Surgical_Life_March_April by Medical Life Publishing

SURGICALLife MARCH/APRIL 2011

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Conversation Killer Do doctors make bad conversationalists?

Altruism in Medicine

Is it declining? Part Two: The Reason Why

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Highlights

08 12 18 34

Are Doctors Dull at the Dinner Table? Conversational habits of medicos

Altruism in Medicine ...Is it Declining? Part 2: The reasons why

Research Fraud in Surgical Journals

Why you can't always believe what you read

Operation Outsource Putting a value on your time and reducing your administrative work

Departments 08 Features 30 Business & Finance 52 Risk Management 56 Medical Legends 58 Alpha: Technology & Reviews 64 Lifestyle 66 Travel

contents 12

FEATURES

Are Doctors Dull at the Dinner Table?

Altruism in Medicine...Is it Declining?

Research Fraud in Surgical Journals Why you can't always believe what you read

Taking a Sabbatical from Medical Practice

Conversational habits of medicos

Part 2: The reasons why

Not an impossible dream

BUSINESS & FINANCE

Supercharge Your Estate

How planning can help to ensure equitable, efficient and tax-effective distribution of benefits

Operation Outsource

Putting a value on your time and reducing your administrative work

Investing in Health

Which new technologies or health sectors should you invest in?

30 34 38

Preventing Pain at the Time of Claim

Financial Strategies for Surgeons

Navigating your way through a life insurance claim

The principles to maximise your medical wealth

MARCH/APRIL 2011

RISK MANAGEMENT

Downloading Indecent Images Queensland health care professionals deregistered and forced to use a chaperone

Boy Scarred for Life after GP Performs an Elective Circumcision Plastibell obscures urethral meatus

52 54

MEDICAL LEGENDS

Hugh Hampton Young

Urologist, leader and inventor

ALPHA

The Top 5 Digital SLRs

LIFESTYLE

Floods Stink

A limited vintage for 2011

TRAVEL

Life on the Edge

The Zambezi River & the mighty Victoria Falls

editorâ&#x20AC;&#x2122;s note We have received numerous e-mails and letters, thanking us for exposing the topic of bullying in medicine. I have been inundated with calls from victims who have since shared their experiences with me and who are now hoping more will be done to help vulnerable students, registrars and doctors in all positions. What has been most enlightening is the prompt this has given some of you to contribute on further topics linked to this issue. Many of you have also highlighted various concepts/challenges that we were unable to cover.

elcome the March/April Edition of Surgical Life.

The response from the January/ February edition really got our mailbox overflowing, and your feedback forms about articles even from previous editions are still coming through in the hundreds. Your letters and e-mails have been encouraging and a delight to read. I am blown away with your support for the publication as well as your openness in sharing your vision for our future. I would, however, like to apologise for the slight delay you had in receiving the January/February edition, caused by the terrible chaos as a result of the Queensland floods. Here at Medical Life we would like to extend our support to all of you with practices and homes that were affected. The January/February edition was about starting the New Year and unveiling some issues that are often brushed under the carpet, yet affect many of you directly or indirectly. And it seems that they these topics have struck a chord. The article on bullying was one that generated a huge reaction.

If you would like to have your say and add your comments about any of our articles and engage in rich discussions with fellow readers, I would suggest you visit our website at www.surgicallife.com.au which is updated regularly with all the articles featured in all our published editions. As you will have noticed, we have been advertising our Part3Course Event, which is the perfect conference for those of you eager to learn more on running your practice efficiently. Even if you have been running your medical business for some time and just feel you would like to polish up your existing skills, I would encourage you to attend to hear about the business and financial secrets of running a successful practice. The first conference is to be held on 16 April 2011 at the RACV Club in Melbourne. For further information, please register online at www.part3course.com. Regards,

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MARCH/APRIL 2011

Selina Vasdev

Editor selina@medical-life.com.au

Ravi Agarwal

Business Editor Production ravi@medical-life.com.au Contributing Sources

Dr. Tanveer Ahmed Dr. Tony Blinde Dr. Richard Cavell Dr. Lisa ferrier-Brown Prof. Paddy Dewan Dr. James Nguyen The Surgical Life magazine is published bi-monthly by Medical Life Publishing Pty Ltd. Surgical Life & Medical Life Publishing are proud to be independent of any academic institution or professional association. Suggestions, content ideas or complete articles written by readers are welcome and will be reviewed by the Editorial Committee. Please direct all inquiries and submissions to: Medical Life Publishing PO Box 2471, Mount Waverley VIC 3149

Selina Vasdev Editor

The information contained in this magazine, while believed to be correct, is not guaranteed. Medical Life magazine and its directors, employees and consultants do not accept any liability for any error, omission or misrepresentation in relation to the Information. Nor does it accept any loss, damage, cost or expense incurred by any person whatsoever arising out of or referable to the Information displayed within the magazine. The Editor has the right to omit or edit contributions for style, space or legal concerns. Any view expressed in Medical Life magazines are not necessarily the view of the Medical Life Publishing. No part of this magazine can be reproduced or copied without the express prior consent of the publisher.

Phone: +61 (03) 9001 6373 Fax: +61 (03) 8677 9554 Email: mail@medical-life.com.au

CAB Member

n order to share some of the comments that I receive, I have decided to introduce a new section—Letters to the Editor. This idea has also been supported by many of you who felt there was not enough encouragement for you to submit your thoughts to me publicly. So I take this opportunity to ask you all to take a few moments to send in your comments about Surgical Life that you would be happy for me to publish in our next edition. I would like to hear more about your thoughts on our content and I am also open to your criticism about how we handled subjects and where improvements can be made. Please send your comments to editor@medical-life.com.au marked letters to the editor. JULY/AUGUST 2010

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Altruism in Medicine... Is it declining?

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I also commend you on your article, ‘Crossing the Boundary’. I was impressed with how you handled the subject and the level at which you discussed the behaviours associated with such an act. This is a difficult subject to approach and you have done a fantastic job— probably the best that I have read so far.

Out-of-pocket Costs and the Surgeon

BULLYING IN MEDICINE

fees to us because we speak the same language as you. How you can avoid them We think we know just about every tax deduction and financial planning secret for doctors and their medical practices because that’s what we have chosen to specialise in.

Narcissism Amongst Doctors

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LETTERS TO THE EDITOR

11/1/2010 12:14:15 PM

I would like to thank the magazine for introducing some practical advice on how to manage my practice.

Hi Selina I enjoyed Karen Tonks’ article on bullying, having experienced this in my training. When I read the final fantasised reply by the bullied junior, I initially wished I’d known this information when I was bullied as a junior doctor. However, my next response was to realise that this reply would only happen in my dreams. Because, this sort of empowered reply would have been a declaration of war, only to be risked by someone prepared to lose their career. Bullying occurs within cultures which permit it. Onlookers have seen it before and possibly experienced it themselves, so they have already made a decision not to intervene on behalf of the victim. In order to win the battle, the junior doctor would have to obtain witnesses, most of whom would value their own careers, mortgages and providing for their families over truth, justice and altruism. The junior would also have to find allies in the senior ranks who often don’t care what the HR Department thinks. Then there would be the hospital administrators who are often in conflict with senior clinicians anyway, so the fate of one junior doctor may be swamped by other political battles. And asking other victims to speak up may be an isolating experience as frightened juniors didn’t want to know, or have their own plans for surviving and getting out. Certainly, communication workshops, education and powerful allies will help, but cultural change will not occur easily. In my opinion, the most relevant factor has been that of medical schools enrolling graduates, adults who have come to medicine with an identity of their own and are not as easily intimidated as school leavers. Anyway, thanks for raising this issue. - Dr (withheld by request)

I am new to private practice and struggled at first to get to grips with it all. I found it particularly difficult to get suitable advice. The articles have given me a good grounding for business and have enabled me to spend time ‘on the business’ rather than ‘in the business’. The article about ‘Growing your medical practice from solo to symphony’ has been kept as a reference document and has been passed around my staff. I would like to see future articles talking more about managing people and leadership. I look forward to the next edition. - Dr J.P.M., NSW Dear Editor, A note of appreciation for Dr Nguyen on his recent article, ‘To Gap or Not to Gap’ (January/February Edition). I am in complete agreement about the health funds incorrectly branding their policies and presenting their features to misinform patients into thinking they are less likely to receive an out-of-pocket expense. This leaves us in a tricky situation, where we have to engage in awkward conversations with patients and manage their wrongly formed expectations. An interesting read with a legitimate analogy of why some doctors do charge gaps. That is not to say it doesn’t aggravate those doctors who don’t. Thanks. - Dr P.B.T., VIC

Please send your comments to editor@medical-life.com.au marked letters to the editor. SURGICALLife

DULL ARE DOCTORS AT THE DINNER TABLE?

conversational habits of medicos

et’s take a moment to reflect upon the sacrifices of our partners, especially those that are not doctors. Not because of the many nights they have spent alone while we roamed sterile hallways manning overtime shifts. Nor is it because of the sudden intrusions of phones ringing in the middle of the night, piercing their REM sleep. Neither is it the countless functions, school plays or family dinners that our partners have been forced to attend alone, informing the other guests that we are too busy working. While such proclamations may be greeted with un-

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derstanding nods and tones reflecting their respect towards the serious work being undertaken, our partners remain Friday night widows and widowers. For all the things our partners have to deal with, perhaps the greatest sacrifice, which is largely unheralded, is the many hours they spend listening to us bang on about our work, detailing specific patients and their treatments and discussing our colleagues. I have attended countless dinner parties that have rapidly descended into mini medical conferences and have watched my partner’s at-

tention slowly drift away, with her backdrop being something like: ‘I’ve got a guy with myeloma that we’re giving the latest chemo to and he hasn’t responded at all.’ ‘I can’t believe this cirrhosis patient of mine who crapped all over the floor this week.’ ‘Hey, who’s that psychosis patient of yours that wanted to kill the medical superintendent?’ While I love intense banter about the latest infectious disease protocol at the hospital as much as all of you, I suspect many of our partners aren’t quite as thrilled. Few professional groups are as prone

F E AT U R E S to talking shop as medicos. There is no doubt all professional groups are likely to talk about their work when they gather, whether it is planned or otherwise. But in my experience, no other group does so with the intensity and frequency that doctors do. The most common complaints I hear from partners of doctors, including my own, is that doctors seem to forget that there is a world of work beyond their own. Furthermore, there can be an element of medical exceptionalism where we view other people’s jobs as fundamentally less stressful and less demanding when discussing it at social events. Another is our propensity for gallows humour. Talking about death, very ill patients and their ailments in a humorous light can appear insensitive. Most of us would agree that it is probably a healthy defence mechanism in the face of tragedy, loss and hopelessness, but it can appear shocking to the uninitiated. So why are doctors at the top of pyramid when it comes to talking shop?

Doctors often use small gatherings, with or without their partners, as support groups. I found this to be the case particularly as a junior doctor where the stresses were great and often undertaken in isolation. I remember as an intern resorting to drinking a glass of scotch a day when I arrived home from work. I had barely touched the stuff beforehand. So whenever the opportunity to unload with similarly placed colleagues arrived, especially if encouraged by alcohol, the impulse was to talk shop as a kind of therapy. I remember that this was also the time my partner felt my colleagues were least sympathetic to the stresses experienced in other occupations. Our educations are increasingly narrow, especially at a postgraduate level. This is perhaps the most worrying reason that doctors’ conversation can be limited.

from other fields of knowledge, the result is a narrowing of intellectual and occupational experience, limiting the broad experience that can be one of the hallmarks of engaging conversationalists. It is not cause for clamour and its urgent need for reform is unlikely to receive more funding in the latest health budget, but the conversational habits of doctors may be a problem for everybody else who loves, lives with or hangs around doctors. Next time you feel an urge to inform the table of the latest developments in your haemodialysis ward or why angiograms aren’t what they used to be, spare a thought for your company. Change the subject.

Our daily grind is often material ripe for prime time dramas, as well as lending itself to good old plain gossip

I think there are several reasons for this phenomenon. One is the obvious fact that there is a great deal of human drama in our everyday work. After all, it usually comes down to life and death. Even when it isn’t, it still involves people at their most vulnerable periods, times when they are emotionally stripped bare in the face of serious illness. Our daily grind is often material ripe for prime time dramas, as well as lending itself to good old plain gossip. As someone who works in mental health, I sometimes observe my colleagues and wonder if the attraction of the job was to have permission to madly engage in gossip about the private lives of strangers, anything from their sex lives to their drug habits, and get to call it work? This human drama makes good material for dinner party conversations and often pricks the ears of those not from a medical background. The same can’t be said when the ins and outs of a stunning merger are laid bare or when the details of a transformative administrative meeting are explained to tipsy, hungry guests.

Modern medical education is intensely detailed but increasingly specific to subgroups of specialisations. This, in part, reflects the broader economy where super specialisation is the trend in big urban centres. Why shouldn’t it also happen in medicine? As a result, something with which we can all probably relate to, many of my friends are now specialists in arenas like foot injuries alone or epileptologists or the intensive care of respiratory diseases. When such a trend is combined with long hours and isolation

Dr Tanveer Ahmed Consultant Psychiatrist, Sydney Images Page 8, "The blah blah man" by everywhereisimagined http:// www.flickr.com/photos/everywhereisimagined/4806038198/. Page 9, "hi i am not interested in what you are saying ok" by nozomiiqel http://www.flickr.com/photos/ nozomiiqel/4121753039/. Images licenced under a Creative Commons Attribution 2.0 Generic Licence http://creativecommons.org/licences/by/2.0

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have your say. . .

SURGICALLife READERSHIP SURVEY 2011 We're keen to know your thoughts on Surgical Life magazine â&#x20AC;&#x201C; What you think, what you like and what you want to see more of. At Surgical Life magazine, we're committed to providing the most relevant features, views and analysis on life as a medical professional, and your insights will help us deliver exactly what you want from Surgical Life magazine. The online readership survey should take approximately 10 minutes to complete.

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Go to www.surgical-life.com.au/survey to have your say and enter the draw.

F E AT U R E S

‘Altruism: unselfish concern for the welfare of others.’ ‘Selfish: chiefly concerned with one’s own interest, advantage, to the exclusion of the interests of others.’1

The Decline of Altruism in Medicine.

s noted previously, this is a problem within our profession, as some of us become increasingly disenchanted with our professional and personal lives. To recap, this can be explained (perhaps) by a number of things, particularly by the sheer pressure of population density. The Dunbar number (200), representing the maximum number of people we can meaningfully know, is a reflection of this and probably reflects our cortical wiring. Medical professionals are, of course, equally vulnerable to the consequences of this situation: seeking solitude amongst the crowd, due to the sheer pressure of the crowd.

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Altruism

ininMedicine... Medicine...IsIsititdeclining? declining? PART PART2:2:THE THEREASONS REASONSWHY WHY

F E AT U R E S

One of the changes that crept up on us whilst we were busy looking after our patients was to the way hospitals are managed. But are there other more pervasive and well entrenched causes of the decline that we should be aware of? I would like to suggest that there are a number of easily identifiable causes that fall under two broad headings. The reader who has reached this far will undoubtedly be able to think of others, but these are probably the most significant. The two broad categories are adulation of administration and the denigration of doctors. Both are a result of the medical profession taking their collective eyes off the ball and dropping it on their feet.

Adulation of Administration There was a time when hospitals were run by a small number of informed and dedicated people who were drawn from the senior medical and nursing staff, and other experienced hospital employees. In this situation, there was a clear chain of command and responsibility was in the hands of the decision makers. One of the changes that crept up on us whilst we were busy looking after our patients was to the way hospitals are managed. Quite noticeably, nowadays,

medical facilities are run primarily as businesses, by armies of people with layers of managers and assistants, most of whom have no hands-on experience with patient care. Or if they did have hands-on experience in the past, they got out of these roles as quickly as possible. There is no clear chain of command and, worryingly, responsibility lies with anybody BUT the decision makers. ‘Key Performance Indicators’ are no longer based on patient satisfaction but on ‘bums in beds’. This is problematic thinking. The deeply entrenched idea that a health care facility can be run like a pea processing plant is clearly indicative of the problems that are inherent in applying woolly theories of ‘economic rationalism’ to health care. Why is this sadly so? It takes a little thought to grasp the obvious, but people are not quite the same as peas—they are not standardised. They vary in their needs and their responses. To pretend otherwise and then express surprise is to miss the point entirely. (For details and a critique of one of the early armchair theorists responsible in large part for the present situation, see Dr. Michael Wynne’s excellent articles on Samuel’s presentation to the World Bank back in 2000.2) Administration has become a means to an end. That end appears to have more to do with furthering administrators’ careers and rewards than improvements in patient care. This is the exact opposite of how medicine arose, and awareness of this fact can be quite crushing to the embryonic altruist. It could also be the beginning of the curse of US style managed care here in Australia.3 4 We cannot allow such a situation (where grotesque sums are paid to already rich management figures whilst patients are denied the health care they need) to develop in Australia. Adulation of Administration leads to a number of related problems: Diversion of Money from Medical Care One does not have to be an economic genius to realise that if there is a finite pot of money available and if increasing amounts of this are diverted towards the

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F E AT U R E S important financial needs of burgeoning numbers of administrative bodies, then less goes towards patient care. The extreme consequences of this can be seen today in the UK. Latest raw figures indicate that the NHS now has 24,000 more ‘admin’ staff than hospital beds. The effects on staff morale can well be imagined. Monetisation of Medicine Nobody would suggest that we work for nothing. However, the early arrangements whereby a specialist accepted an honorary or low-paid public hospital post, with the attendant commitments to teaching and administration in recognition of the opportunity to earn significant rewards from private cases is long gone.

In its place, we have been forced into a system where everything has a price and nothing has value unless it adds to the bottom line and thereby improves ‘value’ for management and (where they exist) shareholders. Within the private system, the presence of such shareholders is a further burden. Clearly, money diverted to them is not available for patient care and ‘adding shareholder value’ would appear to be an unspoken ‘mission statement’. Money Mismanagement As individuals, we would not be able to run our practices and homes according to the standard ‘hospital’ model. The practice of compartmentalising available

finances and forcing departments and staff to ‘compete’ against each other for available funds is of no benefit whatsoever and causes wasted time, money and frustration. Can you imagine if your partner had to (explicitly) compete with your children for available funds? Hospitals should return to overall budgets with centralised control and impose tracking of materials and supplies to be overseen by the minimum number of capable people. Money should not be spent at financial year’s end to ensure next year’s allocation, but sensibly saved and used when necessary. Wasting money recklessly in this way is usually only done by bureaucracies funded by taxpayers, but this also seems to be the practice of various layers of administration in private hospitals, when the controlling boards lose sight of what is going on in their far flung medical empires. At the end of the day, patient care suffers and medical and nursing-staff become despondent. Divide and Conquer First espoused by Sun Tzu5 about 2500 years ago, this tactic is as effective now as it was then. Medical professionals are seriously divided, and this situation is encouraged and exploited by some administrators, both medical and none medical ... which we will discuss more of later. Denigration of Doctors

Hospitals should return to overall budgets with centralised control and impose tracking of materials and supplies to be overseen by the minimum number of capable people.

Once, a doctor’s word was akin to a message from the gods, but not anymore. This is not a bad thing. The rise of relatively freely available information on the internet, broadcast media and in magazines has helped to educate the public to a degree (but not enough to constrain various life threatening habits!!) so that they can ask intelligent questions of the medical professionals they attend. This is a good thing as long as people do not go away with the idea that what the doctor does is easy and without risk and should be priced accordingly. This way of thinking is a bit like somebody believing flying is easy because they

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F E AT U R E S only crashed in their flight simulator program twice. Unfortunately, this is not uncommon and it is not just members of the public who demonstrate such misplaced confidence. See later.

good managers?’ and ‘Why are they not content with being good nurses?’ are topics for another day.

Denigration of Doctors occurs due to a number of factors and factions:

Medical litigation is another cause for concern and loss of enthusiasm. We are victims of our own successes in that patients do not understand that life is a terminal condition and biological systems are inherently fallible (their bodies and the results of what we do for them). Consequently, there is an entire industry devoted to extracting recompense (and a percentage for a win) for often inevitable

Doctors without Degrees Pseudo-health interests which attract the gullible through the reliable efficacy of the placebo effect and by charging large fees for supportive chats and mysterious potions further undermine the standing

Interested Lawyers

failed to check his references or look at his resume and pick up easily noticeable and investigated clues. One of the consequences of this particular catastrophic maladministration is to reinforce the process whereby ALL medical practitioners are now treated as potential Patels and, in the event of any criticism or complaint, however vexatious or malicious, are subjected to harrowing ‘investigations’ by largely untrained but interested investigators. During this considered process, which usually proceeds at glacial pace, the practitioner is often unable to practice, earn money and support their family.

We are victims of our own successes in that patients do not understand that life is a terminal condition and biological systems are inherently fallible. of conventional medicine, which is somewhat harder pressed due to higher patient numbers and lower fees. There is an increasing push amongst nursing hierarchies to supplant the role of the doctor, prescribing (so far) a limited range of ‘safe’ medication without reference to the physician and positioning the nurse as a patient’s advocate, protecting them from maligning medical machinations. This is because of an overconfidence born of ignorance on the part of these nurse administrators who do not realise that medicine only looks easy because application to training and years of practice make it look so. Yet they really do believe that doctors can be replaced by ‘up-skilled’ nurses6. It is with this misplaced confidence that they teach this attitude to all nursing students from day one. There are ways to manage this situation. Look out for another interesting read ‘Sexual Politics in Medicine’. The nurse as an administrator is not confined to interference with medical matters either. It is not uncommon to see nurses ‘managing’ radiology departments and even trying to tell physiotherapists how to do their job. The questions ‘Why do they think nurses are automatically

adverse outcomes. The risk of this can be minimised by careful attention to the details of doctor-patient interaction and information, but this is still a cause of much anxiety, almost as much as that caused by the next category. Interested Lay People A critique of the ethics and behaviour of medical boards could take up all the pages of this topic and more. Whilst there is clearly a need for some oversight, the present process is out of control and quite uncaring. Contrary to their cosy messages, they are not the doctor’s friend in any way, shape or form. They are seemingly above the law, do not observe ‘rules of evidence’ and are composed of ‘interested people’, most of whom are not doctors and have little or no empathy or understanding. It is of great concern that when genuinely dangerous doctors have ‘slipped through the net’, the net is actually held by these boards who have accredited and the administrators who have employed that person. This fact is almost always glossed over. In the case of Dr. Patel in Bundaberg, for instance, hospital administration

Many careers and lives have been blighted by cavalier and carefree attitudes, impenetrable logic and protracted pseudo-legal processes. It is not uncommon that whilst the board ‘investigates’ a practitioner, they can in their turn do immense damage not only to the practitioner but also their family. The boards, of course, are not answerable to the profession and clearly care little for this not uncommon, but predictable, consequence of their institutional hypocrisy.

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F E AT U R E S

Some doctors unwisely go too far too fast and end up with massive financial commitments, and the only way they are able to service them is to take what is thrown at them and keep quiet.

Merely reading about their activities is dispiriting and depressing and a major reason for spreading disillusionment. Medical practitioners are, in fact, the only group of professionals who are assumed, often on the basis of unsubstantiated complaints, to be guilty liars and prematurely punished, until they have been proven so.

This unprofessional and dishonest behaviour quite rightly puts the gossiper in a very serious position vis-a-vis charges of professional misconduct and personal defamation. It also plays into the hands of those who would demean and denigrate the medical profession for their own personal, political and/or other short-term interests.

Much board activity would be very difficult if not impossible were it not for the next category of colleagues.

Doctors and Money

Disinterested, Dysfunctional Doctors If all the above was not enough, we also have to deal with some of our own who, through a combination of personal interests and personal problems, can do a great deal to sabotage their colleagues. And then there are those of our colleagues who make a living from appearing in the guise of ‘expert witness’ even if they a) have ceased to practice or b) have an interesting history of their own. We all know of gossips and story tellers, who gain some vicarious thrill and imagined personal gain spreading often mean and utterly destructive untruths about others, often in the most important of circumstances. We all know of doctors who exploit their colleagues from positions of seniority in various ways. Some are just ignorant, incompetent (The Peter Principle) others are wilfully mean. Secret contracts, hospital or departmental, are a good example of this. Secrecy in this matter is unnecessary and can only lead to suspicion and antagonism between those who should be co-operative friends.

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This is another huge topic in itself. But very briefly, anybody after years of training and dedication to their profession can reasonably expect to be able to provide a safe comfortable life for themselves and their families. Some doctors unwisely go too far too fast and end up with massive financial commitments, and the only way they are able to service them is to take what is thrown at them and keep quiet. Administrators, medical and other, obviously know this, and a number of them are not averse to taking advantage of playing on this vulnerability. This may be seen as efficient management, beneficial to their organisation (and bonuses) in the short term, but in the long term it is extremely unlikely to be beneficial to anybody7. Some Possible Solutions. 1. Recognise the constraints suggested by the Dunbar Number and organise accordingly. 2. Become involved, play their game. (EBM could be your best friend.) 3. Call mendacious administrators to account. Shine a light on THEIR wrong doing. 4. Recognise your strengths and weaknesses. 5. Stand by your friends and colleagues. 6. Reduce your vulnerability.

7. Do what you know is right. 8. Remember General ‘Vinegar Joe’ Stilwell’s motto … 'Nil carborundum illegitimi'. In Conclusion Altruism has made us the dominant species on the planet but led to serious problems of population pressure. These problems have wide ranging effects on all of us and can be compounded in our professional lives in a number of ways. The result of this is general unhappiness and demoralisation. Whilst this may, in fact, be a ‘natural consequence’ of population pressure which leads to a useful decline in fertility8, as a thinking species, surely we can do better. Simplest idea: we can work to improve the lives of others and this will then improve ours. Dr Tony Blinde References 1 Collins Concise Dictionary 2 http://www.uow.edu.au/~bmartin/dissent/documents/health/ critic_samuel.html 3 http://www.adf.com.au/archive.php?doc_id=96 4 http://www.healthissuescentre.org.au/documents/ items/2008/05/206739-upload-00001.pdf 5 Sun Tzu The Art of War.. Various publishers 6 The Peter Principle 7 Aesop’s Fables “The goose that lay the golden eggs.” On Papyrus. 8 http://www.un.org/esa/population/publications/ worldfertilityreport2007/wfr2007-text.pdf Images Page 12 & 13, "High priced medication" by Brooks Elliott http:// www.flickr.com/photos/8011986@N02/2689975613/ Page 14, "Hospital lobby escalator" by Stephen Cummings http:// www.flickr.com/photos/spcummings/2355907682/ Images licenced under a Creative Commons Attribution 2.0 Generic Licence http://creativecommons.org/licences/by/2.0

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RESEARCH

FRAUD IN SURGICAL MEDICAL

JOURNALS Why you canâ&#x20AC;&#x2122;t always believe what you read

Of all the heinous crimes committed by doctors, nothing seems to provoke the wrath of our medical colleagues more than research fraud. Even though we frown with contempt at doctors who mistreat their patients, defraud Medicare, form relationships with their patients or self-prescribe narcotics, we are particularly repulsed by those doctors who cheat the wider medical community with falsified research findings.

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F E AT U R E S

aybe it is the thought of ‘our own kind’ cheating us or the fact that that this is an abuse of privilege by a surgeon ‘just like us’ to further his own agenda (usually status, money or both).

In the medical world, the biggest research fraudsters of all time are: Dr Jon Sudbo, a researcher at Norway’s Comprehensive Cancer Center, reportedly admitted to fabricating research results to show that common over-the-counter painkillers like ibuprofen lowered the risk of oral cancer but increased the risk of heart problems and death from heart disease. As it turns out, Sudbo’s study1, published in the prestigious journal, The Lancet, was completely fictitious. Apparently, Sudbo made up all the patient data for his supposed study of 908 persons with oral cancer and was eventually caught when it was noticed that the study was stated

as using data from a cancer database which hadn’t even been created at the time the data was supposed to have been obtained.2 It further transpired that 250 of the patients had an identical date of birth.3 Further investigation of Jon Sudbo’s work revealed that 15 out of 38 articles he had published (including his PhD dissertation) were based upon fraudulent data or manipulated data. 4 In November 2006, he was deregistered as a medical practitioner from the Norwegian Board of Health. 5 Professor Woo Suk Hwang, a professor of theriogenology and biotechnology at Seoul National University (dismissed on March 20, 2006) who fabricated a series

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F E AT U R E S of experiments, which appeared in highprofile journals, in the field of stem cell research. Until November 2005, he was considered one of the pioneering experts in the field, best known for two articles6, 7 published in the journal Science in 2004 and 2005 where he reported to have succeeded in creating human embryonic stem cells by cloning. At the peak of his fame in 2004, he was listed as one of Time Magazine’s 'Top 100 People that Matter'.8 Both his papers in Science were later editorially retracted after they were found to contain a large amount of fabricated data. 9 He received a two-year suspended prison sentence at the Seoul Central District Court in October 2009, after being found guilty of embezzlement and bioethical violations but cleared of fraud. One of the other most significant research frauds of recent times is a 1998 paper published in The Lancet which reported a potential causal relationship between the MMR vaccine and autism.10 Dr Andrew Wakefield, an English general surgeon, published this groundbreaking paper in the Lancet describing this correlation. Following his radical statements, the MMR triple vaccine was withdrawn in many jurisdictions globally11 and many parents chose to opt out of immunising their children in fear of precipitating autism. Further research in Japan12 and elsewhere failed to corroborate Dr Wakefield’s findings, but he maintained his stance and continued to write about the potential link between MMR and autism. In February 2004, Wakefield was accused of a conflict of interest: The Sunday Times, a reputable British newspaper, reported that some of the parents of the children in the Lancet study were recruited via a UK lawyer preparing a lawsuit against the manufacturers of the MMR vaccine13. Following an investigation of The Sunday Times allegations by the UK General Medical Council, Wakefield was charged with serious professional misconduct, including dishonesty14. In December 2006, The Sunday Times further reported that the lawyers responsible for the MMR lawsuit had paid Wakefield personally more than £400,000, which he had not previously disclosed15. The Lancet responded to the

20 22

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There are no scientific police and most journals do not routinely check the raw data for signs of data manipulation. In essence, it is easy to cheat and even easier to get away with it. public furore by publishing a statement describing Wakefield’s research as ‘fatally flawed’ and then 10 of his 12 co-authors retracted their research findings en masse16: We wish to make it clear that in this paper no causal link was established between (the) vaccine and autism, as the data were insufficient. However, the possibility of such a link was raised, and consequent events have had major implications for public health. In view of this, we consider now is the appropriate time that we should together formally retract the interpretation placed upon these findings in the paper, according to precedent. Between July 2007 and May 2010, a UK General Medical Council tribunal ‘fitness to practice’ hearing found Wakefield guilty of professional misconduct and struck him off the Medical Board register17. A British investigative reporter for Channel 4 also uncovered that

Wakefield had applied for a patent for a single jab measles vaccine and was planning to create ‘autism diagnosis kits’ which he was planning to commercialise for personal financial gain18. The diagnostic kits were to be used for testing for bowel bacteria called autistic enterocolitis. Leaked forecast financials for this venture allege that the predicted revenue to be generated from sales of this diagnostic kit was to the order of $43 million.18 As a consequence of Wakefield’s fabricated research, immunisation rates in children plummeted from 92% to 73% nationally.19 This also led to a resurgence in the incidence of measles. In 2008, the number of measles cases being reported was the highest since 1997 and 90% of these were in unvaccinated children. Paul Hébert, editor-in-chief of the Canadian Medical Association Journal (CMAJ) has stated that: There has been a huge impact from the Wakefield fiasco. This spawned a

F E AT U R E S fabricate results.  Laziness – Even on the rare occasions when scientists do falsify data, they almost never do so with the active intent to introduce false information into the body of scientific knowledge. Rather, they intend to introduce a fact that they believe is true, without going to the trouble and difficulty of actually performing the experiments required.  Ease of Fabrication – With degrees of error and random spread of natural results, falsified data is relatively easy to inset without detection. There are no scientific police and most journals do not routinely check the raw data for signs of data manipulation. In essence, it is easy to cheat and even easier to get away with it. Professor Lord Ara Darzi, Former NHS Tsar and Health Minister of the UK, devotes an entire chapter to research fraud in his book entitled Key Topics in Surgical Research and Methodology 22. He subdivides research fraud in to the following categories: whole anti-vaccine movement. Great Britain has seen measles outbreaks. It probably resulted in a lot of deaths. 20 There have also been calls for Wakefield to face criminal charges in the same manner that Woo Suk Hwang did for his research fraud. So what makes a seemingly, highly motivated academic doctor who has chosen to devote his time to further science decide to fabricate his results and commit research fraud? David Goodstein21, a renowned academic at the California Institute of Technology has cited three reasons for researchers to commit scientific misconduct:  Career Pressure – Some scientific positions and academic chairs depend on the ability to receive ongoing support and funding. Where the loss of a job, academic title or status is at stake, some humans will be motivated to

 Fabrication – falsifying data or omission of significant negative findings. For example, Dr Scott S Reuben with his multiple publications demonstrating the supposed analgesic benefits of multimodal analgesia with COX-2 NSAIDs and Pregabalin instead of opiates.  Redundant Publications – duplicate publication of the same conclusion obtained with the same methodology in different journals. The best example of recent times is the near identical papers published by a team led by the highly respected Dr Andrew Ochroch from the University of Pennsylvania. Their article in the May 2010 issue of A&A23 on ventilation of patients recovering from bariatric surgery plagiarised an April 2009 paper in Anesthesiology24 — written by the same group. Ochroch et al issued a retraction of their A&A paper: ‘We sincerely apologize for the inappropriate and unacceptable

intellectual overlap and plagiarism of our paper’. 25

self-

 Plagiarism – Substantial unreferenced, textual copying of another’s work. Even though most scientific journals claim that it is near impossible to prevent a motivated author from breaching scientific integrity in his handling of research data, it is substantially easier with newer electronic technologies and with an increase in e-publishing of most published scientific material. Plagiarism can be prevented with ‘Copyscape’26 software which reguarly scans the whole World Wide Web for near-identical content and notifies the author of any such breach of copyright. Redundant publishing is being reduced now with registration of all clinical trials and the mandatory declaration of authors submitting original work about whether they have submitted elsewhere. Fabrication of data is perhaps the most difficult to detect, as this can be very carefully manipulated by the astute researcher. However, through a combination of careful statistical methodologies, it is possible to estimate the likelihood that the research data has been falsely obtained. Marris27 describes how the fabricating researcher will tend to create data which does not lie on the extremes of in terms of values within a set but which instead approximate the mean. Also the human mind exhibits ‘digit preference’ which reduces the normal variability which would be seen in authentic data. Evans et al have also devised a correlation matrix which can show anomalous relationships helping identify which data sets are too weak or too strong to be genuine data. In the wake of new technologies and increased rapidity with which research findings are disseminated, there is perhaps a greater responsibility on scientific journals to screen their content for signs of scientific misconduct. The potential for harm/death to patients because of treatment suggested by fraudulent research data has been labelled as murder. Perhaps the scientific journals should shoulder the responsibility of reviewing all raw data

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Fabrication of data is perhaps the most difficult to detect, as this can be very carefully manipulated by the astute researcher. sets submitted by would-be authors to assess the likelihood of fraud and determine authenticity? What has emerged in the aftermath of the Wakefield scandal is that the vast number of research fraud still goes undetected. All the fraudsters who are apprehended are usually caught through coincidental situations or where one of their co-researchers decides to act as a whistleblower. There is no rigorous system in space to eliminate the nonauthentic data. This lends the question as to what percentage of scientific data that we read is actually true and what has been concocted by doctors on the payroll of drug companies?

Dr James Nguyen

References: 1. Sudbø J, Lee JJ, Lippman SM, Mork J, Sagen S, Flatner N, et al. “Non-steroidal anti-inflammatory drugs and the risk of oral cancer: a nested case-control study”. The Lancet 2005; 366:1359–66. 2. Ferrie, Helke (April 2006). “Medical Research Fraud”. Vitality Magazine. http://www. vitalitymagazine.com/medical_research_fraud. Retrieved 2009-04-15 3. “Cancer study patients 'made up'”. BBC News. 2006-01-16. http://news.bbc.co.uk/2/hi/ health/4617372.stm 4. Atterstam, Inger (2006-07-01). “Norskt forskarfusk allvarligare än väntat” 5. http://www.helsetilsynet.no/Norwegian-Board-of-Health-Supervision/ 6. Hwang WS, et al. “Evidence of a pluripotent human embryonic stem cell line derived from a cloned blastocyst”. Science 2004; 303 1669–1674. 7. Hwang WS, Roh SI, Lee BC, et al. “Patient-specific embryonic stem cells derived from human SCNT blastocysts”. Science 2005; 308: 1777-1783. 8. “People Who Mattered 2004”. Time. December 27, 2004. http://www.time.com/time/asia/2004/ personoftheyear/people/hwang_woo_suk.html 9. Kennedy D. Editorial retraction. Science 2006; 311: 335. 10. Wakefield A et al: “Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children”. The Lancet, 1998;351, 9103. 11. Smith MJ, Ellenberg SS, Bell LM, Rubin DM (April 2008). “Media coverage of the measlesmumps-rubella vaccine and autism controversy and its relationship to MMR immunization rates in the United States”. Pediatrics 121 (4): e836–43. 12. Honda H, Shimizu Y, Rutter M (2005). “No effect of MMR withdrawal on the incidence of autism: a total population study”.. J Child Psychol Psychiatry 46 (6): 572–9. doi:10.1111/j.14697610.2005.01425.x. PMID 15877763. 13. Deer, Brian. “Taxpayer cash for MMR action is stopped after £15m that stoked fear was spent”. briandeer.com. http://briandeer.com/mmr/lancet-lsc.htm. Retrieved 2007-08-10. 14. General Medical Council press office (2007-10-08). “Dr Andrew Wakefield, Professor John Walker-Smith, Professor Simon Murch: Fitness to Practise Hearings”. Press release. Archived from the original on 2007-10-27. http://web.archive.org/web/20071027142725/http://www. gmcpressoffice.org.uk/apps/news/events/detail.php?key=1970. 15. Deer, Brian. “Revealed: undisclosed payments to Andrew Wakefield at the heart of vaccine alarm”. briandeer.com. http://briandeer.com/wakefield/legal-aid.htm. Retrieved 2007-08-10. 16. Murch SH, Anthony A, Casson DH, et al. (2004). “Retraction of an interpretation”. The Lancet 363 (9411): 750. 17. Meikle, James and Sarah Boseley (2010-05-24). “MMR row doctor Andrew Wakefield struck off register”. The Guardian (London). http://www.guardian.co.uk/society/2010/may/24/mmrdoctor-andrew-wakefield-struck-off.

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18.

19.

20.

21. 22. 23.

24.

25.

26. 27.

Russell, Peter (2011-01-11). “MMR Doctor ‘Planned to Make Millions’, Journal Claims”. WebMD Health News. http://www.webmd.com/brain/autism/news/20110111/mmr-doctor-plannedmake-millions-journal-claims. Retrieved 2011-01-12. “Will autism fraud report be a vaccine booster?”. Associated Press. 2011-01-07. http://www. google.com/hostednews/ap/article/ALeqM5ikh0N7yFEnFGWrqH8eczGq8NGKqg?docId=b136 13eaa5bc4836bbc8276bd4e9a654. Retrieved 2011-01-08. Ross, Oakland (2011-01-07). “Andrew Wakefield's fraudulent vaccine research”. The Star. http:// www.thestar.com/news/insight/article/918362--andrew-wakefield-s-fraudulent-research. Retrieved 2011-01-08. Goodstein, David (January-February 2002). “Scientific misconduct”. Academe Thanos Athanasiou, Ara Darzi. Key Topics in Surgical Research and Methodology. Chapter 23, Pages 283-290. Springer Publishing. Neligan PJ, Malhotra G, Fraser M, Williams N, Greenblatt EP, Cereda M, Ochroch EA. “Noninvasive ventilation immediately after extubation improves lung function in morbidly obese patients with obstructive sleep apnea undergoing laparoscopic bariatric surgery”. Anesth Analg. 2010 May 1;110(5):1360-5. Neligan PJ, Malhotra G, Fraser M, Williams N, Greenblatt EP, Cereda M, Ochroch EA. “Continuous positive airway pressure via the Boussignac system immediately after extubation improves lung function in morbidly obese patients with obstructive sleep apnea undergoing laparoscopic bariatric surgery”. Anesthesiology. 2009 Apr;110(4):878-84. Retraction Letter for Neligan P, Malhotra G, Fraser MW, Williams N, Greenblatt EP, Cereda M, Ochroch EA. “Noninvasive Ventilation Immediately After Extubation Improves Lung Function in Morbidly Obese Patients with Obstructive Sleep Apnea Undergoing Laparoscopic Bariatric Surgery”. Anesthesia & Analgesia 2010;110:1360–5 http://www.copyscape.ccom Odling-Smee L, Giles J, Fuyuno I, Cyranoski D, Marris E. “Where are they now?” Nature. 2007 Jan 18;445(7125):244-5.

Images Page 20 & 21, "Just_In_Jail" by Mark Strozier http://www.flickr.com/photos/r80o/1583486/ Page 22, "Project 365 #30: 300109 Never Say Die" by comedy_nose http://www.flickr.com/photos/ comedynose/3239472516/ Images licensed under a Creative Commons Attribution 2.0 Generic Licence http:// creativecommons.org/licences/by/2.0

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Part3

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TAKING A SABBATICAL

FROM MEDICAL PRACTICE... Not an impossible dream

As a psychiatrist of nearly 20 years, I knew it was time to take a break. I was chronically tired and felt cheated of time, with never a moment to explore my own interests. Although I was still giving my all to my patients, I had an overriding feeling that continuing like this for another fifteen years or so wasnâ&#x20AC;&#x2122;t going to work. After taking a break of three months and realising how therapeutic it could be, I have become a firm believer in the mid-life sabbatical and have since encouraged many of my colleagues to consider the same. Most of them have been envious but remain doubtful as to whether it would work for them.

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F E AT U R E S

Taking time out will help to reverse burn out and attend to those long held dreams which have been placed on the “back burner” while the demands of work and family life are at their greatest.

university funding, allowing them to achieve other career goals without having to worry about the financials. Staff specialists and other hospital employees who have “done their time” in the government system are also some of the few who are entitled to the privileges of long service leave. While, it seems the rest of us have less flexibility and more excuses not to pursue this idea.

Asking my colleagues what they did with their sabbatical time inspired me to add at least one out of the ordinary goal to my own time. A surgical friend realised that at age 45 his dream to run in each of the world’s three headliner marathons and to spend a whole season improving his skiing might not happen if he postponed his public-funded long service leave for even five years. He explained:

So the question remains, ‘Is it possible for a specialist in busy private rooms to take a break of two months to a year and still come back to an active practice?’ Just as importantly, ‘Is it possible when doing so, to survive financially?’

The decision to take three months to ski in Japan seemed a waste of the time to some colleagues but it was something I’ve always wanted to do and I don’t regret it ... bar the sprained wrist! I don’t know if the overseas marathon goal will happen anytime soon, but in the meantime, I’ve upped my running in local competitions and increased my standing. It wouldn’t have happened without the time off which gave me time to train.

By the time most doctors reach midadult years, say the age of 50, they have already worked for over a quarter of their lives. Yet they still have another fifteen years till retirement, if not longer! Taking an extended break at this stage or any other time in your career makes sense. Taking time out will help to reverse burn out and attend to those long held dreams which have been placed on the “back burner” while the demands of work and family life are highest. Why take time out? Our insecurities and realistic concerns as to how our patients and practices would manage without us often means the idea of taking a long break remains a distant dream. Following on from my own personal experiences and the testimonies of others, here are some ways for making your ideas a reality... Over the years those doctors who took an extended absence from their day-today role to pursue an alternative goal, whether it be to further their education or research, were typically academics. Such individuals were the ones who had

Some of the reasons commonly cited by medical specialists for taking a non workrelated sabbatical include being able to spend more time with their children, helping care for elderly parents and/or to pursuing personal interests. This latter goal may be as diverse as finally achieving a reasonable level of physical fitness, at a time when you notice your health is starting to decline; travelling for an extended period of time; or revisiting hobbies which have been neglected. It might even be the perfect time to take up a new interest or sport.

An obvious but important first step when making a decision to actually take the sabbatical involves deciding how long to be absent for. Accommodating all bookings and work commitments in the office diary is the starting point to a process which usually needs to be planned many months in advance. Without setting dates, there are always a million and one reasons to do it another time. By starting discussions with your spouse or partner, and informing work colleagues about your plans, you signal a firm commitment to the goal of taking time out. Medical specialists who have successfully taken a sabbatical often need to be realistic about what can be reasonably achieved. Three months leave might be sufficient to travel overseas and pursue a new interest, but would be too limited to undertake a twenty year backlog of chores. It is not uncommon for doctors

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further comment that “they even think medicine mightn’t be a bad career choice after all!” was a sign that a career choice unrelieved by a balanced lifestyle will not be tolerated by Generation Y as they move into medicine. You’ve made the decision – how do you actually go about doing it? Once the time off has been booked, a number of practical steps may smooth the inevitable disruption for the practice. •

Informing patients and colleagues as soon as the dates are set will allow adequate time for clinical handovers and for referrers, including insurance companies and solicitors to make alternative arrangements.

•

Pro forma letters for each group are likely to help avoid frustration and

Three months leave might be sufficient to travel overseas and pursue a new interest, but would be too limited to undertake a twenty year backlog of chores.

who have successfully undertaken a sabbatical to wish they had taken longer. Indeed, there are many doctors who are heavily work focused who may find an extended period of time off to be personally challenging. They usually struggle with the lack of familiarity and lack of structure to their time. When asked about why he took two months out of private practice, Tom T., a 55-year-old gastroenterologist friend commented that retirement had always seemed daunting to him. He was, however, reassured about the future. “After holidays of only two weeks a year for nearly two decades, the time out was an eye-opener; I became an active part in the lives of my teenagers in a way that has lasted long after my return”. His

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offset a potential fall in business on return. •

Specialists often underestimate the loyalty of both their referrers and patients and are often surprised, if not a little daunted, to find they are booked well ahead on return. Because office staff will be the ones left fielding requests during your break, spending quality time running through possible scenarios and giving them the tools and techniques on how to effectively deal with the occasional disgruntled patient or referrer will be time and training well spent.

•

Finding a colleague, or more sensibly a number of colleagues, to care

F E AT U R E S for patients who need urgent or more regular reviews can be a particular challenge. This is especially difficult, given that most of them will already be busy carrying their own load. However, offering a similar favour in return for a colleague’s leave may be fruitful. Alternatively, engaging a junior colleague starting out in practice is another option, as long as an agreement about a return of patients is achieved. The idea of taking a sabbatical usually means not being disturbed. But being subpoenaed to attend court is one exception to the general rule of being unavailable during a sabbatical leave. Although most legal firms try to accommodate periods of leave, being excused is not invariable. Expert witnesses are sometimes required to give evidence from overseas. Having endured an all night videolink session to court from Istanbul, this is an experience I know all too well as sometimes being an unavoidable aspect of the forensic aspects of practice. Another practical issue to consider well in advance is to review cash flow estimates during the leave period. Accountants should be able to advise you on paying reduced tax as a consequence of lower earnings, an unexpected bonus for the higher income bracket. Working extra hours before or after the leave period is one way some doctors attempt to fill the “income gap” but it can defeat the purpose of taking a break. Once the planning is in place, setting down goals or aims in writing is helpful, both in providing a general direction and in individualising them. Some plans will need advance booking if courses or travel are involved, whereas more diffuse goals of learning how to relax are difficult to encapsulate but are just as important to specify. Headlining different areas of goals as education related, personal development and interest versus fitness, social and relaxation may help to provide a focus on what is more, or less, important. Being reasonable about what can be comfortably achieved during any particular time period is an area most doctors find particularly difficult. Relinquishing the curse of “busyness”, which most doctors are plagued by, can come hard.

Perhaps one of the most useful aspects of a sabbatical leave is that, like travel, it can open the mind and allow for some serious reconsideration of longer term goals.

Once the long awaited start of a sabbatical arrives, taking a well earned break, without pressure or guilt to “do” rather than “be”, is a good way to start. Once rested, having some planned structure to the days may help those doctors who find the new experience of having time to themselves challenging. That said, many specialists find that plans change when life brings unexpected diversions! Perhaps one of the most useful aspects of a sabbatical leave is that, like travel, it can open the mind and allow for some serious reconsideration of longer term goals. For Paul M., a 40 something psychiatrist with a mixed hospital/private practice, coming back from four months long service left him feeling less jaded and ready to contemplate a long delayed career move. Many years of working excessive and at times unsociable hours, and feeling weighed down by the demands and responsibilities of clinical care can all cause a serious loss of balance in lifestyle. It is not uncommon for specialists to have fantasies about early retirement as a function of overload and lack of self resourcing usually to manage ‘burn out’. Rather than sustaining the losses, both personal and financial, which can come from relinquishing medicine early, a preemptive break which restores mind and body can be a ‘life saver’, particularly at the right point of doctor’s career. Reflecting back on my three months leave, one of the disappointing aspects for me was how little I managed to tick off from the list of goals I had created. But then, looking at it from a different angle revealed an altogether new perspective. Having time to take ailing parents to appointments and to help a friend who broke her arm was a revelation. I realised how little time I previously had to help people who weren’t patients but

who mattered to me the most. Best of all, I stopped feeling so pressured and always worrying about how everything would get done. The most valuable lesson of all was that life can flow without being forced and still be productive at its own pace. Perhaps the final word should go to a dermatologist friend who lived out the dream of spending a year residing in Europe as a local: “I’m back to the daily grind now but the memories sustain me, particularly of the freedom I had to explore myself without fear of censure and without the responsibilities which are an inevitable part of medical life. I realised that I liked my work more than I knew and it’s o.k. to be back in the same place...” If you’re contemplating taking “time out”, be prepared for both disapproval, sometimes unspoken, and envy from colleagues. As doctors, our conformist tendencies are strong and guilt about leaving others to shoulder the load has been inculcated since internship days. Taking a sabbatical is not leave in the service of others, our usual modus operandi in clinical life. Rather, it is a time to revitalise whatever remains of a satisfying career and to reflect on how our use of time can bring us and those we care about the most happiness. Dr Lisa ferrier-Brown is a forensic and general psychiatrist. She divides her time between prison work and private practice and is a Clinical Lecturer at the University of Sydney.

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How planning can help to ensure equitable, efficient and tax-effective distribution of benefits

Supercharge your ESTATE O ver their professional careers, surgeons will generate significant wealth. But if they have sought good professional financial advice, chances are they will finish their lives owning nothing!

For tax efficiency and due to the relatively high risk nature of their profession, it's not wise for medical professionals to accumulate assets in their own names. Therefore it's common that over lifeâ&#x20AC;&#x2122;s journey assets are accumulated in their spouseâ&#x20AC;&#x2122;s name, a family discretionary trust, their own self-managed superannuation fund and sometimes a company. Structuring your affairs through the use of such entities enables medical professionals to exercise control over assets without directly owning them and therefore provides a level of protection against litigation. Tax minimisation and asset protection through the use of such structures is a sound strategy to shore up your financial future in retirement. But what happens when you finally leave this planet?

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Assets owned in trusts, superannuation funds, companies and in joint names are not estate assets and cannot be passed on to chosen beneficiaries in your will. Only assets a person actually owns can be passed on in a will. Another key issue for medical professionals is the inadvertent inheritance of assets in their own names as a result of their parentâ&#x20AC;&#x2122;s death or in the situation where their spouse predeceases them. Having structured your own affairs appropriately, the last thing you want is to inherit substantial assets and the family home in your own name. This presents a number of challenges for medical professionals. Properly managed estate planning ensures that the right assets are transferred to the intended people at the appropriate time.

BUSINESS & FINANCE It involves complete consideration of a person’s assets and liabilities—whether technically owned by that person or otherwise—to ensure that the transfer and control of assets are managed to maximise the benefit to the deceased’s estate and beneficiaries. Unique control and tax issues must be addressed when passing control and assets from trusts, companies and super funds. However, superannuation often ends up becoming the entity in which medical practitioners accumulate the majority of their wealth, so we will focus on this entity. Here are some key tips and strategies to help protect your family’s wealth into the future. Superannuation, Often Your Largest Asset Given the considerable tax concessions associated with investing in superannuation, it has become for many their primary, if not only, retirement savings vehicle. This has the advantage of minimising tax during the member’s retirement, but may present considerable difficulties for estate planning purposes. Estate planning for those without a spouse or minor children, or for those who wish to leave benefits to other nondependent beneficiaries (as defined by the taxation legislation), presents a number of issues for a superannuation member trying to ensure an equitable, efficient and tax-effective distribution of their benefits. Assets in an SMSF, such as cash, direct shares, managed funds or property, cannot be left in a will. When a person dies, their interest in the superannuation fund will be paid out as a superannuation death benefit. Within an SMSF, it is the surviving trustee(s) who ordinarily makes the death benefit payment decisions. While a member can often make a direction to the surviving trustees regarding the payment of their death benefit, they cannot leave assets directly in a fund to the people they want to benefit. Generally, the payment of death benefits is governed by: • any binding or non-binding death benefit nominations the member made • the fund's trust deed

• superannuation law which sets out to whom death benefits may be paid • tax law—which determines how those benefits will be taxed. Where they have the discretion to do so, trustees will pay the benefit to those they deem to be the most appropriate person or persons in accordance with the rules of the superannuation legislation. For instance, benefits might be paid directly to your dependants, to your estate or to a mixture of both. Depending on your circumstances, special consideration needs to be given to what sort of superannuation death benefit nomination you might make. Should you make the nomination binding or nonbinding? Should the nomination direct your benefits to your estate or directly to your dependant/s? Where certainty of distribution is paramount, such as ensuring children from a previous marriage are looked after, then binding death benefit nominations are preferable. However, you will never be able to fully predict changes in laws, circumstances of beneficiaries and assets at the time of death. So as a general rule, using non-binding nominations that are directed to the deceased member’s

children under 18, and children up to age 25 who are financially dependent. Non-tax dependants can pay up to 16.5% on death benefit lump sums and up to 46.5% on life insurance proceeds paid out through superannuation. To paint a clear picture of how tax can bite if you do not have a well thought through estate plan, let's look at the case of Dr Jones. Dr Jones has $1.5m of taxable benefits in his SMSF. He also has a $1m life policy held inside his fund. Dr Jones’s wife had previously passed away, so on his death the $2.5m of benefits are paid out to his two sons, who are 17 and 22 years old. The tax consequences for his two sons on receiving the lump sum death benefits were very different. The 17-year-old met the definition of a tax dependant, so he received his inheritance tax free. However, the 22 year old was not so fortunate. Being fully employed, he did not qualify as a tax dependant so he incurred the following tax on the lump sum death benefit paid to him: • On the 750k of taxable benefits he was subject to tax at 16.5% and paid

Properly managed estate planning ensures that the right assets are transferred to the intended people at the appropriate time. estate and provide the most flexibility to be able to manage the estate in the most effective way is preferable. Tax on Super Lump Sum Death Benefits As they say 'there is nothing more certain than death and taxes'. If you do not structure your estate plan carefully and comprehensively, a death benefit payout to your loved ones can be significantly reduced due to the potential tax consequences. Generally, benefits paid to tax dependants, as defined by tax legislation, will be received tax free. Tax dependants will include your spouse,

$123,750 tax • On the $500k of insurance proceeds, because these have come from an untaxed source, he was subject to tax on this money at 31.5%, a total of $157,500. All up the older son’s inheritance was reduced by $281,250—all of which went to the tax man. Saving Death Benefits Tax Some tips in managing your affairs to negate the impact of any tax on superannuation benefits are: • operate through an SMSF where as

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trustee you can hold tighter control • nominate a reversionary pension beneficiary on pension accounts to maintain capital inside super where possible • don’t over insure in super • maximise non-concessional contributions • implement withdrawal and recontribution strategies to increase your tax free component • don’t be too prescriptive, rather build in strategies for flexibility • include provisions for equalisation of benefits in your will. Some of the options that Dr Jones could have made available to his executors through a properly thought through estate plan to reduce this tax impost are: 1. Employing a withdrawal and nonconcessional re-contribution strategy in the fund whilst he was still alive to increase the proportion of the tax free component in the fund. Once over 60, by using his 3 year $450k non-concessional cap twice he would have converted $900k of his taxable component to tax free. The tax-free component of a super fund member account comes out to dependants and non-dependants tax free. 2. Restructuring the ownership of his life insurance policy from his super fund to his own name. This may be problematic depending on Dr Jones's health conditions at the time. 3. Use a non-binding death benefit nomination to direct his superannuation money to his estate. The distribution of his super would then be governed by his will and his executor would then have

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greater flexibility in allocating his assets across both sons in the most tax-effective manner. This would enable other estate assets with no tax consequences (e.g. the family home or cash) to be allocated to the older son with more of the superannuation assets being allocated to the younger son. To ensure all beneficiaries are dealt with equitably, it is vital that equalisation clauses be built into the will. Avoid Being a Beneficiary of Your Parent’s Estate It’s also important that you work with your parents to ensure their own wills do not leave their assets to you as a medical professional in your own name. It is vital that they build in the option for you to take your inheritance in the form of a testamentary trust. Within a testamentary trust, a trust created by will, you can continue to control those inherited assets so that they are not exposed to risks such as litigation or threats from divorce. You will also be able to distribute taxable income earned on investments held in a testamentary trust to your children at adult tax rates. This means your children can be earning up to $16k per annum each tax free–a significant tax advantage for your family that will see your parents' gift to you stretch further. A Comprehensive Estate Plan A will should be used in combination with ownership structures as they provide direction to the parties or beneficiaries involved. I favour having

a will that attempts to take control of all those other structures, including your superannuation assets, so the will becomes a very creative and powerful document which acts as the conductor of the orchestra of wealth that the client may have. But that’s not just done by wishful thinking; you’ve got to sit down and go through it thoroughly, systemically and comprehensively. It requires a good understanding of all the tax and other laws, and certainly requires someone with a creative mind. This is not something that can be done in a hurry so, generally, it costs money to do this properly, but it’s usually money well spent. Roger Wilson is a Partner – Wealth Management at Lachlan Partners. Lachlan Partners is a private client advisory firm with offices in Melbourne, Sydney and Brisbane. www.lachlanpartners.com.au or telephone (03) 9605 9200. Disclaimer: This advice may not be suitable to you because it contains general advice that has not been tailored to your personal circumstances. Please seek personal financial and tax advice prior to acting on this information. Before acquiring a financial product a person should obtain a Product Disclosure Statement (PDS) relating to that product and consider the contents of the PDS before making a decision about whether to acquire the product. The material contained in this document is based on information received in good faith from sources within the market, and on our understanding of legislation and Government press releases at the date of publication, which are believed to be reliable and accurate. Opinions constitute our judgement at the time of issue and are subject to change. Neither, the Licensee or any of the National Australia group of companies, nor their employees or directors give any warranty of accuracy, nor accept any responsibility for errors or omissions in this document. David Davidson Financial Services Pty. Ltd. trading as Priority Life is an Authorised Representative(s) of Apogee Financial Planning Limited ABN 28 056 426 932, an Australian Financial Services Licensee, Registered office at 105 –153 Miller St North Sydney NSW 2060 and a member of the National Australia group of companies.

Protect your investments in 2011 and get a FREE consultation to make sure you are on track! 2011 is shaping up to be a challenging year for investors - getting the right advice will make all the difference. Lachlan Partners is bringing together some of Australia’s foremost experts at their key seminars to be held in March 2011 across the Eastern Seaboard. Our eminent speaking panel includes Chris Caton Chief Economist BT Financial Group ‘Global Economic and Market Outlook’

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John Marasco Paul Saliba Managing Director Investment Services Chief Investment Officer Colliers International Lachlan Partners ‘Investing in Commercial ‘Dynamic Approach to and Residential Properties Asset Allocation - Applying what is happening the new Zone System’ Australia and Globally’ Seminars are being held in the following locations Sydney Melbourne

Tuesday March 8th 2011 2 - 4pm The Novotel Brisbane 200 Creek Street, Brisbane QLD

Wednesday March 16th 2011 7.30 - 9.30am The Portside Centre, Level 5, Symantec House, 207 Kent Street, Sydney NSW

Thursday March 31st 2011 4.30 - 6.30pm Level 1, Crown Towers, 8 Whiteman Street, Southbank VIC (Free Parking Available)

Lachlan Partners is a Private Client Advisory Firm focused on client needs and financial goals with offices in Melbourne, Sydney and Brisbane. REGISTER NOW AS SEATS ARE LIMITED To attend, obtain a Seminar DVD, receive a 3 month complimentary subscription to Investing Times or a free consultation email your details to update@lachlanpartners.com.au Investing Times, Australia’s foremost independent newsletter providing financial and investment wealth creation strategies since 1971. www.lachlanpartners.com.au Telephone 1800 643 631 (Freecall)

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s a surgeon, you are used to multitasking and being resourceful, even in areas where you aren’t necessarily the best person for the job. This is usually fine at the start of the specialist career when you have the expectation that you will need to ‘bootstrap’ your practice growth and keep expenses down by being the IT specialist, the web designer, the marketing specialist, the bookkeeper and the business manager. But PCMC has fallen on hard times. First, there reaches a point, however, where you can no longer value your time at zero. If you counted all the time you devote to tasks that could have been performed by someone without specialist surgical training, only then can you recognise the amount of time you can free up through outsourcing. From previous surgeons that I have worked with, the time spent on non-core-competency tasks (I make the assumption that your core competency is the practice of surgery), varies from approximately 10 to about 30 hours per week. The opportunity cost to you of these 10 to 30 hours could include not consulting/ operating, not spending time with family, not playing sports or not having dinner out with your spouse. These are all significant costs to us and the inability to recognise this and to delegate is a major weakness in the psyche of the doctor who believes he is all things to all people. The principle of outsourcing has the twin goals of: •

removing ‘low-value’ tasks from our agenda which we can delegate to others on a lower hourly rate than we are (Administrative tasks such as bookkeeping, billing, transcription etc fall into this category.)

•

delegating tasks to others in which we often perform a substandard job and take many excess hours to complete (The best example I can give for this is doctors who try and build their own website.)

Health professionals unknowingly already outsource many areas of their

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Operation

Outsource Putting a value on your time and reducing your administrative work

work. You would not think twice before outsourcing medical work that is not under your remit to specialists of other craft groups. We recognise that the diagnostic services of radiologists and pathologists are far superior to ours and hence we outsource this work to the professionals who have specialised in this area. However, when it comes to the more mundane tasks of medical billing, bookkeeping or even marketing, we find ourselves diving head first into a sea of paperwork. So why do the same principles not apply? Why do we insist on putting ourselves in the driver’s seat, for tasks that we don’t have expertise in and zap our time? Time is quite simply money. Priceless hours can be lost if you don’t put a value on your time. Doctors who put close to zero value on their time can be found spending undocumented hours playing around creating a website, submitting their own bills manually, etc only to end up with a wasted weekend and a half-finished inferior product. Surely, if there is an option which allows you to do this in less time and half the cost, you would. Well, outsourcing has always been the sensible choice. The pressures of the mundane tasks are lifted off your shoulders and put in the hands of a professional, leaving you with more time to spend looking after your patients or even leaving work early to spend some quality time with your family and friends. Outsourcing services like claims process-

ing, medical billing, insurance follow-ups, transcription and other such similar administrative jobs are always very timeconsuming.

•

Medical practices can achieve greater efficiencies without hiring people or utilising extra resources by pushing non-core tasks to external parties.

Running and growing a medical practice takes many skill sets, and doctors, eager to keep costs in check will try to do it all. From hiring decisions to compiling accounts for the practice, practice owners spread themselves thin running from task to task.

•

Outsourcing offers standardised and timely service levels within practice functions.

•

Outsourcing removes the ‘flight risk’ of the loss of valuable employees who had access to critical data or information. For example, the practice manager who knew the computer passwords or the only one who knew how to use the practice software.

•

Outsourcing converts a fixed cost to variable cost. Hiring staff means you incur a fixed cost even if the staff member is under-utilised or ends up being unable to complete the task at hand. Outsourcing means you have a variable cost based on how much you use the services of the outsourcing company.

What are the benefits of being the super-doctor? You achieve all the items with ‘zero' capital outlay. The negatives? You spend much longer. You often perform the job to a lesser standard than someone who performs that duty repeatedly professionally. You frequently exceed all the deadlines. It may cost you more in the long run to redo the task properly. According to the Harvard Business Review, outsourcing is one of the most important management ideas and practices of the last 75 years. Medical practices using outsourcing cite innovation as their number one reason for bringing in a fresh perspective to key functions. Doctors and practice managers say they derive the following four benefits from outsourcing: •

Outsourcing allows a practice to focus on their core competency—providing medical care to patients.

However, before you sack every member of your staff and replace them for a halfpriced outsourced equivalent, you should familiarise yourself with the disadvantages of outsourcing: Loss of Control Problem: When you hire another company to perform the function of an entire department or single task, you are handing the management and control of that func-

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BUSINESS & FINANCE tion over to someone other than yourself. True, you will have a contract, but the managerial control will now belong to other party. This could also be a posi-

current requirement for safe transfer of patient data is 256-bit SSL.

Smart doctors regularly make outsourcing work for them. They understand the importance of leveraging their time and money while obtaining critical tools for success. tive, as a busy clinician you already have enough demands on your time. Solution: The best way to circumvent this is to incorporate some form of intermittent reporting. Any company who you currently outsource tasks to—including accountants, payroll companies, bookkeeping, billing, etc—should be providing you with monthly reports demonstrating exactly what they have done for you and what they have charged you for that work. Hidden Costs Problem: You will sign a contract with the outsourcing company that will cover the details of the service that they will be providing. Anything not covered in the contract will be the basis for you to pay additional charges. Solution: Create a Service Level Agreement (SLA) which delineates exactly what is and what is not included in the price being paid. This also provides a clear breakdown of the services to be performed, the timelines and potential extra prices that may be incurred for additional duties. Some careful cost-analysis at the start will put you in the best position to assess whether outsourcing is for you. Threat to Security / Confidentiality Problem: If you outsource the handling of sensitive information—including transcription, billing, medical records, payroll or any other confidential information— you run the risk that confidentiality may be breached and data may end up in the wrong hands. Solution: Ensure the outsource company has a privacy policy and uses encrypted data for transfer of information. The

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Bad Publicity Problem: The word ‘outsourcing’ brings to mind different things to different people. Reducing staff numbers may result in a drop in morale in the short term. Solution: By using outsourcing solutions to ease workload of the remaining staff, you will reduce your stress in managing an additional employee and reduce the ‘flight risk’ if that staff member was to leave and create a ‘knowledge gap’ in your remaining staff. The smaller team can then focus on a set of tasks which are comfortably within their remit. So, if I’m interested in outsourcing, how do I get on with it? Change Management is a complex series of tasks where your goals are to create new business efficiencies and make significant changes to business processes without endangering the existing ones in the processes. Business consultants spend years learning how to do this and even for a small medical practice business, it would be wise to nominate a staff member as the project manager to take overall command and responsibility. The practice manager is the obvious choice to manage the outsourcing of the projects and developing and maintaining the relationships with the new stakeholders. Smart doctors regularly make outsourcing work for them. They understand the importance of leveraging their time and money while obtaining critical tools for success. Bottom line: the choice to outsource comes down to dollars and sense. When doctors add their time spent on adminis-

trative duties, the price tag is high. And, not all practice managers are equally savvy at navigating the maze of available outsourced solutions. This can leave everyone dazed and confused. Using your practice manager or practice consultant will ensure that you have the relevant people possessing business performance management knowledge and can add an extra dimension that positively affects other areas of your practice, including productivity, operating efficiencies and internal systems. It takes time to make the decision to outsource your administrative work. Aligning practice growth goals with clinical time, and comparing that to the benefits an outsourced solution can bring to the picture, enables you to determine if outsourcing is right for your medical practice. If you still aren't sure, call your practice advisor to discuss the pros and cons of this type of arrangement. Ravi Agarwal is the Chief of Marketing at Marketing Doctors and assists medical specialists through-out Australia to build their medical practices. www.MarketingDoctors.com.au

Items which lend themselves to being outsourced by medical practices include: • insuring your practice practice indemnity, medical indemnity renewal • bookkeeping • payroll - running a payroll for a small of team of staff can be a big waste of time • IT systems • marketing • web design • medical billing • medical transcription • data mining.

AUSTRALIA’S ONLY MEDICAL PRACTICE MARKETING SPECIALISTS

(03) 9008 6348 info@MarketingDoctors.com.au Marketing Doctors operates within the AMA Code of Ethics guidelines on Advertising

www.MarketingDoctors.com.au

BUSINESS & FINANCE

INVESTING IN HEALTH Which new technologies or health sectors should you invest in?

e’re an ageing population, and more importantly we are demanding better and more effective health care. As a result, industries related to medical technologies and health services are increasingly in demand. Which of these medical technologies and health service providers have you have you heard of and which should you invest in? Established companies Investing in these larger listed companies will offer you a nice slice of the healthcare pie. Let’s see what these well-established healthcare companies are doing. Medical Technologies CSL CSL’s business is in health care; it is involved in producing life-saving products derived from human plasma, pharmaceuticals and diagnostics essential to community health, and animal health vaccines and diagnostics to protect livestock and companion animals. An ageing population means a greater demand for blood plasma products. CSL has significant scale which enables it to lower its costs considerably. It also has pricing power, given that it controls supply. Recently, the strength of the Australian dollar has negatively impacted earnings; however, we expect exchange rate volatility to settle down over time which will allow CSL to deliver improved earnings. The other risk to CSL remains regulatory changes from governments which may prevent them from charging their current prices.

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CSL’s Environment rating from EcoInvestor has recently been increased from 4 to 5 stars. The company has also published its first Corporate Responsibility report detailing significant improvement in its environmental performance, particularly in its energy and water use. Total Shareholder Return (average annual rate): 1 year 10.2%, 10 year 13.6% Sonic Healthcare Sonic Healthcare Limited (SHL) is an international medical diagnostics company, providing pathology and radiology services in Australia, the UK, US, New Zealand, Germany and Hong Kong. SHL´s competitive advantage is aligning the interest of its pathologists and radiologists to grow revenues through profit share agreements. Strong cash flow generation means the balance sheet remains healthy and healthcare expenditure is set to increase faster than inflation as the population ages and the demand for services increase. Combining this with acquisitions will lead to increased earnings growth over the next five years. Sonic has recently announced the acquisition of Cen-

tral Coast Pathology Consultants (CCPC) located in California, USA. Given that the acquisitions of their centres in the US and Europe are sunk costs, these operations should soon start to deliver earnings growth. While domestically, Sonic’s operations have consistent cash flow and good scale which makes it difficult for competitors to enter the market. The main risk to continued growth is a policy shift by government that would reduce diagnostic expenditure. Total Shareholder Return (average annual rate): 1 year -9.3%, 10 year 7.4% Natural Medicine Blackmores Blackmores (BKL) manufactures and markets vitamin, mineral and herbal supplements and natural beauty products throughout Australia and South East Asia. Health awareness and educa-

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tion is also offered. Blackmores provides customers with access to a team of health experts to give advice on natural healthcare, research findings, issues, news and information on products. Healthy living is part of their corporate culture. Staff are served healthy meals at the staff canteen, and have access to a fitness program at the local health centre. Looking after the environment is also important. In 1995, the company’s warehouse and distribution centre won the Environment Achievement Award for Industry in the Warringah area, for initiatives to reduce waste, water, and energy consumption. The management of Blackmores has an excellent track record. The brand remains well-trusted and this means that replicating their success is difficult. Additionally, demand is increasing for complementary medicines, as they are accepted as more mainstream. Blackmores continues to look to expand to

Asia, however, at this time, it is focused domestically. Total Shareholder Return (average annual rate): 1 year 46.80%, 10 year 23.00% Health and Medical Services Primary HealthCare Primary Health Care Ltd (PRY) Limited provides a range of services and facilities to those medical professionals that run their own practices at its medical centres, licensed day surgeries, specialist and dental clinics. The group’s earnings proportionally by area are as follows: Pathology 40%, Medical Centres 40%, Radiology 15% and Health Technology 5%. The group has recently established new centres in Victoria and the Australian Capital Territory. With these new additions the group now has a total of 31 large scale medical centres. Additionally, the group also owns and operates

SDS Pathology located at North Ryde, Sydney. The laboratory services Primary Health Care’s Medical Centre’s and other practitioners and health care providers. The medical centres are a lucrative part of the business with EBITDA margins running at 55%. These high margins deliver a great return. However, there is a risk that they may be reduced if the government looks at cutting costs and rolling out public healthcare centres to alleviate the pressure on hospitals. Total Shareholder Return (average annual rate): 1 year -13.1%, 10 year 3.0% Medical Property In addition to the above sectors, you can look at investing in hospitals and medical centres. Australian Unity Healthcare Property Trust

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BUSINESS & FINANCE However, they do have an opportunity for growth as government is committed to spending on IT infrastructure for the healthcare sector. As the business risk remains high, this stock would only be suitable for investors with a high risk appetite. Total Shareholder Return (average annual rate): 1 year -87.2%, 10 year -12.8% Medical Technologies Here are a few medical technology companies involved in a range of medical treatments: • • The Australian Unity Healthcare Property Trust owns the physical infrastructure supporting the healthcare system, including the land, bricks and mortar of hospitals, medical clinics, nursing homes, day surgeries, consulting rooms, rehabilitation units, radiology and pathology centres. The properties are geographically diverse and include regional areas, such as the Ipswich Medical Centre and Day Surgery, and Illawarra Private Hospital. Some of the major tenants include Ramsay Health, Sonic Health, Vision Group, Calvary Health, and Healthscope. The wholesale fund has returned 7.65% over the past 12 months, and 11.27% pa over the past 5 years (for the period ended 31 January 2011). Ramsay Healthcare Ramsay Healthcare Ltd (RHC) has a mixture of acute surgical, regional and psychiatric hospitals which are located throughout Australia. They have grown to a global group with operations in the UK, France and Indonesia. Certain hospitals hold a competitive advantage over other participants, because Ramsay hospitals have a superior location, reputation and scale. There is also scope for further growth as they take their business model overseas for further expansion. It is also important to note, however, that as a private hospital operator, Ramsay is reliant on the health of the private insurance industry. Any regulatory change or economic weakness could result in a contraction of spending which could deprive the private industry of funds.

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Total Shareholder Return (average annual rate): 1 year 43.6%, 10 year 26.0% New companies If your risk appetite is large and you are keen to support the new players in the market, then you might like to consider the following companies which are making medical advances. Medical IT iSOFT Group iSOFT Group Ltd (ISF) provides healthcare information systems and e-health services to public and private hospitals as well as community and primary care organisations. Installations are in hospitals and clinics in the UK, Europe, Australia, New Zealand, Asia and the Middle East. The technology and communication solutions are designed to connect providers, payers, patients and communities. The software works across hospitals, clinics, aged care and primary care, as well as, claims and payment processes. They also offer financial software (accounting and purchasing), and bespoke solutions. It currently has a weak balance sheet, as they are at the early rollout stage.

• • • • •

Alchemia Ltd (ACL) – develops anti-coagulant and cancer drugs Avita Medical Ltd (AVH) – regenerative and respiratory medicine Circadian Ltd (CIR) – cancer therapies Phosphagenics Ltd (POH) – bloodstream delivery systems Resonance Health Ltd (RHT) – magnetic resonance imaging ResMed Inc (RMD) – sleep and breathing disorders Tissue Therapies Ltd (TIS) – wound healing

Returns Investing in the healthcare sector has been financial rewarding. The S&P / ASX 200 Health Care Accumulation Index has risen 12.09% over the past year (to 31 January 2011). While the 5-year return is an outstanding 10.03%. If you’d like more information about the above investments, feel free to contact our office. Karen Mcleod is an Authorised Representative (No. 242000) of Ethical Investment Advisers (AFSL 276544). References: Returns information sourced from Morningstar, www.morningstar. com.au

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 DavidsoAn Financial Services Pty. Ltd. trading as Priority Life is an Authorised Representative(s) of Apogee Financial Planning Limited ABN 28 056 426 932, an Australian Financial Services Licensee, Registered office at 105 –153 Miller St North Sydney NSW 2060 and a member of the National Australia group of companies.

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Pain of Claim

Preventing at the Time

NAVIGATING YOUR WAY THROUGH A LIFE INSURANCE CLAIM

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nsurance is one of life’s necessary evils. We all pay our premiums with the expectation that if we become victim to accident, ill health or other misfortunes, we can make a claim with relative ease. Even though Australia’s insurers enjoy a reputation for fairness and reliability, insurance claims are invariably a formal and complicated process requiring much paperwork, verification and negotiation. Policy wordings vary greatly and cheapest can often mean that ‘fine print’ will work to your disadvantage (although this is not always the case). This article focuses on some of the more common and preventable claims issues within the area of personal risk insurances, namely Life, TPD, Critical Illness, Income Protection, Business Expense and Needlestick covers. 1. Meeting the Definition of Disability

2. Events covered under Critical Illness

Medical specialists have a very unique skill set which is naturally dependent on their physical function. For this reason, the definition of disability is perhaps the most important term in a Disability Insurance policy such as Income Protection or Total & Permanent Disability (TPD). Better definitions will not only be occupation specific, they will also contain criteria that are both reasonable and realistic. To illustrate, a surgeon with an injured dominant hand may still be able to consult with patients. pre- and post-op. A serious problem can therefore arise when a policy requires the individual to be unable to perform ‘any occupation’ before paying out a disability claim. Similarly, a policy that requires the inability to perform ‘all of the duties of one’s occupation’ is much more difficult to satisfy than say, ‘one of the important duties of one’s own occupation’. The most progressive of definitions for self-employed specialists will actually allow the claimant to work up to 10 hours per week without any reduction in their claimable benefits.

Critical Illness cover (also called Trauma) provides a lump sum benefit on diagnosis of defined events, irrespective on one’s ability to work. This makes both the breadth of the illnesses covers as well as the quality of their definitions of paramount importance. Today’s insurers compete by adding claimable events. Recent additions include diabetes, rheumatoid arthritis and severe burns. It is not uncommon for older policies to be missing what are now fairly standard events such as benign brain tumours, blindness, cardiomyopathy and kidney failure. The introduction of partial payments for early stage cancers and partial blindness and deafness make such upgrades even more important. Surprisingly, these conditions can generally be added without the need to pay any more for your Trauma cover (however, you may need to have your application accepted as part of the insurer’s underwriting process). Be sure to upgrade your policy ahead of such an event or before other changes to your health make the upgrade unviable.

The most progressive of definitions for self-employed specialists will actually allow the claimant to work up to 10 hours per week without any reduction in their claimable benefits. SURGICALLife

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3. Disclosure Matters Before you enter into a life insurance contract, you have a legal duty to disclose to the insurer every matter you know is relevant to the insurer’s decision. Your failure in meeting this duty when taking out the policy is the main ‘get out’ clause an insurer will consider when called upon to pay a claim. Conversely, thorough and thoughtful disclosures at the time of application will typically lead to a smooth claims process. There is often a tendency for applicants to assume that one’s medical issues are not worth noting, as they are not all that serious or are now long since passed. It is, however, prudent to err on the side of caution here. It is also important to note that your Duty of Disclosure continues until you are informed that your application is accepted. For this reason, it is important to have your applications progress through the underwriting process as effectively and efficiently as possible. A lack of specialist advice and assistance in this area can mean serious problems during a future claim. 4. Fast-Tracking the Claims Process Disability and Critical Illness claims will always require reports from the treating doctor/s. Alert them to this requirement and be sure to obtain the required forms as soon as possible, so that you are appropriately prepared during your next visit. It is also important to establish your first medical consult for the illness or injury that is the basis of your claim and most insurers start to count down the ‘waiting period’ from that first visit. Consequently, seeking medical advice sooner will only help you get paid faster. During most claims, insurers will conduct due diligence around your medical history to confirm that you had not failed to disclose any facts of material importance. The primary method of this

There is often a tendency for applicants to assume that one’s medical issues are not worth noting, as they are not all that serious or are now long since passed. is for the insurer to obtain your Medicare history information after receiving your authorisation. It is common for Medicare to take up to 6 weeks turnaround in providing this information, so it is crucial to get this form signed and sent to your insurers as soon as the claim is lodged. 5. Knowing When a Claim Can Be Made Which would you expect is more common: the policy holder puts in a claim when they have now valid claim or the policy holder who fails to put in a claim when they are actually entitled to a payout? In our experience, it is the later. This is partly due to the comprehensive nature of many policies today. Two recent examples from our practice include a lawyer paid out several hundred thousand dollars following a Clark Level 3 melanoma and an accountant who was paid a similar amount for having had heart valve surgery 2 years prior. Both clients had no idea that they could make a full claim under their trauma policies until it was explained to them as part of their insurance review process. Since the problem is about failing to understand a policy’s provisions rather than a lack of medical understanding, it is common for medical professionals to fail to realise a claim can be made. One of our surgical clients recently required several days of hospitalisation for having his gall stones removed. Even though the ‘waiting period’ on his income protection was the standard 30 days, he was able to make a claim on account of

being confined to bed and under medical supervision. Another medical specialist client reported a clavicle fracture from a recent skiing trip. He had concluded that no claim could be made, as he was back at work prior to the end of his waiting period. Again, his policy allowed for such a claim under the ‘Specified Injuries’ feature of his professional-grade policy. It is fair to say that some claims are too small to bother with. Nevertheless, it is worth knowing your potential claim— something your adviser should be able to explain to you with minimal effort on your part. 6. Claims Assistance Navigating your way through a claim can be an arduous process during a time that is invariably stressful and emotional. Even insurers with an excellent claims service require claimants to call 1300 numbers, fill in a barrage of forms and then take weeks to process basic tasks. It is therefore important that you and your loved ones have someone reliable and competent to assist with the process. As issues arise, it can be invaluable to have someone in your corner to negotiate a successful outcome on your behalf. Just as insurance needs to be in place prior to a claimable event, appointing the right people to help you and your family must be done prior to your time of need.  Aaron Zelman is a partner of specialist risk advisory firm, Priority Life. He can be contacted at aaron@prioritylife.com.au, 1300 12 24 36 or after hours at 0412 366643.

Disclaimer: This advice may not be suitable to you because it contains general advice that has not been tailored to your personal circumstances. Please seek personal financial and tax advice prior to acting on this information. Before acquiring a financial product a person should obtain a Product Disclosure Statement (PDS) relating to that product and consider the contents of the PDS before making a decision about whether to acquire the product. The material contained in this document is based on information received in good faith from sources within the market, and on our understanding of legislation and Government press releases at the date of publication, which are believed to be reliable and accurate. Opinions constitute our judgement at the time of issue and are subject to change. Neither, the Licensee or any of the National Australia group of companies, nor their employees or directors give any warranty of accuracy, nor accept any responsibility for errors or omissions in this document. David Davidson Financial Services Pty. Ltd. trading as Priority Life is an Authorised Representative 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.

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FinanciaL

strategies for Surgeons The principles to maximise your medical wealth 46

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ou’ve probably achieved a measure of financial success in your medical career. Your lifestyle is comfortable and you earn enough money to satisfy your everyday needs. But what I am about to discuss is a way to leverage your medical career to achieve true financial liberty—the choice of an early retirement, the ability to live and give to your family and community well beyond the years of your career and practice—this is an achievable and realistic option. As you approach the end of the financial year, it is a good time to pause and review to ensure you are not missing any key steps. It’s far too easy to become complacent in the presumption that you have ‘arrived’ (financially) now that you are a surgeon. You and I both know that your six years at medical school and then another seven or eight years of training and specialist exams to achieve this end have prepared you to fulfil your potential professionally. The same is true of your finances; the foundation that you choose to lay today will provide the platform to achieve your financial potential in the future.

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BUSINESS & FINANCE gearing. • Pay the maximum amount of superannuation annually (up to the Government allowed limit) and use gearing through non-recourse loans as needed to grow your superannuation in a stable, accelerated fashion. Contributions to superannuation must be in the member account prior to June 30 each year, the time is now to confirm you are maximising this opportunity. • Use gearing in investments and SMSFs to maximise the returns on your investments and to optimise tax deductions to reduce taxable income. Choose the Correct Legal Structure for Your Practice.

One trap many surgeons fall into is that they simply assume they will become wealthy, by default, and fail to take active control of their finances. As the proverb says, ‘The best time to plant a tree is twenty years ago. The next best time is now.’ The same applies to financial planning, especially as we approach the end of the financial year and position ourselves for the future. One trap many surgeons fall into is that they simply assume they will become wealthy, by default, and fail to take active control of their finances. Although every surgeon’s situation is unique, there are some fundamental financial strategies which apply to the majority of surgeons and should form part of your annual financial health check. Applying them will ensure that you are in the best position for the future and that you are protected in the present. Here are the most important financial rules for surgeons: • Choose the correct legal structure for your practice. This will usually be a trust based structure for most surgeons with the maximum amount of income distributed to lower tax rate beneficiaries and will usually include an investment

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company. • Claim every single deduction that is legitimately claimable including cars, home office expenses, phones, IT expenses, medical indemnity and income protection insurance as appropriate. • Structure non-deductible vs. deductible debt. This involves minimising and eliminating non-deductible debt (bad debt) connected to home purchases and renovations, through the careful management and re-cycling of work and investment cash flow. It also involves structuring your deductible debt (e.g. car loans or leases and business capital requirements to establish and operate your practice) so it is connected to your work/investments and deductible at the highest possible marginal rate. • Defer tax as far as possible and use the improved cash flow for investment strategies and non-deductible debt-elimination. • Invest in your home as a tax-free investment and additional properties from which you can benefit from negative

Choosing the correct structure for your medical practice is vital from day one. The two main reasons are asset protection and tax efficiency. The corporate structure of your practice is the financial foundation that can enhance how much wealth you are able to generate and retain from your business. It is extremely important to 'begin with the end in mind'. We find it disappointing to see medical specialists who take huge tax-hits after all those years of gruelling study and hard work, simply because they did not take the time upfront to ensure their corporate structure suited their business operation and growth plans. In general, the options will involve some combination of trusts and companies but the exact tree and arrangement of these should be determined by a quality accountant prior to even starting your business. If you are already operating under one structure and find out that this is not the best structure for you, rolling over to another business structure may have Capital Gains Tax implications. Be sure to check this before making any changes. A few of the issues to consider when choosing the legal structure for your practice include: • whether your assets will be protected from patient litigation risks • costs of setting up and running the structure • ability to share income with family

BUSINESS & FINANCE members and related trusts and companies • administrative simplicity • payroll tax and other employment oncosts • regulatory requirements • ability to change the ownership structure easily and cheaply • administration of GST compliance • the ability to pay fully deductible superannuation contributions for the practitioner and related persons. You should source a medical accountant with experience in structuring or restructuring medical practices to discuss your options. Claim Every Single Deduction that is Legitimately Claimable Many surgeons (and their advisors) don’t pursue every legitimate tax-deduction in fear of upsetting the tax-office or because they are unsure what is permissible. You should be guided by Tax Rulings which are the financial equivalent of ‘EvidenceBased Practice’ and where precedents can be used to clarify exactly what has been permitted in the past. Deductions which are commonly the source of confusion but are frequently applicable to surgeons include: • deductions related to investment property co-owned with your super fund • car-related Deductions • home Office Expenses • continuing education expenses (including overseas travel, accommodation, meals) • professional associations/ASA/AMA/ ANZCA fees • medical indemnity • income protection insurance • financial advisory fees. We all like to maximise our deductions. However, most surgeons will need some expert clarification to achieve this. Accept that there is a science to it and look to your tax advisor to simplify any grey areas of tax law. Non-deductible vs. Deductible Debt The difference between deductible and non-deductible debt lies in the after-tax cost. Non-deductible debt and interest

costs are repaid with after-tax income, while deductible debt reduces assessable income and hence provides a tax benefit. Debt generally becomes deductible when the purpose of the funds is to produce assessable income. All surgeons should aim to reduce or even eliminate all non-deductible debt (any borrowings on personal-use items e.g. homes, boats, lifestyle items etc) and to re-structure debt so it is connected to their work or investments and deductible at the highest possible marginal rate. This will usually tie in with how you restructure your whole cliniWe all like to maximise our deductions. cal practice and alter your However, most surgeons will need some borrowing from external entities (such as banks) and expert clarification to achieve this. also borrowing within entities you own (Division 7a loans). For surgeons who do private work, an optimised structure will usually involve a trust with an investment vehicle as one of the beneficiaries. In addition, a self-managed superannuation fund (for you, your spouse and up to two additional family members) will commonly be linked to your structures. Invest in Your Home as a Tax-free Investment Yes, your home is a lifestyle asset. Rarely will it be used to provide a passive investment income stream for you now or in retirement. And, as you know, while it may grow in value, so will every other house around you! Your home, however, is still a key part of your wealth accumulation strategy. Structured correctly to ensure asset protection, your home can provide a funding base for long-term investments that provide a virtuous cash cycle – lower tax

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BUSINESS & FINANCE

For surgeons who do private work, an optimised structure will usually involve a trust with an investment vehicle as one of the beneficiaries. to transfer assets to your super fund via in-specie contributions or via your super fund acquiring assets in co-invested unit trusts. All of these strategies can be used to lower the total cost of your investments, to increase the flow of non-contribution style funds to your SMSF where you have used up your contributions capacity, and beyond age 60 to generate a tax-free income stream while protecting your wealth in a capital-gains-tax-free environment. Don’t Let Time Pass You By... Most surgeons who come to us have rarely laid the basic foundation for optimising the generation and preservation of wealth. Many fail to integrate one or more of these strategies into their core wealth plan. What is described above is really only the tip of the iceberg with regards to financial planning for surgeons and I encourage you to begin the planning process in the early stages of your career. paid and investment income provide extra cash flow to reduce non-deductible debt, which is then replaced (re-cycled) with deductible investment debt to fund new investments, further lowering tax and increasing investment income to again pay down more private debt.

Use Gearing in Investments and SelfManaged Super Funds (SMSF)

Further, your home is a Capital Gains Tax free investment. It may be used to provide a rental income stream (with associated tax deductions) for extended trips away, and can be down-sized in retirement all without capital gains tax consequences.

A number of strategies are now possible to co-own assets with your super fund, to borrow within your super fund and leverage your investments in shares and property (commercial or residential), to lend money to your super fund (within limits) from related entities or businesses,

A self managed super fund is one of the most effective tax-shelters for the accumulation of wealth and the provision of passive income streams in retirement.

As the 'sage of Omaha' (Warren Buffett) said, 'Someone’s sitting in the shade today, because someone planted a tree a long time ago.' Adam Faulkner MEDIQ Medical Financial Services advises medical practices and individuals on structures, accounting, taxation and finance. Visit www.MEDIQfinancial.com.au to learn more tax and finance strategies for surgeons.

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You wouldn’t trust a non-specialist to operate on you or your family? So why trust a non-specialist with your finances?

Specialist Medical Accountants and Financial Planners for Doctors You will never need to explain ‘salary packaging’, ‘Medicare Safety Net’ or 'out-of-pocket' fees to us because we speak the same language as you. We think we know just about every tax deduction and financial planning secret for doctors and their medical practices because that’s what we have chosen to specialise in.

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SMSF

Downloading Indecent images

Queensland health care professionals deregistered and forced to use a chaperone Dr CB was a general practitioner. Mr TG was a medical radiation technologist. Mr BG was a pharmacist. All three were from Queensland.

r CB, the GP downloaded child pornography to his home computer. He downloaded between 20 and 100 images, on a single day. Unfortunately for him, his downloads were monitored by the Australian Federal Police, who passed on information to the Queensland Police.

Mr TG, the radiation technologist paid a monthly fee to access an Internet site that contained images of child pornography. He had a password to access the site, and visited it regularly from home, but never from work. His fiancĂŠ knew that he had been accessing the images for some time. The police discovered his use of the site and questioned him about it. He admitted that he might have accessed 'possibly up to 20 images.' The police examined his computer and

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The Tribunal desires to uphold professional standards and maintain public confidence in each of the health professions. found 2,634 images of child pornography. Many of them were images of naked children who were posing in a sexual manner. Others were images of sexual intercourse between children and adults. Mr BG, the pharmacist, downloaded 3,290 images while at home. He too did not access any of these images at work. Several of the images depicted what a judge called 'sadistic sexualised violence.' Mr BG saved the images in a folder called Glock (a brand of firearm) and hid his activities from his wife. Dr CB, the GP, pleaded guilty to accessing child exploitation images and was given a suspended sentence in November 2010. Mr TG, the medical radiation technologist, pleaded guilty to possession of child exploitation images and was also given a suspended sentence. Mr BG, the pharmacist, pleaded guilty to accessing and possessing child pornography and child abuse material, and was given a suspended sentence with a $100 bond. The Queensland Civil and Administrative Tribunal then had to consider what to do about their registrations in their respective areas. Dr CB accessed all of the images in his case in a single day. The Tribunal indicated that he was driven by depression and relationship issues, and that he did not gain sexual gratification from the images he had downloaded. The Tribunal decided that because Mr TG was paying a monthly fee, and had a password to enter, the child pornography website in his case, his interest in the images was not passing or incidental. The fact that he did not access the images from work counts in his favour somewhat but that did not prevent him from being deregistered as a health professional. The Tribunal said 'it reflects upon his character that he knowingly participated in criminal conduct. This brings into question whether he possesses the qualities expected of a member of the profession.'

concern over his 'professionalism', given his knowing engagement in criminal conduct. The Tribunal said that the crimes were 'not victimless'. Disciplinary proceedings are not intended to be punitive. However, the proceedings are designed to protect the public, so deterrence is one of the matters considered by the Tribunal in deciding whether to deregister a professional, and if so, for how long. The Tribunal desires to uphold professional standards and maintain public confidence in each of the health professions. The Medical Board of Queensland said that the board was obligated to take the least 'onerous' action to protect the well-being of “vulnerable persons”, being patients under the age of 18. Dr CB was suspended from admitting patients to the local hospital. Although he was not deregistered, he is required to have a chaperone whenever he is with a person under 18 years old, for three years during his sentence. The Tribunal decided that Mr BG presented less risk to patients because he had not come into physical contact with a child, and pharmacists do not generally have one-on-one consultations with their customers. The Tribunal chose to deregister Mr BG for two years, starting March 2010. In contrast, the practice of medical radiation does involve unsupervised contact with patients, including children. Patients, including adolescents, are alone with the technologist. The lights are dimmed and the patients are in a state of undress. The technologist must touch the patient to position them correctly. The Tribunal decided that this made the radiation technologist’s case far more serious. The radiation technologist was therefore deregistered for three and a half years. The Tribunal observed that protection of the public is a primary concern in its decisions. These cases also demonstrate that actions taken by a health care professional in their private life, apparently unconnected with their work, can count against them professionally. Dr Richard Cavell

In the case of Mr BG, the Tribunal said that the offences were not concerned with his practice of pharmacy. However, there was a

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Boy Scarred for Life after GP Performs an Elective Circumcision Plastibell obscures urethral meatus Dr MJ is a general practitioner from the Osmania Medical School in Andhra Pradesh, India. He works in Victoria and has done a total of 1565 circumcisions throughout his career.

The Royal Children’s Hospital in Melbourne had decided that it will no longer perform non-therapeutic circumcisions.

he Royal Children’s Hospital in Melbourne had decided that it will no longer perform non-therapeutic circumcisions. As a result, doctors such as Dr MJ have taken on the task of performing circumcisions for cultural or religious purposes.

A boy of 26 months was referred to Dr MJ for an elective circumcision. The boy was a Type I diabetic. Dr MJ saw him and performed a circumcision using a Plastibell the same day. During the procedure, the boy was ‘extremely distressed’ and his father and grandfather held him down. The Plastibell was invented in 1950, and has a complication rate of 1.8%. More than 50% of circumcisions in the United States are performed with a Plastibell. It is a clear plastic ring with a groove. It is applied to the head of the penis, and a ligature is tied firmly around the foreskin, crushing it into the Plastibell’s groove. The ring normally falls off in 3 to 7 days.

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CAREERS RISK MANAGEMENT

After the procedure, the boy was sent home. Later that night, his father was concerned that he could not pass urine and phoned Dr MJ. Dr MJ told his father to give him liquid, believing that his inability to pass urine would have been from the psychological shock of the procedure. The next day the boy’s parents took him by ambulance to the Royal Children’s Hospital, where it was found that a section of the foreskin’s inner layer had been trapped across the Plastibell ring causing a complete occlusion to the urethral meatus. The child subsequently developed Fournier’s gangrene, which is naturally more prevalent in diabetics, and has a mortality rate approaching 40%. Most patients would frequently require surgical debridement of the perineum. To date, the boy in this case has had six operations and has severe scarring to his groin and abdomen. He has lost part of his scrotum and required skin grafts. A further two operations are planned. The head of urology at the Royal Children’s Hospital in Melbourne took the opportunity while giving evidence at the Tribunal to express his concern at the fact that the hospital is refusing to carry out elective circumcision procedures. The hospital’s refusal to perform circumcisions is in line with government policy, but may expose patients to an increased complication rate. The Victorian Civil and Administrative Tribunal found that Dr MJ had engaged in unprofessional conduct. They considered that a Type I diabetic boy should have been treated in a hospital with the availability of an anaesthetist, rather than a GP in his private clinic. The Tribunal also suggested that a 26-month-old was too old to be treated in a private clinic. An older boy is capable of feeling distressed, squirming and interfering with the procedure. Also, Dr MJ appears not to have checked the urethral meatus at the end of the procedure, as he should have.

More than 50% of circumcisions in the United States are performed with a Plastibell.

Unfortunately, this is the fourth time that Dr MJ had been found guilty of unprofessional conduct. His registration was cancelled for three months and restrictions were placed on his future practice. In particular, Dr MJ was forbidden from performing circumcisions on boys between four months and five years old. The Tribunal found that in Dr MJ’s future practice, such boys should be treated by a paediatric surgeon. The Tribunal also found that any boy over 5 years old should be properly anaesthetised, as should any Type I diabetic. The Tribunal had stated that these rules apply only to Dr MJ, and had not created them as rules that are binding on all general practitioners. However, there is nothing about Dr MJ’s practice of performing circumcisions that is unique. This case sets a precedent which may result in these rules becoming formalised in the future and becoming applicable to all medical practitioners. Dr Richard Cavell

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Nowadays, if you have a blocked drain, the plumber will come armed with an endoscope that makes the one used by Dr Young in the early twentieth century look as primitive as it was. Yet Young was able to make several discoveries with his ‘ancient’ endoscopic equipment. In fact, Hugh Hampton Young as the chairman of the Urology Service at the Johns Hopkins Hospital in Baltimore pioneered the use of the cystoscope, and much more.

oung was born on 18 September 1870, five years after the end of the American Civil War, when Ulysses Simpson Grant was the 18th President of the United States, Queen Victoria ruled England, diamonds were discovered in South Africa, Vladimir Lenin was born in Russia, and both the Australian poet Adam Lindsay Gordon and the English novelist Charles Dickens died. Hugh Hampton Young was born in San Antonio, Texas where he spent most of his early life, before he moved to Charlottesville to study at the University of Virginia, from where he graduated at only 21 years of age in 1891, acquiring BA, MA, and MD degrees in just four years.

Hugh Hampton Young Urologist, leader and inventor 56

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A German Physicist, Wilhelm Conrad Röntgen, whose invention was to greatly assist Young’s work, was 25 years old when Young’s mother gave birth to the urological genius. However, Röntgen was still 25 years from the discovery of the X-rays, which was in November 1895. The budding urologist would use the discovery—made just months after Young was appointed to a teaching role at the Johns Hopkins Institute—to develop urinary tract investigations. The impressive new appointee became Head of the Urology Service in November 1897—at the age of 27— and held the position until 1941. His achievements in urology were so significant that he is the only person to have ever had his obituary published in the Journal of Urology. He also had an American Urology Association medal named in his honour. Fortunately, his wider contributions to science and medicine were also recognised during his lifetime. This included the Keyes Medal from the American Association of Genito-Urinary Surgeons in 1937, for an ‘outstanding contributions in the advancement of Urology’, of which he was the third of only 29 recipients. He is one of the few urologists to receive the Francis Amory Septennial Medal, from the American Academy of Arts and Science, which

MEDICAL LEGENDS

His achievements in urology were so significant that he is the only person to have ever had his obituary published in the Journal of Urology. was awarded in 1940. In addition to his numerous awards, Hugh Hampton Young was president of many medical organisations: in 1908, he was President of the American Urological Association; two years later he was President of the American Association of Genito-Urinary Surgeons; in 1912, President of the Medical and Chirurgical Faculty of the State of Maryland; and in 1925, President of the Clinical Society. Young's contributions also included several inventions and discoveries, primarily relating to surgery. Significantly, the antiseptic, merbromin, more popularly known as Mercurochrome, was developed in association with colleagues. He developed the ‘boomerang surgical needle’, which was designed for working with deep incisions and he also invented the Young punch, an instrument used in prostatectomy procedures and for the obliteration of congenital posterior urethral obstruction. After using a perineal approach for prostatic outlet obstruction in 1903, Young performed the first radical perineal prostatectomy for cancer of the prostate on 7 April 1904, assisted by Dr. William S. Halsted, who had performed the first radical mastectomy in 1882. Some years later, Young developed the bladder neck enhancement operation now know as the Young-Dees procedure and then published the first classification of congenital posterior urethral obstruction. The United States entered World War I on 6 April 1917 and Young left on 29 May for Birkenhead, England as a Major aboard the Baltic. Yet despite all this, it did not slow or hinder Young’s pace of achievements. Incredibly this was the same year that the first edition of the Journal of Urology hit the shelves, with Young as the founding editor. He also completed a 300-page Manual of Military Urology in January 1918, after

being appointed by the chief surgeon as the Director of Urology for the military services where he was to oversee the venereal health of the Doughboys in France, a position which led to his campaign against prostitution near American bases. Amongst Young’s many publications was his textbook, Young's Practice of Urology, which was co-authored by David M. Davis, published in two volumes, in 1926, by W. B. Saunders. The text represents a treatise on the diagnosis and treatment of many urological conditions based on his experience gained from the care of 12,500 patients seen in the James Buchanan Brady Institute, located at the Johns Hopkins Hospital, which Young was instrumental in establishing. Two papers that represent Young’s contribution to Paediatric Urology were those on the classification of congenital posterior urethral obstruction. The first, 63 pages in length, produced a six-part classification based on 12 patients, published in the journal he had established two years earlier. The second paper, created 10 years later, only added a further nine patients with a diagnosis that exists now, particularly with the assistance of prenatal ultrasonography, commonly seen in paediatric urological clinics. Taking on board all his contributions, one can well imagine how Young’s busy schedule caused him to miss the inconsistencies between the 1919 and 1929 illustrations of the classification. Also, it would not surprise readers to know that modern radiological and endoscopic equipment have provided new information to suggest that the earlier iterations of these investigative tools had been misconstrued. For example, the obstruction being a congenital posterior urethral membrane, rather than posterior urethral valves that Young had suggested. Although the variation from Young’s original description should not be seen to

detract from the enormity of his developments in a vast array of activities. Young's participation in his community was also legendary. He had interests in music which encouraged him to raise money to purchase and renovate the Lyric Theatre, so the Metropolitan Opera Company could continue to perform in Baltimore. Some of his many campaigns included focus on the treatment of tuberculosis, the establishment of a Municipal Hospital for the insane, the establishment of the School of Engineering at the Johns Hopkins University and acquisition of the portraits of the Lords Baltimore. His interest in aviation culminated in Young being appointed as the chairman of the planning committee for the Friendship Airport (now the Baltimore Washington International Airport), in 1929. Despite his many interests, Young also found time to attend the 1932 Democratic National Convention to support his friend Albert Richie’s presidential nomination against Franklin Delano Roosevelt. Even now, we are reminded of Hugh Hampton Young in many ways, not the least of which is a bust commissioned by his friend, Robert ‘Bob’ Worth Bingham and created by the famous British sculptor, Claire Sheridan. It was unveiled at the University of Virginia and now sits in the James Buchanan Brady Institute Library of the Johns Hoskins Hospital. A possibly apocryphal story has emerged about Young responding to a woman in the audience at the unveiling ceremony. When she said, ‘I hope you appreciate that I have come fifty miles to see your bust unveiled’, he said, ‘I would go a thousand to see yours.’ Professor Paddy Dewan, MBBS PhD MD MS BMedSc MMedSc MRACMA MAICD FRCS FRACS Paediatric Surgeon/ Urologist

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The

TOP

FIVE Digital SLRs

2010 was a peculiar year for the digital SLR.

or the entire first half of the year, virtually no new cameras were released. There was no news about upcoming cameras, and no indication about what the manufacturers were planning next.

And then - towards the very end of the year â&#x20AC;&#x201C; eight new cameras were released within the span of two months. Anyone considering the purchase of a new digital SLR was quite suddenly overwhelmed with options. The bad news is that you now have a lot of cameras to compare and contrast. The good news is that all of these new cameras leverage the latest technical innovations to help make your photos and videos look spectacular.

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ALPHA

anon long ago established itself as the dominant player in the digital SLR market.

They were one of the first to develop digital SLRs and were also the first to lower prices enough so that amateur and beginning photographers could buy them. Canon has four distinct lines of cameras: beginner, intermediate, advanced and professional. The 60D is one of their intermediate models. The 60D interests more advanced photographers for a variety of reasons. The first one is speed: a high-performance 9-point autofocus is paired with the ability to capture 5 consecutive photos per second. To further distinguish itself, the Canon 60D has a robust video mode. It captures Full High Definition 1080p video clips that can be played back on computer LCD screens and widescreen televisions.

The 60D interests more advanced photographers for a variety of reasons. The first one is speed: a highperformance 9-point autofocus is paired with the ability to capture 5 consecutive photos per second. The most notable aspect of the 60D is its LCD screen. This is the first time that Canon has applied a flexible LCD (one that flips out from the camera and rotates) to one of their DSLRs.

The flexible LCD is immensely useful when you capture video – it lets you see exactly what you’re capturing even when you’re not holding the camera right up in front of your face.

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59 59

he D7000 has two memory card slots instead of just one and you can customise how data is stored. For example, if you want to keep videos separate from photos, you can save still images to one card and videos to the other. The E-5 takes weather sealing to the next level: you can expose it to rain and dust without having to worry about damaging the camera. Like the Canon 60D, the 3 inch LCD on the E-5 flips out from the camera body and swivels 270 degrees for easy viewing from all angles. This flexible LCD can be used to capture High Definition 720p video – a first for an Olympus digital SLR camera. Those who want superior sound quality can connect a stereo microphone to a built-in port. To reduce image blur due to camera shake, the E-5 includes a built-in image

stabilisation system. This system works with any Olympus Zuiko Four Thirds® lens, and it’s a great tool for photographers who want to take pictures in dim light without flash. For creative types, the E-5 has a variety of art filters that can be applied to any image on the memory card. These filters allow you to manipulate the look of your images in camera, without having to spend extra time in front of your computer. Some of the 10 filters include Pop Art, Soft Focus, Grainy Film, Gentle Sepia and the latest addition: Dramatic Tone. Each year, digital SLRs get better at taking pictures in dim ambient light. They are able to do this because of a feature called ISO, which affects how quickly the sensor absorbs light. With very high ISO settings, you can take pictures in

The E-5 has a variety of art filters that can be applied to any image on the memory card allowing you to manipulate the look of your images in camera, without having to spend extra time in front of your computer. 60

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low light without needing a flash.

n older DSLRs, 6400 was considered a pretty high ISO. The Pentax K-5 trumps that with a maximum ISO of 51200 – the highest of any DSLR currently available. The high ISO setting would be impressive enough, but the K-5 has plenty of other features to keep photographers happy: a faster improved 11-point autofocus is paired with the ability to capture 7 photos per second. Video enthusiasts can capture Full High Definition 1080p movies and still photographers can snap blur-free shots thanks to the built-in image stabilisation.

Sony SLTA55

ven though the Sony SLT-A55 isn’t a “true” digital SLR, it still belongs in this lineup because of its unique innovation.

For landscape photographers, a built-in High Dynamic Range (HDR) mode helps to capture nature in all its glory, preserving details in every part of the image.

The K-5 is compatible with every Pentax lens ever made, great news for anyone with a collection of old Pentax film SLR lenses.

Many digital SLRs cannot leverage the power of their multi-point autofocus systems when you take video. This is due to a mirror inside the camera that reflects the image from the lens up to the viewfinder. In movie mode, the mirror must be locked up – this blocks the viewfinder and disables the autofocus system. DSLRs with mirrors rely on an alternate form of autofocus called contrast detection which is terribly slow.

ALPHA

through the mirror to the camera’s sensor, you can continuously focus in movie mode with no loss of autofocus speed. A second benefit of this new system is that the camera is capable of capturing images at an astounding rate of 10 per second – a great tool for sports photographers who want to capture the peak of the action. The flexible 3 inch LCD works equally well for stills as for video, and a sweep panorama mode lets you capture majestic landscapes merely by pressing and holding the shutter button.

Sony has eliminated this problem by placing a semi-transparent mirror inside the SLT-A55. Since some light passes

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ALPHA

ne thing is for sure: the Nikon D7000 is built with durability in mind.

The camera borrows its body material – magnesium alloy – from Nikon’s line of professional cameras. Its shutter can capture images at a rate of 6 per second and is rated for 150,000 activations. The D7000 has a Full High Definition 1080p video mode, activated via the press of a single button on the camera’s back. This makes it easy to capture a video in the middle of a photo shoot. The 3 inch LCD screen is not flexible, but it does have a live view mode so you can preview the image you’re about to take. Unlike its predecessor the Nikon D90, the D7000 can autofocus during movie capture. It can also control multiple remote flash units, and with an added GPS accessory it keeps track of location information for every photo you take.

Chris Roberts, since 2005, has been providing photographers with straightforward plain-English information about digital SLR cameras, lenses and accessories through his web site, The Digital SLR Guide.

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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

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LIFESTYLE

Floods stink A limited vintage for 2011

was a teenager when the 1974 floods wrought havoc in my hometown of Brisbane. I remember listening to the radio reports with fear, awe and guilty gratitude that my parents had the foresight to build our home far from angry waterways. When the rain finally stopped and the floodwaters began to subside, we emerged from our safe, dry haven and were shocked at what we saw. We wanted to help. We needed to help. It was the last week of the school holidays and tuck shop mums ferried carloads of teens to the muddied suburbs, where we queued for a tetanus jab, then headed for a house (any house) to start work. Our soft student hands blistered after about an hour of shovelling muck. By day three they were as tough as navvies. We worked incredibly hard, but not always effectively. Well, none of us had ever before cleaned a house which had been completely submerged by river water. Who knew you had to check the roof cavity for dead livestock before starting to mop the floors and walls? When the ceiling of the lounge room we had enthusiastically cleaned began to groan and buckle, we suspected we were in trouble. But, like typical teenagers, we ignored the warning

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Who knew you had to check the roof cavity for dead livestock before starting to mop the floors and walls?

LIFESTYLE

be serious impacts for grape growers up and down the Eastern seaboard. Obviously, complete immersion can be catastrophic for vines, and growers from South-East Queensland to South-West Victoria and even Tasmania have lost complete crops. And that’s not all. Areas which escaped the path of floodwaters can still be affected. Heavy rains and high humidity bring the ravages of powdery mildew and botrytis, which can seriously compromise fruit quality. It’s clear that we can expect a limited vintage in 2011. Australian wine producers are accustomed to doing it tough. The ubiquitous wine glut has been forcing prices ever downward. The big retail chains add to pricing pressures, and competition from imports (from New Zealand, for example) has never been stronger. For some, this may be the final straw.

Kaeserberg Vineyard in Queensland Photos by Jason Kaeser

signs. The bulging ceiling finally gave way with an ugly ripping sound, spewing onto the floor mud, water, and (to our enormous surprise) a dead cow. There’s something truly unforgettable about the sight of a bloated beast in the middle of the lounge room floor. I’m sure it’s no coincidence that the thing I remember most strongly about those humid, muddy days is the incredible stink. As it happens, I was back in Brisbane in January this year, just as the 2011 floodwaters began to recede. Glued to the radio, as I had been all those years earlier, I listened to the stories of the heartbroken, the frightened, and the stoic. Once again, from all over Brisbane and well beyond, friends, neighbours and absolute strangers came together for the cleanup. Carloads, truckloads, and busloads of wonderful

people put in days and weeks of sweaty, stinky, and sometimes dangerous, work to help out. Why? Because they could. Then, just as they were shovelling the last of the putrid silt from bedrooms and lounges, along came Yasi to terrorise the Queenslanders of the north. Thankfully, early warnings, and sound infrastructure kept casualties amazingly low. But the damage has been well and truly done. Through all this, hard working people across rural Australia quietly and warily prepared for their own wall of water to descend. Forewarned may well be forearmed, but it certainly isn’t fun. I am filled with admiration and compassion for them all.

Many of us, particularly city-dwellers, will be only indirectly affected: no rivers will flow through our bedrooms; our livelihoods may not be lost. Our pain will be mostly supermarket-based, as prices soar to match demand. But it’s time to show where our loyalties lie, and support our brave and tenacious Australian growers: Send those flawless lemons back to California! Bring me the Aussie citrus! So what if they’re a bit spotty? (Who eats lemon skin anyway?) And drink up! Those of you in the medical fraternity are well-apprised of the health benefits – and it’s time to spread the joy! Take yourself to your local bottle shop (an independent, if you can find one!), or pick up the phone and call the friendly wine advisor at your wine club, and make a purchase of quality Australian wine. Then sit down with a kindred spirit and enjoy a delicious, heart-friendly, antioxidant laden glass of rural recovery. That warm glow you feel may not be alcohol related at all. Gillian Hyde, ten years ago, 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

As with all primary producers, there will

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Life on the Edge SURGICALLife

TRAVEL

A hotel on the edge of the Zambezi River is near neighbour to the mighty Victoria Falls. Hilary Doling follows in the footsteps of Livingstone—but in a lot more luxury. "Is that a croc or a rock?" asks my companion as our water taxi buzzes like a tsetse fly across the surface of the Zambezi River in Zambia. Over the other side of the boat a hippo rises like doe from the depths, just its nostrils and eyes showing, and surveys us with disinterest. This has to be the world's best hotel arrival. Ahead of us, the spray from mighty Victoria Falls rises hundreds of metres into the air and, as the water gathers speed toward the edge of the falls, I am more than a little relieved when our tiny boat swings towards the landing stage of The Royal Livingstone Hotel. We've been tipped straight from the plane into the heart of Africa, to the place where Livingstone first set eyes on the falls and named them after his queen. The locals of the time called the rushing water 'The Smoke That Roars' (Mosi-oa-Tunya) and fewer are closer to the Big Smoke than The Royal Livingstone. Any closer and we’d be plunging over. Liveried staff are waiting at the private dock with African-sunset coloured cocktails and cold towels. Soaked by spray, my sun hat appears to be wilting in the heat and I’m not far behind it, so the cold towel is more than welcome . Although it was only built in 2001, The Royal Livingstone has channelled its namesake in a big way. It oozes colonial charm from the wind-up gramophone on its terrace to the triple gin and tonics served in the bar. (I like this place already). Oh, and did I mention the

Opposite page: Aerial view of The Royal Livingstone and Victoria Falls. Left: Exterior view of The Royal Livingstone at night

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TRAVEL

Liveried staff are waiting at the private dock with African-sunset coloured cocktails and cold towels.

Cocktails on the Sundeck

cucumber sandwiches for afternoon tea. There is a languid charm about the place that instantly relaxes you. Perhaps it’s the easy charm of the Zambian staff, or Internet slower than snail-mail, which means crack-berry types are forced to wind down, or the sound of the Zambezi constantly flowing past the edge of the manicured lawns, which makes me so relaxed. Or perhaps it’s the size of those damned gins. Whatever the reason, by late afternoon I am so relaxed I’m virtually catatonic. It is all I can do to leaf indolently through the

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pages of my novel and gaze at the river and those smoking falls. At breakfast the next morning, zebras graze gently on the hotel grass as we drink our morning cup of tea and, when my guard is down, a monkey leaps onto the breakfast table and grabs a handful of sugar packets. I flap my white linen napkin but it is too little too late. Evading capture by the groundsman, he shoots off across the lawn and sits triumphantly in the nearest tree, pouring the packets down his throat as fast as he can—now that’s one speedy monkey that really

didn’t need a sugar high. Later, I see him running round and round the edge of the swimming pool with the guard in hot, but ineffective pursuit. Rooms at Royal Livingstone are in ostrich-egg cream-coloured buildings which fan out on either side of the main lobby. The decor is suitably ‘Out of Africa’ with wooden bed-heads, animal prints on the wall, black and white tiled bathroom floors and marble-edged baths. The rooms are set for a ‘refresh’, as they call them in the trade, and the new rooms will have shades of mint green and white

TRAVEL

The Courtyard

The Royal Livingstone has channelled its namesake in a big way. It oozes colonial charm from the wind up gramophone on its terrace to the triple gin and tonics served in the bar. nets draped romantically over the beds. Balconies will be enclosed so that guests can sit out on warm nights and not be bothered by mosquitoes or anything else beginning with “M”(Take that, monkey). One afternoon we fly over the falls and see just how close our hotel is to the edge, closer than the orange ring of its

sister property Zambezi Sun and closer than Elephant Hills and the historic but faded Victoria Falls Hotel over the border in Zimbabwe. From here it looks as if the hotels are facing each other across a tiny crack in a pond not a yawning canyon cut by the relentless river. Another day we take a boat trip out to

Livingstone Island and I stand in the very spot where Livingston first saw the falls and called them ‘The most wonderful sight I have witnessed in Africa'. I am inclined to agree. This is my fourth visit to Mosi- oa- Tunya and I’ve seen her in many moods. I wouldn’t be standing here in the rainy season because the island would be virtually submerged. After

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TRAVEL

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TRAVEL TRAVEL

The Sundeck

At breakfast the next morning zebra graze gently on the hotel grass as we drink our morning cup of tea the rainfalls, thunder strikes so loudly you almost need earplugs and the spray rises so high into the sky you think it will soak the planes. This time, however, it is dry season and the falls are in a quieter mood. It means that those braver than I can clamber out and swim in the Devilâ&#x20AC;&#x2122;s Pool on the very, very edge. Back at the hotel, white canopied massage tents have been set up at the very edge of the river, their muslin curtains blowing gently in the breeze.

Strong hands knead away the knots, while I listen to the sound of the river and the strange bassoon cry of the hippos. When I come out of my massage the sun is a blood orange in the sky. It looks as if its juice is leaking into the river, a shiny red trail that glimmers across the water as the sun setsâ&#x20AC;&#x201D;the end of another perfect day in Africa.

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TRAVEL

NIAGARA FALLS, Canada/USA Obviously the most famous falls in the US and possibly the most visited in the world . This powerful waterfall ranks as the largest one by volume of water with an impressive average of 2.8 million litres a second pouring over. Don’t expect to have these falls to yourself, as Niagara is tourism central. It is worth queuing to ride the boats which take you to the bottom of the falls, packed full of tourists in multi-coloured plastic raincoats. Stay at: Sheraton on the Falls, www.sheratononthefalls.com

VICTORIA FALLS (MOSI-OA-TUNYA), Zambia/ Zimbabwe The largest singular waterfall in the world, spanning a width of 1.7 km, a height of 108 m, and an average flow of 1 million litres per second. It’s no wonder this ‘smoke that roars ‘ is a UNESCO World Heritage site. At the end of the rainy season when the falls are at their fullest, you really will find the end of the rainbow here, as completely circular rainbows dance all around you. Stay at: The Royal Livingstone, www.suninternational.com

World's Great

Waterfalls IGUAZU FALLS, Argentina/Brazil It takes a long time to walk around these stretched out falls which are actually 275 individual cascades combined. However, a series of catwalks makes exploring easy. Little yellow butterflies dot the route and rainforest curls down to the catwalks. Its brink spans a distance of 2 km and its average flow is 1.3 million litres a second. Stay at: Hotel das Cataratas, www.hoteldascataratas. com

ANGEL FALLS, Venezuela These are the falls where they shot The Mission (remember the priest plummeting over the falls?) Now that is some way to fall! Widely credited with being the world’s tallest falls, the water drops a staggering 979m from a mysterious tabletop mountain in the heart of the Venezuelan rainforest. The biggest mystery of all is its source. There is no river, just the moisture from the cloud forest on the plateau. Stay at: Waku Lodge, www.wakulodge.com

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Hilary Doling is Editor in Chief of www.Luxurytravelbible.com, the world’s ultimate on-line destination guide. For further hotel information contact www.suninternational. com. South African Airways flies to Zambia from Australia, for flight details contact www.flysaa.com.

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