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Surgicallife SEPTEMBER/OCTOBER 2011

Our Dirty, Cheap, Fuel Addiction Breaking carbon’s bond

Surviving the ‘Hot Tub’ A personal experience of joint expert conferences and evidence

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When Doctors Collide Why are we prone to conflict with other doctors?


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Highlights

26 32 48

I Dont Know What To Say

52

Our Dirty, Cheap, Fuel Addiction

Communicating with surgeons in the modern era

When Doctors Collide

Departments 10 Features 36 Business & Finance 48 Risk Management

Recognising the triggers and communication flaws which make us prone to conflict with other doctors

52 Alpha

Surviving the 'Hot Tub'

62 Lifestyle

A personal experience of joint expert conferences and evidence

Breaking carbon's bond

58 Arts 70 Travel


FEATURES Doctor, Doctor Can You Help Me?

How to negotiate the doctor/family member relationship?

Making Peace With My Pacemaker Medical transparency towards the end of life

Myth and Magic in Western Medicine From the West to the East

10 14 20

I Don’t Know What To Say

Communicating with surgeons in the modern era

26

When Doctors Collide

Recognising the triggers and communication flaws which make us prone to conflict with other doctors

32

BUSINESS & FINANCE Trading Strategies Getting value for your investing dollar

Personal Services Income What is it and how does it affect me?

Insurance Premiums To claim or not to claim?

36 40 44

RISK MANAGEMENT Surviving The 'Hot Tub'

A personal experience of joint expert conferences and evidence

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48

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52 70

58 ALPHA Our Dirty, Cheap, Fuel Addiction Breaking carbon’s bond

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ARTS A Beginner’s Guide To Australian Art Collecting or investing?

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LIFESTYLE Doctors, Diet And Exercise Do we practice what we preach?

Your Own Clinic

Creating better patient care and a flexible lifestyle

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TRAVEL A Walk With The Kobo Daishi

Searching for nirvana atop Japan’s holy mountain

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Surgicallife

Editor’s Note

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elcome to the September / October Edition of Surgical Life. We hope that you enjoyed the last edition. Our feature article ‘Why doctors are targets of fraud’ received a positive response, with personal stories and examples that have since been sent into us bringing to light some recent cases here in Australia. We trust that this article will increase your awareness and encourage further due diligence.

Our team’s recent interactions with doctors and administration staff also sparked ideas for articles in this edition – particularly the importance of communication. Research has been swamped with evidence indicating that when doctors use communication skills effectively, both they and their patients benefit. But there are also huge gains to be made through improved methods of communication between colleagues and staff. This edition includes a powerful example of an interaction between doctors that clearly demonstrates the lack of effective communication. Another article looks at some of the ways you can avoid or dilute negative interactions through effective conflict management strategies. We hope you will find these articles both useful and interesting. Finally, we are also thrilled to introduce a new ‘Arts’ section to the magazine. We are passionate about celebrating the talent of doctors outside of medicine and welcome ideas/articles about your creative past times. Please feel free to send your contributions to editor@medical-life.com.au Regards,

health...wealth...lifestyle...

SEPTEMBER/OCTOBER 2011

Selina Vasdev

Editor selina@medical-life.com.au Contributing Sources

Dr. Tony Blinde Dr. Lisa-ferrier Brown Sammy Carroll Dr. John England Dr. Anne Harrison Dr. Michael Levitt Dr. Rebecca Lim Dr. Richard Middleton Dr. Ranjana Srivashtava Jane Wilkinson 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. Editorial Please direct all inquiries and submissions to: Medical Life Publishing PO Box 2471, Mount Waverley VIC 3149 Phone: 03 9001 6373 Fax: 03 9923 6662 Email: mail@medical-life.com.au Advertising

Selina Vasdev Editor

Joe Korac Phone: 02 9872 7708 Fax: 02 9872 1002 Mobile: 0414 487 199 Email: joe@medical-life.com.au

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.

CAB Member


Surgic allife MAY/JUN

E 2011

LETTERS TO THE EDITOR

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hank you to all those individuals and groups who have written in to us at Surgical Life with your comments, suggestions and replies to articles. We will continue to take on board your feedback whilst helping educate and inform you on matters of business, finance and lifestyle. Your feedback and thoughts are appreciated and encouraged. Please continue sending in your comments and letters to editor@medical-life.com.au marked letters to the editor.

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Dear Editor, Commission Against Corruption) enquiry found that the whistleblowers were generally unreliable witnesses. Some of the whistleblowers were themselves under investigation at the time they went public. Their only vindication was a settlement for wrongful dismissal (an error in process) for Multiple enquiries spent millions of dollars three of them. The negligence that was found to find clinicians to blame, rather than was evidence of severe Government neglect NSW Health. After abuse of its legislation of facilities for a health service rapidly by NSW HCCC (Health Care Complaints being outgrown by its community and that Commission) in its initial investigation community's needs. The Facilities' clinical by denying right of reply toinpractitioners the austRalian in the austRalian review process (from which material was healthCaRe healthCaRe sYsteM involved (pretty well every doctor insYsteM the taken to the media) suffered a mortal blow Service), middle of the night legislation Ethics, professionalism was Ethics, professionalism and healthcare management and healthcare management and are now just getting back to the standard passed in the NSW Parliament to prevent they were when it all started. Campbelltown practitioners from suing the HCCC. Through multiple case reports and Since then, this process has been given credit enquiries, not a single clinician (doctor, for improvements in services in Camden nurse or allied health person) was found to and Campbelltown but this coincided with be negligent. Many careers were cut short improvements which were already starting to and a number of attempted suicides and take place and which have continued since heart attacks ensued. with the commencement of the UWS Medical School. The publicity did improve funding Patients delayed treatment, and many staff and also resulted in better support from positions remained unfilled during the process. Litigation nearby better staffed and equipped health facilities. The against Campbelltown practitioners increased dramatically. scars still remain however. In the end, the media and opposition politicians simply dropped the issue when a NSW ICAC (Independent Dr. Andrew Gatenby, VMO Surgeon, NSW MY INTEREST in your article in Surgical Life, May/June 2011 on whistleblowers turned to horror when I read your conclusions on Camden and Campbelltown hospitals.

RISK MANAGEMENT

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

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LETTERS TO THE EDITOR

Dear Medical Life,

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Tim Field, founder a pea ent ms ‘bu run like on states deeply sectorbestaff junior Doctor goes on to say, “The atmosphere in bullying advice line in the UK, Thehealthcare g.that tive of can ility the operating theatre was tense. The criticism comprise about 12% of the thin 5000kin calls his service receivesarly yearly,indica lying fac e car is cle(6-8%).nt in app continued, if not with words, then with sighs and angry ahead of social services (10%) andlth the voluntary nt sector a hea gthepla alism’ inhere sin ion tutting. The staff had all seen this happen many times According to Field, experiences such as one described here are ces t rat pro ic tha It blems before—hard working, pleasant trainees reduced to nonare common. ‘econom ly so? the pro ion ories of y is this sad obvious, functioning wrecks in the space of an operation. ... I didn’t istrat olly the statee.ofWh Admin It’s not just in thewe woworrying know what to do. I felt uncomfortable continuing UK affairstoisgra thesp the as of such rethat this n in lth car ugh t ls same ulatio pitaUnited distress. Either my consultant didn’t Ad notice or she didn’t case. hos States, several studies ereport of the to hea tho a culture te and They en In the rme qui a littl throughout whmistreatment and care. I wondered what would leave and or d bullying of medical their rdised. takes students . are not sta a time ber m vasive happen if I asked towas nda of info fro ple perprobably ponses decided that it would just make things worse for me. medical school years, with this pattern often continuing well re peo wn line not mo dra dec but There At sm all num into reearly their res y aresituationand the hostility ress otherThree hours the training years5, 6. In Australia ff, and likeand criticism. who we by a the end s—the the nee ds was then exp y. theIrestayed.cau ses of of gsosta uld pea ple run sin are wo ir In peo I ripped off my mask and gloves and turned, only to find regarded as serious that the Queensland Government set up a I d and nur irel s. But che of ted re of? y in thewasoth renher ployee nt ent erwise ber registered dical and ded standing myica swollenme eyes Workplace Bullying Taskforce. Taskforce numShe be awa behinda me. in of Thisvar the poi one of the well ent sho pital em tend commissioned ior seen uldtear er s cha hos are pre sen d mis und ar and stained face in complete silence. I have never with producing a thorough report on the extent of bullying in re of To the cle e in t fall t the erience workplaces that we tsuch e is to in the and devising was a across exp hasI hope oth a critiqu responsible never again.”1there Australia, a strategy on addressing er to ses tha stare, oand ges thaa cold, emotionless surpris and n, ility was see ts der wh able ails to sug ntifiable cau sib atio n, rea oris this problem. One Specialist Registrar in Forensic Psychiatry situ r det the respon kers. ide (Fo thislikely t situatio gs. The a phenomenon chair above tedly be that dindocuments writing of bullying This case haveand all easily nd presen nt articles on n main response to the accountear ly arm outlined bably we most ad heahappening l undoub us comma k decisio says “My medical experience countries the last in pro hospitals and practices where t for inthe are two bro seen far wil around on usspanning four of thewe ’s excelle rld Ban e par these d this – workplace pt upfor me larg 20 years tis cre sufficient to declare that the kind of nne bullying to the Wo is ds surprisingly ers, but bullying. Workplace bullyinghan reache work r our hael Wy s tha here isgnotafte of oth and is. becoming more so. In recent surveys carried outchange described unique to the United Kingdom.”7 sentation kcommon, Dr. Mic to thin in the ificant ’s pre 2 ls are y lookin of the European the epercentage lationUnion, On st signUK, the US, Australia, andadu Samuel ) re bus way hospita to 0. we ys, are the mo of people who had been 200 we bullied in their workplace ranged from 8 to So what causes bullying and why do some k people bully? Firstly, nowada a means to tion of tolet’sthe egories figure bac in whilst study ably, 20 per cent take a look at the kinds of behaviours that constitute bullying become In medicine this denigra is even ice ad2. cat alhigher. A recent more ts was ite e not bro the dic ien has hav me n pat s in an NHStion trustand in the UKof found third of medical staff Qu – you may well recognise some of these from observations the that oneoff The two ears to istratio of your career naged. inistrahaving been result intive eyes year3. This Admin colleagues or peers. Lyn Quine, in her study of bullyingtamongst reported the previous maproportion end app inistrators’ t are a bullied of adm . Tha patien ir collec ir feet. s. Both an end furthering adm ements in how ing the doctor the with n improv opposite of fact sion tak pping it on do tha fes s pro ct ard Physician l and dro and rewlifes is the exa reness of this onic the bal awa bry Thi care. the em ing of se, and ine aro crushing to inn medic the beg e here te qui be can be It could also managed car t. style altruis se of US the cur lia.3 4 ere n (wh in Austra a situatio ady rich alre w such ts are not allo are paid to patien s We can que sum res whilst y need) to tes figu gro care the ement manag the health denied in Australia. ds to a p ion lea develo istrat Admin ms: ble tion of Adula of related pro al Medic number from Money ion of Divers ic econom Care be an finite have to there is a sing s not t if if increa the One doe realise tha and s le to toward availab genius money are diverted pot of ts of this amoun

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Dear Editor

I ENJOYED reading all articles in the Jan/Feb and Mar/April issues, especially the insightful ones on'Bullying in Medicine' and 'Altruism in Medicine'. Dr Blinde is spot on about the reasons why Altruism is declining. I am an ex-public hospital Staff Specialist and Clinical Department Director. My latter years in the hospital were increasingly painful because of the “Adulation of Administration” culture. As a Department head, I had all the responsibility but no authority at all – the Divisional Director had all the authority but no responsibility – an ideal situation for bullying.

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Your Magazine is excellent in general. I like the focus on the often neglected business side of medicine. But articles can be too short and difficult to understand. Very good article on solar power but it was sadly lacking in one very important aspect – the economics of initially installing solar power. Best, Dr. F.S., VIC ______________________________________________ Dear Selina, 'Why DOCTORS are targets for fraud' was a great article, especially for someone like me who strongly believed that "I would never fall for that". This should be a wake-up call to all doctors who don’t talk to their partners, financial advisors and/or colleagues about the high risk strategies that they are about to embark on. What may be sold as a great idea with fantastic returns, may in fact be a boiler room scam and you may become one of the many victims. Thanks, Dr. A.T., NSW ______________________________________________ Dear Medical Life Team, MY HUSBAND and I both read your magazine with great interest and enthusiasm. Every edition has something new and unique to offer. Thanks to your travel articles we have booked numerous vacations based on the coverage. The New Zealand ski article was really helpful for our July break. Regards, Dr. L.D., VIC

Prof. (withheld), NSW

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

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F E AT U R E S

Doctor, Doctor can you help me? W How to negotiate the doctor/family member relationship?

How many times have you heard, “It must be so wonderful to have a doctor in the family? Free advice whenever you need it and someone to help you through it all.”

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any believe that the family of a doctor enjoys immediate and timely healthcare. Unfortunately, it is not that easy. Determining their professional role within their own family is difficult for doctors. Do they treat their family? Do they refer them to a colleague or do they step back and allow their family members to make their own health choices and play no part? Working through these situations can result in confusion amongst the family; serious offence; late or incomplete medical advice; or even missing serious medical problems. Some medical families employ the objective services of an

external general practitioner but most continue to swim through the murky waters of the doctor/family relationship. What Doctors should do? Australia’s code of conduct for doctors’ Good Medical Practice published by the Medical Board of Australia states; Whenever possible, avoid providing medical care to anyone with whom you have a close personal relationship. In most cases, providing care to close friends, those you work with and family members is inappropriate because


F E AT U R E S

of the lack of objectivity, possible discontinuity of care, and risks to the doctor and patient. In some cases, providing care to those close to you is unavoidable. Whenever this is the case, good medical practice requires recognition and careful management of these issues. The war stories War stories abound from medical family members about the apparent mismanagement at the hands of their beloveds. Sweating wives in labour saying, “Honey I think we should go to

 Family members hope that in their darkest hour, they will reap the reward for all the hardships endured for being part of a doctor’s family.

the hospital now” only to be met with “Don’t panic. We have time.” Children with high temperatures and bizarre rashes dismissed as having viruses that should get better with time. Disfigured limbs diagnosed as sprains. Coughs that would shame a pack a day smoker shrugged off as upper respiratory infections. The stories become embellished each time they are dragged out at family occasions. Different approaches, drugs versus denial There seems to be two ways doctors manage the medical complaints of family

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F E AT U R E S Why do doctors choose to treat family and why is it so hard? Doctors feel a sense of responsibility towards their family. They want to be able to help. Often it is more cost effective, more convenient and more accessible for family to ask the doctor standing in their kitchens rather than make an appointment, take time off work and drive to a clinic. If it is so easy for family, why is it so hard for doctors?

members and they seem to be specialty specific. The first is drugs, an approach that may be favoured by physicians, anaesthetists and psychiatrists. “If you are feeling sick you should try this.” “If that doesn’t work try this AND this.” “If you still aren’t feeling well? Take this and this AND this, but don’t tell anyone I gave you that last tablet, take only one and for goodness sake don’t drive.” That should do it. For surgeons the first line of defence for family medical complaints might be dismissal. “What do you think about this rash?” “I think it will get better.” “How about that cough?” “Let’s just wait and see how it goes.” “I have a really sore arm.” “Talk to me after you have had some panadol and a rest. That will definitely help.” Any requests for higher levels of intervention, namely, antibiotics, imaging or even hospital admission, tend to be met with a blanket “No.” Will the knight in shining armour save them all? When family members aren’t feeling their best, they hope that the doctor in their life will come to the rescue. Step up on their

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behalf. Defend and protect their brood. Go that extra mile. Advocate for better outcomes and thorough investigations. Search every corner of the globe to ensure that the treatment received by their family is state of the art. Family members hope that in their darkest hour, they will reap the reward for all the hardships endured for being part of a doctor’s family. They want their knight in shining armour to save them. Sick family members aren’t rational. They can often be found bearing their flesh for hallway consults. They are used to having their most intimate health concerns becoming dinner conversation with colleagues. Many family members will accept phone consultations as appropriate management. Only when things get really bad do they slink to the GP.

 When family members interpret this advice as dismissive and cursory, it is just that, an interpretation.

The scope of questions doctors field from their family and friends is extremely broad. With the belief/expectation that “Doctors know everything.” In their opinion a cardiologist should immediately be able to diagnose and treat the unusual lump on the side of a face. In reality, medicine, like any other profession, breeds a certain amount of specialisation. Doctors cannot and should not be expected to know everything. So why then can’t they say, “Darling I have no idea what that lump on the side of your face is, but it seems to be blocking your vision to the left so maybe we should take you down to the GP?” Is it because doctors feel they should know everything? Doctors are high achievers, perfectionists for the most part. They have studied long and hard to get where they are. Specialisation still involves working with complex patients. If the doctor hasn’t seen the exact thing they are being presented with, chances are they have dealt with something similar and surely they can work it out. Confidence goes a long way in medicine. Fall back to basic principles and sound convincing. There are a lot of conditions that will get better with two panadol and rest. Providing advice to such effect is not a random stab in the dark, it is born out of experience. When family members interpret this advice as dismissive and cursory, it is just that, an interpretation. Of course no person in pain wants to hear there is nothing much wrong, family or not. Doctors’ dobbing on doctors What then happens when a doctor


F E AT U R E S treating a family member of a doctor gets it wrong? When a family member is being mismanaged or has been misdiagnosed? This is the hardest situation for doctors to face, the thought of having to undermine one of their own. To question a colleague is difficult and getting angry with a colleague or team member is damn near impossible. Doctors want and need the system to work whether or not they are on site. That sort of faith gets them home at the end of a shift and allows them to step away from their patients. They protect each other and the decisions made. Without that buffer, medicine would be a very lonely job. To step in when the treatment of a loved one is not going as planned means sacrificing a bit of themselves and a lot of their colleague. But if they don’t step in, they risk losing the faith of their loved one. Is there a resolution? Perhaps the way to work through this quagmire is to talk and not assume. By

 The scope of questions doctors field from their family and friends is extremely broad. increasing understanding and lowering expectations on both sides of the relationship, an appropriate role can be found for the doctor within their family. Family members need to understand the professional boundaries associated with being a doctor. Just because they’re family doesn’t entitle them have their doctor permanently on call for their needs. It is

ridiculous to expect any doctor to know about every medical condition. Family members as well as doctors must lower that expectation. Doctors should understand that caring for families doesn’t always mean having the answer. It can just be a matter of being involved. In a family, being a doctor means being objective. It means giving advice in a straightforward way, sometimes without eye contact and usually without a hug. For the most part, doctors make the right calls at home, but both sides need to communicate when medical problems arise and know when they are playing for sheep stations and when they should get off the field. Jane Wilkinson is a physiotherapist married to a wonderful surgeon. She values the work of her local GP in relation to their family’s medical complaints.


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Making peace with my pacemaker Medical transparency towards the end of life I am a cardiologist who has had a pacemaker for the last 35 years. In 1972, I contracted the same Coxsackie heart virus that was attacking my patients’ hearts. So I know more than a thing or two about pacemakers and defibrillators.

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acemakers speed up the heartbeat when it slows or stops. Pacemakers have an algorithm to try to suppress atrial fibrillation. Defibrillators have a pacemaker function but can also prevent cardiac arrest by delivering a short electric 32 joule shock to suppress

sustained ventricular tachycardia or revert ventricular fibrillation. These technological wonders have saved and improved many lives, but also create new and difficult problems. During a recent clinic visit in a small

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F E AT U R E S country town out West, Justin (a medical scientist and pacemaker technician) and I received several phone calls from the local GPs. Requests such as "Would you mind dropping into the Nursing Home around the corner and switching off the defibrillator on Mr Jones in Bed 32?" And another "There’s a demented patient in Bed 64 – Mr Smith – could you adjust the power output of his pacemaker lead to below the threshold?" By doing so, the pacemaker would no longer be able to stimulate and Bill Smith’s heart beat would be reduced to 34 beats per minute or less. This is the idioventricular rhythm of the heart muscle cells when people are in complete heart block. With AV dissociation the outlook for life is bleak, four to six weeks, four months maximum. In rural practice, patients place unreasonable requests on the pacemaker clinic staff to do whatever they wish. Imagine … Mrs Williams has had enough with her dreary surroundings and the frequent deaths of hostel residents. This afternoon is her clinic visit and she wants us to turn off her pacemaker – she’s given away all her assets and she’s said farewell to her only remaining friend that morning. Understandably Justin, the technician, could be a bit on edge – "Why me?" This leads us to a genuine problem that has actually been created by scientific advancement. The pacemaker’s interrogation equipment is set to go but ultimately it must be the doctor who clicks the mouse to deactivate the pacing. This is like a doctor writing out an order for a large dose of morphia and expecting the nurse – like a robot – to inject the dose intravenously and watching life to be extinct 30–60 minutes later. We could turn the pacemaker rate down to 40 beats a minute, but not take that irretrievable step and switch it off. I had another patient out West who wanted her local GP to take out her pacemaker – extirpation, complete removal, her justification “It is evil – it’s driving me insane”. With such a distressed patient it is very hard to find a doctor who will envisage rooting out a life-saving device for the psychiatric well being of the patient. The old saying

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 The pacemaker’s interrogation equipment is set to go but ultimately it must be the doctor who clicks the mouse to deactivate the pacing.

“primum non nocere” - first do no harm, do nothing. Closer to home there are some issues that have to be faced day in day out patients with dementia. The patient who is in a nursing home, 89 years of age, bedbound, incontinent and her pacemaker check shows her battery is at ERI, that is, elective replacement interval – end of life or should we say ‘end of service’? If only someone years ago suspended pacemaker checks for this woman there would be no way to define the inexorable battery decline to the point that the pacemaker interrogation computer tells you the pacemaker will stop! Some would say it’s so much better if we avoid legal confrontation. Well just a simple box battery change? The logistics are a bit

difficult to organise: patient transport, nursing home, hospital admissions office and so it goes. Can we just do it and avoid talking to the family? That will be very difficult for consent purposes because the next of kin don’t visit from interstate. Ultimately we will have to get Guardianship Board approval to replace the pacemaker. If her doctor calls it lifesaving and absolutely essential, there will be no problem for the Guardianship Board, approval will be given instantly over the phone. Three weeks later the same patient is feverish and short of breath. The Death certificate would concentrate on postural pneumonia and Alzheimer’s disease. Robots controlled by medical protocols Medical intervention can take over and control a person’s life, decide whether they live or die. Doctors can switch off a pacemaker upon which, over time, a person has become artificially dependant. The principles concerning proportionality of treatment and the avoidance of futile treatment need to be kept in mind, and the decision should be governed by principles of sound palliative care and respect for human life as it comes to its natural close. At times there is an impasse between quantity and quality of life. Deactivating a pacemaker may be ethical and appropriate when a patient is in the last stages of terminal illness and when


F E AT U R E S

the device has become useless or overly burdensome, or is likely to increase pain and interfere with a peaceful and natural death. Families find it difficult to avoid typecasting the defibrillator patient as a victim. The more patients learn to overcome heart disease – that is putting in the hard yards – by changing risky lifestyles – the harder it is now to accept another new disease, and they believe they are being robbed of the entitlement to survival. I wish to explore the whole concept of palliative care where examples of giving are followed by taking away – and when the patient has become dependent on a life-sustaining therapy – a doctor can just take it away.

 I had another patient out West who wanted her local GP to take out her pacemaker – extirpation, complete removal, her justification “It is evil – it’s driving me insane”.

Give and take My first example is a lung cancer patient – where the tumour has spread to the adrenal gland. The patient is kept alive by giving prednisolone or dexamethasone. The palliative care physician can give morphia to ease the pain. But the same physician can take away the cortisone therapy after dependence has developed over a few weeks. When the doctor abruptly stops the cortisone tablets, the patient dies within 24 – 48 hours, and the patient’s family only observe the comfort delivered by the ongoing morphia therapy. Let’s consider a totally different illness: HIV infection and AIDS with triple anti retroviral drug therapy. A patient usually goes into remission. Some

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F E AT U R E S years later this same patient develops a sudden new illness, like bowel cancer or prostate cancer – which has spread or metastasised all over the body. The palliative care physician or ‘Angel of Death’ can first take away the life protecting anti viral antibiotics and then substitute cortisone. When the inevitable infection of pneumonia sets in, the physician can go through the motions of giving an antibiotic, but abruptly take away the cortisone – and the patient dies. My Ockham’s Razor is that we as doctors can give with one hand and take away with the other. Audits drive statistics Every day we have to question what are we actually doing to our patients and why? The media and the community in which we live are desperate for medical information, often news of negative outcomes. Audits are so expensive and time-consuming. In the words of the Aboriginal people – "Do we have to look backwards to go forwards?" Do we need transparency? The way it has been done in the past has often been a charade. Mark Twain said "Facts are stubborn things but statistics are more pliable". Do we really want a Cardiac Implanted Device Registry? Do we use audits to erase fear about hospitals in the eyes of the community? Or should we have Internet access to each Sydney hospital’s performance, as well as each implanter’s report card for the last three years, so the family can choose? The referring cardiologist must also understand variations in surgical techniques and the brand of pacemaker chosen. A mate from the same school or medical university year may be a great friend for life but may let your patient down in the end. Pacemaker problems have continued despite the introduction of annual audits in individual hospitals. Private hospitals are simply ‘Untouchables’. The audits are incomplete because patients are inconsiderate and don’t go back to the same hospital where the complications arose in the first place. It is difficult to compare the performance of surgeons versus cardiologists

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implanting pacemakers throughout Australia, where in some hospitals all the pacemaker patients have is the choice of cardiothoracic surgeons. Most cardiology departments whinge that they don’t have anywhere near the staff or budget they need to follow up people who don’t attend after the initial operation. If you don’t look – you don’t find. Everyone in the department can happily sign off as having attended the rosy annual hospital pacemaker audit meeting. The meeting is often scheduled to start at 7.30 a.m., often with a slow

 Audits are incomplete because patients are inconsiderate and don’t go back to the same hospital where the complications arose in the first place.

doctors have a unique overview of what different city centre hospitals can do. The spectrum of complications in each hospital will be different, but each doctor has his or her signature mistakes. We have to improve the process – we want people kept alive by technology. Pacemakers have come a long way in just 80 years, and have revolutionised medical care for all those people who just used to ‘black out’ of life. To conclude, let me mention the story of Earnest Codman in Boston in 1916. The ill-fated Dr. Codman, a surgeon, proposed to report his hospital’s mortality rates, earnestly believing that this would attract more informed patients. Unfortunately this did not work – shortly afterwards his hospital went out of business. Nobody would follow his example of open transparency and he died a broken man. Now in 2011 concern about the costs of medical care, driven by huge computer databases, has produced a new era of accountability that Dr. Codman foreshadowed a century ago. We can turn off pacemakers but not computers. Dr. John England, Cardiologist and author of KICKSTART Recharging Your Life with a Pacemaker or Defibrillator.

start, and delays as late PowerPoint presenters struggle with technology. The cardiologists and surgeons are restless by 8.10 a.m. and start to leave for rooms or ward rounds. So when the time comes to discuss the outcomes, there is often no longer a quorum of doctors to make any recommendations. The exodus could include the implanters who have the greatest number of complication issues, while those who stick out the meeting to the end are often the obsessive personalities who not only irrigate the pacemaker pockets with antibiotics – to reduce the possibility of infection – but also spend extra time to ensure good pacemaker lead thresholds to get perfect results. But that doesn’t rule out dud batteries. Each local Health Network has its signature mistakes. Out in rural Australia


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F E AT U R E S

Myth & Magic in Western Medicine W From the West to the East 20

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F E AT U R E S

The early days Rome was established in 753 BCE, from the antecedent Etruscan civilisation. It continued as a kingdom until 510 BCE, when the rape of Lucretia precipitated a revolt that led to the creation of the Republic. This endured for almost 500 years until Julius Caesar became dictator (44 BCE) and the Senate granted power to Augustus (27 BCE).

A

lexander the Great established the city of Alexandria in 331 BCE as a centre of learning and culture for all the people under his dominion. The Empirical (Medical) School was established one year later in 330 BCE and soon became the centre for ‘World Best Practice of its day’ and from here medical knowledge spread to Rome.

Hitherto, Roman medicine had been based upon Etruscan ideas. There were no ‘medical practitioners’ but soothsayers and priests, who specialised in various exotic, mysterious arts. These included ‘gazing at goat’s guts’ (divination) and consulting prognostic charts. Similar to the Egyptians, there were many diseases, each with its own deity who required proper appeasement. This was done, for a fee of sorts, by one of the College of Augurs (7th Century BCE). A little later, in 295 BCE, Aesculapius arrived as a snake, to help the college... As Rome came to dominate Greece politically and militarily, the population began to recognise the benefits of Greek medical learning and knowledge and Greek ideas were absorbed. Superstition gave way to rational thinking. People expected more than prayers and snakes and asked for real medicines. Much of this was provided by Greek doctors, some of whom came as visitors, others were captured during campaigns as in 30 BCE, when Augustus captured Alexandria with its extensive libraries, universities and doctors, whilst looking for Mark Antony. Many such doctors were purchased by the wealthy Romans as personal physicians and after time bought their

freedom, setting up practices in Rome. These physicians proved popular with the Emperors and people because until this time, it usually fell to the (untrained) head of the household to minister to the sick. However the Aquilian Law (3rd Century BCE) made practitioners liable for negligence in treating a slave, so some specialisation did exist even then.

 Superstition gave way to rational thinking. People expected more than prayers and snakes and asked for real medicines. Asclepiades of Bithynia (120 – 70 BCE), friend of Ciscero, stands out from this time. He was advanced in his thinking, decrying Hippocrates and believing that physicians cured, not nature. He rejected prevailing theories of unbalanced humours in favour of his own theory of ‘abnormal atom activity’, developed by a pupil, Themison, into Methodism. However, he used bleeding, purging and restricting food and drink during fevers. His healing practise ‘tuto, celerites at jucunde’ (safely, quickly and pleasantly) endeared him patients and of course holds to this day.

His methods and theories were denounced 200 years late by Galen so effectively that he disappeared from history for a long time. However, he was very influential in improving the reputations of Greek physicians in Rome in these earlier days. Initially there was no regulation of practice and anybody, freedman or slave, could set up as a practitioner. No doubt some tried but others were charlatans or plainly unscrupulous. As more people came to Rome, more became ‘practitioners’. This was encouraged by exemption from taxes (Augustus) military service and other civic duties (Vespasian and Hadrian). These admirable benefits were finally restricted by Antonius Pius and then Severus Alexander, who passed laws covering training, licensing and regulation. Public health and hospitals The Greek steam bath or Laconia inspired the Romans who, believing that a fit mind and body were good, took to the idea of bathing with alacrity. Baths rapidly developed into lavish affairs with bathing areas, hot and cold water, toilets with running water and sewage systems (not to be seen in Europe for many hundreds of years) gymnasiums, food and drink and of course slaves to look after every whim. These were the first combined extensive public health and sports facilities. The Roman water supplies and sewage removal was extremely advanced, one of their many great achievements. In Rome, fresh water, flowing from kilometres away via a number of aqueducts and settling cisterns, was readily available to

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F E AT U R E S About this time, Forensic medicine, first practised by the Egyptians, became more common. Notably, Julius Caesar was examined by Antistius who concluded that only one of 23 stab wounds was fatal - presumably blood loss was not recognised as a cause of death. The Justinian Code was promulgated in Rome around 550 AD, laying down rules for expert witnesses that are as pertinent today as they were then. Personalities Notable Greco-Roman physicians who practised in Rome include:

all but the poorest - who only had access to wells. Sewage removal was similarly well directed, although there was no treatment, except biological and dilution, in the river Tiber. Not everybody received treatment, Romans adopting the Spartans approach to the deformed, those deemed too ill to live and unwanted babies. There were purpose built hospitals where a more rigorous and methodical, (protoscientific) approach of proper rest, relaxation, diet and musical remedies were used and the patient carefully observed. However such facilities were only for the military. Sick civilians were cared for at home or in the physician’s rooms, if they could afford to pay. The first private hospitals? Therapies The Greco-Roman period was one of rational use of extensive herbal remedies1 and surgical techniques, in an attempt to systematically treat injury and disease. Most physicians believed in four Humour; Sanguine, Choleric, Phlegmatic and Melancholic, to explain various conditions. They used and no doubt refined, an extensive pharmacopeia of herbal remedies, some of which would not taste very nice (like Willow as an antiseptic (and analgesic and antipyretic)) but others, including garlic,

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 Sick civilians were cared for at home or in the physician’s rooms, if they could afford to pay.

fennel, and sage, no doubt made the patients themselves smell appetising. ‘Anaesthesia’ was induced by narcotics or significant bleeding. Using instruments not too dissimilar to today’s (but not disposable), they performed extensive procedures. These included wound repair and exploration, bone fixation and amputation, catheterisation and removal of bladder stones. Also of course, from this time we have Caesarian Sections which probably take their name from the ‘lex caesarea’ or Imperial Law, (Julius Caesar) intended to save the baby of a dying mother. There was early plastic surgery, for removal of slave and gladiator tattoos. They also performed the oldest of procedures, trephing and added cataract removal, by maceration and suction.

Erasistratus (304 – 250 BCE): A remarkable man who came very close to understanding the basic functions of the cardiorespiratory and nervous system and some simple metabolism. Some of these discoveries may be due to the horrid fact that he and a friend performed vivisections on unfortunate prisoners. Celsus (25 BCE – 50 AD): Amongst other things he described the first four signs of inflammation, hernia repair and ligating and dividing bleeding vessels. He wrote De Medicina and the following timeless advice... “The physician of experience is recognized by his not at once seizing the arm of his patient as soon as he comes to his side, but he looks upon him and as it were sifts him first with a serene look, to discover how he really is; and if the sick man manifests fear, he soothes him with suitable words before proceeding to a manual examination.” Gaius Pliny (23 – 79 AD): A vociferous critic of (money grubbing and uncaring) doctors, especially Greeks…was killed at Vesuvius. Pedanius Dioscorides (40 – 90 AD): Wrote De Materi Medica, an early MIMS. Soranus from Ephesus (Early AD): Was the first great Obstetrician and Gynaecologist who recognised the benefits of Breast Feeding.2


F E AT U R E S Rufus also of Ephesus (Also Early AD): Impressive early neuro-anatomist and psychologist with an interest in dreams.

many of the Greco-Roman texts of Aristotle, Hippocrates and Galen and much practical knowledge was thus saved.

Galen (129 – 200 AD): A man of historic achievements who then used this advantage to put other people down. Not quite the first great anatomist (in my opinion) but made some impressive discoveries. Either found or made various Intra-cardiac Septal defects to support his theory of the circulation. Physician to Marcus Aurelius (of ‘Gladiator’ fame). Thoroughly denounced Asclepiades’s alternative views. Purveyor of polypharmacy, further developing an ancient preparation called ‘Theriac’ so that it contained more than 70 ingredients.

Greek philosophers and physicians had travelled and lived in the East since the time of Alexander, (4th Century BC). Others arrived later from Gundishapur. Christians and Jews arrived, fleeing the Romans, bringing their knowledge. By the time Muhammad established Islam in 622, the Arab world was familiar with Greco-Roman ideas including medicine. This disparate group of settlers, known as the Arabists, followed Greco-Roman



Decline All empires decline and in so doing, their knowledge is often lost. The Greco Romans sustained and developed the learning of the Greeks as far as the technology of the day allowed - an astonishing feat.

All empires decline and in so doing, their knowledge is often lost.

concepts of aetiology and treatment and also founded the pharmacological and chemical sciences. They devised many Physical Chemical processes still in use and systematically identified, prepared and tested numerous remedies and formulations. Disease was still believed to be punishment from an all-powerful, loving god, but no moral stigma applied, although some devout refused treatment - it being Alllah’s will. Physicians were seen as adjuncts to prayer and willingly aided the sick, both to ease their own access to heaven but also because they valued compassion. They believed in an afterlife and forbade dissection of the dead - as not to interfere. Despite this, they developed their knowledge of anatomy from Galen’s teachings and observation producing some starling theories. Diagnosis was still based upon the nature of various bodily wastes, taste testing (urine) sometimes used, combined with the ubiquitous Astrological chart.

With the end of the Western Roman Empire in 476, overrun by the Goths, it was left to the Eastern Roman Empire, effectively cut off from the West by various invaders, to continue as a centre of enlightenment and knowledge. This it did, as the Byzantine Empire, lasting until final defeated by the Ottomans, at Trebizond, in 1461. During this time the torch of learning was taken firmly in hand by the Muslims. The Muslim world In the first 500 years or so, A.D., Europe declined from barbarian invasion, disease, famine, and the vigour with which the ascendant Christian church destroyed much Greco-Roman learning and achievement. This destruction contributed enormously to the widespread misery of these centuries. As the Muslim world expanded at this time, through respect for learning, they assembled a vast collection of information from practically all areas of known human achievement. In medicine,

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F E AT U R E S Public health and hospitals Public health was very much the same across Europe and the Muslim world. In one word – dreadful! Disease and death were accepted as inevitable. Clean living and decent medical care was usually limited to the rich and connected. The Hospitals at Baghdad, Damascus, and Cairo however, were of a high standard, splendidly built and maintained, with specialised wards, good food and attentive physicians. See Rhazes, later.

for his teaching and collections of clinical data, he wrote over 200 books and is still inspirational today. He died poor because of his great generosity. On the down side, he was a proponent of the healing properties of crystals. Two other little known Physicians from later in the millennium, should be mentioned. These are Avenzoar in Seville and Averroes in Cordova and Morocco. I leave it to the reader to follow up on the contribution made by them and others.

Therapies

In Closing

Arabist therapy built upon the work of Dioscorides, adding many new medications, some of which came from China and/or India.

The Greco Roman period was one of development and refinement of medical care. Within the constraints of their technology they achieved quite remarkable results.

Surgery was limited to cautery and simple superficial procedures with anaesthesia provided by what is described as ‘narcotic acid’. This became the ‘soporific sponge’ of the 12th Century. One mistake was the belief, which became widespread throughout the known world at the time, that pus formation and retention (‘laudable pus’) were good. How many people died needlessly from failing to drain abscesses? Personalities One who stands out for me is a Persian physician at Damascus, Rhazes. Known

it fell to Islam to protect and nurture what they could rescue. This they did with enthusiasm and skill, adding greatly to the broad body of medical knowledge and science of the time. We have much to be grateful for. We would not be where we are today but for them. Why is their hugely significant role in the protection and development of medicine (and scientific thought in general) not more widely recognised or acknowledged? Dr. Tony Blinde believes science can easily explain all the many wonders we enjoy on this our only planetary home.

With the involution of the Roman Empire,

 Clean living and decent medical care was usually limited to the rich and connected.

References

Gundishapur The Persian Academy of Gundishapur was the Medical Centre of excellence of the day in the 6th and 7th Centuries, under the Sassanid Empire. The facility provided training in medicine, philosophy, theology and science. It was a meeting place for many cultures of the day, Zoroastrians, Persian, Greek and Indian. It was the place where East truly met West and traded ideas. Gundishapur became even more important under Muslim rule in later years.

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http://www.unrv.com/forum/blog/19/entry-186-a-romanherbal/ 2 History of Medicine, Henry E Sigerist. Out of Print 3 A number of references are from a fascinating series, ‘Medical History’ by Albert S. Lyons - http://www.healthguidance.org/ authors/486/Albert-S.-Lyons 1

Pictures p20, "Colosseum in Rome, Italy" by David Iliff p22, " Erasistratus the Physician Discovers the Love of Antiochus for Stratonice" by Benjamin West (1738 - 1820) at Birmingham Museum of Art, Birmingham, Alabama, USA. Images licensed under a Creative Commons Attribution 3.0. Generic Licence http://creativecommons.org/licenses/by/3.0/


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F E AT U R E S

I Don’t Know What To Say WCommunicating with surgeons in the modern era

O

ne evening, my phone rings and a familiar voice appears on the line, that of a surgeon I have known since my student days. Hearing his voice, I express my relief that he has made a complete recovery from a serious illness that could have proved career-ending. He mumbles incoherently, providing me the first sign that he is not into social niceties today. "You saw this chap, John?" "Yes, what a devastating blow", I respond, immediately feeling downcast. A healthy 24 year old university student was admitted with severe abdominal pain. A scan revealed the diagnosis of widespread liver metastases and a nearobstructing bowel cancer. John and his whole family walked over to my clinic that same day. From John’s first comment, "So tell me who stuffed up the x-rays" to "So let’s say, 10 years or 15 years from now, will I feel completely normal again?" his disbelief was evident. It took more than an hour of an unscheduled appointment to gently go through the news and discuss his options, all palliative. He arrived, a

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confident young man and left a broken, dying one. His parents asked what the parent of any child diagnosed with a terminal illness does, "Why him, why us?" I wish I knew, I thought, affected by their courage and dignity. "I am the surgeon on-call and I was asked to see him. I couldn’t find your notes."

 He lets loose a string of harsh comments about being backed into a corner and rails about the intricacies of surgery that no physician can appreciate.

"I am sure one of the registrars will put something in – all this happened very quickly today and everyone is still coming to terms with it. But how can I help?" The surgeon had been asked for an opinion on the need for upfront resection of the primary cancer lest it become complicated later. "I think it’s very poor that you personally did not write in the notes on a matter of such importance." This isn’t about the notes, is my instinctive feeling, yet I bristle at the criticism. A dozen responses come to mind, including the fact that the unscheduled hour had put so many other needy patients behind that adding to the already comprehensive notes from earlier in the day did not seem like a hanging offence. Instead, I ask lightly, "So now that you have me, how can I help?" "I don’t need any more of your help", he growls. "You have already told him he needs an operation."


F E AT U R E S

"Actually, I only told him that he needed to seek your expertise about an operation", hoping the truth will placate him.

I have had no sleep lately and a switch in my brain just flicked. And by the way, I will operate on John tomorrow."

"I walked in and he nearly jumped at me for an operation time. You should know better than to present an operation as a fait accompli!"

I nearly choke on my dinner. For an oncologist, expressing regret is commonplace. Regret for the torrid toxicities of chemotherapy; for there being no other therapeutic options; for a life not fully lived thanks to the ravages of disease. But for a surgeon to say sorry is the stuff of fantasy. Ridiculously I feel sorry that he had to bring himself to apologise while wondering whether I had been too harsh on him.

"That’s not true. I told them all explicitly that only you could make that decision, and I repeat the same to you now." But the storm has been unleashed. He lets loose a string of harsh comments about being backed into a corner and rails about the intricacies of surgery that no physician can appreciate. He is in no mood to listen and perhaps, reminded of my days as a medical student that quavered under him, in every mood to lecture. This seems to be his evening of having it out with the traditional rivals, the physicians who know nothing and spoil everything, who think that talk is cheap but won’t enter the operating theatre to see just how hard it can be to operate. As his diatribe continues, I am struck by its growing vitriol and unprofessionalism. I am not even sure why I continue to listen, but being an oncologist gives you a sense of seizing the moment if nothing else. So finally, I say, "Stop, you are being offensive." To my surprise he stops. My gut instinct tells me that despite being famous for his outbursts, no one has ever told him that before. Then I say the only other thing I want to say. "How would you feel if you were 24 years old and diagnosed with terminal cancer? Wouldn’t you be aggressive?" This time the mumbling stops. Maybe he has thought of his own children, about the same age. "Well, I’ll see", he then grumbles before hanging up. Later that night the phone rings again. Hearing the surgeon, I brace myself for another round. But the surgeon says, "I am calling to apologise for my behaviour.

In the aftermath of the event I reflect on the surgeon’s fury. Despite the personal nature of the attack, I did not for a moment think it was directed at me. I believe it

 Younger generations of doctors are also far less willing to put up with perceived imperialism by their bosses. was because he, like me, was completely thrown by the challenge of seeing a robust young man who had surrendered his fate in our hands only to be told that not even the best amongst us could stretch his tenuous hold on life. Perhaps my chance comment about his own recovery had reminded him of his own mortality and he was angered that he could not save another man’s life. I don’t know. But while other doctors acknowledged their impotence and even shed a private tear, the surgeon simply did not have the means to express a fundamental emotion like sadness. He only knew how to dress up sadness with anger. Changing attitudes Community attitudes towards doctors are changing. Doctors are increasingly being held accountable for their behaviour

and both the medical profession and the public have a range of ways in which to lodge complaints about doctors. Hospitals encourage transparent reporting and invest heavily in deflecting the stream of complaints. No longer is "because the doctor said so" accepted without question, and plenty of people are willing to laugh in the face of those who can still say with a straight face, "Trust me, I am a doctor." The community demands more than a doctor’s innate confidence in a decision or procedure – it expects that the doctor communicate this is in an understandable way to the patient. As part of this shifting community attitude, younger generations of doctors are also far less willing to put up with perceived imperialism by their bosses. They will pay respect to those who have earned it but dismiss those who demand it while treating their colleagues with disdain. The days of cultivating quiet awe under sufferance are probably gone for good although many surgical specialties are still perceived to be bastions of dominance, guarded by a few influential figures. This is not so true of non-surgical specialties. I noted with some interest that when I discussed the surgeon’s behaviour with close colleagues, there was general consensus that only a surgeon would dare speak to another colleague in that manner, and, importantly, expect to get away with it. People shrugged – there are a lot of unsavoury workplace encounters, but almost everyone has a surgeon story to tell. So in the modern world of medicine, how do we teach the younger generation of surgeons to be better communicators? The easiest, and in my opinion, the most insulting thing to do is to dismiss all surgeons as arrogant and disinterested in learning how to communicate. Some of my wisest colleagues are surgeons; to watch the lengths they go to in the interest of the whole patient is extraordinary and humbling. It is also true that when you need a surgeon to save your life, you are unlikely to care whether he smiles through his mask. But it is facile to argue that as long as surgeons are technically proficient, someone else can do the talking on their behalf.

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F E AT U R E S workers, nurses and physicians, he was mortified and spent the whole session looking out of place. Although he gained a few valuable skills by his own admission, I cannot see him returning in a hurry. The absence of his colleagues was a sorry confirmation that surgeons just don’t do these things. I cannot imagine that communication training will flourish anywhere without the support of those in positions of power. The tide is beginning to turn, albeit slowly, in many other areas of medicine, but surgical training has still some distance to cover.

Communication skills Effective communication means being able to demonstrate understanding and empathy whilst conveying usually highly complex information to patients, the vast majority of whom have a surprisingly basic understanding of the human body. As a rule, we have given communication short shrift throughout the medical curriculum, fooling ourselves to believe that the entry interview process weeds out all the poor communicators or that good communication is inherent and cannot be taught. But there is evidence that communications skills training, even at an introductory level, delivers benefits. Who amongst us would not like to listen more actively, deliver bad news sensitively, recognise unspoken fears, and facilitate a truly informative family meeting? Program directors carry much of the responsibility for encouraging their trainees to build these skills. Some time ago, I was asked to address new surgical trainees, who probably attended with some cynicism when they could have been in theatre. It took them time to warm up until we began talking about a patient who was unhappy with an awkward breast reconstruction following a mastectomy for cancer. One after the other, the trainees recalled seeing the woman on rounds and watching her dissatisfaction turn to distress, but they took their lead from their boss who did not see there was a problem. "I could see that a lop-sided

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 It is also true that when you need a surgeon to save your life, you are unlikely to care whether he smiles through his mask. breast was terrible for a woman who had just gone through the ordeal of breast cancer, and I wish someone had sat down with her, but I felt it wasn’t my place to do it because I was just a trainee", one clearly regretful doctor said. Another reflected, "We duck and weave through patients’ rooms – it doesn’t feel right to be in a rush all the time, but we get away with it and no one tells you differently." I came away with the sense that this new generation of surgeons cared about communicating with their patients, recognised the difference between competent and good, and wanted help to improve. Yet they never returned, probably because their log book did not mandate it. This year, I held a 'Giving Bad News 'workshop to which a single courageous surgical trainee signed up. When he arrived and found himself amidst social

Prestigious institutions such as the University of Chicago have shown innovation by attracting some of their brightest young surgeons onto the faculty of their ethics and communication skills programs. These surgeons set a fine example to their peers, effectively proclaiming, "It’s good to do this", something that no amount of printed advertising material can do. I recently met a neurosurgeon who took himself to an ethics seminar at the Cleveland Clinic, mostly out of curiosity. He came back so impressed with the depth of discussion that he now directs all his trainees there. The surgeon told me that it gave him insight into some of his routine behaviour and reactions that he wished he had had 30 years ago. I hope that those in positions of power will note the winds of change and realise the value of investing in formal training in communication skills. At an intangible level, it makes better human beings out of us; at the most practical level, it cuts down on the number of complaints and lawsuits. This story about an encounter with a surgeon by no means detracts from the great need for communication skills training throughout the profession. It behoves none of us to sit back in complacency, thinking we have arrived.  Dr. Ranjana Srivastava is a medical oncologist, director of physician education, and author of Tell Me The Truth: Conversations with My Patients about Life and Death. She is a Fulbright scholar with a special interest in communication and ethics.


MB

F E AT U R E S

The Futur e Of A esthetics My Botique - Cosmetic Injection Specialist is Australia’s No 1 Cosmetic Clinic Brand. Established in 2009 by a highly motivated team of entrepreneurs, MB has taken the Clinic Industry by storm. Already opening three successful clinics and employing over 20 Doctors, Nurses and Therapists. My Botique has the most experienced team of staff and partners than any other clinic group in Australia. We deliver high quality, affordable, non surgical procedures in 5 star luxury clinics. Our alliance with Allergan, Galderma, Syneron and Ipsen offers our clients the widest range of products to give you the choice they deserve.

FACT: DID YOU KNOW?

Australians spent over $560 million in 2010 on non-surgical cosmetic treatments, most on Anti-Wrinkle Injections 30% Growth in Australia 40% Growth Internationally Despite GFC “Australian Franchise sector has out performed the economy” (PWC)

With over 10,000 patients treated in the last 18 months and over 30% growth in sales, My Botique truly is “The Future Of Aesthetics”. We are passionate about the business of aesthetics and have a proven, successful model that we are excited to replicate across Australia. Although MB has access to some of the best clinical trainers in the world, we have gone one step further and created the MB Academy. We offer a comprehensive step by step training program for doctors, nurses and skin therapist eager to join the industry. Being part of the MB group gives you access to the very best and most current services available today. Equal to our focus on training is our business development system. Our KPI management system is not only unique, but also clear, effective and powerful. Our unique Software allows complete focus on performance and income which is unparalleled in the industry.

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the

FUTURE of COSMETIC MEDICINE

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F E AT U R E S

Part3

Protect your The investments in 2011 2011 is shaping up to be a challenging year for investors - getting the right advice will make all the difference. Lachlan Partners is bringing together some of Australia’s foremost experts at their key seminars to be held in March 2011 across the Eastern Seaboard. Our eminent speaking panel includes Chris Caton

John Marasco

Paul Saliba

Chief Economist BT Financial Group ‘Global Economic and Market Outlook’

CEO Colliers ‘Investing in Commercial and Residential Properties what is happening in Australia and Globally’

Chief Investment Officer Lachlan Partners ‘Dynamic Approach to Asset Allocation - Applying the new Zone System’

SMSF returns, ? Seminars are being held in the following locations

nd (SMSF) you Tuesday are Brisbane not only March 8th 2011 2 - 4pm nt investments but may also

The Novotel Brisbane 200 Creek St, Brisbane QLD

C ourse

Sydney

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

ntial or commercial property, ash deposit rates, and ortunities not readily available

Melbourne

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

Targeted Business Knowledge for Specialists in Practice

Lachlan Partners is a Private Client Advisory Firm focused on client needs and financial goals with offices in Melbourne, Sydney and Brisbane. REGISTER NOW

Contact your local banker, call .com.au/professionalfinance.

To attend OR obtain a Seminar DVD and receive a 3 month complimentary subscription to Investing Times 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)

Experien

30

tice Purchase Loans • Home Loans

Surgicallife

k (Australia) Limited ABN 55 071 292 594 AFSL 234975 (Investec Bank). x and legal advice, as appropriate. Deposit products are issued by Investec


ONE DAY BUSINESS COURSE • Practice Setup & Review COVERING • Accounting Concepts F E AT U R E S

• Banking & Finance • Financial Planning • Indemnity & Risk • Marketing & IT

T

his is a one-day intensive and practical course catering exclusively to medical doctors who are establishing a medical practice or who would like to improve the efficiency of their current practice. (CPD points allocated) Throughout your specialist training program you develop excellent clinical skills. However,

it is recognised that there is a general lack of information provided to doctors on managing the business aspect of their medical practice. Business experts will offer advice in a program that will enable delegates to establish, maintain and promote their medical practice and effectively drive their business forward.

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F E AT U R E S

When Doctors Collide W Recognising the triggers and communication flaws which make us prone to conflict with other doctors

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F E AT U R E S

All human interactions have the potential to develop conflict and the situation in health care is not different. Conflict can be defined as a disagreement within oneself, or between people, that causes harm or Covey, he describes this process in to create some form of structure from ll human interactions have has the the potential may welldetail be aand precursor suggests that while the which toDisagreement produce a plan of action. potential to to cause develop harm. stressors responsible for conflict may conflict and the situation in to conflict, however, expressing a different opinion doesbenotunavoidable always or inappropriately Phase three represents the actions we health care is not different. perform based the conceptualisations can be defined lead to aConflict situation whereas conflict will on occur. Underlying conceptualised, factors thatthe behaviours and outcomes can be modified (for the we created in phase two. We direct a series a disagreement within oneself, or better) by prolonging of behaviours targeting our hypothesised to between that causes harm usuallypeople, precipitate the transition from a disagreement a conflict arethe time between phases two and three. In other words, 'cause'. The conflict situation is then or has the potential to cause harm. highly varied include inthese ideas, perspectives, priorities, by simply withholding any actions after formalised when behaviours result Disagreement may wellbut be a precursor to differences a conflict stimulus for as long as possible, in a series of destructive outcomes in conflict, however, expressing a different preferences, beliefs, values, phase andfour. goals. we may reduce the risk of a maladaptive opinion does not always lead to a situation

A

1

where conflict will occur. Underlying factors that usually precipitate the transition from a disagreement to a conflict are highly varied but include differences in ideas, perspectives, priorities, preferences, beliefs, values, and goals.2 A range of misconceptions about conflict exist based on the premise that harmony is 'normal' and conflict is 'abnormal' and that conflict is the result of 'personality problems'. These fixed ideas may present a barrier to resolving conflicts. Saltman and Kidd3 describe conflicts as going through at least four phases in which thoughts and emotions interact with actions: • •

• •

In the bestselling self-help book - 'The 7 Habits of Highly Effective People'4 by personal development guru, Steven

CONFLICT PATHWAYS HIGH SELF

Compete

Collaborate

Useful: with limited resources

Useful: trying to satisfy all parties

Best: goal is to win

Best: goal is long term

Worst: goal is to cohese group

Worst: trust, respect and communication skills are limited

Phase one – The stimulus for conflict occurs Phase two – The conflicting individuals conceptualise and create a semi-logical explanation to explain the recent events Phase three – A behavioural response is directed at the postulated cause of the conflict Phase four – The phase three response results in a less than optimal outcome.

In the first phase, the conflict occurs and is quickly followed by conceptualisation of the cause. This is a form of quasirationalisation and is frequently a kneejerk response to the perceived conflict. Based on past experiences, our brains create ‘rational explanations’ to explain the painful thoughts and feelings and

phase four response. However, in general, almost all conflicts develop as per the described four stages and result in one of four pathways described below:

LOW

Avoid

Accomodate

Useful: in early stages

Useful: immediately

Best: nothing to lose, no time,

Best: issues more important to others,

inappropriate context

harmony needed

Worst: goal is long term

Worst: teasing out differences

HIGH OTHER

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F E AT U R E S Aggressively pushing your own stance

There are four main ways doctors deal with conflict Conflict Avoidance or 1 Conflict Minimisation (pretending that no conflict has occurred)

Total Acceptance 2 (Accommodating) of the other party’s position

3 Collaboration to look after 4 your own interests but include the interest of others.

Aggressively pushing your own stance (Competing)

Conflict Avoidance or Conflict Minimisation Avoiding a conflict usually involves no declaration or statement from one of the parties to the other and therefore no cooperation from the other party is sought or gained. It is useful as a short term strategy when there is a lot of 'heat' in the situation, but rarely works to achieve long term change. It may be an appropriate strategy where there is no incentive to seek long-term cooperative goals. For example, a locum doctor working in a new unit who has a conflict with his superior is highly likely to understate the conflict as collaborative efforts to create a long term solution would be of minimal benefit. Total Acceptance of the other party’s position Accommodating someone else’s point of view places the emphasis on achieving the other party’s desired outcome. Like avoidance, it is expedient; but accession is unlikely to result in a successful strategy in the long term because the accommodating party’s needs will never be exposed or understood. For example, the junior doctor completely and wholeheartedly accepts the consultant’s position and disregards their own stance as they believe it to be futile to try and argue with the authority of their supervisor.

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‘Standing your ground’ is another conflict management strategy that entails little, if any, cooperation. It is similar to any contest where the goal is not to work with other parties but simply to win. Where the outcomes are most important and resources are limited, rivalry is often seen as the best strategy by a potential victor. Obviously, contest works against any attempts to cohese a group or forge an alliance with someone. Collaboration Collaboration is by far the most timeconsuming conflict management strategy. The process of trying to satisfy all parties can also be very draining of energy and other resources. While best suited as a strategy to effect sustainable change, it may be of limited use where the parties have longstanding mistrust or limited capacity to communicate in-depth with each other. Management of doctor-doctor conflict Conflict is a dynamic process, just as conflict management is. Conflict does not always surface in gale proportions. An essential element of a conflict management process is recognition that there are stages of conflict, with appropriate interventions at different stages. The stages of conflict can range from robust argument within a single meeting to longstanding opposing, entrenched positions of medical staff, administration, and the governing body. Depending upon the culture or needs of the organisation and the type of conflict, an administrator or leader can use various communication skills and negotiation techniques to manage a conflict. A more formal process conducted by an experienced, skilled mediator may be appropriate in managing more complex conflicts. Therefore, any conflict management policy or system must allow for a variety of interventions, from informal methods, such as persuasion, facilitation, conciliation, or negotiation, to formal methods, such as structured negotiation, mediation, or serial mediations. An effective conflict management system must be staged and proportional to allow

for application consistent with the nature and seriousness of the conflict. It goes without saying that early recognition of conflict and an appropriate level of intervention must be a primary objective of conflict management. Informal conflict management will suffice in the majority of intra- or inter-departmental disputes within an organisation and in such cases, utilising a neutral ‘intervener’ is paramount to its success. Informal Conflict Management

1

Identification of the Intervener The intervener generally would be internal to the organisation, as identified in the organisation’s conflict management policy. However, the intervener could be external, depending on the organisation’s culture, needs, and the nature of the conflict.

2

Intervener’s Identification of and Instructions to Participants The intervener should explain his/her role in implementing the conflict management process according to the organisation’s policies and procedures. The intervener should emphasise the foundational principles of the process to assure the participants of his/her commitment to follow the process. The intervener should discuss the expectations of confidentiality of the process, as defined in the organisation’s conflict management policy.

3

Efficient Conduct of the Information Gathering Stage The intervener should move quickly since conflict can conflagrate. The intervener should set a time frame or schedule for interviews and other information gathering. The intervener should ask questions and listen carefully to answers. If necessary, the intervener can ask for written information, documents, or statements from the participants. Additionally the intervener may seek information independently as circumstances or subject matter may require.

4

Objective Analysis of Information The intervener should objectively analyse the information gathered first to determine if additional information is necessary and/or if more questions need to be asked and answered. Next,


F E AT U R E S the intervener should attempt to state the problem in an objective way since “a problem well-stated is a problem half solved.”

5

First Meeting with Participants The intervener should ask each participant to make an initial statement. The intervener may wish to revise his/her previous attempt to state the problem based on new information or positions taken in the initial statements.

Where the outcomes are most important and resources are limited, rivalry is often seen as the best strategy by a potential victor.

6

Seeking Common Ground: Techniques and Settings The intervener should attempt to obtain the participants’ agreement on the statement of the problem. Once there is a working agreement, the intervener should try to bring the participants or positions to common ground by using techniques such as (1) using reflective statements of the positions, (2) attempting de-positioning by eliminating non-issues or less important issues, or (3) asking questions regarding key issues such as “what is the best way to....?” or “what options are there to....?” Formal Conflict Management If informal methods of conflict management following the organisation’s conflict management policies and procedures have failed to resolve the dispute or reduce the disruptions flowing from the conflict, then legal/ compliance/risk management issues or threats to patient safety and quality of care may require more formal dispute resolution methods. As alluded to in the introduction, the organisation will need to move along the continuum of conflict management. The organisation will still want to find a way to address the issues in ways that are efficient, timely, confidential as appropriate, conducive to re-establishing or preserving relationships as much as possible, and productive consistent with the facility’s mission of providing quality health services. The organisation may recognize a need for greater expertise or an 'outside' neutral. Types of Formal Conflict Resolution Along the continuum of conflict resolution, mediation is a more formal

process than the conflict management process. Often described as a facilitated negotiation, the process features a skilled third party neutral who acts as facilitator and not a decision-maker, leading the participants to consider their long term interests rather than positions, and consistent with those interests to explore possible solutions. Neutral case evaluation is a tool that involves a neutral third party who with agreement of the disputing parties provides an objective evaluation of a matter in dispute such as its merits or monetary value. Neutral case evaluation can be invoked when the participants cannot agree on facts or terms of a compromise that is under discussion in mediation, negotiation, or other discussions. Arbitration is the most formal of these three options. It is often described as private litigation and is useful when the need for a binding decision by a third party is recognised but still hoped to be attainable through a process that offers benefits of timeliness, efficiency, and lower cost, with potential for confidentiality. Conclusion The objective of conflict management is related to the goal of advancing the quality of health services. While improvement in patient care through the reduction of error rates is an outcome that can be measured, the author believes that conflict management processes aim more broadly at creating culture shift,

which is more difficult to measure but which is a key to achieving quality goals. Conflict management is a means to establishing a cooperative learning and performance culture in which all players know and understand their roles, support each other in them and learn from each other. Conflict management should not be handled as a perfunctory process designed to merely shut down disputes. Rather, it should be considered a process to open difficult situations to effective discourse, resolution, and learning. Consistent with that view of the process, we recommend that an organisation’s conflict management program include periodic assessment and re-thinking as the organisation gains experience from its initial efforts. Sammy Carroll, MSc.Psych _____________________________________________________ References 1 Porter-O’Grady T. Embracing conflict: building a healthy community. Health Care Management Review 2004;29:181–7. 2 Picker B. American Bar Association. Section of dispute resolution mediation practice guide: a handbook for resolving business disputes. 2nd ed. Washington, DC: American Bar Association Section of Dispute Resolution, 2003. 3 D C Saltman, N A O’Dea, M R Kidd Postgrad Med J 2006;82:9– 12 4 Covey S. The 7 habits of highly effective people. Melbourne: The Business Library, 1994.

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Trading Strategies

W Getting value for your investing dollar A perennial issue for investors is how to get the best value for their investing dollar. Investing directly can help keep costs down as well as open up trading opportunities. 36

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B U S I N E S S & F inance

Why invest directly? Investing your money is an effective way to build your wealth. You can choose to invest directly, indirectly (through a managed fund) or a combination of both. A key attraction of using self-managed super funds is the flexibility and control it gives you to invest directly. By doing so, you gain access to valuable tax advantages and trading opportunities. Which is better - direct investment or managed funds? Managed investments are often referred to as indirect investments because you effectively give up control and responsibility for investment decisions to a fund manager. In return, fund managers generally charge entry and exit fees, which are normally a percentage of the value of your investment, plus an ongoing management fee of usually between one per cent and three per cent per annum. To compensate for these fees, a fund manager has to outperform the returns that could have been achieved by directly investing in the market. This is not often the case.



What many self-managed fund owners overlook is the fact that investing in managed funds inside your selfmanaged fund creates layer upon layer of unnecessary fees, which – over the years – could significantly erode the value of your portfolio.

well”. As an individual investor, you have the flexibility and ‘nimbleness’ to make quick buy and sell decisions to make or avoid losing money, and as a small investor, you are unlikely to affect the market. If a large fund manager suddenly buys or sells large parcels of a particular share, they could adversely impact the share market. Like the lumbering giant – fund managers simply cannot do what individual investors can without being noticed. Some trading strategies to generate portfolio income Equity option trading is just one strategy that can enhance investment portfolio income with very low risk. Equity options are available for most of the top 100 companies and many indices on the Australian Stock Exchange (ASX). Put simply, equity options are where you enter into a contract to buy or sell shares at a particular price. These contracts are more commonly known as ‘call and put options’. Trading strategy one - call and put options A call option gives a buyer the right, but not the obligation, to buy an underlying parcel of shares at a set price, on or before a pre-determined date. •

Outperforming the fund managers

As an individual investor, you have the flexibility and ‘nimbleness’ to make quick buy and sell decisions to make or avoid losing money...

Trying to outperform fund managers is a little like Jack outsmarting the lumbering giant – it’s not always about investing big, it’s about investing smart. A good stockbroker or investment advisor can provide you with trading strategies that leverage your ability as an individual investor to buy and sell quickly to take advantage of quickly changing trends in prices. Famous investor, Warren Buffet said, “Most people get interested in stocks when everyone else is. The time to get interested is when no one else is. You can’t buy what is popular and do

If, for example, you are the buyer of a BHP September 2011 $45 call option, you could exercise your options and buy a parcel of BHP shares at $45 from the option seller on or before the expiry in September 2011.

A put option gives a buyer the right, but not the obligation, to sell the underlying parcel of shares at a set price, on or before a pre-determined date. •

If, for example, you are the buyer of a Westpac June 2011 $20 put option, you can exercise your options and sell a parcel of Westpac shares at $20 to the option seller on or before the expiry in June 2011.

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37


B U S I N E S S & F inance Strike (or exercise) price The strike (or exercise) price is the price at which an option buyer is entitled to either buy or sell the underlying share parcel (and the price at which an option seller must either sell or buy the underlying parcel if the option holder exercises the option). In the above examples, the strike price for the BHP call option is $45 and the strike price for the Westpac put option is $20.

If, for example, you have 1,000 NAB shares with a current share price of $24, you could write a call option to expire in three months’ time with a strike price around 10% higher than the current share price. To do this, you could sell the September 2011 call option with a strike of $26.50 and earn a premium of $0.37 per share being total premium of $370.



Trading strategy two - covered calls A covered call strategy can be a low risk way of increasing portfolio income and involves holding shares and selling a call option for the same shares. The strike price of the call option would typically be higher than the current market price for the shares and if the option was exercised the shares held are sold to an option buyer at the strike price. As the call option that is sold is 'covered' by the shares held by an option seller, the strategy does not increase investment risk.

"Most people get interested in stocks when everyone else is. The time to get interested is when no one else is..."

Features of managed funds and direct equities FEATURE

Managed

Direct

Professional fund management

Yes

No

Immediate application and redemption of funds

Yes

Yes

Traded every day

Yes

Yes

Wholesale execution

Yes

No

Low minimum investment

Yes

Yes

Corporate actions administered

Yes

No

Tax reporting

Yes

No

Fee transparency

No

Yes

Ability to view underlying shares

No

Yes

Minimise CGT when switching

No

Yes

In specie transfers

No

Yes

Avoid embedded CGT

No

Yes

Automatic tax optimisation

No

Yes

Netting of transactions

No

Yes

Blended individual portfolio

No

Yes

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If the option is not exercised, you would earn a total premium of $370, which is an annualised return for the quarter of a little over 6%. If this process was implemented successfully over a 12-month period, premium income of around $1,440 could be generated. Combining the premium income with NAB’s current dividend yield of around 6%, could result in total income before franking credits of around 12%.

A decline in the share price during the period and/or the approaching expiry date of the call options would usually decrease the price of the call option. If this occurs, you could buy back the call options that were sold and lock in a profit. You could then re-establish a covered call strategy by selling another call option and thereby generate additional premium income. If the option is exercised, the shares would be sold at the strike price. However, the seller’s return is enhanced by the option premium received during the period. Unless the share market moves rapidly and unexpectedly, it should be possible to repurchase the shares close to the strike price and implement a new covered call strategy. Final thoughts Investing directly has its advantages and disadvantages. Trading strategies too have their risks but if employed with the help of a trusted and experienced investment advisor, they can be more effective in generating additional portfolio income than by leaving it to the lumbering fund managers. Roger Wilson is a Wealth Management Partner and Eric Maillard is the Lead Business Advisory Partner at Lachlan Partners, Melbourne.


At Lachlan Partners everything connects At Lachlan Partners, you’ll be dealing with professionals who have a proven track record. They are committed to building meaningful, long-term relationships with you and are passionate about making your financial master plan connect perfectly. We help you get the most out of life. You can see it in our brand mark. You can see it in the relationships we’ve established with generations of clients. You can see it in the way our services have been designed to work in harmony with each other. As one of Australia’s most trusted and reputable private advisory firms, our range of business and financial advisory services has been created with pure financial synergy in mind. It enables us to look at the bigger picture of your overall needs and provide one powerful integrated solution. We offer the kind of solution that comes with the outstanding level of personal service that you expect from a more intimate financial establishment like Lachlan Partners. But that’s not all that sets us apart. It’s worth noting we operate on a fee for service basis, which means the advice we offer is totally independent and objective. Our sole purpose is to help you achieve your financial and lifestyle goals. Lachlan Partners publishes Investing Times, Australia’s foremost independent newsletter providing financial and investment wealth creation strategies.

LACHLAN PARTNERS Chartered Accountants, Business & Financial Advisors

Melbourne Level 35, 360 Collins Street Melbourne VIC 3000 T 03 9605 9200 F 03 9605 9249 Sydney Level 18, 201 Kent Street Sydney NSW 2000 T 02 9291 2800 F 02 9291 2888 Brisbane Level 5, 49 Sherwood Road Toowong Qld 4066 T 07 3871 0599 F 07 3871 0522 Freecall 1800 643 631 E info@lachlanpartners.com.au W www.lachlanpartners.com.au


PSI B U S I N E S S & F inance

Personal Services Income

W What is it and how

does it affect me?

The concept of Personal Services Income and the rules we are about to explain all came about to address the once common practice of using company and trust structures to move income away from a key person to other family members or lower tax rate entities.

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B U S I N E S S & F inance

L

et’s start at the beginning, what exactly is regarded as PSI?

PSI is defined under s84-5 ITAA97 as ordinary or statutory income that is gained mainly as a reward for the personal efforts and skills of an individual. The ATO takes a simple approach to their assessment of ‘mainly’, if the income you earn is more than 50% for your effort and skill then you classify this income as PSI. It is important to understand that a business can have both PSI and non PSI income. So the concept of PSI is not applied across an entire business necessarily. You can, however, immediately see that for the bulk of medical professionals their income could be deemed to fit into this category. It is their personal effort and skill that is generating the income, it is not the sale of a product or the operation of certain equipment that generates the income. Once we accept that the income received fits the PSI definition, the question becomes whether the individual circumstance mean the operator is conducting a Personal Services Business or whether they are in fact subject to the PSI Rules. As such the classification of your income as PSI is not the end of the process however, there are other rules that are applied to PSI to determine whether the income must be attributable back to the individual or whether the individual is in fact operating a business.

The Results test simply looks at whether the engagement of your services and the payment due is dependent on a certain result being achieved. Take the example of a carpenter who provides a quotation for a job, it is a fixed price for a fixed outcome. This satisfies the Results test, he doesn’t get paid until the job is complete. The same carpenter who is engaged on a daily or hourly rate is not dependent on achieving a certain result to receive their income; this does not satisfy the results test. Generally medical professionals get paid regardless of whether a specific outcome is achieved, many are engaged on a daily rate via locum placements and as such they do not satisfy the Results Test. Some elective or cosmetic surgeries may fall outside of this as they are a fixed price for a set result, if there are complications the practitioner is required to provide further services for no further income. It comes very much down to the service offering and particulars of the arrangement. For your business to avoid the PSI Rules you require 75% of your PSI income to satisfy the Results Test. If your PSI classified income does not satisfy the Results test, it then goes through a second set of tests to see whether the PSI Rules apply. There are two elements to this second filter, you now need to satisfy one of three tests and also pass the overarching test, the 80% Rule. The three alternative tests we have available are the following;

The first rule is known as the Results Test. You will satisfy this test if you can answer yes to the following: 1 Under your contract or arrangement, will

your business only receive payment when the work has been completed, that is, after producing the contracted result? 2 Does your business need to provide the equipment or tools necessary to do the work? 3 Do you have to rectify defects in the work?

1 The Unrelated Clients Test, 2 The Business Premises Test, or 3 The Employment Test.

The Unrelated Clients Test is satisfied if the business provides services to two or more clients who are not associates of each other or associated with the key individual. Due to the number of patients seen by medical professionals there is no question that the unrelated clients test is satisfied.

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Company / Trust / Partnership Income PSI?

B U S I N E S S & F inance

No

Yes

The Business Premises Test is satisfied if at all times of the year the business premises are used solely for the operation of the business and are not connected in any way to the residence of the individual performing the services. As most medical professionals either operate in the hospitals or shared rooms, medical businesses rarely satisfy the Business Premises Test. The Employment Test is satisfied where more than 20% of the income generated can be attributed to the activities of an employee who is not an associate of the key individual. Alternatively to this if an apprentice was employed for more than 50% of the year, the employment test can be satisfied.

PSI Tests

Business Income

Unrelated clients

Fail Results

Business premises Employment Fail

Pass Pass

Satisfy 80% Rule

No

No

Yes

As can be seen, of the three tests mentioned the Unrelated Clients test provides the best opportunity for medical business to move through to the next and final test.

PSB Determination? Yes

Income Attributed

Income Not Attributed

The 80% Rule The catch-all provision in this second tier of tests is the 80% Rule. This is determined where you derive less than 80% of your income from one source or set of associated entities. Even if you were to deem Medicare as one source, most medical professionals would not derive 80% of their income from Medicare, income received from health funds and patient gaps would see the Medicare fall below the 80% threshold. However if you apply these rules to your own practice or private income sources and conclude that the PSI Rules apply, the impact is as follows: 1 Your business cannot claim certain deductions against the PSI. You are basically limited to deductions available to an individual tax payer. Such things as paying a salary to a spouse for administrative support, and making superannuation contributions for them is no longer an available deduction, 2 The PSI (less relevant deductions) your business received will need to be attributed (treated as belonging) to each individual who performed the services – that is, the profits can’t be retained in the business, 3 Your business needs to meet certain

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tax return obligations and 4 Your business may have additional pay as you go (PAYG) withholding obligations. If on the other hand you run the tests over your business and conclude that, due to the Unrelated Clients test and the 80% rule, you are operating a Personal Services Business, the PSI Rules do not apply and you avoid the extra requirements outlined above. It is important for all medical professionals to understand these subtle differences (or work with an accountant who understands them), even if you are operating a Personal Services Business you are still required to disclose the level of PSI that you receive. The ATO will maintain a high level of scrutiny in regard to how you are managing this PSI income through your business and ultimately the AntiAvoidance provisions contained in Part IVA of the Income Tax Assessment Act will apply as always. For those unfamiliar with these provisions, they aim to be a ‘catch-all’ for any tax structure or strategy whose primary benefit is the reduction of tax.

Historic tax saving strategies of retaining earnings in a practice company, distributing business profit to lower tax rate individuals and paying the key person a below market rate for their services have all been expressly stated as the type of thing that would attract the Anti-Avoidance provisions. James Clyne is the Accounting Partner and Adam Faulkner is the Medical Wealth Strategist at MEDIQ Medical Financial Services.

References ATO document NAT 72510-05.2009 - Personal Services Income for Companies, Partnerships and Trusts. 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.


R BU I SSKI N M E SASN & A GF inance EMENT

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.

1300 589 527

www.MediqFinancial.com.au Accounting & Taxation Commercial Loans

Life Insurance

Equipment Finance

Investments

Melbourne Sydney Brisbane

Financial Planning Home Loans

Medical Indemnity

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Medical Practice Strategic Consulting

MEDIQ Financial Planning is a Corporate Authorised Representative of Synchron AFSL 243313

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SMSF

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B U S I N E S S & F inance

INsurance Premiums W To claim or

not to claim?

At tax time every year, it is common practice for us all to tally up our potential deductions for the previous tax year. When it comes to risk insurance premiums, there is a great deal of difference depending on policy type and ownership. In our professional experience we have seen two common mistakes: clients neglecting to claim valid deductions and others assuming certain covers were deductible, when in fact they were not. This article seeks to bring to your attention the types of covers that are deductible and the circumstances in which this occurs.

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B U S I N E S S & F inance

D

o I need to be selfemployed to claim a deduction on Income Protection premiums?

The short answer is no. The deductibility of income protection premiums is available to any type of policy owner; whether it’s an individual, trustee of a super fund or under a company structure. Individuals may be employees or self-employed although the level of tax deductibility differs for each of the ownership entities. Furthermore, benefit proceeds are assessed differently also. Does owning Income Protection (‘IP’) via Super provide more or less of a tax deduction than owning outside of Super? The level of tax deductibility is identical, in or out of the super environment. The premium amount payed is a 100% deductible expense. The difference is that a personally owned policy is deductible against the tax payer’s marginal tax rate, which may be higher than the 15% concessionally taxed super environment. Generally, medical specialists fall into the 38.5% or higher tax bracket.

Example (A) Salary $175,000 Income Protection premium: $8,000 Tax rate: 38.5% Deductibility: $3,080 Net premium: $4,920

Is Business Expenses Insurance tax deductible?

In what circumstances can Trauma Insurance be deductible?

Yes, the deductibility of Business Expense (overheads) premiums is available to any type of policy owner; self (individual), payed by an employer or owned by a business. The premiums paid are fully tax deductible and the benefit proceeds are fully assessable.

There are two situations where Trauma insurance premiums can be deductible:

Is there a benefit to claiming Business Expenses as a business expense rather than as a personal expense?

2 When the purpose of the policy is 'Key Person' * (revenue protection) generally the premiums are tax deductible when the following conditions are met:

As a business expense, there are no exceptions to the deductibility of the insurance premiums paid and owned by a business. Conversely, claiming Business Expenses as a personal expense, there may be difficulties to justify the 'purpose' of the policy and furthermore its deductibility status.

• policy owned by the business, and • policy premiums are paid by the business, and • the beneficiary is also the business.

1 Policy owned by an individual, but paid by an employer and the beneficiary is the life insured. There may be Fringe Benefits Tax applicable in this scenario.

*please note for the previous situation, benefits are assessable When can Life and TPD covers be deductible?

Is Trauma Insurance tax deductible? No, however the proceeds are tax free.

TYPE OF LIFE INSURANCE LIFE COVER

Please review the following table outlining the deductibility of both Life and TPD premiums:

POLICY HOLDER/ PURPOSE

BENEFICIARY

Self (individual)

Nominated

Paid by employer but

PREMIUM DEDUCTIBILITY

BENEFIT ASSESSABILITY

No

No

Yes

owned by individual

Nominated

(conditions apply)

No

Key Person - Revenue

Business

Yes

Yes

Partnership Protection

Business

No

(conditions apply)

Superannuation

Trustee on behalf of

Yes

No

Trustee

member

(conditions apply)

(conditions apply)

Self (individual)

Self

No

No

Key Person Example (b) Salary $350,000 Income Protection premium: $8,000 Tax rate: 46.5% Deductibility: $3,720 Net premium: $4,280

TPD COVER

No

Paid by employer but

Yes

owned by individual

The insured

(conditions apply)

No

Key Person - Revenue

Business

Yes

Yes

Partnership Protection

Business

No

No

Superannuation

Trustee on behalf of

Yes

No

Trustee

member

(conditions apply)

(conditions apply)

Key Person

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Is TPD owned via super always deductible? Yes, although the level of deductibility since July 1st 2011 for 'own occupation' TPD premiums has changed from previous years. Since the superannuation legislation (SIS Act 1993) defines permanent incapacity in broader terms than those under a ‘own occupation’ policy, the deductibility for such a policy is limited to what the cost would be for the more standard ‘any occupation’ definition. As a general guide, 60% of the premium of an ‘own occupation’ policy held via super may be claimed as a deduction. How can I maximise the deductibility of my super owned TPD whilst maintaining an Own Occupation Definition? There are specialised products in the market place that offer a ‘hybrid’ solution in that the cover is simultaneously owned via super and outside super. If the claim requires the ‘own occupation’ definition, the benefit is paid from the non-super component. Alternatively, if the ‘any occupation’ definition is required, the benefit is paid via super. Importantly, in either circumstance, 100% of the TPD benefit is paid. One insurer names this product option 'Superannuation Optimiser' and this option does not cost any more. The diagrams to the right illustrates this product solution.

Not trapped

if payable under ‘Own’ if payable under ‘Any’

TPD

Any Occupation under Super Fully tax deductible

if payable under ‘Any’

if payable under ‘Own’

TPD Own Occupation outside of Super

Not tax deductible

 Rodney DeGabriele and Aaron Zelman are both client advisers of specialist risk insurance firm, Priority Life.

In today’s knowledge economy, reference information is readily available. Tax guides can provide guidance, but as illustrated above, it is the understanding of legislation and the application of strategic know-how that will optimise your financial results.

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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B U S I N E S S & F inance

Physician ife Surgicalllife

39 47


R I sk management

Surviving the

'Hot Tub' W A personal experience of joint

expert conferences and evidence

“The greatest

deception men suffer is from their own opinions� - Leonardo da Vinci

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R I sk management

In August 2009, the Supreme Court brought into effect new practice guidelines in NSW which would change the way both expert witnesses and treating doctors would present evidence in court. Other courts across Australia have since established or are as a result bringing in their own legislation. The NSW Supreme Court guideline 11 requires that, doctors who have provided a medico-legal report in a legal case meet in a so-called 'hot tub' conference to work out areas of agreement versus disagreement as specified by the parties. The guideline also mandates for the concurrent provision of evidence in court, rather than the previous, more adversarial, style of individual examination and cross-examination. Giving evidence in the company of colleagues allows doctors to work with the court rather than as potential adversaries of a 'hired gun' type.

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R I sk management

Giving evidence in the company of colleagues allows doctors to work with the court rather than as potential adversaries of a 'hired gun' type.

H

aving now attended around 20 such conferences in my role as a forensic psychiatrist I can look back and sometimes feel embarrassed about mistakes made whilst learning a new process. Although as doctors we often discuss cases, it is usually in the interests of patients and there isn’t the 'emotional heat', the kind of 'heat' which, can erupt when experts strongly hold their opinions and don’t want to be seen as losing face by backing down. There are, however, a number of advantages of the process, including having the opportunity to test and discuss ideas in an inquisitorial 'hot tub' meeting. Why the change? Mooted as a cost effective and fairer way of examining different opinions amongst experts, the joint process is also a way of identifying and narrowing the important issues in a case, before it goes to court. Other advantages include the shortening of trials, reducing bias and enhancing the chances of settlement prior. The parties choose which experts will be involved out of those who have provided a report and agree on a list of questions designed to distil the most disputed issues.

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What do I have to do? Although medico-legal specialists are used to reviewing documents, if you are involved as a treating doctor be prepared to step outside your usual role and be asked to comment on information you would normally not be privy to in the treatment setting. Leaving sufficient time to review the documents is important, as is carefully reviewing the questions and thinking about how your opinion might need to be changed. Once a time is agreed upon, the experts meet at a designated venue. Sometimes an expert will volunteer their rooms, at other times the solicitors will arrange a central office. Although a personal meeting is preferable, the option of a phone conference is available if distance is an issue. Sometimes, the solicitors for both parties will ask to attend to listen to the experts’ discussion and gain a 'feel' for the prevailing opinions. However, they are unable to participate or try to influence the process other than to provide medical records the experts may wish to review. Leaving enough time for the process is vital. All of us are busy, but neither you nor

your colleagues will be keen to arrange a second meeting because of inadequate allocation of time. In one complex case I participated in there were 32 questions and four experts expressing, at times very heatedly, differing opinions. The process took over several hours and was quite draining for all who were involved. 'Hot Tub' etiquette Whether or not a recording should be made is a request to think carefully about. Because the aim of the conclave is to allow experts to talk through and debate the issues before committing to an opinion, the risk of a recording is that it may stay the property of one expert and only be given to one set of solicitors. What was meant to be an exploratory discussion may become the source of information on which to cross-examine. Personality plays a large role in how comfortable and, ultimately, how useful a joint meeting will be. Although we all like to think of ourselves as reasonable and polite professionals, the tub can get very hot when experts take a strong view about the rightness of their opinion and become intolerant of other’s ideas.


R I sk management of trying to accurately decipher notes afterwards is not only time consuming but fraught with possibilities for flawed recall and can lead to angry colleagues who insist that wasn’t what they said! Similarly, a post-meeting dividing up of questions between experts to lighten the load can lead to a nightmare word processing situation of different typists trying to meld a document together. Also, there always seems to be one expert who doesn’t complete their section in time. So it makes sense to have the dictation or typing done at the time, while memories are fresh and all experts have heard their colleagues’ opinions. You will have an opportunity to proof read the report before a final sign off of copies to both sets of solicitors.

If the atmosphere becomes heated, or alternatively frosty, it’s important to remember that as experts we are required by the court to be impartial and this involves not letting our personal beliefs about a case interfere with the process. Sometimes, a potential confrontation can be derailed by 'agreeing to disagree' and moving on to the next question. It is rare for experts not to be able to find some common ground in one or other area of diagnosis, causation or prognosis. In other cases, the issues will be ones of liability and criticism of the doctor involved in a medical negligence case need to be treated with the same respect you would wish to receive from your own colleagues. Getting your view across Following general discussion the experts need to verbally summarise their responses to each question, which should be recorded, preferably by dictaphone for transcription or by having a typist in attendance, which can be organised by the parties. One of the biggest mistakes neophyte experts can make when gaining experience with the process is to prepare the report at a later date, based on handwritten summary notes. The task

It’s important not to be cowed by the presence of more senior colleagues. As a low level clinical academic I have sometimes met with up to three professors colleagues who didn’t get to their positions without holding strong opinions. Your view, including as a treating doctor, has its own weight. Some preparation prior such as, jotting down what you would like to express is a useful exercise and also gives something to refer back to in the heat of the moment, if it’s hard to think clearly. 'Hot Tub' stereotypes The combatant expert is out to prove a point: their own. It’s personal and it’s a battle to be won, rather than a negotiation of opinions. This expert can be outright rude and hostile in defence of an idea. If you start to hear your own voice elevating, take a deep breath and start again! The immoveable expert continues to insist on his or her opinion even when new information is available. They may hold idiosyncratic views based on their own experience or research. Remember, there is no loss of face in altering an opinion in the face of new evidence; that is part of our scientific training and is also required of us by the court. The senior expert is not used to being challenged from whatever academic or clinical position they hold. They are at risk of patronising junior colleagues. They may also fall into the trap of becoming statistics experts who rely on the research literature alone and cannot

Although we all like to think of ourselves as reasonable and polite professionals, the 'tub' can get very hot when experts take a strong view about the rightness of their opinion and become intolerant of other’s ideas. consider an individual’s case and whether the studies they quote are relevant. The ideal expert is one who can calmly and clearly express an opinion, listens carefully to their fellow experts and respects differing views. One or more ideal experts in a 'hot tub' have a great opportunity to save themselves and the court time later on and may even lead to the case being settled prior. Like any new experience, being part of a joint expert conclave is a steep learning curve. Bringing an open mind and the same type of respect for our colleagues that we bring to our clinical interactions gives the best opportunity for the experience to be rewarding.

Dr. Lisa Ferrier-Brown is a forensic psychiatrist who has learnt to enjoy the 'hot tub' experience and share the witness box with colleagues of all types.

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ALPHA

As the ‘underdeveloped world’ catches up with the ‘developed’, this global energy craving will continue to increase considerably. 52 50 52

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ALPHA

Our Dirty, Cheap, Fuel Addiction W Breaking carbon’s bond We are all faced with one huge, fundamental problem. How do we cure our need to meet the increasing demands from an ever increasing global population (1,2) addicted to cheap and dirty energy?

T

he more ‘developed’ a human society, the more energy it craves. As the ‘underdeveloped world’ catches up with the ‘developed’, this global energy craving will continue to increase considerably. The clear challenge is how to fulfil this craving, without rendering our planetary home unfit for any life except some type of hardy fuzzy anaerobic mould. Currently we are witnessing the results of our unrestrained addiction to dirty energy supplies. But in reality- what is it, what does it do and how can we begin to cure it? Aetiology of dirty, cheap fuel

Since the Industrial Revolution, man has used ever increasing quantities of readily available, energy dense materials like wood, peat, coal, oil and lately gas. The more that he used, the more he needed. Such energy dense, carbon based fuels produced CO2 and other combustion products. Many of the newly developed industrial processes also produced similar compounds.

Even though industrial injuries, diseases and local environmental degradation from producing and using these fuels were soon obvious, very few people understood the insidious and serious long term side effects taking place on a planetary scale. The two people who did were; Svante Arrhenius in 1896 and Edward O. Hulbert in 1931, both of whom, performed laborious calculations (there were of course, no computers back then). Despite inadequate data,

Since the Industrial Revolution, man has used ever increasing quantities of readily available, energy dense materials like wood, peat, coal, oil and lately gas.

the predicted changes in global [CO2] are remarkably close to what we see today 3,4. Until the advent of the Industrial Revolution (1750), natural GHG (greenhouse gas) production was stable, moderated by natural mechanisms. Since then, all have increased by varying amounts. Water Vapour is the most abundant, naturally occurring GHG. This was previously in balance until a warmer earth resulted in increased atmospheric (water vapour), which amplifies the effects of other GHGs by about 50%. Pathophysiology: The greenhouse effect Very short wavelength ultraviolet (UV) energy from the sun strikes the atmosphere of the planet. About 33% is reflected back into space immediately. The remaining 66% is absorbed by the atmosphere and the ground. Fortunately for life on Earth, a balanced amount is radiated back out but as (cooler) longer wavelength infrared (IR) energy. Much of this is absorbed by the atmosphere,

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ALPHA including clouds and re-radiated such that it keeps the planet at a life sustaining temperature. Without GHGs the planet would be about 33°C cooler. The corollary is that the more GHGs in the atmosphere, the warmer the planet. Pathophysiology: Some Biochemistry The oceans contain about 50 times more CO2 than the atmosphere and 20 times more that land biosphere. Atmospheric CO2 goes into solution in the oceans, obeying Henry’s Law. Once there, it is ‘buffered’ by formation of Carbonic acid and dissociation to Bicarbonate and Hydrogen ions or by take up by marine organisms, either to contribute to growth, formation of CaCO3 (zooplankton) or growth and O2 by photosynthesis (phytoplankton). As the buffer capacity is reached, the CO2 increases and pH decreases. Coupled with increased temperatures this decreases the solubility of CO2. The seas become more acidic and hostile to fastidious organisms. Atmospheric CO2 increases more quickly. Plankton are quite fastidious organisms and easily killed or weakened by small changes in their environment. They are at the base of the ocean’s food pyramid. Interestingly, Phytoplankton produce about 50% of our oxygen.5 Perhaps we should try not to kill it? Pathophysiology: Some Oceanography As seas warm, despite well documented stratification, deeper layers of the oceans will gradually warm too. At the bottom of some of the deeper waters are frozen CH4 hydrate complexes. As temperatures increase these will thaw and outgas, increasing atmospheric (GHG). As cold seas warm, the effective albedo, reflectivity of sea ice coverage decreases and more heat is absorbed by the darker water. As ice decreases, so does structural support for coastal icesheets. Melting sea ice does not change sea levels. Melting land ice does. As melt water flows into the sea, it can change the salinity. In an enclosed body of water with little mixing, this can have significant effects.6

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Pathophysiology: Some Glaciology Glaciers all around the world are shrinking.7 It has recently been demonstrated that the melt water from glaciers can act as both a lubricant and a hydraulic shear that destabilise the ice/ rock interface8. Paradoxically, increased snowfalls (increased evaporation leads to increased precipitation) makes the glacier heavier. These combined mechanisms increase speeds towards the sea where the land based ice will melt and add to volume of water already in the sea. Huge volumes of cold water can affect various oceanic conveyor systems, such as the Gulf Stream, which keeps Europe quite warm considering the latitudes involved. A very informative review of the inevitable consequences of continued glacial melting can be found on the United States Geological Survey (USGS) site.9

The oceans contain about 50 times more CO2 than the atmosphere and 20 times more that land biosphere. Atmospheric CO2 goes into solution in the oceans, obeying Henry’s Law. Pathophysiology: Some Botany Every school child knows that as plants grow, they take up CO2 and produce O2. If trees are cut down, then CO2 is not absorbed and O2 is not produced. Furthermore considerable CO2 is released as the cut trees rot or are burned. Clearing of tropical rainforest is thought to be responsible for about 25% of all Global CO2 production. On

the plus side, Gaia is looking after her dumb dependents and trees appear to be growing faster and compensating (to a degree) for all those that are being cut down10. Grasping at this, many in denial claim that more CO2 is good for plants but in so doing demonstrate their ignorance. Up to a certain point, this is true as long as water supplies are adequate and too high an increase in [CO2] results in stunted, poor quality plants. Trees and plants are starting to 'migrate' away from previously equitable growing areas now turned ‘hostile’. This usually means growing higher up, if and where possible. Pathophysiology: Some Zoology (and Medicine) Clearly as habitats change, then animals will have to adapt, move or die. The long term effects of this forced migration of unimaginable numbers of different species can only be guessed. Seen through human eyes, no doubt there will be some benefits. There will also be significant deleterious changes. Some are already being seen. For example, warming waters around many coasts are attracting increased numbers of seals which in turn attracts increased numbers of sharks. Some are as yet theoretical. JAMA in 1996 reported that “The incidence of mosquito-borne diseases, including malaria, dengue, and viral encephalitides, are among those diseases most sensitive to climate. Climate change would directly affect disease transmission by shifting the vector’s geographic range and increasing reproductive and biting rates and by shortening the pathogen incubation period. Climate-related increases in sea surface temperature and sea level can lead to higher incidence of water-borne infectious and toxin-related illnesses, such as cholera and shellfish poisoning. Human migration and damage to health infrastructures from the projected increase in climate variability could indirectly contribute to disease transmission.”11 Pathophysiology: Some Climatology The world’s weather is driven by an incredibly complex series of interactions between the spin of the planet, the temperature(s) of the land, the oceans and the nature of our atmosphere. The


R I S K MAALNPAHG AEMENT

first law of thermodynamics is that energy can be changed from one form to another, but it cannot be created or destroyed. Simplistically, the more energy into a system, the more energetic that system becomes. In the case of planet earth, this translates to more frequent and severe storms, increased evaporation and rainfall, changeability of previously stable weather patterns, etc. etc. The climate models really only got two things wrong: The severity and speed of the onset of changes. Both were significantly underestimated... Pathophysiology: Methane Methane is particularly worrying. As permafrost (lands frozen for centuries) gradually thaw, enormous stores of frozen vegetation will begin to decay and produce literally millions of tons of methane. Similarly, the methane hydrates referred to earlier will also outgas. In fact, it is wrong to say ‘will’. These changes are occurring now and are creating a huge positive feedback which can only

increase atmospheric temperature even more.

Clearly as habitats change, then animals will have to adapt, move or die. The long term effects of this forced migration of unimaginable numbers of different species can only be guessed.

Epidemiology One of the more curious aspects of the disease is that even though ‘epidemiologists’ (climate scientists) around the world have spent a great deal of time and money tracking and predicting the likely course and consequences of our addiction, at each and every turn they have been hindered and sabotaged by others. These can be people who have very little (to no) understanding of the basic science. Or are those who wilfully ignore established science and/or deliberately seek to deny and bury the truth for mysterious and obscure reasons. Much is still made of errors in data that really only effect time scales, not end results. E.g. The recent ballyhoo about an error in the rate of melting of the Himalayas12. They won’t all be gone by 2035, but what about 2085, or even 2135?

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ALPHA

...‘epidemiologists’ (climate scientists) around the world have spent a great deal of time and money tracking and predicting the likely course and consequences of our addiction, at each and every turn they have been hindered and sabotaged by others. 56

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Rivers that supply almost two billion people will become seriously depleted or dry, a few years later than initially predicted, but what are 50 or 100 years compared to the thousands they have flowed regularly? Who would try and gain some cynical high point from this? Does it matter, except to maybe give us more time to respond to the problem? Why would anybody do this? What sort of people would jeopardise the future of our planet? Let us look at a couple of such human beings, the Koch Brothers. This small extract from The New Yorker13, is a good point for the uninitiated to start their research on these two men who together hold the unenviable record of making the most personal profit from polluting our world, literally and ideologically... “The Kochs are long time libertarians who believe in drastically lower personal and corporate taxes, minimal social services for the needy, and much

less oversight of industry—especially environmental regulation. These views dovetail with the brothers’ corporate interests. In a study released this spring, the University of Massachusetts at Amherst’s Political Economy Research Institute named Koch Industries one of the top ten air polluters in the United States. And Greenpeace issued a report identifying the company as a “kingpin of climate science denial.” The report showed that, from 2005 to 2008, the Kochs vastly outdid ExxonMobil in giving money to organizations fighting legislation related to climate change, underwriting a huge network of foundations, think tanks, and political front groups. Indeed, the brothers have funded opposition campaigns against so many Obama Administration policies—from healthcare reform to the economic-stimulus program—that, in political circles, their ideological network is known as the Kochtopus.” These two men and their cronies can buy and sell governments and bend


ALPHA

‘government’ policies to their own needs for continuing profit. They are proof positive (if any was still required) that governments are really for the benefit of such narrow private interests, with public interests a distinct second or third. It is they and/or their lower echelon ilk, who establish various so-called ‘think tanks (propaganda ponds?)’, always at a great many arms lengths, to parrot their denials in doubtful detail. Additionally, they pay the salaries of various denying mouthpieces in the less sophisticated popular press. Conclusion...the symptoms and signs There is not enough space in around 2,000 words to catalogue the changes already occurring, but it is hard to believe that anybody, even with only one eye and half a mind, could miss what is plain for all to see and understand that things are going from bad to worse. One wonders whether a “Microbial Malthus” ever looks about itself in a petri dish and worries about the degrading quality of the blood agar.

But all of this is a continuing distraction. Much time has been wasted trying to debate with entities that really do not debate but just waste time whilst the facts are established on the ground. Whilst the inattention, quibbling and distraction has continued, sea temperatures around the world have risen by an alarming 1-2oC compared to before the Industrial Revolution.14 There is no denying the consequences.15 Suffice to say that all the serious scientific panels around the globe accept the facts of mankind driven global warming. There are no dissenters from this view. The next steps are to find ways to ameliorate the changes as it is, in fact, too late to prevent changes from occurring, 60% reductions on 2,000 levels of CO2 from Australia by 2050 notwithstanding.16 There are technologies and tactics we can employ but they require a clear vision, will and the ability to ignore the sirens of the selfish, dirty fuel industry and their multitudes of paid enablers.

Dr. Richard Middleton _____________________________________________________ References 1 http://www.tranquileye.com/clock/ 2 http://www.census.gov/main/www/popclock.html 3 http://cdiac.ornl.gov/pns/current_ghg.html 4 http://en.wikipedia.org/wiki/Greenhouse_gas 5 http://science.nasa.gov/earth-science/oceanography/oceanearth-system/ocean-carbon-cycle/ 6 http://www.iol.co.za/scitech/science/environment/globalwarming-decreasing-salt-in-sea-1.1089154 7 http://www.nytimes.com/2010/11/14/science/earth/14ice. html 8 http://www.skepticalscience.com/print.php?n=483 9 http://www.usgs.gov/global_change/glaciers/glaciers_sea_ level.asp 10 http://www.independent.co.uk/environment/climatechange/global-warming-makes-trees-grow-at-fastest-rate-for200-years-1886342.html 11 JAMA. 1996 Jan 17;275(3):217-23. 12 http://www.timesonline.co.uk/tol/news/environment/ article6991177.ece 13 The New Yorker, August 30th 2010, “Covert Operations”. 14 European Environmental Agency, 2008 15 http://www.independent.co.uk/environment/climatechange/extreme-weather-link-can-no-longer-be-ignored-2305181.html 16 http://www.climatechange.gov.au/en/submissions/ cprs-green-paper/~/media/submissions/greenpaper/0524hutchison .ashx

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ARTS

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ARTS

A beginner’s guide to Australian art W Collecting or investing?

N

ot infrequently, there can be some status or even snobbery attached to a piece (or pieces) of art. Our choice in art – what we choose to collect and, more importantly, display - might reflect what we want others to think about our taste, our judgment or even our wealth.

Nearly every Australian household has some sort of artwork hanging from its walls, displayed on its shelves and tables or standing on its floors. Mostly this is purely for decoration, the pieces of art reflecting the tastes and budgets of the respective households.

Anyone who acquires one or more works of art can be regarded as being an art collector. Our collections might be small or large, narrowly focused or broad and eclectic, randomly assembled over time or meticulously planned and executed. In reality, we are almost all collectors and every time we acquire a new piece, however grand or unimposing, we are adding to our collections. Someone who collects art for the sheer joy of it will only ever buy works that they like. And where art is acquired primarily for its role as decoration, you’d be absolutely mad to buy something you didn’t like. Furthermore, if it is an expensive piece, you’d hope that you absolutely loved the work. Even for would-be investors, the usual advice they are given is to only buy art that they like. That way, given the relatively low likelihood that an unselected work of art will appreciate significantly in value over time, they will at least retain their enjoyment of the piece. And any appreciation in value will be seen as a genuine bonus. I do not entirely agree with this advice and have found that, like our taste in books or in wine, our taste in art continuously changes with exposure.

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ARTS What is an art investor? A true art investor is someone who collects art with view primarily to its capital appreciation over time and not (primarily) its’ decorative appeal or its’ ability to fill a particular spot on a particular wall at home. Yet even art investors nearly always start off as collectors, so the collections of most investors (mine more than most) also contain works that are not truly investment quality. In truth, it is difficult for even the most disciplined investor to overlook works that appeal for purely decorative reasons, for their bragging rights value or because they are representative of a specific area of sub-interest for the investor-collector in question. But a sensible art investor ensures that, irrespective of other reasons that they like the works they acquire, for each piece they collect there are sound reasons to believe that its dollar value will rise over time. Contemporary Australian homes and contemporary tastes in art generally demand contemporary (i.e. brand new) art works whose future value is especially hard to predict. That is, when most Australians buy the art they love for their home, they are genuinely unlikely to be acquiring a worthwhile investment regardless of what they have been told. Yet many brand new works, especially those by the myriad of up-and-coming artists in this country who are represented by unequivocally reputable galleries, are remarkably expensive. Even in the current economic environment, it is common for the exhibitions of such artists to be sold out despite the prices of individual pieces regularly exceeding $10,000. It is not unusual in Australia for the larger, new works of well-established (but by no means critically acclaimed) artists to attract prices of $50,000 or more. Cost versus re-sale value Clearly, when one is spending such large sums on a work of art, it makes sense to at least consider the future value of that piece. In this respect, the advice of the gallery selling the work needs to be balanced against their intense interest in

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achieving a sale. The fact that an artist is having sell-out exhibitions or that their gallery prices have risen steadily (or even dramatically) over recent years simply does not mean that the re-sale price of these works of art will also increase over time. Most importantly, one must appreciate that the gallery takes about 50% of the sale price to cover its own, considerable expenses. This is a fair reflection of the costs to the gallery of staffing and maintenance as well as promotion of the artist. But it is a stark reminder that the immediate re-sale value of the piece of art you have just purchased is likely to be considerably less than your purchase price. Furthermore, when any work is re-sold, the owner is likely to incur a seller’s commission. Should you fall out of love

It is important to distinguish clearly between what we love to look at and what will, in addition, appreciate in value over time. with the piece you bought a year or two ago and wish to sell it and should your gallery be able to find a buyer for it, the amount you actually receive will be less than you might imagine. It might take many years to find a buyer for your work at a price that is acceptable to you and many more years for your work’s re-sale price to rise sufficiently to allow you to recover your initial outlay let alone make a profit. It has been estimated that, even with the new works of a successful, mid-career

artist, the purchase price of a brand new work incorporates 10 – 20 years of capital growth. And there is no guarantee that this work will appreciate at all. The artist in question might lose interest, lose favour or die prematurely meaning that re-sale value might be negligible. Various scenarios – inability to sell, slow capital growth or actual fall in dollar value – can be disillusioning for the would-be investor who has misjudged the investment value of the piece, has overspent and is reasonably entitled to conclude that investing in art is for “mugs” only. What is a good investment piece? A good investment piece is, to simplify matters, one that can be re-sold readily (if need be) at about the price you just paid for it. A gallery will be only too keen to take back a good investment piece as it will have little trouble in selling it and taking (quite appropriately) another, generally smaller (10 – 20%) commission on the sale. If the gallery cannot be confident of its ability to re-sell the work within a year or two, at or about what you are being asked to pay for it now, this might not be a good work for an investment portfolio, however beautiful and skilfully crafted that work might be. Don’t get me wrong – there really are some brand new paintings by some current artists that will appreciate strongly in value and any collection that is completely devoid of brand new works (albeit speculative from an investment perspective) can be a dour, even cold assemblage. But it is important to distinguish clearly between what we love to look at and what will, in addition, appreciate in value over time. Fortunately, there really is a sound basis for understanding this distinction and, therefore, for sound and secure investment in art, something which need not be devoid of aesthetic enjoyment or very considerable decorative appeal. Quite the opposite, the knowledge that a given piece of art has a recognised place in the admittedly broad landscape of Australian art history only adds to the pleasure of owning it; that it will reliably increase in value over time is undeniably cause for even more content appreciation of its aesthetic qualities in the interim.


ARTS

Future columns Future contributions to this column will address the criteria that determine whether or not a piece of art is worthy of investment, how to go about buying art and building a collection for investment purposes and other issues pertaining to art in Australia. Hopefully, this will be of interest to Australian doctors.

ďƒ¨ Dr. Michael Levitt is a Colorectal Surgeon in Perth. He has been collecting art for investment purposes for over a decade and is an outspoken advocate of the art industry and of the enriching effect of both private and public art collecting.

Picture: "200609 ned kelly" by iambents, http://www.flickr. com/photos/superciliousness/239148209/. Images licensed under a Creative Commons Attribution 2.0. Generic Licence http://creativecommons.org/licenses/by/2.0/

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LIFESTYLE

Doctors, diet and exercise W Do we practice what we preach?

Eat healthy, exercise for 30 minutes daily and get enough rest. Sounds familiar? Doctors universally have no problem rattling this formula off to patients. The difficulty, it seems, is putting this into practice ourselves.

N

umerous studies have looked into the mental health of Australian doctors. However, few examine the nutrition and exercise habits of our profession. We assume that in this regard, doctors know best. But do we really? And even if we did, does this knowledge translate into better health practices? Looking around me, I am not convinced that we are setting a good example as a

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LIFESTYLE profession. Many doctors I know hardly get any regular exercise and struggle to meet the recommended daily intakes of fruits and greens. Our abysmal amount of physical activity was demonstrated by a 2008 survey of 4,110 Australian and New Zealand junior doctors undertaken by the Australian Medical Association Council of Doctors in Training.1 Among other things, the study found that a mere 27.5 percent of respondents exercised at least four hours p e r

that we doctors know better when it comes to choosing our chow.

Free food Why doctors struggle with regular exercise and good nutrition There a many reasons why doctors are failing in this area. I am inclined to believe that it has more to do with the circumstances of our jobs, rather than plain laziness. Lack of time One of the main reasons for our poor lifestyle is the lack of time. While we no longer work the gruelling 50-hour shifts our predecessors did a generation ago, our working hours are still relatively long and unpredictable. A 2008 survey of 1,072 specialists in training in Australia found that the mean number of hours worked per week was 48.4 hours for males and 45.2 hours for females.2 Surgical registrars, on the other hand, worked an average of 65 hours a week regardless of gender.2 Another Australian study of 1,451 interns and medical officers in the same year found that junior doctors in the first three years of training work an average of 50.7 hours a week.3 With working hours like these, we are always pressed for time. What little time we have left must be very wisely allocated. Studying for our next specialty exam, doing research to improve our resumes, and getting enough sleep to endure another punishing day often take priority over cooking and exercise.

week. In other words, just over a quarter of junior doctors met the Australian National Physical Activity Guidelines which recommend that adults do 30 minutes of moderate-intensity physical activity on most days. On the lower end of the scale, 37.5 percent got an hour of exercise or less per week while 15.4 percent reported no exercise in the preceding month. As for nutrition, no studies examining the eating habits of Australian doctors could be found, underscoring the assumption

for good nutrition.

As a result of not having the time to prepare healthy meals, we find ourselves grabbing whatever food we can on the go. Breakfast is skipped to make it to 6.30 am ward rounds and replaced with a cup of coffee after rounds. Lunch might be a cup of fries or potato wedges if we need to eat on the run, or a meal of meat and rice (often without vegetables) if we can afford the time to sit down to eat. Sometimes, acutely aware of the lack of greens in my diet, I head over to the salad bar in the hospital’s cafeteria, only to find that a small salad costs more than the hot foods. It appears that even the hospital cafeteria is conspiring against our quest

After lunch, we head back to the ward and find a few boxes of chocolates lying around, courtesy of a patient’s family grateful for the care we have provided. Also, the nurses happen to be celebrating a colleague’s birthday with a pot-luck afternoon tea party. They welcome us to share in the overabundance of Tim-tams, party pies, muffins, cheeses and dips. Free food galore. How can one say no? Free food, we discover as medical students, is one of the perks of the profession. Representatives of drug

While we no longer work the gruelling 50-hour shifts our predecessors did a generation ago, our working hours are still relatively long and unpredictable. companies, ever eager for a slice of our time, have devised a way to achieve this - by providing free lunches at teaching sessions. In appreciation of their efforts, we listen politely to a short pitch about how their latest drug is better than their competitors. The lunches provided vary from company to company. But the spread usually include butter-laden sandwiches or wraps, some deep fried hot food, miniature irresistible cakes and other desserts and a colourful plate of cut fruit. While this spread isn’t heinously unhealthy, it makes for a meal high in refined carbohydrates, sugars and saturated fats, but low in protein. Not quite deserving of an approval-tick from the Heart Council. Sometimes these drug reps woo us harder with dinner invitations to fancy

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LIFESTYLE restaurants. Again, excellent quality food that is free. How can we say no? The Meals & Entertainment Card The Meal & Entertainment card provides yet another reason for doctors to eat out. Why spend precious time grocery shopping and cooking when we could simply walk into Nandos for a hearty meal that, unlike our home-cooked meal, is tax free? The tax-free dollars on this card also encourages us to splurge on higher-end food. Spending 120 tax-free dollars on an Italian dinner at Il Bacaro goes easier on the conscience than spending 120 taxable dollars. In fact, though clearly illogical, I cannot help but relish each swipe of the card; as if each dollar denied to the tax man is a small triumph for me. What we can do about it

Since we have now identified the factors that sabotage our intentions to live healthily, we are in a better place to do something about them. Below are some suggestions for getting started. Why we should be serious about living healthier lives Studies in the United States have shown that active doctors prescribe activity.4 Similar trends have also been reported for smoking and nutrition. In other words, the way we live our lives impacts the type of lifestyle counselling our patients receive. Adopting a healthier lifestyle then, should start with us. Whether we like it or not, it is an unescapable fact that patients look to us as role models for healthy living. We can share with them the guidelines on nutrition and exercise, but there is nothing like showing them. Sharing is

easy, inspiring is not. But inspiration might just be what our patients need to institute change in their lives. Dr. Rebecca Lim is a medical intern and fitness aficionado who is constantly looking for efficient ways to keep fit before commencing surgical training. ________________________________________________ References 1 Markwell AL, Wainer Z: The health and wellbeing of junior doctors: insights from a national survey. Med J Aust 2009; 191: 441-444 2 Hills D, Scott A: Focus on doctors enrolled in a specialty training program. MABEL Matters No. 4, December 2009. Melbourne: Melbourne Institute of Applied Economic and Social Research. 3 McIsaac M, Scott A: Focus on Interns and medical Officers. MABEL Matters No. 5, December 2009. Melbourne: Melbourne Institute of Applied Economic and Social Research. 4 Frank E, Bhat SK, Elon L: Exercise counseling and personal exercise habits of US women physicians. J Am Med Womens Assoc 2003;58:178–84.

Tips for eating well

Tips for getting more exercise e Join the hospital gym. Some hospitals have gyms which open round the clock to cater for staff knocking off at odd hours. Such gyms would allow you to get a quick 30 minute workout before heading home after work, without having to waste time travelling. Even if the hospital gym doesn’t open at odd hours, it is still worth joining for the convenience of a lunchtime workout.

e Workout at home. Exercise does not need to be confined to the gym. There are plenty of simple body-weight exercises you could do at home to get that 30 minutes of cardio daily. These include burpees, jumping jacks, squat jumps and mountain climbers to name a few. If you can spare a few hundred dollars, it is worthwhile investing in dumbbells, kettlebells and resistance bands which can provide a fullbody workout and be stored under the bed when not in use.

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e Have healthy snacks on hand and munch regularly every three hours. Carrying an apple or a tupperware of almonds in your bag or storing them in the locker is effortless and can prevent one reaching for that chocolate bar when hunger strikes. Also, munching at regular intervals on these healthy snacks prevents overeating at the next meal and keeps energy levels up throughout the day. On the ward, I sometimes have an apple while re-writing drug charts, writing pathology slips or updating patient’s notes.

e Prepare meals in bulk. When cooking that chicken stew for tonight’s dinner, why not add more ingredients for it to last a few meals? Instead of pan frying that chicken breast for lunch, how about grilling a tray of chicken breasts to take to work for the week? As for vegetables, you could spend half an hour on Sundays chopping enough broccoli and bok choy to fit into five lunch boxes to microwave at work. Little things like these can significantly cut down the amount of time spent in the kitchen. e Learn to say no. A patient who lost 40 pounds from her 180 pound frame in six months told me that she owed her new svelte figure to ‘won’t’ power rather than to ‘will’ power – she constantly told herself that she won’t eat this or drink that. Doctors who are constantly confronted with free yet unhealthy food on the ward and from drug company representatives should do likewise.


LIFESTYLE

Case Study

Case 1: Dr. B - Rheumatologist in his 30s, married Case 2: Dr. M - Intern, 24, unmarried Case 3: Dr. H - Emergency Physician in his 30s, unmarried

Case 4: Dr. L - Internal medicine physician in her 40s who is heavily involved training junior doctors, married with two teenage children

Do you think doctors generally make better lifestyle choices than the rest of the population?

snacks (chips, biscuits, etc) alcohol or coffee, very rarely drink tea. I actively avoid sugars and saturated fats.

NO, quite the opposite. However, this is a direct function of

I don't have a particularly healthy diet, but I try to avoid

the job they're doing - when one is just trying to survive as a busy surgical registrar, keep a relationship intact, and look after a child(ren), self-care can really take a hit.

take-away food for most meals. I normally have cereal for breakfast, a sandwich made at home for lunch, and then dinner is often the standard "meat and two vegetables" meal that many Australian families have. I eat fast food once a week.

Doctors do make better choices but the nature of our work and the stresses in our lives make it difficult to achieve this.

No. I have a lot of doctor-friends who don’t exercise at all, eat unhealthily and are overweight. Having a busy schedule is part of the reason. Being doctors, they have better insight than the general population, but this doesn’t necessary mean that they have the motivation to live a healthy lifestyle.

Yes. Most docs are stronger advocates for their own health and fitness and many though not all doctors like to be in control so this often includes fitness. What is your exercise regime like?

I get tennis coaching once a week now for about 90 minutes. I train on a clay type surface, which is much easier on my body than hardcourt. I train hard in the gym for about 90 minutes twice a week, concentrating on large compound movement exercises with good form.

I don't currently have a regular exercise regime. I try to do a weights based workout at home at least once a week for an hour. I also do 1,000 steps every second week and do a two hour cardio workout. I would like to do more, but haven't been able to work it into my weekly routine at the moment.

I cook three times a week when I don’t work and eat out the rest of the time. When I do cook, it’s only healthy stuff… nothing deep fried, it’s either steamed, stir fried or roast with plenty of fresh veggies. I have fruits everyday at lunch and dinner. I have fish four-five times every week. I also take omega 3 (salmon oil) b.d.

I eat well mostly but if tired and busy my diet can get unhealthy. I happen to need chocolate most days. Any tips for busy doctors who wish to improve their fitness and nutrition?

There are many things busy people can do that don’t involve going to the gym or spending a great deal of time: first be patient with achieving your desired goals. Consume half the amount carbohydrates and dessert. Try and increase fruit intake.

Exercise more and that doesn’t have to involve the gym. Take the tougher options – stairs instead of lift, walk/bike instead of car where possible.

Use your weekends wisely when it comes to fitness. Plan

to run.

your meals the night before, you'll opt for healthier options and save money! Try and get some exercise at the hospital. Walk around the wards more often, use the stairs when you can, go for a walk during a lunch break if you manage to get one. Finally, even 20-30 mins of exercise here and there is better than doing none at all.

Do you practice healthy eating? What is your diet like?

It’s important to have a partner, friend or family member

I swim at least three times a week. I get up twice a week at 5.45am and on weekends at 8am

I try and consume five-six small, nutritionally dense meals daily. At least two serves of fruit, lots of vegies where possible. 1g/kg of protein total, liberal water intake, no soft drinks,

who could encourage us to do healthy things together; preferably something we both enjoy doing. These may be anything from jogging to preparing a healthy meal together. My advice is to make it a habit if possible.

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LIFESTYLE

Your Own Clinic

Creating better patient care and a flexible lifestyle At some stage in their

career, many surgeons and healthcare professionals feel the urge to create an operating environment that is uniquely their own. A place where everything they need to provide their desired level of patient care has been meticulously planned and designed to work exactly in the same way that they do. In essence a practice that resonates with their personality and where patients and staff can identify with their vision for the provision of care. Dr Alastair Taylor and his wife Cheryl, have created such a place in the new CAPS (Cosmetic and Plastic Surgery) Clinic in Canberra. Located in Canberra’s medical precinct, the CAPS Clinic consists of over 1,400m2 of specialist consulting rooms, surgeries and private hospital facilities over two floors, allowing resident specialists to provide comprehensive services and recovery care to cosmetic and plastic surgery patients. After 13 years of successfully operating from part of the premises that would eventually become the CAPS Clinic, Alastair and Cheryl decided that the time had come to make their mark and build a clinic that would be uniquely their own. The decision to build new facilities from scratch was taken after detailed consideration and extensive consultation with patients and staff. Feedback from patients and staff revealed generally poor levels of satisfaction with the quality of care provided to

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LIFESTYLE

While the new facility is a completely functional private hospital, careful consideration was made to ensure the environment was as warm and welcoming as possible. cosmetic surgery patients in private hospitals. Nursing staff were doing their best, but typically operating in ratios of 4 nurses for 25 patients. Providing first class care at that staffing level is simply unsustainable in the medium to long term. In addition, some cosmetic surgery patients felt that they were being subtly discriminated against, with their surgeries and subsequent recovery being seen as “self-inflicted” by overworked nursing staff. Alastair and Cheryl knew instinctively the best way to address these concerns was to survey former and current patients and approach the issue from a patient centric perspective. By understanding the patient’s point of view and their expectations for what constituted quality care, Alastair and Cheryl were able to take a new approach to improve the level of care provided and give patients a better hospital experience. From the outset, it became clear that better staffing would be a key driver for positive

change in the patient experience. Patients responded well when they were able to recognise and build relationships with their caregivers. Rather than a large pool of rostered nursing staff and surgeons where patients may be treated by different staff on each day of their stay, the CAPS Clinic concentrated on attracting, training and retaining core staff. Surgeons and nurses are able to build specific experience by working together, rather than random rostered combinations. By providing staff with a stable workload and attractive conditions, staff are happier, staff retention is excellent and the feedback from patients on the levels of care has been overwhelmingly positive. While the new facility is a completely functional private hospital, careful consideration was made to ensure the environment was as warm and welcoming as possible. During the planning process, patients responded they didn’t want the new clinic to feel like a hospital at all, but

rather they wanted somewhere they could feel relaxed and recuperate in comfort. The resulting design boasts bold but tasteful use of vibrant colours with soft furnishings throughout so the clinic feels more like a stylish home than a hospital. Creams, golds and oranges are used to promote healing and a sense of positive energy throughout the building and give the facility a distinct personality - a far cry from the more traditional sterile white and blue. Cheryl says “Patients and staff are ecstatic about the new look and feel. Patient's reactions when they walk in are instant, they immediately feel relaxed and comfortable, while the extra space makes it easier for staff to care for patients.” The Transition The site originally consisted of two distinct buildings linked by an exposed stairwell. After consultation with local architects

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LIFESTYLE and planners, a proposal was submitted to combine the two buildings into one cohesive branded space.

hindsight, we should have appointed a single company to handle the entire job, including the building and fit out. Coordinating the various suppliers and keeping everyone in constant communication led to a lot of wasted energy and some costly delays. ” “If you are going to build your own facility, choose your construction company carefully. Medical facility construction is a complex undertaking and entrusting your build to a generalist architect or builder can be problematic. A lot of specialist knowledge is required and the building approval process as it currently stands can be incredibly frustrating.”

In the CAPS Clinic, Alastair and Cheryl went from operating from a single 280 sqm practice offering four specialists services under one roof to a specialist 1,400 sqm facility for four individual specialist businesses offering services in their own space. The flexibility offered in the new space lets work fit in with the owner’s lifestyle. In Cheryl’s own words, “building a facility from scratch is a difficult and demanding process, and you must be prepared to sacrifice your income for your lifestyle. Delivering a superior level of patient care was very important to us. At the CAPS Clinic, we know our patients are always safe and getting the best possible care.” Previously restricted to treatments requiring local anaesthetic, the addition of a private hospital including complete overnight facilities gives surgeons at the CAPS Clinic the opportunity to significantly increase the range of operations available. An Investment in the future Frustrated by the administrative and operating processes dictated by some health fund providers, Alastair and Cheryl wanted the flexibility to be able to control their environment, their team and the training that was provided. Financing the operation of a private hospital is very difficult and many private hospitals offset their operating losses with income from cosmetic surgery. It can be a

Financing the operation of a private hospital is very difficult and many private hospitals offset their operating losses with income from cosmetic surgery.

SURGICALlife

Would they do it again? The simple answer is that we shouldn’t need to. Was it expensive? Absolutely Was it worth it? Absolutely

delicate balancing act. With the clinic fully operational the owners expect to pay for the development of the CAPS Clinic in 5 -10 years, but look forward to flexibility it offers their lifestyles for the next 20 years.

“We have glowing referrals coming through all the time from everyone who visits the clinic. We count ourselves extremely lucky to have the beautiful, flexible life we have."

With such an impressive outcome, is there anything they would have done differently?

Nathan Reid, National Marketing Director, Medifit

Cheryl Taylor shares her insights... “In

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“Also, research prices and equipment suppliers... we were quoted almost $200k for a steriliser from one supplier and eventually managed to find one for less than a quarter of that price”.


The specialists for the specialist Medifit are medical design and construction specialists, it’s all we do. Whether you are building from the ground up, renovating an existing surgery or fitting out a commercial space you’re in great hands. We’ll show you how to get the most out of your available space and make it look incredible. And we’ll do it on time and on budget with comprehensive schedules, established trade networks in every state of Australia and fixed price contracts with no hidden fees or charges. We believe that your practice should work as hard as you do, and we can make that a reality for you. Contact us today for a no obligation consultation. Your patients won’t be the only ones smiling.

1300 728 133

www.medifit.com.au

SPECIALIST MEDICAL EXPERIENCE COMPLETE DESIGN & CONSTRUCTION FIXED PRICE CONTRACTS FULL REGULATORY COMPLIANCE 12 MONTH WARRANTY ON ALL WORK GROUND UP CONSTRUCTION OR RENOVATION OF EXISTING PREMISES


TRAVEL T R A VTERLA V E L

Searching for nirvana atop Japan’s holy mountain At the tail end of a Japanese summer, we walked hand-in-hand with the Kobo Daishi, a monk who has spent the last thousand years waiting for the Buddha of the Future. One of eight mountains which comprise a lotus-shaped mandala, Koya-san was sacred even before the Daishi established his monastic retreat here in 816 AD. Famed not only for bringing Shingon Buddhism to Japan, but also as a poet, painter and calligrapher, the Kobo Dashi remains of the most revered figures in Japanese history. Today he sits in repose in his mausoleum, the Oko-in, where monks bring him food twice a day.

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T R A VTERLA V E L Arriving in Koya-san Speeding through the Osaka’s outskirts, the maze of alleyways and traditional wooden houses, (with vegetable plots and tiny rice paddies filling any space), slowly became farmland. The train came to an unexpected stop, and as everyone else melted into the countryside, we were left standing on a deserted station. We dripped with sweat. Farmers with conical straw hats worked fields cultivated for centuries. It was a scene lifted straight from the anime of Hayao Miyazaki (famous for classics such as Spirited Away and My Friend Totoro). Another train soon arrived. As the land climbed, the summer heat faded. Fruit trees heavy with blossom became primeval forests of pine and cypress. At Gokuraku-bashi Station, along with black-robed monks with their shawls of saffron, we were ushered into a cable car which carried us over an impenetrable forest to the top of the holy mountain. Despite both its age and being listed as a World Heritage site, Koya-san has not fallen asleep. It remains a mix of Buddhist monasteries and white-robed pilgrims with their staves of bells, sun-drenched cypress groves and school kids running home for lunch. The main street is cluttered with supermarkets, restaurants, ceramic shops, even a chemist who stocks sun-block and mosquito repellent amongst bottles of dried flora and fauna. Walking with the Kobo Daishi The journey with the Kobo Dashi begins at a stone basin. Ubiquitous to Japanese temples, these basins overflow with running water, usually from a nearby stream. After ladling icy water over our hands, we bowed on crossing the graceful Ichinohashi Bridge; the Kobo Daishi then joined us. A lady in the shop opposite smiled and waved. A path then wound through the Okunoin, a grove of cypress and some half a million tombs. Here the faithful have been buried since the

Kobo Daishi’s death. Many tracks lead to even more graves hidden in dells and forgotten grottos. Simple stone plaques and wooden markers, or animal shaped-stones bedecked with red cloths or aprons rested beside the mausoleums of shoguns. Shafts of sunlight tumbled through the ancient trees, and mites danced in the sunbeams. We walked through streams of light and shadow. Although the dead have been waiting here for over a thousand years, workmen were repainting the markers in one section, and at another grave a monk chanted a service. The Heart of Koya-san After a thirty minute stroll, the track opened onto the main temple complex. The air was saturated with the scent of candles and incense. Pilgrims ladled water over huge Jizo statues, and at one shrine, families queued to offer the ashes of their loved ones. The Oko-in remains the heart of Koya-san. Amongst the crowds, this dark but spacious

building remains an oasis of calm. A section is reserved for those who wish to merely sit and, along with the Daishi, contemplate the road to Nirvana. Nearby stands the Hall of 3,000 Lanterns (the Toro-do), where two lamps have burned for a thousand years without needing fresh oil. Another hall houses the Buddhist writings brought here by Tripitata, the prince of Monkey Fame. Despite hosting over a million pilgrims a year, Koya-san remains a spiritual place. With most leaving by mid-afternoon, the tempo changes as the day passes. Once boasting nearly one thousand temples, over one hundred still remain, including the Konpon Daito (or Great Stupa), begun by the Kobo Daishi himself. The oldest building, the Fudo-do, dates to 1197. It is part of the Danjogaran complex, which houses Japan’s largest rock garden: 140 pieces of granite arranged to resemble a pair of dragons emerging from the clouds. A unique place to sleep Some of the temples offer shukubo, or lodging. In our room, a bamboo screen opened onto

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T R AV E L a garden of contemplation; a sea of mosscovered rocks and sculptured azalea bushes, with white pebbles scattered around the larger stepping-stones. A stone lantern stood in one corner, as if it had done so for centuries. At dawn, a deep bell summoned the faithful from sleep, while the chanting of the monks flowed from the centuries-old temple into the mist of dawn. The flames of their offerings shot into the air, the light licking the wooden walls. A traditional Japanese breakfast, followed by a bus ride back to the station, then the cablecar back down the hill; it felt as if we were slowly returning from a distant land to the chaos of the present. Dr. Anne Harrison is a hospital-based locum.

Travel Facts

Access Koya-san is some two hours by train on the Nankai line from Osaka, terminating at Gokurakubashi St. A cable car completes the journey.

Accommodation Aside from temple lodging, there is also the Youth Hostel (offering traditional ryokan-style accommodation). It is a ten minute walk from the Tourist Information Centre, with a bus stop nearby.

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Dining Most of the restaurants have plastic models in the window displaying the food on offer. There is also a supermarket for selfcatering.

Relevant Websites http://www.jnto.go.jp Japan National Tourism Organization http://templelodging.com/ A guide to temple lodging across Japan


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Surviving the ‘Hot Tub’ Why are we prone to conflict with other doctors? A personal experience of joint expert conferences and evidence Brea...

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