, selecting the right insurers means that such events can be covered to age 70. Consider Owning Cover via Super (But Beware) Australia’s superannuation legislation sees many potential advantages arise from owning personal insurances within a super environment. These include tax deductible premiums as well as the cash flow benefits of paying for covers with funds you are not reliant on for living expenses and debt management. At the
Insurers lawfully discriminate on the basis of age as seen in the vastly different premiums and options available to say, a 55 year old compared to a 65 year old.
Benchmark of Maximum Ages For New Cover and Policy Expiry Maximum age for new owners
Policy expiry age
Latest Age on Market
Latest Age on Market
Total and Permanet Disability (TPD)
Critical Illness (Trauma)
B U S I N E S S & F inance same time, super provides a minefield of potential negative outcomes. These include insurance payouts becoming trapped within super and payouts being taxable in the hands of their recipients (as distinct from being tax-free to recipients outside of super). The various pros and cons will need to wait for another article but in the meantime, it is worth double checking that you are using super appropriately. Reduce Your Covers When You No Longer Need Them Financial vulnerability is often greatest when debts are high, children are young and you are still a long way off from meeting your financial goals. Thankfully, there comes a time in the lives of most professionals where financial freedom becomes more of a reality than a dream. While there may be an emotional attachment to keeping one’s covers going, reducing covers may well be an appropriate action to take. With the compounding effect of accepting CPI increases insurers offer each year, you may also find that your current covers are well more than you ever needed. Before taking a knife to your covers, quality personalised advice should help ensure that you do not ‘cut your nose to spite your face’. For example, you may find Critical Illness cover to be a sensible substitute for a soon-to-expire Income Protection policy. Similarly, you may find that reducing your life cover levels to an amount less than the other bundled covers (eg Crticial Illness), results in you paying stamp duty and even higher premiums. Professional advice should also help prevent the tendency to take an ‘all-or-nothing’ approach which is likely to see you either un-insured or over-insured down the track. When Premiums Get Astronomically High Premium increases of 14% to 16% are not uncommon for the over 60 (based on the actuarial assessment of the increased likelihood of claim as we get older). Premiums that may have started as several hundred per month may have crept up on you over the years to be many
Financial vulnerability is often greatest when debts are high, children are young and you are still a long way off from meeting your financial goals.
thousands per month. Medical specialists with premiums of between $25,000 and $50,000 per annum are becoming increasingly common. Aside from reducing covers to levels that are more reflective of your needs, it is imperative that your covers represent excellent value for money. This is not a suggestion that you pursue cheap over quality but rather, that you take a well informed and pro-active approach regarding the best offerings on today’s market. The table below shows current annual premiums amongst the major life insurers for a 60 year old, non-smoking male seeking $1m of cover: The price variation across the market is quite astounding, especially considering that life cover (paid on death) is the most commodity-like product of all the covers. The more expensive half of the market
% more than most Annual Premium competitive
OnePath (ex ING) $7,520
is on average 20% more than the most competitive offering available. As overpriced some of the more expensive covers may appear, these may still be relative bargains compared to your current covers. As life expectancy has increased, insurers have been able to reduce their premiums and still remain highly profitable. You might naively think that your insurer will reward your loyalty by reducing your premiums accordingly. Sadly, most often this is not the case. Consequently, life cover premiums that are five or more years old are often 5% to 10% more expensive than the same insurer’s offering on new policies. It is therefore of great benefit to revisit the options available to you (even with your current providers). Aaron Zelman, is a partner of specialist risk advisory firm, Priority Life.
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 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.
B U S I N E S S & F inance
End of year
B U S I N E S S & F inance
Top 5 tax-saving tips for physicians
sing the following checklist, most physicians should be able to reduce their taxable income by a substantial amount. We highly recommend systematically working your way down this list with your accountant or financial advisor and seeing which of the following five categories can benefit you:
Summary 1. Defer Income 2. Prepay Tax-deductible Expenses a.
Medical indemnity fees
b. RACP fees, AMA fees c.
Prepay all travel expenses and registration fees for next year’s medical conferences
d. Prepay rent for rooms (if applicable) for the 12 months ahead e. Prepay staff bonuses, superannuation (if applicable) f.
Purchase any education-related expenses (e.g. medical books)
g. Purchase any work-related equipment including laptops, software, mobile phones, PDAs h. Prepay interest on business related loans (e.g. car loans, equipment finance, rooms fitout finance) i.
Prepay marketing expenses including website development, printing, advertising costs
Prepay the medical group fees (if you are an associate in a group, it may be possible to pay an estimated ‘service charge’ in advance for the whole financial year ahead)
3. Scrap obsolete equipment to bring forward the unused depreciation value —for physicians this would include anything from old ultrasound machines, ECG machines, stethoscopes to old examination couches. 4. Personal and Spousal Superannuation Contributions a.
Up to $25,000 concessional (under 50 years of age)
b. Up to $50,000 concessional (over 50 years of age) c.
Non-concessional contribution of up to $450,000 in any three-year period
d. Spousal superannuation contributions 5. Prepay interest on investment loans used to purchase investment property or shares.
B U S I N E S S & F inance Physicians are an extremely variable bunch when it comes to income and expenses. The expenses are highly dependent on your subspecialty, the number of staff you employ and the location of your rooms. In addition, the income generated by physicians is highly variable both between subspecialties and within any single subspecialty. To the right is a worked example of a physician in a metropolitan solo practice with a single full-time equivalent staff member (receptionist/ practice manager) as an employee.
Typical Value (annualised) $
Anaesthetic Group Fees/ Billing Agent Fees
Annual Rooms Rental
Conferences/ CME (books, travel, conference registration, (books, travel, conference 15,000 Conferences/ CMEhotels, 15,000 courses) registration, hotels, courses) petrol, insurance, Work-related travel Work-Related Travel (car,(car, petrol, maintenance, loans) loans) insurance, maintenance,
Income Protectionand Insurance superannuation training) Premiums
Mobile Phone Costs
Employee related costs (wages,
Income protection insurance premiums Rooms running costs (stationery, lighting,
Home Office Costs (stationery, heating lighting, heating
Professional subscriptions and memberships (RACP, AMA) Professional Subscriptions and (internet, phones, Telephony(ANZCA, and IT costs Memberships ASA, AMA) practice software, hardware, website hosting)
Physicians are an extremely variable bunch when it comes to income and expenses.
The categories are more or less standard 1.5% Medicare levy). for most physicians but the actual costs The dilemma that now arises is that after will be highly variable depending on thisanaesthetists point, the and incentive The many categories arephysicians more or less standard the rangetoin continue costs how other the roomsfor most for each of the categories are not that varied. Based on these typical figures, there working hard is limited because for every are shared with and the location of the reaches a point in the financial year at which you have earned enough money to paygoes dollar you earn, almost half (46.5%) rooms. Basedprofessional on these typical figures, for all these expenses. towards tax. there reaches a point in the financial year at which you have earned enough money One (short-term) solution is to simply to pay for all these professional expenses. not submit any more patient bills until Anything after this belongs to you (and the following financial year. However, this the ATO). usually means you have merely deferred your tax liability until the next financial Then later in the year, there reaches a year so is not really a well thought out new point where you have earned enough strategy. to cover all the expenses and $180,000 above this to reach the top end of the 37% tax bracket. All income earned from this point onwards (i.e. above $180,000) will be taxed at the highest rate of 45% (plus
In reality, the only way to circumvent this issue is to build your wealth (the asset value of the possessions you own)
B U S I N E S S & F inance in a low-tax environment. So how do you achieve this? Here is a quick and simple summary: If a typical good investment generating a 10% growth per annum is owned by an investor with a marginal tax rate of 46.5%, and all the return from the investment is taxable, then the after tax rate of return will be 5.35% of the original investment. (Calculated as 10% x (100-46.5) = 5.35%) If we assume inflation is approximately 3%, the real post-tax return (i.e. after inflation) will be 2.35%. That reward is not enough for most of us to consider taking any investments. Why would you want to take any form of risk when a ‘good’ return will only return a meagre 2.34% after tax and inflation? Maybe it’s better to simply take some time off work, work fewer hours, go on holiday or purchase a new car? So how do you avoid your investment returns being destroyed by tax and inflation? You cannot do much about inflation, although staying in growth assets and avoiding non-growth assets is one way to overcome inflation. (Growth assets are items such as shares and property which provide investment returns usually in excess of inflation. Non-growth assets are items such as fixed-securities or cash deposits whose returns are eroded by inflation). What you can do is reduce the tax applied to your investment returns by following these three simple rules: - Choose investments where the return is either tax-free or concessionally taxed - Choose tax efficient legal structures, or combinations of legal structures, i.e. legal structures that are taxed at a rate less than the top marginal individual tax rates, i.e., use companies, trusts and SMSFs
(self-managed super funds) to hold your investments. - Choose concessional (i.e. deductible) super contributions and non-concessional contributions (i.e. non-deductible) Here are the typical investment strategies we would offer physicians to accumulate wealth through tax-savvy investment plans: Superannuation fund
Make sure you buy a home, structure your debt so you can pay off your home as early as possible, and then reap the rewards of any rise in value of this asset being CGT free.
Building up wealth and assets in your SMSF is a great opportunity for nearly all physicians. This money is concessionally taxed when it enters the super fund, capital gains are taxed at a modest rate of 10% and income generated from it is taxed at 15%. Superannuation, especially an SMSF, because of the additional freedom to choose your asset classes is an excellent way to accumulate wealth in a low-tax environment. Principal place of residence The appreciation in value of your personal home is 100% Capital Gains Tax free. Pay off your mortgage and any rise in value over the years is yours to keep untouched by the tax-man. Make sure you buy a home, structure your debt so you can pay off your home as early as possible, and then reap the rewards of any rise in value of this asset being CGT free. Negatively geared investment properties Buying investment property can be a highly tax-effective means of reducing your taxable income and building up your asset base. Prepaying interest on the loans and also having an accelerated depreciation schedule for the investment properties allow you to maximise your taxdeductions in the immediate years. The growth in value of the properties remain untaxed until you choose to sell them (which will often be after retirement)
B U S I N E S S & F inance
Similar to buying negatively geared property, you can buy shares in your own name or an investment entity .
or in financial year when you have lower earnings (e.g. a sabbatical year) or even in a financial year when you may incur a business loss (e.g. a share market crash). Even then, when you do dispose of the properties, they will be entitled to a 50% exemption on any CGT (if they have been held by you for over 12 months) making this a brilliant way to reduce your taxable income in the short-term and accumulate wealth over the long-term. Geared share investments Similar to buying negatively geared property, you can buy shares in your own name or an investment entity (we frequently set up an investment trust
entity for many of my clients). The option is there to use margin lending to gear your share portfolio. The interest for these loans for the year ahead can be prepaid making this an excellent way of bringing forward tax deductions. In summary, as a physician, your income is likely to always be high and substantially above your costs of living. The problem with working harder to generate a higher income is that this now increases your tax burden and becomes a case of diminishing returns.
your private practice is, but it depends on how much you save, invest and shield from tax.
ď&#x192;¨James Clyne is the accounting partner and Adam Faulkner is the medical wealth strategist at MEDIQ Medical Financial Services.
Your success in building up wealth during your working lifetime depends not on how hard you work, not even on how lucrative
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.
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MEDIQ Financial Planning is a Corporate Authorised Representative of Synchron AFSL 243313
The Rise and Rise of Natural Medicine Dilution of the words ‘doctor’ and ‘medicine’
In recent years, there has been widespread proliferation of books and courses relating to so-called ‘natural’ or ‘alternative’ medicine. Practitioners of these arts are everywhere. There are naturopaths, osteopaths, traditional Chinese medicine practitioners, chiropractors, iridologists, reflexologists, and many other kinds of –ologist, -path and -practor as well.
ne type of natural medicine is homeopathy. Homeopathists believe that the activity of pharmacologically active substances is enhanced by dilution. A typical homeopathic remedy is diluted to one part in 10 to the power 60, which makes it extremely unlikely that any molecules of the original substance remain in the bottle. Who is allowed to call themselves ‘Doctor’? There have been changes to the law that have allowed some of these people to call themselves ‘Doctor’. Previously, the
Alternative practitioners have, of course, pounced on the opportunity to market themselves by putting the word ‘Doctor’ in front of their names. This cheapens the very word ‘Doctor’.
There is a ‘College of Natural Health’ across the road from Melbourne Central train station, which hands outs ‘degrees’ and operates a ‘clinic’. The clinic has professional sign writing, glossy fullcolour pamphlets and cubicles wherein professionally dressed people dispense medicines of various types and usually at considerable expense. There is also an Australian College of Natural Therapies in Brisbane and Sydney. Lay people might have trouble telling the difference between the Australian College of Natural Medicine and, say, the Australian College of Emergency Medicine. They may not understand that natural medicine is outside the circle of traditional medical specialties. The first college is not from the same tradition as the second – it’s something completely different. Its foundations are not scientific, and its practitioners are proud of this. Yet they have named their college similarly to the scientific ones in order to give the appearance that they belong in the same category. Private patients and insurers are willing to spend money on alternative health care
word ‘Doctor’ was restricted only to practitioners of conventional medicine and dentistry. Even within the medical profession, use of the word ‘Doctor’ is restricted. South of the Murray River, most surgeons call themselves ‘Mister’, or (for the handful of female surgeons) ‘Miss’ or ‘Ms’.
Alternative health care has gained considerable legitimacy in the eyes of the public. Most private health insurance schemes offer their customers access to alternative health care in addition to conventional (for want of a better antonym to the word ‘alternative’) health care. Doctors have to compete with alternative health for the finite amount of money that private patients and their insurers are willing to spend on health care.
Alternative practitioners have, of course, pounced on the opportunity to market themselves by putting the word ‘Doctor’ in front of their names. This cheapens the very word ‘Doctor’. An art such as osteopathy is to doctoring as Scientology is to science. Osteopathy is not medicine; it is a belief system.
So far, Medicare and the state governments do not insure citizens for visits to an alternative health care practitioner, but it may happen one day. With all this in mind, it seems that the boundary between conventional medicine and alternative medicine is blurring. Some conventional medical practitioners are
happy to refer to alternative health care as ‘complementary’, implying that it is compatible with conventional medicine. Conventional medicine practitioners should protect their territory! But alternative medicine is not compatible with conventional medicine. Conventional medicine is (or should be) based on empirical observation. It is possible to demonstrate conclusively, that antidepressants, beta-blockers, cholecystectomies and topical steroid creams work. The very basis of alternative medicine is that it rejects empirical observation. It rejects science. Just as the homeopaths would dilute medicine to the point where it is no longer effective, the reputation of conventional medicine is in danger of being diluted by its unwanted association with alternative medicine. The unique features that attach to being able to call oneself a ‘doctor’ will dissolve if doctors do not actively protect their territory.
Doctors have to compete with alternative health for the finite amount of money that private patients and their insurers are willing to spend on health care. Dr Richard Cavell This article is based on Dr Cavell's “What does it mean to be a doctor?” (2007) Panacea.
Whistleblowing in the australian heaLthcare system
Ethics, professionalism and healthcare management
here have been four recent, memorable examples of whistleblowing in the Australian healthcare system, involving three States and one Territory1,2. Perhaps the most famous episode is the Bundaberg Hospital disaster in which Chief Surgeon, Jayant Patel, was accused and convicted of manslaughter for planning and then undertaking the operations on several patients treated at the Bundaberg Base hospital. In this event, a senior intensive care nurse, Toni Hofmann, had already raised concerns about the quality of surgical care within the hospital. Despite involvement of the senior general and medical management of the hospital little was done to curtail the dangerous operations until a State MP was contacted, who raised the concerns within Queensland Health and publicised the shortcomings of the surgical service through a Brisbane Newspaper. While there has been significant publicity of Jayant Patelâ&#x20AC;&#x2122;s subsequent flight to the United States and his fight to avoid trial in Queensland little publicity has followed the heroic whistleblower, Toni Hofmann. Despite her excellent qualifications and work record Toni Hofmann has not worked as a nurse since the affair was first made public and she must be identified as one of tragic victims of Dr Patel. Interestingly she was undertaking a Masters degree in Medical Ethics at Monash University when the Bundaberg tragedy was unfolding. Other whistleblowers in the Australian healthcare system have fared equally badly. Gerald McLaren, a conscientious rehabilitation physician at the Canberra Hospital, noticed a number of severe complications occurring in the work of one of his neurosurgical colleagues. When he tried to raise these issues with the neurosurgeons as a group and the hospital management he was initially unsuccessful and was forced to ask the ACT ombudsman to inquire into the issue. Unfortunately even under this independent inquiry the medical professionals felt unable to fully comply with the ombudsman and even ignored their statutory duty to cooperate with a lawful investigation, which the ombudsman duly noted in his report. Despite the fact that a subsequent inquiry by the ACT Medical Board found
that the surgeon had failed in his ethical duties and removed his name from the medical register, Dr McLaren was forced to resign from the Canberra Hospital and has not been successful despite applications for permanent positions in other hospitals, representing a second, well-qualified victim of poor practice and whistleblowing in the Australian Healthcare system. The nurses that raised their concerns about clinical practice at the Camden and Campbelltown Hospitals have been completely vindicated by a subsequent inquiry that judged clinical standards to have been poor and the service provided to patients to have been below an acceptable standard. A redesign of health services in the area has followed and care for patients is now of a much higher standard. However, the failure to acknowledge the nurses as heroes or heroines of the event has led to allegations of harassment and criticism when they returned to work such that some of them do not now practice nursing and others have moved jobs and hospitals to avoid retaliation for their noble actions. Again, more victims of Australian healthcare, part of a group courageously trying to
improve services to patients and prevent patient harm at all costs. Even if that cost was their own career. The final case from Western Australia involved a senior manager at the King Edward Hospital in Perth, who raised concerns about clinical standards in the hospital collected through the normal reporting systems. The response of the healthcare profession was vigorous and defensive. Even when a commissioned report identified improvements to the service that could be achieved, and recommended changes, the profession still chose to blame the CEO, who had raised the concerns in the first place. He resigned but obtained work as a healthcare manager in another State. What then is the problem in Australia? It is the same problem as the NHS, where a similar episode led to a reduction in mortality from 30% to <3% (See Figure 1.) in about three years, but the whistle blower had to leave the UK and settle in Australia and it is as deeply rooted in Australian Public Hospitals as the UK3. I suspect the issue is in the secrecy of the healthcare professions, particularly the medical profession in not wanting to admit that complications or
Figure 1. Mortality for paediatric cardiac surgery in Bristol and other UK centres 1991-20013
Annual Litigation Costs
Average time to resolution of claims and lawsuits
No. of claims and lawsuits
$3 Million $1 Million
20.7 Months 9.5 Months
RISK MANAGEMENT deaths may be attributable to poor care instead of patient related factors. This fear is partly generated by the medical indemnity organisations that encourage doctors not to criticise colleagues to patients and certainly not to publicise high complication and mortality rates for fear of the financial consequences of medical indemnity payments to those patients harmed. In the UK this has led medical students to achieve a <5% level of reporting poor care when they have been asked about reporting in clinical scenarios at the completion of medical training4. The authors blamed the hidden curriculum for this transformation of reporting but it was noteworthy that only 13% of students would have reported poor care at the commencement of training. The power of the profession, to select and achieve the norms of behaviour that endorse secrecy, seems to be unassailable.
responsible for the expenditure of between US$17 billion and US$29 billion per annum in the Institute of Medicine Report ‘To Err is human. Building a Safer Health System’ has led to significant efforts to improve healthcare safety5. (There is no evidence that Australian healthcare is any safer than the US. This means that the cost of systemic error in Australian Healthcare is likely to be Au$1.5-2 billion each year we don’t make it safer) These efforts in the US have been coupled with the innovative “Open disclosure” policies developed by Steve Kramman and Ginnie Hamm in Kentucky and translated into significant savings in a Michigan public hospital6. The problem with publishing this data required that it was published with non-medical authors (Clinton H & Obama B) in the New England Journal of Medicine (Figure 2.). So the conclusion from this work is that reporting incidents requires improved ethical behaviour. However, this improved ethical behaviour improves healthcare
The recognition in the United States that systemic errors in healthcare were
Figure 2. University of Michigan Risk Management Program Legal costs, claim numbers and duration in the first 4 years after introduction of ‘Open Disclosure Program’ 6.
safety. Open disclosure, also indicative of improved ethical standards, reduces legal payments in the US. Then finally there is evidence that Australian trainees will report 97% of the incidents in their work if provided with appropriate tools7. Thus correct behaviours can be achieved, using technology that is attractive to generations X and Y, underpinned by improved ethical standards. I would like to think that the encouragement of improved ethical behaviour should be a key goal of medical education in order to cement this improved capacity in future healthcare systems. The key requirement is that this behaviour must come from the medical profession because it cannot and will not come from management and administration whose goals are financially and organisationally aligned. The bottom line is that it is down to doctors and the sooner we achieve it the less our healthcare system will cost us. Dr Stephen Bolsin is an Adjunct Clinical Professor of Perioperative Medicine at Monash University and Specialist Anaesthetist at Geelong Hospital Dr Mark Colson is a Specialist Anaesthetist at the Geelong Hospital.
Mortality at Bristol Mortality for 11 center combined Total number of procedures for 11 centers combined
9 9/ 20 0 20 0 00 /1 20 01 /2
91 / 60
No. of procedures
References 1. Faunce T, Bolsin S. Three Australian whistleblowing sagas: Lessons for internal and external regulation. MJA 2004;181:44-47. 2. Van Der Weyden MB. The Bundaberg hospital scandal: the need for reform in Queensland and beyond. Medical Journal of Australia 2005;183(6):284-285. 3. Spiegelhalter DJ. Mortality and volume of cases in paediatric cardiac surgery: retrospective study based on routinely collected data. BMJ 2002;324(7332):261-262. 4. Goldie J, Schwartz L, McConnachie A. Students' attitudes and potential behaviour with regard to whistle blowing as they pass through a modern medical curriculum. Medical Education 2003;37:368-375. 5. Kohn CT, Corrigan JM, Donaldson MS. To Err is Human. Building a Safer Health System. Washington: Institute of Medicine; 1999. 6. Clinton HR, Obama B. Making Patient Safety the Centrepiece of Medical Liability Reform. N Engl J Med 2006;354(21):2205-2208. 7. Freestone L, Bolsin S, Colson M, Patrick A, Creati B. Voluntary incident reporting by anaesthetic trainees in an Australian hospital. International Journal of Quality in Health Care 2006;18(6):452-7.
so you want to
the things you need to know and do
build your first practice?
ave you walked past the ideal location or just got out of bed with a voice in the back of your head urging you to go out and start up on your own? Well if you have, you are not alone. â&#x20AC;&#x153;So what do I do about it?â&#x20AC;? you ask. Essentially, no one project is the same. Therefore, it is paramount that you do a small amount of basic research before plunging into what should be, both an exciting and pleasurable experience. To ensure a smooth start and to avoid wasting valuable time, you should seek out specialist financiers to find out just how much you are able to comfortably
lease or borrow to purchase. Even if you are in a position to be paying directly from your own cash reserves, seeking professional advice on leasing the fit-out, depending on your position, may improve your future taxable outcomes. Once you have ascertained your project budget, you can go out and search for prospective locations that suit your budget and brief. It is no use contemplating a location that you cannot afford to purchase, or a space that is too big, as you will be paying rent on area you do not need. There is no such thing as the perfect size for a practice. However, depending on your area of speciality, two to four consulting room practices can easily be accommodated within 80 to 130 square metres of floor space.
Before settling on a location there are a number of other factors that need to be considered. The relevant local council should be your first point of contact and they will be able inform you of the various conditions which must be met in order to obtain the necessary planning approval. For instance, will they allow a medical practice to operate at this location? Does it require you to provide extra car parking before granting planning approval? A property professional such as an independent advocate can assist you through the buying or leasing process. You may already have a good idea of how you would like your practice to look and the space you need to work in. With all this in mind, designing your own practice may seem like an attractive option and for
CAREERS some of you with the time and expertise it may also be a good idea. However, there are many design factors you need to consider that you may be unaware of. Factors such as disability access, energy efficiency compliance, infection control and the level of documentation required by contractors are all areas which require investigation to ensure a good outcome and are usually best handled by someone with the inside know how. By ensuring that you have allocated a realistic budget and come up with a detailed brief of what you want and need will be an invaluable step if you’re planning on dedicating the job to a designer. Good design is the basis of a successful outcome. Your nominated designer will exercise due diligence through a thorough site assessment and space planning to demonstrate that the proposal will be able to satisfy any council conditions for planning approval,
The adage "a failure to plan is a plan to fail" holds particular relevance to practice design.
Combined design and construction firms have the advantage of being able to more accurately estimate the cost of a project at the concept design stage, before you embark on the next stage of the process documentation. These estimates are usually 90% correct and are provided at no extra cost. Ideally, as concept design is nearing completion you should finalise any specialist equipment requirements with your supplier. This is critical to the success of the documentation stage. Importantly this information allows the practice design, function and location of specialist equipment to be finalised and ergonomics and services to be correctly addressed in consultation with the equipment supplier or suppliers. It is important to understand that although design documentation will indicate the location of what is required, it will not demonstrate how to actually build, install or manufacture the operational service required for your specialist equipment. Depending on your contract, you may have the option of putting the construction out to tender. There may be immediate cost benefits to this approach, as each component of the construction is shopped around to the lowest bidder, however the time and energy commitment for managing a construction project should not be underestimated. Coordination of the various providers on site can be a significant logistical challenge and may not prove to be worth any apparent cost savings. If you choose to use a combined design and construct firm, once the documentation is completed, then you do not have to do much more than wait for the project quotation to be tendered to you. You may also find the design component is provided to you at cost if you proceed with construction. Another bonus of using one company throughout the design and construction process is that it is solely responsible for the entire project life cycle. This way you don’t find the contractor blaming the designer if something has been missed or left off the drawings, which in your opinion should have been noted in the first place.
and allow you to proceed with your purchase or lease. The adage "a failure to plan is a plan to fail" holds particular relevance to practice design. To create an effective design brief, you will need to think about your intentions for the practice now and into the future. Your designer will ask you a series of questions that have been formulated to help capture the essence of your vision for the practice. The process of compiling a design brief is often a catalyst for further discussion that may identify options and opportunities you may not have considered. Your designer will work with you to develop the concept design, at times with the aid of coloured three - dimensional renderings, until you are satisfied with the space planning and proposed design theme. It can be that easy when your brief is well communicated and you do not lose sight of the original project budget.
Be aware that taking the traditional approach of using one office for the design and contracting another to do the construction as it can introduce errors or cost. For instance, if it’s not on the drawings it may then be regarded as a variation, which you may have to end up paying for. With the design and construct option it is the responsibility of the firm to get it right the first time. Sure there may be variations in the future, but these more than likely will be items, introduced by you, during the course of construction, or factors beyond the control of everyone involved. So, do you still want to open your first practice? Of course you do! Nathan Reid is the marketing manager for Medifit, who offer comprehensive design and construction services to medical specialists throughout Australia. www.medifitonline.com
BEST PRACTICE As medical fitout specialists, best practice is something we take very seriously. Whether you require ground-up design and build project or a transformation of your existing surgery, Medifit follow industry best practices and have developed systems to ensure consistent excellent results, on time and on budget. Wherever you are in Australia, Medifit will bring your vision to life and create the operating environment that your patients and staff deserve. To join our large and ever growing portfolio of happy clients, call us today on (08) 9328 8349 or visit our website at www.medifitonline.com
SPECIALIST MEDICAL EXPERIENCE COMPLETE TURN KEY SOLUTIONS DESIGN EXCELLENCE EFFICIENT & OPEN COMMUNICATION EXPERT PROJECT MANAGEMENT A COMMITMENT TO BEST PRACTICES
(08) 9328 8349 www.medifitonline.com
The doctor's preferred tablet
iPad 2 I
t’s hard to imagine that little under a year ago, Apple unveiled the iPad to the world, with the tag-line “...a magical and revolutionary device”. The product launch was met with its usual collection of critique and praise from the technorati and fans alike. However within a year, the fastest selling consumer device ever to be sold has undergone a complete re-design, offering more and without a price increase – quite an achievement considering the closest competitors have yet to release their first device. The most common reaction to the launch of the original iPad was “I don’t really need one...” With the mass-migration to smartphones and laptops in the last five years, most users have all of their computing needs satisfied, without a need to introduce a third device. Despite this, the iPad went on to sell 15 million units worldwide (making it the fastest selling consumer device ever) and has stirred responses in industry from the likes of Google, Blackberry and Microsoft. So why has the interest in tablet computers grown, and how does the new iPad 2 fit in this new world?
Emotions of a device When you pick up the iPad 2, the first thing you notice is how thin it is. It’s easy to forget that you are holding the computing power of your desktop five years ago on a device smaller than a magazine. The iPad 2 is 33% thinner than its predecessor and puts it thinner than the iPhone 4. 33% may not seem much, but at the 3 to 5mm levels, this is quite noticeable. It’s also lighter, making the device more portable than before. Carrying a laptop seems obsolete in comparison. Yet the real charm of a tablet is the intimacy it brings. You don’t need to interface using a mouse or a keyboard, it’s all touch based. The ergonomics of touching a screen that you hold is natural and easy for anyone to pick up and use. And when sharing content on your screen with others, the iPad 2 makes it easy to show someone what you’re talking about or just pass the device over. Something that a laptop just can’t do. The very design of a laptop to lift up the screen, creates a ‘wall’ between you and the world – making it less intimate than before. This simple but important
design shift will have implications when interacting with patients. The nuts and bolts With the new A5 processor from Apple, the iPad 2 is noticeably snappier than the previous model. Web pages load quicker than before, the screen flows are smooth and lag-free, and the apps load almost twice as fast. With over 65,000 apps designed specifically for the iPad, and access to a further 350,000 iPhone apps (that can run on the iPad, but at a lower resolution) – there is enough opportunity to download and install any conceivable need. As of when this article was written, there are currently 1,404 medical apps, written for the iPad in the Australian app store. There are countless apps for medical handbooks, tools to help with eye exams or even human atlases, just to name a few. The iPad 2 now supports a front facing camera, which is useful only if you wish to video conference on the device. Apple includes its FaceTime app pre-installed, however services from others like Skype should follow soon. Battery life remains
ALPHA at the industry leading 10 hours (video) or 1 month standby, which again is an accomplishment given the size decrease and speed increase. Additionally, Apple now provides you the option to buy the new Smart Cover for the iPad 2. Coming in either polyurethane ($45) or leather ($79) in a variety of colours, the cover latches on through the use of clever magnets and can be bent in a variety ways to make the iPad stand, sit and go to sleep. A worthy investment especially, if your iPad goes travelling or is being used by others.
The iPad 2 comes in the either WiFi or WiFi+3G, sporting sizes of 16 GB, 32 GB or 64GB. New to this release is the option of the white model (in addition to the black model, with both having a metallic back) brings a total of 12 available models.
“We are finding with the iPad, that doctors are spending more time with patients, in fact doctors are engaging patients by showing them images, showing them data on the screen,” he added. “So it is empowering doctors to be more productive. But it has also brought doctors and patients together...what is so exciting about the iPad is that it will change the way doctors practice medicine,” Halamka concluded.
Although the iPad 2 has minimal updates compared to the previous model, it may be just enough to bring the would-be-buyers to the table. It still lacks some muchneeded features like the high-resolution retina display (currently on the iPhone 4), and a USB port, yet this may not be deal-breakers for some. For the current iPad owner, upgrading may not reap the benefit you’d expect, but for the first time buyer, the iPad 2 makes the whole tablet experience even more engaging.
A tablet for doctors
With a company like Apple trying to find new ways to improve the doctor-patient interaction, the future for the iPad as a tool in the health professions looks bright. Dev Sharma, technology enthusiast
Apple introduced the iPad 2 with a special event to highlight its use in the medical sector. John Halamka, a spokesman for an American medical centre said:
It’s clear from this event that Apple has the medical sector firmly within its sights.
...what is so exciting about the iPad is that it will change the way doctors practice medicine
the matching game
I have a funny relationship with rules - I’m far too mindful of them (I wish it were otherwise). I put it down to my upbringing…
Ihere used to be rules for everything – from when not to swim (within an hour of a meal), to what not to wear (red and green should not be seen without a colour in between; and of course busty girls should avoid horizontal stripes at all cost). But try telling that to your well-endowed Rabbitohs supporter. There were also rules for what not to eat (green apples – they give you the runs), and what not to drink (Adelaide tap water – same reason). Sorry Adelaide, I’m talking 50 years ago - I’ll bet it’s beaut now.
LIFESTYLE No-one likes rules: they always start with words like Don’t and Never, and who wants to see those words ever applied to wine? The great news is that the number one rule of food and wine matching is: There are no rules. Woo hoo… wine anarchy!! Well… not quite. But it is time to throw out those old notions about white wine for seafood, and red wine for meat. In any case, this is the era of Master Chef – there’s a celebrity chef in every kindergarten in the country. With such an extraordinary level of culinary sophistication, it’s time to get a bit more savvy with our food and wine matches. The thing that distinguishes wine from all those other beverages that make us witty and attractive is its extraordinary ability to partner with food. When it comes to food and wine pairing, you don’t need a great wine, you need the right wine. But here’s the catch: it has to be the right wine for you. So your first step is to work out what you like. Because however dreamy your celebrity chef thinks the aged Riesling will be with his chargrilled eggplant, if you don’t enjoy Riesling (or eggplant for that matter) it won’t be a memorable meal.
But even for a law-abiding kid like me, some rules were hard to swallow - especially the no swimming after a meal rule. It defied logic. On a blistering summer’s day, you’d pack up the Ford, drive to the coast (with the windows wound up in case a passing car kicked up a stone), search for a beach without a rip but with a picnic area; then unpack the car, throw the old Onkaparinga over the bindies, open the Tupperware and force down a limp salad with hard boiled eggs and warm beetroot. You’d think a kid would deserve a treat after that, but no – every time they’d pull the one hour rule. Torture.
So let’s say you’ve put a few toes in the water, and you have a fair idea of the kinds of wine you like. Now it’s time to start experimenting. There are two - equally valid - ways to approach food and wine matching: Contrasts and Complements. The Complementary (like-for-like) approach balances the weight, texture, and flavour of the food with a complementary wine. Think: Sauvignon Blanc with Asparagus risotto; or a spicy aromatic Gewürztraminer with Thai red curry; and, OK –a full-bodied Aussie Shiraz with beef fillet. The Contrast method takes the reverse
view, and pitches food and wine from opposite ends of the flavour spectrum, to create balance. Much like the delights of putting maple syrup on your pancakes with bacon, think: stinky blue cheese partnered with sweet, luscious Tokay; or a lively young Riesling with pan roasted scallops in a rich butter sauce. Whether you decide to opt for a complementary wine, or a contrast, what you are striving for is balance. Pay close attention to the key ingredients in your meal. Consider the weight and textures of your choices as much as the actual flavour, and then play on your hunch. And don’t let anyone tell you your choices are wrong. If you love them, you’ve made the perfect match! If you’re not up for experimentation, there are a number of classic food and wine matches, which will stand you in good stead. For example, Oysters with a squeeze of lemon and fresh cracked pepper are indecently good with Champagne or Sparkling wine. Pinot Noir is sensational with duck. Serve your great big full bodied Barossa Shiraz with Venison or Kangaroo, and bring out the vintage Port to serve with hard cheese and dried fruits. Finally, here are a few guidelines (NOT RULES!) to help you in your quest to find the perfect food and wine match: •
Close your eyes. The colour of your wine is immaterial
All wines go better with company
There is no wine match for All Bran, and there is a reason for this.
Gillian Hyde Ten years ago, she 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
Having a Whale (shark) of a Time Off the Coast of WA 68
Out of the depths of an indigo ocean a shark the size of a small submarine swims towards me. Its eye the size of a soccer ball regards me with distain. And here I am face to face with the world’s largest sharks — eat your heart out Great White — with nothing but a snorkel for protection.
uckily for me this giant shark is benign. Nevertheless it is disturbingly large dwarfing the hull of the small boat above me and disconcertingly close. I’d come to Western Australia, off the coast of Exmouth because this is the only place on the planet where you can see whale sharks in such numbers — where you see them much at all in fact. Every year from April to July following the mass spawning of coral, the world’s biggest species of fish congregate in the Ningaloo Marine Park. Visitors from Europe and the US pay
thousands of dollars to travel to this remote coast to see these extraordinary creatures, yet many Australians don’t even know they exist. The massive fish have a habit of swimming just below the surface so you don’t even have to be a scuba diver to see them. I swim alongside with no more equipment than a mask and my aforementioned snorkel. The sharks don’t necessarily appear on cue. You get in a boat and then wait while small spotter planes, circling like seagulls, search the water for whale sharks. Eight of us are
A huge shark, a monster shark, a colossal shark...the BIGGEST shark you will ever see. on the deck of a small boat, most of us are looking up at the plane, not down at the water but before we even have time to stow all our stuff, the radio began to crackle. The spotter plane had seen sharks and they are close, the boat’s engine coughed into life and we shot out through the foam.
“Two minutes,” yells out boatman. Action is at fever pitch as we reach for fins for our feet and struggle with snaking snorkels. “OK, go, go GO,” he bellows. Masks snapped over our eyes like visors and with snorkels firmly in our mouths we flap towards the back of the boat and jump out in quick succession.
“Get ready”, yells the captain at the wheel. “You’ve got five minutes”. Whale sharks don’t hang around and once they’re spotted you have to get there fast, get in the water and start swimming before they move on.
I feel like part of a naval special operations force. “Move it,” the captain yells like the officer in charge. We jump into the water — and into another world.
We struggle out of our shorts and into the black wetsuits, it’s not an easy task when you’re sweating in 35 degrees and the boat is listing. My suit suddenly seems to be two sizes too small and my mask is steaming up.
From the deck of a boat swimming with the sharks doesn’t look like anything special. Their spotted backs are so well camouflaged that, despite their bulk, when the light reflects off the water you can hardly see them. All you see
is a line of fluoro-coloured snorkels bobbing raggedly in the water accompanied by an excited hum as people try to talk through their snorkels. From the swimmers’ perspective things are very different. As soon as you hit the water you forget all about the boat. Because there it is, right there with you — a fish the size of a submarine. A huge shark, a monster shark, a colossal shark...the BIGGEST shark you will ever see. And it’s less than 3m from your face. You are drawn instantly, irresistibly into the domain of the shark. All around you is the indigo ocean and whale sharks appearing like giant shadows out of the deep.
Nobody knew much about the life of whale sharks until the l970s. Certainly nobody knew they were found off Australia’s shores in such numbers. And it is only in the last ten years that anyone has begun to study them seriously. The creatures are not thought to be migratory. The theory is that they live deep in the ocean only coming up at certain times of the year. Off Western Australia the continental shelf drops away only 20km offshore. This may be why these deep sea dwellers come up so close to land. In most other parts of the world the shelf extends much further out to sea. One possibility is that the sharks come into shallow water between April and the end of June to
Their tail fin is twice as tall as your average basketball player (about 4m) and as I swim alongside its head, I swear that a 10-year-old child could play hide-andseek in its giant swaying gills. feed on the coral spawn which is released at that time of year. Wherever it came from, the shark I am seeing is hard to miss. The thing is immense. Whale sharks grow to up to 18m long, that’s longer than a city bus. Their tail fin is twice as tall as your average basketball player (about 4m) and as I swim alongside its head, I swear that a 10-year-old child could play hide-and-seek in its giant swaying gills. My overwhelming feeling is of being in the presence of an ancient, primitive and very
alien creature. I have been lucky enough to get almost as close to humpback whales, which are similar in size. Both species are equally awesome but with the whales you get some sense of communication, some feeling that they have a curiosity about you. We swim close by the whale shark for around 15 minutes before it dived deeper but there isn’t a flicker of interest in us — not even as potential lunch. Whale sharks feed on plankton, krill and very small fish, although they do have 40 rows of hand grenade- sized teeth; which seems to me an excessively large number for a shark that only need to sieve plankton. However,
Whale sharks feed on plankton, krill and very small fish, although they do have 40 rows of hand grenade- sized teeth the last time they chewed on anything substantial is thought to have been several centuries ago.
I don’t see any teeth, just a yawning grey cavern. I pity the plankton.
I have time to check out the theory on our next encounter. Waddling to the back of the boat like hysterical ducks — “go, go, go” — we get entangled in each others’ fins and I belly flop into the water; one fin still aboard, throat full of ocean.
Hilary Doling is editor in Chief of The Luxury Travel Bible, the world's ultimate destination guide.www.luxurytravelbible. com. She has also been in the water with Great Whites -but that is another story.
Right below me and rising to the surface fast is a mouth the size of an open garbage truck and there I am dressed in rubbish-bag black. I splash sideways just in time - but not before the fate of Jonah and a similarly large creature flashes through my mind.
Details Day tours to snorkel with Whale sharks depart daily during the season from both Exmouth and Coral Bay. For bookings contact the Exmouth Visitor Centre on 1800 287 328. www.exmouthwa.com.au
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