Ho! ho! ho!

Somewhere, someone in administration has developed a sense of humour.

Each morning, we print out a computer list of our patients that tells us how long they have been in hospital and when we are really lucky, where they are.

This morning, my resident showed me my list. Admitted at midnight to my unit was Santa Claus, with travellers' diarrhoea!

We went to see Santa (who looked amazingly like the resuscitation training manikin with cotton wool taped to his chin). At the bedside, we noted very prominent auditory and visual hallucinations (he sees elves and flying reindeer) and also unshakable delusions of grandeur (he is the only one who can make sure every child has a gift).

With these things in mind we sent off an urgent referral to the psychiatry liaison and consultation service.

Meanwhile, a parking permit application form was sent back to admin for processing.

Lighten up, ok?

For more than six months now, I've been regularly sniping at my employer. At first it was a way to let off some steam and indulge in the occasional irony. Really though, it is a hollow solution and it's tiresome. Looking back over the posts, the blog makes me sound bitter and twisted, which I'm not... I don't think...well not much.

Even if I'm simply writing to myself, I'd like to make this here blog (ugh, get out of it, Jethro...) Where was I? Yes, turn this blog into a more open discussion of Western medicine as it appears from my tiny corner of the profession.

I'm sure Q Health hasn't changed a bit but I think, maybe, I have.

Crunch time.

My employer and I may be rapidly approaching crunch time. Three local health districts are to be amalgamated into one mega district. All senior medical staff have been 'invited' to a lunch-to-afternoon tea long meeting at a suburban motel. The email reads "Please be advised you have been invited..." Has the ring of a summons, don't you think?

The only reason Frank Burns would serve lunch and afternoon tea would be to ameliorate bad news. What bad news? Most likely, my colleagues and I will be asked/required to provide after-hours on-call services to more than one hospital at the same time and take weekend rounds at more than one hospital. In my mind, 'amalgamation' is simply a shorthand for decreased services and cost cutting.

I've just Google-Earthed the journey. A round trip through the burbs, from home to each of the three relevant hospitals and back, will mean driving about 84 km. Now, I like driving, I do, and I like Brisbane but I can think of better ways to spend a Saturday or Sunday morning. Oh, you can always listen to the radio or to talking books....yeah....yeah.

Traffic aside, covering more than one hospital at a time is not safe for patients. Murphy dictates that if more than one problem can take place at the same time and in different locations they most certainly will. It is also unfair on junior staff because of the increased pressure caused by removing an immediate source of supervision. I've tried it before and I can tell you: remote control medicine doesn't work.

As for myself, taking the added responsibility of supervising an increased number of junior staff when on call, particularly when I won't have worked with them on a day to day basis is not a good thing. The money side of things is always last on my list but the eleven dollars and two cents per hour I receive for fielding calls after hours is not enough if the number of calls is to be trebled.

As it is, I cannot attend the meeting. Sorry Frank. I'll have to wait and see the outcome. I might be trying to cross bridges before I come to them but on the other hand, just because you are paranoid doesn't mean they're not out to get you. A request to cover two or more hospitals at the same time will mean my resignation.

You've got to be joking.

This is an old joke (and I agree, a morally dodgy one): A GP, a physician, a psychiatrist, a health bureaucrat, a surgeon and a pathologist go duck hunting.

The GP sees a bird in the sky and says, 'It might be a duck but I'm not sure' and the bird flies off.

The next bird is spotted by the physician who raises his gun but then hesitates and says, 'It is extraordinarily duck-like but we do need to consider other possibilities.'

He turns to the psychiatrist who says, 'Well, I know it's a duck but the question is, does it know it's a duck.'

The health bureaucrat cuts him off and says, ' I don't care what it is and in any case you've run out of shot'.

The surgeon suddenly raises his gun and BLAM BLAM, the bird falls to the ground. The surgeon turns to the pathologist and says, "Do us a favour mate and go and see if that was a duck.'

Now, for something really funny: regional Bundaberg health execs, the office of the Director General of Health and the Queensland Medical Board accredit an Indian-American surgeon to work at Bundaberg base hospital under an 'area of need' program.

They then ignore and or threaten clinicians who are telling them he is a psychopath (a fact a simple Google search of the man's name would have confirmed).

The story eventually hits the headlines and before a Royal Commission gets underway, Uncle Beattie buys the surgeon-psychopath an airline ticket back to the States.

Now it has got even funnier. The erstwhile Deputy Director General of Health is now the head of our new watch dog: the 'Health Quality and Complaints Commission.' Quacc! Quacc! indeed.

Seeing and hearing.

If you are reading this, then go to Jem's blog, here:

http://www.jemshaw.blogspot.com/

Find Saturday 17th November, 2007, "Health and Safety Costs Lives"

and

READ IT NOW.


My heart goes out to Jem's son, someone half way around the world away whom I've never met. At the same time, I do know him. He could be the nice lad I saw at clinic last Friday afternoon or my friendly next door neighbour whose little son and daughter run around in the backyard squealing with delight when it rains or the young man who does my accounting and jokes with me about the rising cost of Bic biros.

And I know Jem's frustration and anger. In 2003, I lost a dear friend to uterine cancer. She was living with her husband in the UK. She started bleeding and was told by her GP, after already waiting some time for it to stop, that she should wait some more time for it to stop and then come back for a pap smear. It didn't stop and so eventually the next plan was an ultrasound. The waiting time for an "urgent" scan was about six weeks for an outpatient. By this stage, she was sick and in pain, so they packed up and headed home. A few months later it was too late.

I have also seen my own patients die on cardiac surgery waiting lists, on interventional radiology waiting lists and waiting for specialist clinic consultations and it makes me want to throw things, or worse. The cold rationing of resources and the fiscal waste the politicians and administrators lumber us with never ends.

However, my rage and outrage at the bureaucrats is outweighed by my own guilt. Some of it is vicarious to be sure; a collective shame. Some of it is personal and immovable.

Collectively, as physicians, I ask, why can we not see properly? Why can we not hear properly? Years of training, science galore, every whiz bang tool imaginable and we are still blind and deaf to our patients' needs. It should be so easy to listen and to look and to "be there" and yet we don't and we are not. What makes us so distant that we lose our own humanity?

The following are pieces of my own experience.

In 1991, as a second year resident, I spent some weeks working in a remote mining town on the edge of Sturt's Stony Desert. It was New Years Eve, so about 41 C and at about eleven pm I was called to see a young indigenous man who had got drunk, punched a wall and broken his right hand. He was loud and threatening and offensive. I was hot and tired and fed up. I splinted his hand and wrist and told him to come back in the morning so I could x-ray his hand and see if anything further was needed. At about 2.30 am I was called again, this time to see a 16 year old girl who had been raped and dragged by her hair out to a railway camp on the outskirts of town. She had got away and had walked bare foot back to town. A policeman came and told me that they had apprehended the perpetrator because the girl had described a brand new splint on the man's right hand. If I had been more tolerant, more culturally aware and had organised the young man with the broken hand a meal and a hospital bed for the night, that girl would have been alright.

Then, in about 1998, I was a registrar in Far North Queensland. It was monsoon season, hot and humid. I started a weekend shift on Friday morning and finally got to bed at about 1 am on Monday morning. The night resident rang me at 2am about a young man with pneumonia. He wasn't doing well and so I ordered some changes to his treatment and went back to sleep. The resident rang again. It's now about half past four. We didn't speak for long. She just said, get here, now. It was only a five minute drive. When I got to his bed side he was in extremis. I intubated him and got him to ICU where he died a day or so later. I should have gone in to see him at 2 am when an earlier intubation would, most likely, have made a difference.

These are just the things that come to mind at the moment. There are other things and I'm sure there are some things I'm not even aware have gone wrong. You might say that these things were due to systemic problems such as inexperience, isolation, under-staffing or fatigue. In fact, the real cause was not seeing, not hearing and not being able to care enough. You have to learn to live with the guilt of such things. There's absolutely no room here for intellectual rationalisation, some sort of quasi-existential self pity.

There are times when, because of the deficiencies of medicine, I've thought seriously about leaving the profession altogether or at least leaving the public hospital system but where does that leave the people whom I might help, despite my limitations? For the moment, I try to accept the uncertainties and hope to improve things through teaching and by trying very hard to see and to hear and to "be there".

(A bottomless pit of loathing for health bureaucrats, pharmaceutical company representatives and politicians also helps).

As the sun sinks slowly...

And as the sun sinks slowly in the west, we say a fond farewell to Uncle Beattie. Hard to believe but true. Uncle Beattie has finally retired leaving his top henchwoman, Anna Bligh, at the helm. It is difficult to imagine how she could make us more at sea but I have a sinking suspicion she will. Bligh doesn't even pretend to be a benevolent captain, no Macleans grin from her. The Queensland Labor Party ethos won't have budged a hundreth of a fathom. No mutiny in the works. No Rum Rebellion on the cards. It's going to be life jackets on and every man for himself.

QANTAS Club

A long time ago, Uncle Beattie decided to rid all public hospitals of their doctors' lounges. These were quiet places of varying sophistication where a cup of tea and a sweet biscuit were served each day at 10 am and 3 pm, without fail.

It was, of course, on the basis of removing all traces of professional elitism that the lounges were turned into things like pre-admission clinics and administrative offices. (I'm sure Uncle Beattie employs a band of builders whose only job is to partition larger hospital spaces into smaller ones).

What Uncle Beattie didn't realise was that these quiet spaces were an integral part of the medical staff's work routine. It was the place you would go to find that elusive visiting colleague for a consultation for one of your patients. You knew exactly where and when he would be for at least ten minutes of the day and you could get the answer to whatever the problem was quickly, efficiently and with privacy for your patient ensured.

(Uncle Beattie could not possibly understand such a way of working because it would mean doing away with the layers of faceless decision makers that absolve him from responsibility).

Beyond work efficiency, it was the place where the expertise of a wide range of specialists could be brought to difficult cases and the place where junior staff would hear their seniors discuss difficult problems in real time rather than at retrospective case review hearings and formal grand rounds. This teaching on the hoof was much more effective than any tutorial or text.

Finally, it was the place where you went to crash on a vinyl lounge chair when for some reason the night duty was long but quiet. It was the place where a half cold cheese and hummus toasted sandwich from the Lebanese deli across the street could drip down your blouse because you were too tired to hold it upright without a complaint ensuing and it was the place where you went to fall apart in safety and privacy when the day went horribly pear shaped if that's what you needed to do.

It's not all bad though. My latest registrar, seconded from a major teaching hospital told me that with the return of a clinician to the chief executive officer role at his hospital, the new staff work contract included the building of a new tea room. An empty space was allocated and quite mysteriously, the budget was left open, as in the sky's the limit sort of open. Further to that, the design was left in the hands of one unusually talented and enthusiastic senior registrar who took his brief to design the new tearoom firmly in both hands and set forth.

The new lounge, christened "The QANTAS Club" after the airline's swanky $600 per year establishment, has been built with smokey sliding glass doors, mood lighting, a full bar, media and Internet connections, telephones, elegant bathrooms and bedrooms with en suites. I gather there is also modern art gracing the walls and ceiling!

I think this is where the pendulum has finally started to swing back. Uncle Beattie has run people into the ground so far that there is nowhere else for them to go and for the medical staff, at least, there-in lies a strength. The only way is back again. For our patients, this is a very good thing.

The jetty to heaven

I was doing rounds with my registrar and resident the other day, looked out the window and what should I see? On the lawn outside, there was a brand new, modern sculpture! The new installation has a glass and steel construction in the shape of an off-kilter helix heading up towards the sky. With its many horizontal glass panels, it would do nicely for DNA, in an abstract sort of way but I am told it represents a jetty.

One of my older, less grounded patients volunteered that this new structure was not in fact a jetty but a rocket launcher! Under his bed was where the nuclear warheads were stored. I considered his interpretation for a while, before deciding it wasn't very likely. I think it may have been the computer-timed fairy lights, which illuminate the sculpture at night that put old Joe on the wrong track.

So, while we don't have anyone to file the charts, or a visiting neurologist more than once per month, or a Holter monitor, or bone marrow aspirate needles, or a dedicated procedure room, or enough chairs for people to sit on, or anything with which to treat fungal ear infections, we do have a very lovely "jetty to heaven" to appreciate. Thanks Uncle Beattie.

The case of the disappearing pigeon hole.

Just the other day, I received an email written by admin. For argument's sake, let's call admin "Frank Burns". The email wasn't addressed to me. Rather, it had been forwarded to me by my helpful and reliable colleague and boss, Y.

The email referred to x [that's me] and it said, "X's pigeon hole is full. Please have someone open X's mail and move it on." That was all.

Well, this was all rather curious, I thought. In about mid 2004, I went, one day, to collect my mail from my pigeon hole only to find that my pigeon hole had disappeared, completely. I went to Frank Burns to find out what had happened to it (a stray worm hole perhaps?) and was told it had been 'reassigned'. (If this is starting to sound familiar to a previous post then it should.)

At the time, I asked Frank Burns how I was going to receive my mail. Now, we're not talking pen pal letters, postcards and deliveries of Cd's and DVDs from Amazon here. This mail was important and urgent correspondence concerning patients and their care and, I admit, the occasional pay sheet.

Frank Burns, suggested my mail would come directly to my outpatient clinic. Fair enough, I thought and come it most certainly did - piles of it, week after week.

Then, recently, whilst I was on holidays and involved with a rather nasty adeno-virus for a time, the mail apparently stopped. When I got back to work, what should have been a jammed to overflowing manila file was empty. Nothing. Nada. Perhaps the mail too, was now disappearing into the ether, just as my pigeon hole had done three years earlier.

Reading between the lines (which was a bit difficult as there was only one), Frank Burns' email suggested that my pigeon hole had reappeared. I was intensely curious to see if it now looked anything like a blue police telephone box emitting a loud "whaa! whaa!" noise with a flashing light on top. Sadly, it didn't but it was there, just where it had been three years before, stuffed with mail.

I replied to Frank Burns in my most polite tones. I assured that I would be happy to empty my pigeon hole regularly should someone forward to me a schedule of when it was likely to exist or alternatively provide me with a pigeon hole divining rod.

The lack of existence of a pigeon hole might not be a big deal to some. (It was a big deal to my patients whose correspondence was missing in action, let me tell you). However, it is yet another symptom of the malevolence that is Uncle Beattie.

It is said that for a community of any sort to work well, there needs to be a careful balance between government, governance and the governed. For instance, in Iraq, there is a powerful government in the form of George Dubbelya, no governance because he blew it all up and the huge uncared for, un-governed masses.

In Q Health, we have a domineering Uncle Beattie, whom I'm sure, rues the day his mother failed to call him George Dubbelya, a morbidly obese, philosophically bankrupt bureaucracy and then the sick people and the people who care for them.

And it's not just the balance between the three, it's the whole culture of the structure, from Beattie's bald head to the sole of my shoe, that's important.

If I were to say to Frank Burns, "Can you see why it might be important for me to know when my mail is going to a pigeon hole instead of to my clinic?", Frank Burns would say, "No."

If I were to say,"Would it be a polite thing to call me on my mobile phone and tell me I have been re-assigned a pigeon hole?", Frank Burns would say, "The correct procedure was to send an email to your supervisor."

If I said, "Do you care what happens to my patients?", Frank Burns would say, "They're not patients, they're clients."

Frank Burns wouldn't be lying or be being obtuse. It is simply that admin doesn't know and doesn't have the ability to think there might be a better way. Uncle Beattie could change that but he doesn't want to and he won't.

Not alone.

In the June 2007 edition of "Doctor Q", the monthly magazine of the Queensland Branch of the Australian Medical Association (AMAQ), Dr Zelle Hodge wrote in her president's report that two doctor members had resigned from Uncle Beattie's Queensland Health because of and I quote,"personal bureaucratic harassment inflicted on them".


I don't think I need to say anything else.

Trust no one.

Under pressure (the use it or lose it sort) from Uncle Beattie to take annual leave, I planned four weeks. I even had a locum lined up.

I should have known better. At the last minute, Uncle Beattie decided not to pay for my locum. I only discovered this change in plan during a chance conversation with a receptionist.

The locum, being a sensible fellow, made a hasty exit for greener pastures. Uncle Beattie's deputy then suggested it might be difficult to spare me for more than two weeks without a locum. OK, so two weeks it was and the holiday plans fell through.

I keep asking myself why I was surprised.

Medicare Gold: a bird without wings.

"Medicare Gold", was the grand notion that was supposed to win the federal opposition party and the ghastly Julia Gillard in particular, the last election.

"All persons over the age of seventy-five will be eligible for free health care in private facilities", she boasted.

If you haven't noticed, the world's population is aging. You only have to look around you to know there are already a lot, and I mean a LOT of people over the age of 75. Moreover, the number of sick over seventy-fives is set to explode as so many of the baby-boomers fall ill with obesity-induced diseases.

Conveniently, the opposition party has forgotton that health care actually needs doctors. Not just surgeons but physicians as well.

As one of those physicians who, presumably, was going to have to look after all those over seventy-fives in the private sector, my response was "Ha!! You and what army are going to make me!!"

I'm sure most of my colleagues were thinking exactly the same thing.

Thankfully, Medicare Gold seems to have gone the way of the DoDo.

The case of the disappearing office.

If we put aside for one moment the very obvious benefits of staying well and not coming to hospital at all, I'm confident that most people in hospital would prefer that their medical staff (consultant, registrar and intern) discuss laboratory and radiography results in a private setting ie not in the middle of a corridor. Hence, an office for doctors, in which they could do this, would be useful.

It would be particularly useful if the office contained a computer terminal, as that is where one has the greatest chance of finding laboratory and radiography results (since pride in the careful filing of hard copy results is as rare as it comes).

There once was an office for doctors, with a computer terminal in it. Mysteriously, one day, the computer crashed and was unable to be resuscitated. I asked when it would be resurrected and was told "in due course".

A couple of ward rounds later, the computer was gone leaving only a dusty footprint on the desk. 'How amazing', I thought, 'they are actually going to get it fixed.' Then, when I looked again after a week or so, there was still no computer. I asked when the computer would be back and was told, "Well, you weren't using it so it has been permanently removed. "

The very next day, I found that a doughnut-hoovering senior-echelon nursing administrator had plonked herself, her computer, her filing cabinets and her pedestal fan in the office. When I asked about that, the reply was predictable as night following day: " Well, you weren't using the office, so it has been permanently reassigned."

I 'reassigned' myself to another computer terminal, the one in full view in the middle of the corridor and thought, 'Oh well, the situation is unlikely to get worse.' How wrong could I be! Now, the corridor itself has started disappearing! It's being partitioned into more offices for more nursing administrators, their computers, their filing cabinets and their pedestal fans!

You might think this is just a petulant whinge about a simple turf war and it's time I had a long hot cup of chamomile tea and a lie down. Although I readily admit I may have a few roos permanently residing in the top paddock (and the odd venomous hamster or two - thanks Jem), I'm pretty sure this sort of underhandedness portends a more malign state of affairs.

Uncle Beattie sets an ugly tone in this current government and it filters all the way down to the workplace. Just as it is with any form of governance, all is well in a socialist democracy if no one takes the politico-philosophical credo too seriously. Here, however, we have a man who despises and probably fears anyone who is prepared to think, to challenge and to take responsibility for decisions. He buffers all decisions at all levels of government, right down to the work place with faceless, nameless working parties.He sees an office for doctors as elitist and therefore dangerous and by definition, to be avoided at all costs.

If it were just about elitism, I could understand and agree. However, anti-elitism is, in this case, a label for dis-empowerment and subjugation.Historically, we have seen the tragic results of this sort of politics.

Consider, firstly, Nazi Germany where the independence of the medical profession was completely lost to the state resulting in unethical practice drift. At the other end of the spectrum, consider the late Soviet era when Eastern bloc doctors earning less than street cleaners, completely worn down and isolated from their international colleagues, had to stand back and watch a perfectly good health system go down the gurgler.

Some people ask me (when they're not suggesting the chamomile tea and the lie down), well, if you think it is so bad, why not go into full time private practice? I could do and would probably be happier and definitely wealthier but, you know, sometimes, it's not about me or about the money. Some of us need to stay and fight for proper filing and computers and offices and corridors because they contribute to getting people well again.


bm said...


Now now zimble... we've discussed this tendency to conflate socialism and bureaucratism. Perhaps some words from Che might help.

The following is from 'Against Bureaucratism' (Feb 1963)"Bureaucratism, obviously, is not the offspring of socialist society, nor is it a necessary component of it. The state bureaucracy existed in the period of bourgeois governments with its retinue of hangers-on and lackeys, as a great number of opportunists — who made up the “court” of the politicians in power — flourished in the shade of the government budget. In a capitalist society, where the entire state apparatus is at the service of the bourgeoisie, the state bureaucracy's importance as a leading body is very small. The main thing is that it be permeable enough to allow opportunists to pass through, yet impenetrable enough to keep the people trapped in its nets."

Those of us with long memories recall an era when the most rabidly right-wing government in our state's history presided over corruption, cronyism, and bureaucratic abuse that makes Beattie's (not-so-socialist) operation look like a sunday school picnic.

BM

P.S. Have you been reading Dr Miguel Faria's books? If so, you should know that when not railing about 'socialised medicine' he keeps busy by railing against gun control. He also described the British arrest of Pinochet as "holding Gen. Augusto Pinochet hostage".


BM many thanks for your comment.

I know, I know. My name is Zimble and I am a conflater.

In my totally inadequate defence, the 17th was a very bad day and who better to lash out at in the one breath than politicians and office stealing bureaucrats.

And, you must admit I have been very good lately: I haven't tried to conflate or conflagrate (or detonate for that matter) anything for some time now.

I really don't care whether Uncle Beattie is the re-incarnation of Mao Zedong or a descendant of Genghis Kahn. What I do care about is the loss of transparency in decision making and the devaluation of the small but important things that allow for good care.

The dark before it got darker.

I first met 'Uncle' Peter Beattie in the dining room of the Jardin Hotel on Thursday Island, when, as then health minister for the state of Queensland, he was hosting a dinner for the launch of a new health exercise video across the Torres Straits.

It was about 1995.It was buffet night at the Jardin. As I went back and back again to sample the various dishes on offer, the man introduced himself to me on no less than three occasions. "Hello, I'm Peter Beattie" his Macleans smile dazzled.

Later that evening, as I pecked at a piece of coconut crumble, I looked over and there he was, lording it up at a table of local elders. There were no women in sight. The elders seemed to hang off his every word. Who was schmoozing whom, I wondered.It was interesting at the time, in a sneer inducing way, to see a politician in full flight.

Little did I know the damage this man, as Premier, and his cronies would wrought on the state health system over the next decade.