# Health and Hospitals



## grinner (May 15, 2008)

just thought i'd move this over for mat and duane.

an anecdote / fairy tale to show how we drove health off the rails

1985.
working in cas, dr. john smith rings up "gooday mate, i got little billy here with appendicitis, ive felt his tummy and i'd bet on it, i'll send him up"
no worries johnno, (good communication between gp's and hospitals then)
just the usual "nil by mouth, etc and i'll get him whacked on the end of the registrars list"
little billy arrives, some nice nurses put him in a bed with clean sheets, the doctor whips his appendix out, he stays in for 3 days and goes back to dr smith to get his stitches out.

total people involved, one registrar, couple of theatre nurses and ward nurses. 
chart has about 10 words in it, stuff like 
admitted for appendix
home 3 days if eating
cheap, effective...everyones happy..didnt involve too much in the way of government intervention or machines that go ping.

move forward 30 years

2010
little billy has a belly ache.
goes to gp.
probably sees a different one each time he goes to the doctor.
fills out lots of registration forms.medicare card , expired , heads over to join the queue before medical centre will see him
sees nervous young gp, doc is scared to death of getting sued and this is his main focus. hates kids. would prefer to just do blood pressures all day.
sees billy, rarely examines a patient, only knows how to order tests to cover his arse in case he gets sued. sends billy for blood and urine tests $$$. mum goes home and rings surgery back the next morning
cant give out results over the phone (another legal protocol, dont blame me, i still give them out all the time), billy dragged down to docs, obviously worse, 
ring ambulance to go to cas because mum knows that way you get seen quicker $$$
goes to cas, doctor there sees billy after 4 hours.
does a ct scan of his abdo $$$ (protocol)
cant get hold of his gp pathology results so quicker just to repeat them $$$
rings "nursing bed manager$$$" to arrange a bed.
doc sits at a desk, gets a cuppa, spends 20 minutes righting an encyclopedia of tick the boxes to keep admin staff happy. no hurry, the financial officers like him to work slow cause seeing more patients just costs more money$$$
nursing bed manager is in a meeting with occupational health and safety officer, sexual harrassment officer and various people from HR $$$, and gets him a bed eventually.
anaesthetist sees him and gets an ecg and cxr $$$, anaesthetists always do this .
billy needs some pain relief but ward sister cant get him anything til the order is written and signed and sent to pharmacy and delivered and then checked with 2 nurses and recorded in the drugs of addiction book in triplicate$$$ (this is cause .0001 % of nurses are drug addicts)
billy is given a shower in hibiclens cause of hospital superbugs as well as a nasal swab $$$
registrar tries to tack him on the end of a list but no unapproved overtime so has to organize about 10 people to get a theatre opened.
fill in consent forms for legal (in triplicate) complication, billys parents are divorced and a fax arrives from billys dads lawyers saying that nothing can be done until billys dad also signs the forms)
light broken in operating theatre lights. electrician and tradesmans assistant come and replace light bulb (protocol) at 4hours overtime each..will earn more for the day then the registrar whos probably on $40 an hour.
registrars so tired from working 18 hours a day he nicks the aorta and billy dies(change that one, billy's a strong kid and he makes it). he finishes the op but cant wait til he can get out of this joint and go to the gold coast and do liposuction and botox and pay off his massive hecs debt.
billy rarely sees a nurse or doc. they are busy tapping away on the computer.
one notices a bruise on billy (he plays footy) but she follows protocol and calls a social worker. social worker stresses family out.starts delving into the unresolved divorce issues and wants psychologist to see billy.

instead of changing his sheets, the nurses are filling in things like the "nursing plan" which every patient must have. this will be a 3 page docement dreamt up by the administrators so that a bunch of other administrators can assign hospital resources. it will contain lots of "tick the boxes" and inform everyone (gps get a copy eventually in the mail).
it has such gems as "doesnt have false teeth", and "doesnt require interpreter services"$$$

billy comes back to gp to get stitches out.(sees a different doc)
teachers want a fax the next day form gp so they can give billy a panadol(covering their ass)
billys footy team requires some forms to be filled out to say if he is fit to play (covering their ass)
billy cant go to the gym for 6 weeks , so more forms for the doc to suspend his gym payments.

The Solution

dont have one, off fishing.

no , will require effort from everyone doctors, government and patients

1 the doctors.
many are just dam greedy. it used not to be that way but once they started getting sued,once they started getting investigated by medicare, once hospitals started subjecting young doctors to the equivalent of abuse (forcing them to work long unpaid lonely nights in cas with no back up). many docs just lost all their altruism and started to behave poorly.
some of the older guys are still the most fantastic people you'd ever meet and they hold the system together. i would consider a similar thing has happened to teachers and police (note all 3 mainly run by state governments). it seems older teachers and cops are extremely dedicated , the younger ones seem to have lost that calling to a vocation.
also , in the current environment there is a real "dont get sued" mentality. this has led to the ordering of billions of dollars worth of tests and drugs and a total lack of common sense.
doing very invasive procedures on elderly dementia patients and sending them back to nusing homes on expensive cholesterol drugs might keep the lawyers off your tail but it is sending the community broke.

2 the government and the public service.
medicare is a well run system and i think probably much cheaper to have a universal insurer than lots of little ones(economy of scale).
unfortunately they need to meet budgets and as the population ages and becomes more expensive they keep modifying each and every item number to try and squeeze blood from a stone. result is a yellow pages sized schedule that no doctor could understand.
state governments are indeed quite hopeless.(much much more so than the federal govt) the ammount of useless letters i get from them and the state run hospitals is "mind blowing"
as an example i got a 3 page fax on several occasions last week telling me that my patient , so and so , had attended casualty and the diagnosis was "did not wait"
add to that the constant changing of appointments and letters that flow from each one and sometimes you end up with a chart full of correspondence and the patient still hasnt been seen and is saving to go private.
way too much admin in these places. rebuilt brisbanes second biggest hospital and reduced beds from 1100 to 700.
promised all queenslanders free ambulances as an election gimmick so now people expect to be driven everywhere.

public servants tend to be empire builders.
as an example the current swine flu programme could probably be run by gps but with qld health running it you will notice a very large form collecting data which busy doctors have to fill in and fax back so more people can tap away at computers. cant see how this helps much.

finally politicians tend to try to change too much all at once.
nearly all pollies are lawyers, accountants or union leaders.
systems that have been built up over years shouldnt have the shit kicked out of them every 4 yrs. the system is a critically ill patient and it cant take "shock therapy"

3 the patients.
of the $60,000,000,000 spent on health in oz over half will be spent on a patient in his last year of life.
i had a guy in the other day and i felt up his bum and there was a growth and and i felt his liver and it was palpable . i knew he had no hope of being alive in 12 months. should i tell him.
no it would be very cruel because western society refuses to come to terms with death and face up to the fact that it is inevitable. so he was referred off for literally $100,000 worth of futile scans , and more scans, and tests and expensive chemo which will , in the end , make him so miserable he'll be glad to die.
there is nothing stranger to me than seeing ambulances full of dementia patients with pneumonia clogging hospital ramps on a busy saturday night because someone at a nuring home has decied that if they dont treat granny and prolong her life by a few days, the relatives will be angry that granny wasnt given appropriate medical care.
patients and their families need to sit down and discuss this stuff, because if you leave it to the health workers it is nearly impossible to offer anything less than the rolls royce treatment and to offer anything less leaves you open to all sorts of attack.

finally there needs to be some sort of financial incentive to stay healthy.
did i see some women who weighs 200 kg is going to try to gain 200 kg to get in the guiness book of records. oh dear. thats where your health budget is blowing out.

i would support a subsidy on good food and a big tax on bad food. why should my patients be able to buy 3 packets of tim tams for the cost of one cauliflower. because big food business must have a lot of clout.

anyway , just my ramblings.
should be interesting what kev and tone come up with. as usual though they'll be talking to doctors first....spin doctors that is.

good luck with your health in the future. 
with the population of people over 80 set to quadruple in the next 20 yrs and 1 in 2 surgeons over the age of 55 and thinking about retiring , your gunna need it.

grinz.


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## TheFishinMusician (Feb 5, 2007)

.


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## gummyshark (Jan 12, 2010)

yep grinner the system sucks, not like the old days when people actually cared for 1 another
your just a number on a form nowdays, and as u say to many ruddy forms.
went into hospital for an operation, spent an hour filling out forms :twisted: 
yes i will fill in the forms dont worrie i will try to forget about my pain, went home without medication
cause the phamacy was closed :twisted: 
glad u let some steam off, i hear ya
cheers gummyshark/ norm


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## surfishly (Apr 27, 2008)

interesting stuff as usual grinner -thanks


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## Feral (Oct 18, 2008)

Yeah, back in 80's it was only about a 4 or 5 hour wait in casualty to see a doctor when I had a compound fracture at my local hospital. (Motorbike accident with the bones sticking out of my foot. Was pleasant, as it had been so long since I did it they wouldn't use anesthetic to set the bones.)

My daughter had a fractured thigh a year or so ago, got her to hospital and she was finally in plaster 19 hours and two hospitals later (I had to transport her between the hospitals as well) Had to go to second hospital as she was under 5 and Doctor at first hospital did not want to work on her, wanted a child specialist to look at it. Must of been that fear of getting sued eh Grinner?

All these hospitals were within 40k of the Brisbane CBD by the way.


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## theclick (Jun 25, 2007)

In summary: So the underlying problem here are lawyers and the legal system?


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## Feral (Oct 18, 2008)

No, a Govt that wont spend the necessary money. Even if they employed Doctors in the hospitals at GP ratios (6 minutes per patient) it would be a vast improvement.


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## gcfisho (Oct 31, 2009)

Three visits to hospital last year between jan and nov all to do with kidney stone ,tests each time seen by different person and told different things each time eventually operated on to remove and even with private health out of pocket plenty . I can empathise with a lot of what your saying and you probably clarified a few things for me , cheers .


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## grinner (May 15, 2008)

eric

you are without doubt the best lateral thinker ive even encountered. feeling his liver thru the bum  

reminds me of a funny story about an abdomenal xray we were shown as first year students. showed a quite clearly visible shampoo bottle down in the pelvis. you could even read "wella balsam" written on the bottle in the xray. young female med student next to me says
"how did he swallow that" :lol: :lol:

i was actually wrong, i said $60,000,000,000 but was listening to abc whilst fishing today and the figure is $110,000,000,000.
we are getting very bad value for that.
i would add that gp fees are only $4billion of that $110 billion but i think gp's are overpaid and nurses are underpaid.

i think the only way to curb the cost is to probably use the UK system where a doctor is paid so much per patient per year whether he sees them once or 50 times. certainly reduces the overservicing. but you really cant overservice nowdays, theres just so many diabetics and asthmatics and generally unhealthy people, you are constantly turning them away.

also public hospitals need to get some incentive to up their service. it suits both the staff and the accountants to work slow and do as little as possible. certainly helps you meet your budget.
and finally like monty python, weve got to get rid of all the "machines that go ping"
i cant watch that" house " dude on tele. he never examines anyone and orders 1/2 a million in tests on every patient. truly an appalling doctor.

and andy , are lawyers the problem.

the problem is when the lawyers come a sniffing, everyone runs for cover and leaves the doctor holding the baby.its very similar to what happens to police when the shit hits the fan. the pollies just sit on the sidelines and go "tch tch." doesnt lead to people wanting to extend themselves.


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## Duane (Oct 20, 2007)

Grinner, your a wise man for yak fisho.

I work in a govt dept and it seems like a 90/10 rule has been implemented.
I spend 10% of my time doing something useful and the other 90% of the time filling out the paperwork for the purpose of justifying budgets and being being ready to answer questions that senate committees may never ask.

Empire builders are everywhere in the system, give a public servant a job where they can get performance pay, they take something that isn't broke and change it just to justify there existence.

On a completely separate note, I was in Annaconda this afternoon and found in the "reduced to clear" bin a medico kit, containing suturing equipment, a syringe, a needle catheter and a few other bits and bobs for the bargain price of $15. I didn't realise that sort of gear was available to the general public. I nearly grabbed one but thought I'd be dangerous with a catheter and hadn't seen a laceration that duct tape couldn't hold together for a while yet.


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## ant (Aug 28, 2008)

Phew!! made my head spin mate. If I had to think that much fishing I'd take up a new sport ;-) ;-)

Cheers
Ant


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## Guest (Mar 21, 2010)

Grinner, I agree with alot of what you say.

I think the bottom line is that people are getting older, living longer and the health system has been unable to match that growth.

However from a trainee medical officer/junior doctor perspective, I would say the majority of doctors I work with and know are far from lazy. Sure, there has been a move away from crazy on call hours. However I feel this is a good think and would advocate strongly for safe work hours.
Research from the AMA supports this
http://safehours.ama.com.au/

Speaking from personal experience working in ED, I can guarantee you that the doctors are not kicking back drinking coffee. At my large public metropolitan hospital many things have been done to try and reduce hospital wait time and to expedite discharge. But the fact still remains that the hospital constantly runs at over 100% capacity. I am forced to see people in the corridor, and take a history and examine people in the waiting room. Seeing a patient in a cubicle is a luxury. A good shift for me is one where no one dies, I get a toilet break within 6 hours of starting my shift, and I actually get a meal break, be it an interrupted one. People wait 6 hours at times, but please do not take it out on the doctors and nurses.

Another issue is the de-institutionalization of mental health and the subsequent increase presentations to ED.

Also I think the issue of a perceived doctor shortage is a misunderstood one. There is a doctor shortage, but that is mainly in General Practice in urban and rural areas. In almost all the other specialties, you still to compete, buff the CV, do unaccredited Reg jobs and fight very hard to get into limited training positions. I have friends who are in surgical training and I have seen the hassle they have to go through just to get in training. The physician trainees have to fight to get a hospital position and people are turned away.

The talk among the junior doctors is that those not already in training should get in quick and the medical student wave is fast approaching. Without more specialist training positions, the extra doctors will be shunted into General Practice by lack of other positions rather than by choice. General Practice is a challenging and rewarding profession and those in training should be there because they want to, not because they can't get into another specialist college.


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## grinner (May 15, 2008)

hay kelvin,
good to hear from you mate,
you are 100% right , all the young docs in cas work their butts off. up here in brisbane we get a lot of older no hopers because the hospitals are just so desparate.
i did some cas training (brushing up) a few years ago so i could do a couple of weeks at mornington island / julia creek.
there was one bloke at the local hospital (which shall remain nameless) who bragged to me , he never saw more than 8 patients a day.

i saw 143 one shift at gladstone but i'm a bit manic.

training positions are an interesting subject.the specialists can keep demand (and prices) high by not training enough "apprentices".
i dont want to be down on lady doctors but 60 % of my year were female and a hell of a lot of them have given up practice.
when they do come back and do a few sessions, theyre very timid and send a lot of stuff to specialists which is expensive.
i'm lucky, my patients are so broke , they just laugh if i try to send em to a specialist.
and the local hospital is so over run that ambulances actually take people on weekends from cas to our surgery to be stitched and plastered. quite bizarre really. qld hospitals are a mess mate.
i believe victoria and SA are much better. i did a bit of work at bendigo hospital and couldnt believe how good the specialists were and how good the back up was. 
if you rang a specialist when he was on call in brisbane you usually needed an ent consult to fix your busted eardrum from the screaming abuse you recieved :lol: :lol:


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## Duane (Oct 20, 2007)

Thanks for your input into this Grinner and Kelvin.



Kelvin11 said:


> Speaking from personal experience working in ED, I can guarantee you that the doctors are not kicking back drinking coffee


From what I've seen and heard, nobody in their right mind would accuse anyone working in a public hospital ED of kicking back.



Kelvin11 said:


> Also I think the issue of a perceived doctor shortage is a misunderstood one. There is a doctor shortage, but that is mainly in General Practice in urban and rural areas. In almost all the other specialties, you still to compete, buff the CV, do unaccredited Reg jobs and fight very hard to get into limited training positions. I have friends who are in surgical training and I have seen the hassle they have to go through just to get in training. The physician trainees have to fight to get a hospital position and people are turned away.


I can only speak about Tassie but my GP of choice generally has a 3 week wait so I tend to only visit him when it's something mildly annoying that I think may need ongoing treatment. Otherwise I head to the nearest bulk billing joint and order a med cert or round of anti biotics. But I wouldn't set foot in one of those places if I don't have a strong idea of what's wrong with me.

As for specialists, their little clubs need to have there training powers taken away from them to reduce the artificial demand for their service. I'm aware of a couple of specialists making around $1.5m a year. Do you think there fees would be so high if they didn't have there appointment book filled for the next six months?

Here's a plan to save some of that $110B, an international profit cap on medical patents!


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## Barrabundy (Sep 29, 2008)

Hmm, sounds a like a bit of a basket case. I kind of imagined that some of that stuff might be the case but thanks for the eye opener grinner.

It's understandable that people are nervous about liability but it's a shame that it leads to such a waste of resourses. Sometimes a simple _"you're a d!ckhe4d mate, I can't do that so don't ring me again"_ ends up being _"Put it in writing, go through the right channels, we can then check with our legal guys and get back to you in due course"_

.......$K's in legal fees later you're still dealing with the same issue because no one wants to say it how it is in case they're wrong.

Also seems to be an attitude with some (councils and gov't depts are the worst) along the lines of _"lets commission a report on this...so we can show that it wasn't OUR idea"_


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## ARK (Nov 18, 2008)

Grinner

You clearly know the system better than I, but not everyone is given the runaround. Christmas eve 2008, my small intestine was perforated (I thought my apendix had burst), and by the pain, I knew it was serious. So I called the ambulance for the same reason you gave in your little scenario, to be seen sooner. It worked, I was being given morphine less than an hour after arival (slightly more than half an hour). I had three different scans that evening, a ultrasound, X-ray, and a CT scan.I also had a catheter, and a naso gastric tube inserted, and was seen every fifteen or twenty minutes by a nurse. I was in there around 5 30 and was in the operating theater by 11. This was in Ipswich hospital, and I felt the treatment was professional and timely, and it clearly saved my life.

I have obviously heard the stories other people tell, but I can only go by my own experiance, and it was postitive.

Audrey


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## Rose (Jan 30, 2006)

xxxxxxxxxxxxxx


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## Junglefisher (Jun 2, 2008)

Here's my reply to that other thread, I thought I would try and stay out of this one.
However, as someone who is married to a young, female GP, I find the stereotypes being bandied about here a little annoying.
My wife does work fulltime as a GP, she sees 4 patients an hour - the same number as the males in her practise.
She does not order tests unless she feels they are useful.
She has worked in a palliative care facility - and would have continued to do so if it wasn't being run by Qld health. Believe me, some "young" doctors are quite able to treat the dying with dignity, it often depends on how the family reacts. You may be surprised how many people want their parents kept alive when it's not in the parents best interests.
I don't expect to change anyone opinion here, I've been around internet forums too long to belive in fairies but I could not let this go without a comment. Anyways, I haven't said most of what I really think.



Junglefisher said:


> Duane said:
> 
> 
> > When I hear of surgeries being cancelled it's because of a lack of trained staff, not because the hospital didn't have enough theatres.
> ...


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## grinner (May 15, 2008)

hay sorry jungle, definitely not having a go at anyone mate. and say what you really think by all means.
young/old
male/female
doctors/nurses
patients/health consumers.

everybodies in this together.

what i cant stomach is the bullshit and spin that is fed to the public and the way a once proud profession...like as i say teachers, police has been brought to its knees and is suffering such low morale.maybe morale is good in cairns but i can tell you it aint good down here.

my fight isnt with your wife or anyone else in the system who is seeing patients and trying to care for them.

but the spin is out of control. recently a certain pollie was bragging about the reduced waiting lists at a qld regional hospital. this was because the eye surgeon had quit and the ent surgeon had quit and so the waiting lists had evaporated. total rubbish.

the enormous bureaucracy that is qld health should be there to support doctors and nurse, not make there lives more difficult.
and just ask any teacher or cop if they feel the bureaucracy in the education and police department is really a fantastic support network or not.

when literally billions are being wasted on all this middle management, you gotta ask, are we getting value for money. i say no, but thats just my experience.


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## Guest (Mar 22, 2010)

Rose said:


> Wow, you've really got me giving thanks for my good health Grinner! :shock:
> 
> I haven't been inside a big hospital for years, and I thought things were bad then...but the fancy machines and tests at their disposal were minimal then, and doctors were still willing to treat people based on their experienced opinions of what was wrong. So...if the day comes, how can an ordinary member of the community avoid all the unnecessary tests and red tape? Given that we don't know the reasons for them or the 'real' value of them well enough to argue against unnecessary stuff with somebody who has done all those years in medical school? Is there any way to just get treated for what ails you? (when it's fairly obvious that is, and here I'm acknowledging that something as 'fairly obvious' as appendicitis could turn out to be something else after all) Is it possible to reassure the medical staff that you're not out to get them or after a big compensation payout? Or are they really so firmly bound by all this red tape that they are unable to move in the direction of common sense? :?
> 
> ...


A resuscitation order is one of the important questions we ask nearly every patient. Almost all general medical patients have a clarified resuscitation order before they go to the wards from ED. Unfortunately many patients do not have any clear advanced directives or just have not given the matter much thought. Sometimes families have unrealistic expectations. With patients with multiple medical co-morbidity and a poor prognosis, the last thing the medical staff want to do is to perform CPR. Sometimes the kindest thing we can do is to let people die with dignity.

However it can be a very uncomfortable conversation to have with family members and needs to be done with a great deal of sensitivity and empathy. Many families a great deal of guilt saying do not resuscitate.


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## Duane (Oct 20, 2007)

Junglefisher said:


> My wife does work fulltime as a GP, she sees 4 patients an hour


If I needed a doctor more than once or twice a year I'd be tempted to move to Cairns just for the face time.
I'm surprised her clinic turns a profit when my understanding is the industry standard is 10 patients per hour >> http://www.6minutes.com.au/

Then again I've been in and out with a repeat for anti-biotics in under a minute before, so maybe it's a case of swings and roundabouts.


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## YakN00b (Jun 9, 2008)

I have a simple solution for the lack of funds available for health care. A huge tax on fast food of which every cent goes directly into the health system. Let the fat bastards pay for their increased care.

PS.
A note to the PC police, I am a fat bastard myself so piss off.


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## koich (Jul 25, 2007)

I agree too.


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## FishWhisperer (Mar 5, 2009)

leftieant said:


> It may shock you n00b, but I agree with you wholeheartedly.
> 
> In fact I'd be going a step further:
> 
> ...


Very hard to endorse this one....So I guy with cancer who takes sick leave is paid less because he has used sick leave compared to a healthy person (not the best idea)
Compulsory medicals - agree here good concept
Preventable sickness?? - how do doctors know what you eat, whether you smoke or write yourself off each week. I know I get asked the question during my medicals and there is no way of knowing if your telling the truth or not. Where do you draw the line (what illnesses are preventable) some would argue the flu is preventable (wear masks), sporting injuries, common cold, car accidents the list can go on.

I think it is a harder issue to tackle than most people think.

My 2bobs worth


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## Macbrand (Feb 15, 2010)

grinner/Monty Python said:


> machines that go ping.


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## andybear (Jan 15, 2006)

Oh,

I think that is two separate "feels" one internal and one external.

It certainly is a sorry state of affairs, and thanks for a very interesting post Grinz,

Cheers Andybear


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## matcoburn (Feb 6, 2009)

Pete, 
As long as those tax reciepts from Iron ore exports fill the coffers, there is no shortage of pencil-dick middle managment to fritter away the resources that could make life better for everyone.
Mat
PS. An awesome detailed post pete


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## lowtide (May 21, 2009)

Now I know why you go fishing.

Yup, the health system is crook - costs us a fortune and the service is patchy. And health costs are projected to continually rise and are projected to consume entire state budgets within a few decades. I worked at Gizo Hospital in the Solomon Islands for a year where the health expenditure per capita is ~2% of Australias, but I reckon we would have achieved at least 80% of the outcome (in terms of years of avoided morbidity and mortality). We spend an insane amount of money trying to get incrementally smaller improvements in health outcomes. Hence spending 50,000,000 bucks on folk in the last 12months of their life (actually I heard it was the last 6months, but I haven't any hard data to support this). We also spend an insane amount of money trying to make the system safer, hence all the forms, the endless guidelines and policies and departments of bureaucrats measuring performance, prescribing practice, pathology ordering patterns, adherence to 'best practices' etc. As Grinner points out, there is ridiculous amounts of duplication with multiple staff members handling each patient and appalling pathology ordering practices (it is easier to order a blood test than to find out the result of the same test the patient had last week with a different pathology provider). Australian medicine has developed a culture where there is scant regard for the cost of whatever the provider wants to do, it has also become risk adverse and doctors are not encouraged to back their clinical judgement, hence resorting to all the tests and scans which simply confirmed what they suspected already. In the Solomon Islands, if someone came in with pneumonia you diagnosed it on history and by examining the patient. You then admitted the patient to hospital and gave them penicillin through a drip(cheap) until the fever abated then they went home on tablet antibiotics. In Australia, when someone with pneumonia comes to the Emergency Department, you cannot admit them until the admitting medical registrar has accepted their care. This doctor however will not take your word that the patient has pneumonia and will not even see the patient until the bloods (FBC, EUCs, LFTs, CRP, Blood cultures +/- sputum) and a chest XR done. On the ward the patient will often get a third generation cephalosporin at 2 orders of magnitude of the cost of penicillin. The intern will do CRPs and blood counts daily because they don't understand that examining the patients charts and the patient will tell them if the patient is getting better. And there will be a machine that goes "bing" somewhere in the room as well.

What happened? I guess its a sort of perfect storm situation. Specialization and the fragmentation of patient care happened. Technology and big pharma happened. Litigation and multi-million dollar payouts happened. Medicare happened. The GP used to know their patients and direct their care but now are often out of the loop. Once specialists are involved with their patients the GPs often become disempowered and fear to interfere with whatever the specialist does. There are good GPs who know that old Mabel Smith shouldn't be on warfarin and half her other tablets whatever the cardiologist says, but they are a minority. The frail and demented in the nursing homes no longer have GPs. The docs, in general, will not visit and it often requires an ambulance to get the person to a surgery. So a nurse takes the scripts around to the surgery and repeats are written out. Meanwhile Cecil is shuffling closer to the end of his mortal coil and takes a turn one night. The Philipino RN on tries to call the GP, but there is no after hours number or if he is home, is so out of touch with his patient that he says call an ambulance to be on the safe side. Cecil should have stayed and nature allowed to take its course. What happens to Cecil in the ED is another story and is not pretty because the 2nd year resident who sees Cecil does not have the humility or experience to direct Cecil straight back to his familiar surroundings to die in peace and quiet.

Why do they put nails in coffins? - to keep the oncologists from trying another treatment on the patient. Having sat on hospital pharmacy committees, I can tell you that cancer drugs cost a bomb. But this new drug will lengthen life by a month on average they plead. When is that extra month value for money I ask. The poor bastards with the cancer never seem to go fishing in that last month. In fact they are so buggered, few ever leave the confines of their own houses. Some of these drugs are $2000 per tablet, or $20000 per infusion, and patients are taking them weekly for months to get that extra month. I don't think this is value for money but there are lots of doctors who wouldn't agree. Certainly if you take a global view, that money would save 1000s of lives in the third world. Big Pharma of course develops these drugs, supports the trials to show their purported efficacy and wine and dine the prescribers (the oncologists).

On tablets - suppose you have a modestly raised cholesterol and your blood pressure is a bit high. You doc says take this tablet for your cholesterol and another for your blood pressure, it will stop you from having a heart attack. Well maybe... everyone is going to have a heart attack, or cancer or a stroke or dementia or some other lethal condition eventually. For many of these tablets, you need to treat between 10 and 20 people to save one from having the heart attack (so they get cancer later on instead). This means most people taking their blood pressure tablets or cholesterol tablets are taking them unnecessarily. Unless I have an immediate family history of premature heart disease I'm not sure if I would be taking the tablets. Maybe technology will be able to tell us which folk will benefit from the tablets and which will not but I'm not holding my breath. I see 90 year olds on these tablets and I wonder why. If you've reached 90 then you've got a bloody good physiology and tablets are largely a waste of time. Show me a study of nonagenarians which demonstrates that blood pressure tablets make them live longer and happier.

Defensive medicine is bad medicine but whilst the lawyers are hovering, it will continue. Yes there are bad doctors who injure their patients and these patients should be compensated. There are good doctors who injure their patients also. These patients also need to be financially supported, but the court process has destroyed good doctors or turned them into defensive doctors. There are patients (eg the infant born with cerebral palsy) whose problem has nothing to do with a doctors treatment however the court will find against a doctor simply to find money for the heart wrenching 'victim' in front of them. A no fault compensation system is the answer. Everyone in the above scenarios gets money. The only doctor who goes to court is the criminally negligent one.

Patients need to cop some of the cost of their care. Otherwise they simply don't value it. They will use ambulances for trivial problems, come to emergency departments for a shot of maxalon because they drank too much and they do not value the staff and all to often frankly abuse them. Medicare does encourage overservicing. There needs to be co-payment that comes out of the patients pocket - about the cost of a packet of **** or a sixpack, they seem to be able to afford these items okay.

Our society is less supportive and more dysfunctional. Nearly all the psychiatry that presents to my ED is due to abuse and drugs. Most of the assaults are due to drugs or alcohol, half of all trauma like wise. Young mums with feverish kids have no idea what to do. The knowledge that passed from mum to mum is lost. Grandmum lives in another state or is estranged. GPs spend half their days with people depressed by the tedium of their own lives. GPs can't fix that, nor can tablets.

Where was I up to.. Yep, the system is way less than perfect, and is not easily fixed. The Rudd-meister is correct that something needs to be done but I have little faith in his ability to turn things around. A 60:40 funding split does not fix cost shifting. Local hospital boards just adds another layer of bureaucracy. So - enjoy life whilst you are healthy. Fishing, I am certain, improves mental well being and paddling has got to be good for the pecs (or if you have a Hobie, good for the legs).

Speaking of fishing. Not sure how many hospitals there are where you can catch spaniards from the premises, but Gizo Hospital is one of them. Worked at Thursday Island Hospital for a couple of years - had to walk 10mins to the wharf to catch pelagics unfortunately.

Declaration of interest: I am an emergency physican. Big pharma seems to ignore me.


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## Barrabundy (Sep 29, 2008)

Almost as interesting as the fishing threads!


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## theclick (Jun 25, 2007)

Thats gotta be a record


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## Peril (Sep 5, 2005)

Wonderfully said Lowtide. Western medicine provides excellent acute care but for chronic care it sucks. For health maintenance it is a complete joke.

Fortunately there are many people out there thinking about living for health and there's plenty of info in books, blogs etc


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## grinner (May 15, 2008)

hay lowtide, great post mate. 
as an emergency doctor you probably have the most challenging job in the country.

dont think the public know just how much a good doctor can save them.

one of my colleagues, a south african , can do nearly anything. caesarians, anaesthetics , trauma medicine.

he regularly does stints at domagee and arakun and mornington island and he can treat a lot of stuff on site. arakun with 2000 very unhealthy inhabitants. he was telling me , it costs the local hospital $9000 every time a patient is sent out to mt isa (flying doctor plus staff). he can generally do 3 weeks without sending one out but says often its one a day when less experienced docs are there.

i loved working in cas but even then, the social admissions (elderly people who no one seemed to want to care for) get you down.
used to drink a bit til i started doing long shifts in cas. then you realize just what total arseholes obnoxious drunks are.

quite right about the cancer drugs , but if someone with cancer does a google search and finds some drug from america that costs $40,000 and goes on a current affair and accuses the government of not giving her that extra month of life , the pollies cave in real quick. thats why society as a whole has to make these decisions and say "health is a bottomless pit, lets spend the money wisely" . if that means less money for me , i'll cop it but theyve just got to get the regulators/red tapers off our backs.

the problem with government trying to regulate medicine is that 95 % of doctors and nurses really want to do the best they can. the most you can ask for from a regulator is that he will be utterly useless and just read the paper and leave you alone, because every new bit of regulation just creates more work and distractions.
and you know the only doctors and nurses who need to be regulated are the other 5 % who pay absolutely no attention to it.

i would imagine its the same for builders and car salesmen, the system bogs down the good people and the cowboys carry on regardless.


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## Guest (Mar 29, 2010)

Lowtide, I agree with what you say.

Do you work in Coff's ED? 
Small world if you do. One of the ED Regs here has just come back from there and another good mate who has passed his ED Primary has moved up there to work.


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## ArWeTherYet (Mar 25, 2007)

I think you only need to look at Hollywood to find the answer.

What does it mean when you crystal turns red :shock: :shock:

There's also Soylent Green which will take care of overcrowding and lack of food.


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