We need a Incident Information Management System (IIMS) for Health Care Administration

When something adverse happens in hospital, for example, a patient is given the wrong medication, then we are supposed to log a report in the Incident Information Management System or IIMS. It is especially the case that this system should be used when harm to the patient is the result of the error. This is a good system but under-utilised and poorly designed – nonetheless we should continue to promote it.

We should in fact promote it’s extension to medical administration. If we really want accountability about the health care system, and in particular management of the budget, then we need an incident management system for the administrators. Let’s take the human resources department as one example. I have a potential employee for whom I could offer a job, No offer has been made even though the interview occurred 3 weeks ago. The hold up has been with the HR department and their need for more paperwork, etc, etc…..none of which was communicated as advice prior to the advertisement being released. Overall the whole process has been f’d-up, not to mention slow and expensive. So why shouldn’t I log this to IIMS.

Health care management in the Australian public health system is littered with examples of poor practice for which we should have an IIMS system……this is the way to achieve health care reform.

Things they didn’t teach in medical school: Part 34 Progressing through a career a.k.a getting older

It’s been a while since I did a “Things they didn’t teach in medical school” post but this week has prompted some introspection so let’s give it a go.

Two years ago my dad said he was retiring. Dad is a GP who, for as long as I can remember, worked 10-12 hour days, often 7 days a week. When he said he was retiring it meant he was moving from solo practice to a group practice and possibly working as few as 40 hours a week, but still doing on call well past standard retirement age.

But can this happen in speciality practice in 2013? A surgical colleague 10 years my senior (I’m about to turn 4) and I had a chat about this recently. The conclusion…..it’s hard.

The issue is maintaining the churn. This isn’t meant to disrespect our patients but the reality is we see a lot of them and it’s demanding work – physically, mentally and emotionally.

I look around at the people senior to me and the reality is that many of them, across many specialities, not just my own specialty of oncology, wind back their day-to-day clinical activities as they enter their fifties – a time which is really only in the waning part of their second decade of practice as a specialist. The combination of repetition and stress take their toll over time.

Now I don’t mean to say that this happens to everybody but I suspect it applies to a lot of practitioners.

So what to do about it – I think diversification of interests and practice is important. This doesn’t mean get a hobby but find a role in your profession that doesn’t rely on just seeing more and more patients. Find a research interest, become good at (and interested in) management or simply make enough money to retire early. Find something to keep you going to work in the morning.

And to the future registrars I’ll be interviewing on Monday……start thinking about these things early. Those that don’t will just burn out.

Works by Darius Milhaud

Concerto for Marimba, Vibraphone and Orchestra – Peter Sadlo, Munchner Philharmoniker, Sergiu Celibidache

Cello Concerto No.1, op.136 – Janos Starker, Philharmonia Orchestra, Walter Susskind

Le Boeuf sur le toit, op.58 – Leonard Bernstein, Orchestre National de France

Medical consultations are a bit like elections: people vote for what they want to hear

Australia is in the midst of a Federal Election and for the next 3 weeks we are going to be hearing a lot of promises being made.

Reflecting on this election I’ve been thinking about the similarities between some of the medical consultations I conduct and electioneering.

Many patients come to me wanting be to impart hope. I might get them to live just that little bit longer by giving a new chemo or drug treatment. In political terms this is the promise of money. If you re-elect me I’ll give your electorate/community/organisation X million dollars to build Y & Z. Or I will cut a tax and reduce an expense.

But we (the electorate) are not iterate about these matters. We aren’t prepared to accept the real story…..that throwing some more dollars into the ring isn’t going to change much..it could ecen be wasteful. In the same way many patients are pursue the path that offers hope even though, in reality, the solution offered has little chance of changing the overall situation.

The politicians probably do actually understand the reality of the situation but they choose to play politics. The doctors also understand the reality of situations and either choose not to or are unable to communicate it effectively to patients.

The underlying problem in both circumstances concerns literacy. The economically literate would say you can’t increase spending without increasing revenue (aka taxes). Likewise the health literate individual would be able to acknowledge you sometimes run out of options.

Good Cop, Bad Cop

So I have a close working relationship with a surgeon where essentially I play bad cop to his good cop. The whole Hood Cop/Bad Cop concept is a method of interrogation. In our practice it is ostensibly around the good cop sending a positive message with hope and the bad cop (supposedly me) giving the bad message.

Well this is all around want people want to hear. It happens to be the good cop message.

But let’s recalibrate this. I probably am more pessimistic but the actual attitude I take is not of taking the ‘bad’ side but of being realistic. The statistics I quote are grounded in fact. I can’t and nobody can predict the future and some people have to have a good outcome and some have a bad outcome. Neither the good cop or the bad cop can predict the future but that can be honest about the chances even if they can’t tell who will do well and who won’t.

The realistic message needs to be heard when there is a situation where the gains can be modest and the trade-offs are high. Not everybody will take the odds offered: some people will end up hurt.

Vocational training has a nomenclature problem

Physician trainees having just completed their viva examinations are anxiously awaiting results and are deciding they want to do for the rest of their lives: they are about to embark on what is called vocational training. This is supposedly training for which these individuals have a special calling – like the priesthood.

In reality many of my peers and my juniors seemed/seem to have no idea what they have a vocation for and in fact base their sub-specialty on a variety of factors including exposure (it was the best of a bad bunch), lifestyle choices (financial , overtime/shift-work), brains/brawn (physicians vs. surgeons), and even parental expectation. As a consequence I often see fully qualified professionals who are not suited for their ‘chosen vocation’ for a whole variety of reasons ranging from technical incompetence, through to boredom and burnout.

I ultimately went down two vocational training pathways: medical oncology and clinical pharmacology. Notably I had always thought my vocation was psychiatry. I did a consultation-liaison psychiatry term for my option term in a New York cancer hospital and loved it but when I returned to do a general psychiatry term it really didn’t gel – I didn’t hate it but at the time I thought it was (and perhaps remains) flawed both in philosophy and science.

As it happened I did 2 terms each in medical oncology, haematology and gastroenterology and a term in palliative care and thoroughly enjoyed them: so what to I do now? – gastrointestinal oncology. Oncology lead me to drug development and an interest in quality care and this in turn lead to clinical pharmacology as a second specialty.

I could tell you why I like these specialties but I can’t actually tell you why I ended up here rather than performing cardio thoracic surgery (although I do often tell patients I could take them apart I just couldn’t put them back together again).

Unfortunately many trainees don’t get broad enough exposure to different disciplines in order to find their calling. In addition their modes of practice often don’t reflect what it is like as an actual consultant. For example many doctors get put off oncology because of the death and dying aspects as they only do inpatient work and no outpatient work – this is not a unique problem.

What I can tell you is this: get exposed to as much as possible and then do what you really enjoy and have found satisfaction doing. The success, career-wise, will follow-on and hopefully you’ll never get bored. In medicine never view the practice of medicine as a view to making money: if you take this pathway you need to remember the only way to make money is volume (i.e. lots of work). You’ll make more than enough doing what you really like and perhaps more than you expect. But if you really view financial gain as the reason for your ‘vocation’ then you chose wrong.

Finally don’t view a ‘vocation’ as being a singularity. First and foremost physician sub-specialty trainees need to remember that being a physician brings skills and opportunities to do things in the same way that law or commerce does.