Health services administration

Synopsis Casemix funding has markedly increased surgeons' awareness of the economies of the activities they undertake. Surgery has become a major focus at all large public hospitals, because of its high earning potential, and this pressure to maximise funding could influence surgical practice. Casemix funding's emphasis on length of hospital stay has encouraged forward planning for earlier discharge after surgical procedures. Patients are now assessed in pre-admission clinics, educated about their condition and their hospital stay, and a plan formulated for their discharge and rehabilitation. Funding for major surgical procedures of long duration in patients with complex conditions should reflect the higher level of resource utilisation. Tertiary referral centres, because of their commitment to training and research and their more severely ill patient population, are less cost-effective and require funding to ensure their viability. The improved information that casemix generates should be used to evaluate outcomes and improve patient care; efficiency must not take precedence over quality of care and compassion. Introduction Casemix has been effective in reducing government spending on health and in improving public hospital efficiency.1 Paying hospitals for current rather than previous practice has proven to be beneficial:2 in 1990, acute hospitals in Australia were costing 31.2 cents of every health dollar;3 that figure has now been reduced to 28 cents in the dollar.4 Most importantly, productivity has been increased by 20% in some hospitals.5 Casemix funding has markedly increased surgeons' awareness of the economies of the activities they undertake, and given greater understanding of where money is being spent and where it is being wasted. It has provided a tool for comparing many widely divergent areas of medical practice within the same institution and between different institutions. We are amassing a vast quantity of valuable information, which will be used to monitor outcomes and improve performance. Casemix funding and surgery Under casemix funding, surgical activity has become a major focus at all large public hospitals because of its high earning potential. Regular casemix meetings are held in many surgical units, with the specific aim of maximising reward for work done and hence maximising funding. There can be drawbacks in such a situation. One criticism has been that hospitals now perform procedures rather than care for the sick.6 Furthermore, the recognition that revenue is likely to be higher if a procedure is performed, could potentially influence surgical practice. For example, if a patient were admitted from the emergency department with suspected appendicitis, it is clearly to the hospital's financial advantage for surgery to be performed. For a patient with suspected appendicitis, a condition with significant morbidity and mortality, such a decision is not bad practice. However, casemix funding is not designed to fund specific DRGs, and neither the surgeons performing this work, nor their units, reap the financial rewards directly. The money is used to subsidise less profitable clinical areas.1 Casemix funding has also stimulated surgical activity in units with forward budget planning where funds are allocated according to a predicted level of specialised surgical activity (eg, complex biliary surgery). However, if a unit's activity exceeds forecast levels and the budget is capped, some operations which cannot be deferred may not be appropriately funded. Capping of budgets destroys incentives, closes beds, increases waiting lists and discourages clinicians and others involved in "coal face" healthcare.5,7 Length of stay An interesting benefit of casemix funding, with its emphasis on length of stay in hospital, has been its encouragement of forward planning. Previously, when patients were admitted to hospital for surgery, little thought was given to length of postoperative stay, and an appropriate discharge plan for the patient was not considered until the time of discharge. Now patients are assessed in pre-admission clinics and any special medical and anaesthetic problems are identified. They are educated about their condition and their hospital stay, perhaps given an exercise program, and a plan is formulated for their discharge and rehabilitation. All these measures have the potential to reduce complication rates, and therefore length of stay. Furthermore, the concept of same-day admissions has been considerably advanced by the advent of pre-admission clinics. To further reduce length of hospital stay, casemix must be extended into areas beyond the acute hospital episode,8 such as "hospital-in-the-home" and ambulatory care. With casemix funding, hospitals are rewarded for patients with clearly defined conditions whose hospital stay is shorter than the average for that disorder and, conversely, penalised for patients whose stay exceeds this average. It has been interesting and illuminating to discover just how early patients may be discharged from hospital after major surgical procedures, but there is the potential for them to be sent home too early. Patients need time to adjust to the physical effects of their procedure and its consequences, and to be educated in management of their condition. At the Sir Charles Gairdner Hospital in Western Australia, the practice of discharging patients with femoral neck fractures to nursing homes three days after surgery had to be discontinued because of an unacceptably high mortality.9 Lack of community resources to support early discharge has been a major problem.1 Complexity of care Casemix funding, while it rewards uncomplicated care, does provide some increased funding for patients with complications after surgery. However, AN-DRGs do not adequately take into account variations in illness severity and comorbidities. Patients who have complications during their postoperative recovery obviously consume more resources, but it is paradoxical that more funding is available for patients who do badly than for patients who do well. Tertiary referral centres often treat the most difficult, taxing and hence resource-intensive patients. These patients are referred to these centres because of the complexity of their problem, or because of postoperative complications after one or more procedures elsewhere. Tertiary referral centres are also involved in research, and undergraduate and postgraduate teaching. Because of this commitment to training and research, and their more severely ill patient population, they are less cost-effective and require funding to ensure their viability. In some areas of surgery, as a consequence of casemix funding, patients who will do well and have few complications are being selected to provide a large turnover of trouble-free patients favourable to fund generation. Careful thought needs to be given to funding formulas for simple, short surgical procedures with very low complication rates, as opposed to major procedures of long duration in patients with complex conditions. One technique may be the introduction into DRG classifications of disease-specific conditions as risk adjusters for disorders with known comorbidities and high complication rates.10 Efficiency versus humanity Casemix and budgetary restrictions have created an impersonal atmosphere, in which efficiency has taken precedence over humanity. There has also been a shift from collegiality to contract arrangements.2 Moreover, there is a belief among general practitioners that some patients (eg, the elderly) are not welcome in the public hospital system.11 The lack of time and money to deal adequately with all the facets of care in public hospitals has led to a sharp rise in complaints from consumers.5 At the Alfred Hospital in Melbourne, attempts are being made to monitor patient complaints, and a complaint officer has been appointed. Other measures to counteract this impersonal atmosphere include direct involvement of general practitioners in hospital activities (eg, in outpatient clinics), and there are future plans for general practitioners to be involved with surgical patients before and after operation. Conclusion Although casemix has made us more aware of the need for efficiency, budgetary constraints, including the capping of activity, are likely to adversely affect important aspects of healthcare, such as quality of care and compassion. We must make use of the information that casemix is generating to fully evaluate outcomes and improve patient care, as well as work towards extending the benefits of casemix to total patient care. We need centres of excellence to set and maintain high standards of patient care. References Phelan PD. Casemix funding in Australia. Time to move on. Med J Aust 1998; 168: 560-561. Braithwaite J, Hindle D. Casemix funding in Australia. Time for a rethink? Med J Aust 1998; 168: 558-560. Commonwealth Department of Health and Family Service/South Australian Health Commission. An evaluation of casemix funding in South Australia, 1994-95. Casemix Development Program. Adelaide: Commonwealth Department of Health and Family Services and the South Australian Health Commission, 1997. Australian Institute of Health and Welfare. Health services expenditure by type of expenditure 1989-90 to 1994-95. Health Expenditure Bull 1997; 13: 3-5. Kennedy JT. Perspectives in casemix based funding in Victoria. Good for governments. Med J Aust 1995; 162: 665-666. Tonti-Fillipini N. Negatives of casemix. Australian College of Midwives Inc. Ninth Biennial Conference Proceedings. Melbourne: Australian College of Midwives, 1995: 456-466. Phillips PA. Perspectives in casemix-based funding in Victoria. Med J Aust 1995; 162: 655. Hanson R. Casemix funding in Australia. Have we come full circle? Med J Aust 1998; 168: 561-562. Sikorski JM, Senior JM. Factors affecting mortality in patients suffering a fracture of the proximal femur. J Bone Joint Surg Br 1998; 79 Suppl IV: 410. Andrews JS, Anderson GF, Han C, Neff JM. Pediatric carve outs. The use of disease-specific conditions as risk adjusters in capitated payment systems. Arch Pediatr Adolesc Med 1997; 151: 236-242. Segal GR. Perspectives in casemix-based funding in Victoria. Some patients are not welcome. Med J Aust 1995; 162: 656. Authors' details Monash University, Alfred Hospital, Melbourne, VIC. John A L Hart, MB BS, FRACS, Clinical Associate Professor of Surgery, and Senior Orthopaedic Surgeon. Royal Children's Hospital and Royal Melbourne Hospital, Melbourne, VIC. David Wallace, MB BS, FRACS, Neurosurgeon. Reprints will not be available from the authors. Correspondence: Professor J A L Hart, Clinical Associate Professor of Surgery, Monash University, Alfred Hospital, Prahran, VIC 3181. E-mail: johnhartATmelb.alexia.net.au

Synopsis Teaching and research are not funded directly under a casemix funding system, and individual Australian State and Territory governments have provided teaching and research grants to teaching hospitals to defray these costs. Biomedical research funding in Australia lags far behind that of other countries. The declining per capita expenditure on the health system generally, as well as on universities, is jeopardising teaching and research activities, which are not seen as "core" hospital services. Studies in the United States have shown that healthcare services associated with teaching and research are more costly but result in better patient outcomes. It may be time to promote outcome-based funding of teaching and research in the Australian healthcare system. Introduction Casemix funding models are essentially output-based funding systems which classify patients into different groups according to their clinical characteristics. Each patient's healthcare is funded on the basis of the average cost of providing care to patients with similar characteristics. Under a casemix funding system, teaching and research are not funded directly. It is now recognised -- and this view is supported by two large-scale government funded consultancies (Coopers & Lybrand in 1994 and KPMG Peat Marwick in 1996) -- that the costs of teaching and research, at least in Australian teaching hospitals, cannot be accurately separated from the costs of direct patient care. State and Territory health funding agencies have implemented teaching and research grants to supplement casemix payments in recognition of these activities in teaching hospitals (Box). The first teaching and research grants awarded in Victoria in 1993, based on numbers of trainees and research grants, were clearly a mechanism of providing funds to "top up" the variable casemix payments and ensure continuity of teaching hospitals' historical budgets. The grants were unrelated to the actual costs of teaching and research in the institutions. Teaching and research funding in other States has followed in this direction (Box), but this approach has not been universal, nor has it resulted in similar funding formulas. Teaching and research funding and casemix Biomedical research funding in Australia is inadequate, with government expenditure on research and development being 17% below the average for OECD countries.1 Despite recent increases in funding for medical research announced in the Federal Budget in May 1998, research spending planned by the Federal Government still lags far behind that of other countries. For example, the United States plans to double the budget for the National Institutes of Health (NIH) over the next five years.2 The NIH estimates that the approximately US$4.3 billion invested in research supported by the NIH has the potential to realise annual savings of between US$9.3 and 13.6 billion, which translates into a 200%-300% annual return on this research investment.2 The question of the future of biomedical research funding in Australia is currently being addressed by the Wills Committee established by the Federal Government. The committee's findings are due later this year, and what impact they may have on funding the significant biomedical research role of teaching hospitals remains to be seen. University funding per student is steadily declining (Mr S Hamilton, Australian Vice Chancellors' Committee, personal communication). There is decreasing support in real terms for faculties of health sciences and a greater emphasis on students funding their own tertiary education. Reduced funding and support has put further pressure on the teaching and clinical service loads of clinical academic and hospital staff. All clinical staff are already being asked to reduce costs, which can be done by reducing length of hospital stay for inpatients, and substituting ambulatory services, such as hospital-in-the-home or same-day services, for inpatient services; and by increasing the workload in consulting clinics. This is because payments for services provided are based on State government or Medicare Benefits Schedule fee-for-service, and more services bring in more income. All of these changes have reduced the time available for teaching medical undergraduate and postgraduate trainees, and the number of patients available for clinical teaching. This is not to say that the challenges of changing work practices should not be addressed. However, in times of declining per capita expenditure on the health system generally, as well as on universities, pressure inevitably comes to bear on teaching and research activities, which are not necessarily seen as "core" hospital services. There is no doubt that patients can be treated in an environment that eschews teaching and research, but the logical extension of this -- that no patient care should encompass teaching and research -- is ludicrous. This would require that Australia import the clinical expertise and the research (or products of research) that it might need. Is teaching and research a cost or a benefit? Under current medical student and postgraduate training systems, a significant proportion of teaching must occur in teaching hospitals. This applies to all medical undergraduate courses and all postgraduate training programs (including those for general practitioners). But what evidence is there that this is of benefit to society, apart from the training of doctors? Garber et al3 investigated this issue in the 1980s at Stanford University Hospital, California. They studied 2025 hospital admissions and measured differences in casemix costs and hospital deaths according to whether patients were admitted to services staffed by full time faculty members (with resident medical officers and students) or to non- faculty, community-based services (in which two-thirds of patients received no care from resident medical staff). The faculty service had more patients with costly diagnoses, and their costs were 11% higher (95% confidence interval [CI], 4%-18%) after adjustment for casemix. However, the faculty service provided a much better patient outcome. After adjusting for casemix and socioeconomic characteristics, the community service patients were 34% (95% CI, 1%-66%) more likely to die in hospital. This difference was most pronounced for the highest risk patients, who also had the largest cost differential. The mortality rate advantage for faculty service was maintained for at least six months after discharge, but by nine months there was no difference. More recently, Zimmerman et al4 prospectively surveyed the resource use and outcomes of 15 297 intensive care patients in 35 teaching and non-teaching hospitals in the United States. Patients in teaching hospital intensive care units had more severe illnesses, but these units had a greater staff-patient ratio. Service provision in the teaching hospital intensive care units also came at an extra cost, which was related to an increased use of diagnostic testing and invasive procedures. However, the extra cost was associated with a significantly better risk-adjusted outcome in hospitals that were members of the Council for Teaching Hospitals (odds ratio, 1.21; 95% CI, 1.06-1.38). Obviously, there are differences between these US service provision models and those in Australia, but no similar appropriately controlled studies are available in Australia. What these studies show is that a service associated with academic activities may have an advantage for patient outcomes, but this comes at an extra cost. It is interesting that the extra cost should be so close to the 10%-20% described anecdotally and in various studies5 as the extra cost of teaching hospitals (compared with non-teaching hospitals) in Australia. No one denies that quality of care requires adequate funding. Nor do most people believe that efficiency and cost-effective use of healthcare funding should be ignored. However, it is increasingly recognised within the medical profession, and by external monitoring bodies such as the Victorian State Auditor General,6 that the simultaneous introduction of major budget cuts and casemix funding has had a negative impact on the quality of hospital care. This decrease in quality of care was thought to be related to the budget cuts, with the added pressures on clinical staff6 probably affecting their teaching and research activities.7 Rewarding patient care outcomes The basic rationale for casemix funding of patient services is that it is output based. Teaching and research also need to be recognised as outputs. If they do not receive adequate, appropriate and identifiable funding (over and above the costs of patient care), the marketplace will dictate that staff, facilities and other infrastructure support associated with teaching and research will become eroded so as to preserve the funding of the "core" clinical services. Many clinical academics believe that this is already happening.7 The concept of rewarding patient care outcomes rather than patient care services has been raised in other forums,8 despite difficulties determining the methods by which this could occur. It has not been raised with regard to teaching and research. Perhaps now is the time to promote outcome-based funding of teaching and research so that they become more than just of theoretical value in the Australian healthcare system. Acknowledgements I would like to thank Oon Ying, Deniza Mazevska, Art Huston, Susan Mirls, Danni Caminiti, Ric Marshall, Jim Pearse, Vicki Rundle, and Elizabeth Rohwedder for providing details of their State or Territory teaching and research formulas. References Commonwealth Department of Science, Industry and Tourism. Table of international research and development performance. In: Australian science and technology at a glance. Canberra: AGPS, 1997. Clinton W. Catalyzing scientific progress: special address from the President. Science 1998; 279: 1111. Garber AM, Fuchs VR, Silverman JF. Case mix, costs and outcomes; differences between faculty and community services in a university hospital. N Engl J Med 1984; 310: 1231-1237. Zimmerman JE, Shortell SM, Knaus WA, et al. Value and cost of teaching hospitals: a prospective, multicenter, inception cohort study. Crit Care Med 1993; 21: 1432-1442. New South Wales Department of Health. The costs of teaching hospitals: a review of the literature. Sydney: NSW Department of Health, 1993. Victorian Auditor General. Acute health services under casemix -- a case of mixed priorities. Melbourne: Victorian Auditor General, 1998. (Special Report No. 56.) Phillips PA, Kennedy JT, Segal GR, et al. Perspectives on casemix-based funding in Victoria. Med J Aust 1995; 162: 655-657. Braithwaite J, Hindle D, Phelan PD, Hanson R. Casemix funding in Australia. Med J Aust 1998; 168: 558-562. Authors' details Flinders University of South Australia, and Divisions of Medicine, Flinders Medical Centre and Repatriation General Hospital, Adelaide, SA. Paddy A Phillips, DPhil, FRACP, Professor and Head of Medicine. Reprints will not be available from the author. Correspondence: Professor P A Phillips, Professor and Head of Medicine, Flinders University of South Australia, Bedford Park, SA 5042. E-mail: paddy.phillipsATflinders.edu.au

If you have any clinical casemix queries, contact the Australian Casemix Clinical Committee (ACCC), your State or Territory casemix clinical committee or your own professional body or College casemix committee. Australia Australian Clinical Casemix Committee Professor Paddy Phillips Chair, Professor and Head of Medicine Flinders University of South Australia, and Divisions of Medicine, Flinders Medical Centre and Repatriation General Hospital, Adelaide, SA Ph: (08) 8204 4039 Fax: (08) 8204 5268 Ms Naarilla Hirsch Executive Officer PO Box 852, Woden, ACT 2606 Ph: (02) 6289 8499 Fax: (02) 6289 7630 Australian Capital Territory Casemix Steering Committee Mr David Butt Chair Mr Sebastian Rosenberg Secretariat ACT Department of Health and Family Services PO Box 825, Canberra City, ACT 2601 Ph: (02) 6205 0842 Fax: (02) 6205 1373 New South Wales NSW Casemix Clinical Committee Dr Ralph Hanson Chair, Division of Information Services New Children's Hospital Cnr Hawkesbury Road and Hainsworth Street, Westmead, NSW 2145 Ph: (02) 9845 3482 Fax: (02) 9845 3632 Casemix Policy Advisory Committee Mr Jim Pearse Chair, Structural and Funding Policy Branch Level 9, NSW Health Department Locked Bag 961, North Sydney, NSW 2059 Ph: (02) 9391 9613 Fax: (02) 9391 9615 Northern Territory Territory Health Services Casemix Clinical Resource Management Project Steering Committee Ms Carol Beaver Chair, Territory Health Services 4th Floor Health House, Mitchell Street, Darwin, NT 0801 Ph: (08) 8999 2400 Fax: (08) 8922 8995 Queensland Casemix Steering Committee Dr Glen Cuffe Chair PO Box 48, Brisbane, QLD 4001 Ph: (07) 3225 3261 Fax: (07) 3234 0987 South Australia Clinical Advisory Committee Dr Chris Pearson Chair Ms Sheryn Reid CAC Executive Officer 11-13 Hindmarsh Square, Adelaide, SA 5000 PO Box 65, Rundle Mall, SA 5000 Ph: (08) 8226 6289 Ph: (08) 8226 6116(Executive Officer) Fax: (08) 8226 0793 Tasmania Tasmanian Casemix Clinical Committee Dr Maarten Kamp Chair, Acting Director of Medical Services Launceston General Hospital Charles Street, Launceston, TAS 7250 Ph: (03) 6332 7008 Fax: (03) 6332 7825 Casemix Steering Committee Dr Jon Mulligan Chair, Director of Hospital and Ambulance Service GPO Box 125B, Hobart, TAS 7001 Ph: (03) 6233 2106 Victoria Victorian Casemix Advisory Committee Associate Professor John Wilson Chair Ms Penny Sharwood Executive Officer Acute Health Division, GPO Box 4057, Melbourne, VIC 3001 Ph: (03) 9616 7221 Fax: (03) 9616 7764 Clinical Casemix Subcommittee Dr John de Campo Acting Chair Women and Children's Health Care Network, 132 Grattan Street, Carlton, VIC 3053 Western Australia At present there is no formal Casemix committee. Casemix issues are handled by: Ms Elizabeth Rohwedder Operations Division, Health Department of Western Australia PO Box 8172, Perth Business Centre, Perth, WA 6849 Ph: (08) 9222 4195 Fax: (08) 9222 4067

Restructuring hospital services We must vigorously evaluate the effects of new ways of delivering healthcare MJA 1998; 169: 239 A new drug cannot be introduced into the Australian healthcare system without exhaustive scientific trials, but we usually introduce new ways of delivering health services with little or no scientific evaluation. We rationalise, change and formulate new systems, often based on economic and political imperatives, and yet rarely evaluate their impact on patients. Significant morbidity and mortality may be associated with new models of healthcare delivery. If healthcare system changes were submitted to the same scrutiny as new drug evaluations, they would probably not even be allowed to move from the animal to the human experimentation stage. In this issue of the Journal, Caplan and colleagues1 (page 247) report the impact of a new system for managing elective surgery. Two groups of patients undergoing elective surgery were compared, one before and the other after a re-engineered system of coordinated care was introduced. The changes included preadmission assessment, improved patient education, admission to hospital on the day of surgery and postacute care after discharge.2Most patients, both day-surgery and longer-stay patients, were admitted on the day of operation, thus eliminating the need for an extra night in hospital for investigations and assessment. The new system resulted in a shorter length of stay, reduced risk of wound infection and a higher level of patient satisfaction. The results of this study, which is an Australian first, are important for several reasons. The stereotypical image of healthcare sees managers as intent on saving money with no concern for quality of care, which contrasts with clinicians, who are seen as guardians of quality of care with no concern for cost. The study of Caplan et al demonstrates that the goals of health managers and clinicians can coincide. The patients' shorter stay freed up scarce hospital beds without compromising care, the patients were in favour of the shorter hospital stay, and wound infection rates were lower. Perhaps there is a potential for implementing innovative healthcare delivery systems which are both more efficient and provide equal or even improved quality of care. We will not know until we begin to vigorously evaluate the effects of new ways of organising healthcare delivery. It is regrettable that the present health research agenda in Australia does not extend to evaluation of the performance of healthcare systems. Clinical and biological research seems to be much more highly valued. National research bodies have traditionally funded scientists with track records in more conventional and reductionist research (usually in a single specialised area) rather than in broad system evaluation. Health system research may involve moving out of one's specialty, department or laboratory. The re-engineered system described by Caplan et al1 involved radically reorganising the role of anaesthetists and surgeons, and enlisting support and cooperation from many other hospital departments. The impact of the new system was then comprehensively evaluated, which is a major achievement in itself. Randomised controlled trials involving a drug or single intervention are relatively straightforward. Evaluating a system presents greater challenges. Wide-ranging research expertise covering epidemiology, social sciences and health economics is required. Clinicians are an essential part of the research team. They are often driving the change and, as with a new drug or intervention, they need to know how the changes will affect their patients. It is important to use new or more relevant research methods that serve the scientific question,3-5 rather than to restrict the scope of the question to fit more conventional research tools. Another challenge is having research which crosses many boundaries recognised by peer reviewers with specialised expertise. Acceptance of research by scientific journals is often determined more by the small size of the P value than by the relevance, importance or originality of the research. Health system research usually requires evaluations of many issues from many perspectives by many methods, including qualitative and quantitative, with investigators from different backgrounds working together to produce an integrated evaluation.5 We must be sceptical about health system changes which concentrate only on increased efficiency and cost savings. Introducing re-engineered health systems may have important implications for patient care. For example, in the study of Caplan et al there was no provision for evaluating the effect of early discharge on carers and patients. Future studies should also address these issues. Evaluating better and more efficient ways of delivering healthcare is just as important as developing and evaluating increasingly costly drugs and procedures. Ken M Hillman Professor; and Director, The Simpson Centre for Health Service Innovation Liverpool Hospital, Sydney, NSW Caplan G, Brown A, Crowe PJ, et al. Re-engineering the elective surgical service of a tertiary hospital: a historical controlled trial. Med J Aust 1998; 169: 247-256. Kerridge R, Lee A, Latchford E, et al. The perioperative system: a new approach to managing elective surgery. Anaesth Intens Care 1995; 23: 591-596. Wyatt J, Spiegelhalter D. Evaluating medical expert systems: what to test and how? Med Info 1990; 15: 205-217. Langley G, Nolan K, Nolan T. The foundation of improvement. Quality Progress 1994; (June): 81-86. Heathfield H, Pitty D, Hanka R. Evaluating information technology in health care: barriers and challenges. BMJ 1998; 316: 1959-1961. Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Ken M Hillman

Re-engineering the elective surgical service of a tertiary hospital: a historical controlled trial Gideon A Caplan, Ann Brown, Philip J Crowe, Su-Jen Yap and Shaune Noble MJA 1998; 169: 247-251 For editorial comment, see Hillman Abstract - Introduction - Methods - Patients - Outcome measures - Control group--existing system - Postintervention group--the perioperative system - Operative complications - Statistical analysis - Results - Outcomes - Complications - Patient satisfaction - Discussion - Acknowledgements - References - Authors' details - Figure 1 - Figure 2 - - - ©MJA1998 Abstract Objective: To study the clinical effects of re-engineering the processes associated with elective surgery. Design: A prospective, historical controlled trial. Control patients were enrolled from March 1995 to January 1996, and postintervention patients from February 1996 to October 1996. Setting: A major teaching, tertiary care hospital (Prince of Wales Hospital, Sydney). Patients: 224 patients (123 before and 101 after the intervention) undergoing elective herniorrhaphy or laparoscopic cholecystectomy who lived in the local area. Intervention: Introduction of a re-engineered surgical service consisting of preadmission assessment and education, admission on day of surgery, and postacute care after discharge. There were no changes to the operative methods or infection control procedures. Main outcome measures: Length of stay, operative complications, pain scores and patient satisfaction. Results: The risk of a patient suffering one or more complications was reduced in the postintervention group (postintervention v. control patients: 25.7% v. 38.2%; relative risk [RR], 0.66; 95% confidence interval [CI], 0.44-0.98; P = 0.035) because of a reduced risk of wound infections (5.0% v. 16.3%; RR, 0.30; 95% CI, 0.12-0.78; P = 0.0075). Other complications (perioperative or postoperative) and pain scores were unchanged. Patients treated by the re-engineered service had a significantly shorter length of stay, reported a higher level of satisfaction with the preoperative and postdischarge care, and were more likely to say that they would have the same treatment again (92.9% v 82.6%; P = 0.037). Conclusions: Re-engineering surgical services, with an associated reduction in length of stay, does not lead to a deterioration in care and may decrease postoperative complications and increase patient satisfaction. MJA 1998; 169: 247-251 Introduction Financial pressures from insurance companies1 and governments2 are driving changes in the healthcare systems of many countries. One of the most visible changes is shorter hospital stay, especially for elective surgery.3 Organisational changes include preadmission clinics, enhanced patient education, increased use of day surgery, improved discharge planning and postacute care at home; and clinical changes include less invasive surgical techniques and improved anaesthetic drugs.4 The introduction of a package of these organisational changes amounts to a re-engineering of elective surgery.5Many of these changes have been introduced with little scientific evaluation of their effect on patients, and perceptions of detrimental effects on patient care can make such changes unpopular.1,2 Studies of healthcare changes so far6-10 have focused on changes in surgical procedures and have been unable to identify any clinical effects of initiatives, such as preadmission clinics, patient education, reduction in length of stay, and postacute care. Moreover, in these studies, control patients underwent different procedures,6,7 significant results were not obtained,8,9 or there were worse outcomes in the postintervention group.10 We studied the effects of re-engineering our elective surgical service using a prospective, historical, controlled trial. Our re-engineered service comprised a perioperative unit, preadmission anaesthetic assessment based on self-reported questionnaires, admission on the day of surgery, enhanced patient education, use of clinical pathways, and postacute care (Box 1). 1: A re-engineered surgical service Admission coordinated by Perioperative Unit, which sends out, receives and reviews patients' self-reported health questionnaires, and arranges preadmission assessment, if indicated. Patients admitted to Perioperative Unit on day of surgery. After surgery, day-only patients return to Perioperative Unit, others to the ward. Patient information specific for each operation distributed by the surgeon. Nurses reinforce patients' knowledge. Clinical pathways followed. These provide a diagnosis-specific plan for the episode of care and the role of each member of the multidisciplinary team. Postacute care continues at home after discharge, if required. Methods Patients To minimise variation and ensure adequate patient numbers, we studied prospectively a cohort of patients having one of two general surgical procedures (inguinal herniorrhaphy and laparoscopic cholecystectomy). Patients in the control group were treated before and compared with patients treated after the new elective surgical service was commissioned. Patients who lived outside the local area or were admitted as an emergency were excluded. All patients gave informed consent, and the study was approved by the South Eastern Sydney Area Health Service (Eastern Branch) Ethics Committee. Outcome measures Information collected for comparing the control and postintervention groups included length of hospital stay, level of pain (assessed by a linear analogue pain scale), complications of the operation, and patient satisfaction (assessed by a self-reported questionnaire). Control group -- existing system Patients booked for surgery from the surgeon's rooms or surgical outpatients clinic; Patient information and education provided according to individual surgeon's protocols; Patients admitted to the ward on the day before the procedure, clerked by the surgical intern and assessed by the anaesthetist; Postsurgical care given in the surgical ward; and Discharge plans made by ward staff, subject to individual surgeon's decision. A total of 123 control patients were enrolled prospectively from March 1995. (We had planned to enrol 100, but a delay in commissioning the new system extended the enrolment period.) Eligible patients booked for surgery each day were visited by the study nurse on admission to the ward. After surgery, the nurse obtained patient data, including a pain score on Day 1 after the operation, and arranged to contact the patient by telephone on Day 7. Before discharge, patients were given an anonymous, self-reported patient satisfaction survey, based on the Australian model.11 They were asked to rate their overall treatment, the information provided, preoperative treatment, the operation and care after discharge from hospital on a five-point Likert scale from "very satisfactory" to "very unsatisfactory". They were also asked whether they would have the procedure the same way again, and were given a further copy of the pain scale, and asked to complete both documents on Day 7 after the operation and return them in the prepaid envelope provided. The telephone call on Day 7 reminded patients to return their satisfaction surveys and pain scores. Postintervention group -- the perioperative system A more coordinated system was developed, based on the perioperative system (Box 1).12 The surgeons, nursing staff, operating theatre location and organisation and infection control practices did not change. Although surgical registrars changed surgical units during the study period, they worked with other surgeons whose patients were also studied. The Perioperative Unit included a preadmission anaesthetic clinic where patient health questionnaires were completed, and patients with significant comorbidity were fully assessed. Based on the information provided by the questionnaires, 70% of elective surgery patients were seen by an anaesthetist for the first time on the day of surgery, 15% of patients were seen as outpatients before the day of surgery because of anaesthetist preference, and the remaining 15% required further anaesthetic consultation and one (usually) additional outpatient visit for review. All patients, both day-only and those transferring to the surgical ward after the operation, went to theatre from a day-surgery ward within the Perioperative Unit. Patient care was guided by a clinical pathway developed by the multidisciplinary team to drive and support the system. The role of every member of the multidisciplinary team is specified for each day, with alternative plans available if a patient's condition changes. Improved patient educational material was developed for distribution by the surgeons, and patients' comprehension of the material was reviewed by the study nurse at the preadmission anaesthetic clinic or on the day of surgery. If doubts existed about the safety and suitability of a patient's accommodation for postsurgical recovery, the study nurse made a preadmission home visit. After surgery, study patients were transferred to the surgical ward and an existing postacute care service arranged early discharge with follow-up at home. The new system was introduced at the end of January 1996 and enrolment of the 101 patients in the postintervention group commenced in February 1996. A pain scale was completed on Day 1 after operation. The timing of discharge was entirely at the surgeons' discretion, and the study nurse arranged to visit the patient at home within 24 hours of hospital discharge to assess pain control, wound care needs and general postsurgical progress. This visit generally lasted less than half an hour, and occasional further visits were arranged, as clinically indicated. A contact phone number was provided for use in the event of any complications or concerns. Patients in the postintervention group were also asked to complete the self-reported patient satisfaction survey. Operative complications Data on all complications were collected prospectively and crosschecked with the patients' clinical records. The criteria for wound infections were those of the Centers for Disease Control and Prevention (CDC),13 notably that the infection involves only the skin and subcutaneous tissue of the incision, and at least one of the following: purulent drainage from the superficial incision; organisms isolated from aseptically obtained culture of fluid or tissue from the superficial incision; at least one of the following signs or symptoms of infection -- pain or tenderness; localised swelling; redness or heat; and superficial incision is deliberately opened by the surgeon, unless incision is culture negative; diagnosis of superficial incisional surgical site infection by the surgeon or attending physician. Statistical analysis Statistical calculations were performed using SPSS for Windows.14 Normally distributed continuous variables were compared by t tests, dichotomous variables by χ2 tests. Ordinal variables were compared with the Mann-Whitney U test. Logistic regression was used to obtain a multivariate analysis of factors predictive of wound infection. Results From March 1995 to October 1996, 224 patients were enrolled in the study. Baseline characteristics of the two groups were not statistically significantly different (Box 2). 2: Baseline characteristics of elective surgery patients Postintervention group* (n = 101) Control group* (n = 123) Laparoscopic cholecystectomy 57 (56.4%) 65 (52.8%) Herniorrhaphy 44 (43.6%) 58 (47.2%) Mean time in operating theatre (min, SEM) 100.3 (4.2) 102.1 (3.5) Female : male ratio 46 : 55 54 : 69 Mean age (range) (years) 54.4 (21-85) 54.0 (18-90) Smoker 27 (26.7%) 25 (20.3%) Ischaemic heart disease 8 (7.9%) 9 (7.3%) Requires an interpreter 8 (7.9%) 4 (3.3%) Lives alone 19 (18.8%) 23 (18.7%) Lives upstairs (no lift) 37 (36.6%) 39 (31.7%) *Differences were not statistically significant Outcomes The postintervention group had a significantly shorter length of stay, but there was no difference in pain scores between the two groups (Box 3). 3: Outcomes in the postintervention and control groups Outcome Postintervention group Control group Mean length of stay in days (range) 2.2 (1-8) 3.2 (1-9)* For herniorrhaphy 1.8 (1-4) 3.1 (2-7)þ For laparoscopic cholecystectomy 2.5 (1-8) 3.3 (1-9)§ Postoperative pain score mean (SEM) Day 1 21.7 (1.2) 22.6 (0.9) Day 7 9.4 (1.1) 8.4 (1.0) Number of deaths 0 1 (0.8%) Number readmitted 5 (5.0%) 4 (3.3%) Postintervention v. control group: *P < 0.001; þ P < 0.001; § P = 0.020. Complications The postintervention group had a lower risk of suffering any complication (complications in postintervention v. control patients -- 26 [25.7%] v. 48 [38.2%]; relative risk [RR], 0.66; 95% confidence interval [CI], 0.44-0.98; P = 0.035) because of a lower risk of wound infection (Figure 1). There was no significant difference between postintervention and control patients in intraoperative complications or other postoperative complications (Figure 1). Figure 1: Proportion of patients with each type of complication in the postintervention and control groups, including relative risk (RR) and 95% confidence interval (CI) for comparison between the groups. Intraoperative complications were bile/stone spillage (4 v. 5), conversion to open cholecystectomy (4 v. 1) and, in the control group, one each of cystic duct damaged, cystic artery damaged, unsuccessful exploration of common bile duct, local anaesthetic converted to general anaesthetic, penis injured by towel clips, and aspiration into lungs. Postoperative complications are listed in Box 4. Eight patients suffered two complications and one three complications, so that the total for all types of complications exceeds the number of patients who suffered a complication. 4: Postoperative complications Complication Postintervention group (n = 22) Control group (n = 42) Wound infection 5 20 Cerebrovascular accident, died 0 1 ERCP after operation 2 4 Haematoma/haemorrhage/ooze 4 1 Shoulder tip pain 1 2 Scrotal pain or swelling 2 2 Nausea and vomiting 2 0 Constipation (> 4 days) 2 2 Urinary retention requiring indwelling catheter 1 1 Unstable INR after operation, delayed discharge 0 2 Rash (due to antibiotics) 0 1 Fall Day 1 after operation, low blood pressure 0 1 Delirium 0 1 Difficulty mobilising 0 1 Respiratory infection 3 3 ERCP = endoscopic retrograde cholangiopancreatography. INR = International Normalised Ratio. Multivariate analysis using logistic regression found that the only variables significantly predictive of having a wound infection were being in the control group, length of stay (Figure 2) and the patient having a carer (a proxy for functional dependence). Figure 2: Proportion of patients with wound infection in the postintervention and control groups, by length of stay. Patient satisfaction Completed responses to the satisfaction survey were received from 85 postintervention patients (84.2%) and 89 controls (72.4%). Analysis showed that patients in the postintervention group were more satisfied with both the preoperative (P = 0.0094) and the postdischarge treatment (P = 0.0001), as well as the operation, and were also more likely to want to have the procedure done the same way next time, if required (postintervention v. control: 92.9% v 82.6%; difference, 10.3%; 95% CI, 0.8%-19.8%; P = 0.037). There was no difference between the groups in their ratings of the overall treatment or of the information supplied preoperatively. Although the difference in response rates between the control and postintervention groups was significantly different (P < 0.05), there were no significant differences between respondents and non-respondents in terms of age, sex, type of operation, pain scores, complications, comorbidity, living arrangements, occupational or smoking status. Discussion Patients having elective surgery after a re-engineered system of coordinated care for elective surgery was introduced had shorter hospital stays, a lower risk of wound infection and reported higher levels of satisfaction. Previous studies, rather than focusing on the outcomes of the process, as we did, have examined the impact of elements of our re-engineered service (particularly preadmission clinics) on the efficiency of the elective surgical process.15 Our study found a higher rate of wound infection than is generally reported in surgical series, although the rate was within the range of prevalence of nosocomial infections (3%-21%) in a World Health Organization survey,16 and comparable with rates in an Australian survey which also actively followed up patients for wound infections after discharge.17 Surveys may also identify widely varying wound infection rates if different definitions of infections are used.18 Definitions of wound infections which require the presence of pus19 tend to underestimate the true prevalence, given that most doctors institute antibiotic therapy for earlier signs of infection. With decreasing lengths of hospital stay, most wound infections occur after discharge from hospital, where they are often diagnosed and treated by general practitioners (GP) and not surgeons.17 Thus, it is not surprising for series of laparoscopic cholecystectomies to report infection rates which vary from 1% to 17%.6,17 The 70% reduction in the risk of surgical nosocomial infections which we found is relatively large. We used the CDC definition of infection, and found that most infections were diagnosed and treated by GPs before the wounds developed purulent drainage and without waiting for a positive culture result. The study nurses collected the data in the same manner (ie, prospectively during planned follow-up of patients), but the diagnosis of wound infection was left to the treating GP or surgeon. We tested the observation that there is a dose-effect relationship between iatrogenic complications and length of stay in hospital. A relationship between length of stay and risk of nosocomial infection has been observed in a number of studies.18,19 Cruse and foord retrospectively also found that risk of infection increases with length of preoperative stay,19 but previous studies have not prospectively examined the possibility that decreasing the length of stay will result in lower wound infection rates. Our data demonstrate that a reduction in hospital stay as part of a re-engineered surgical service can decrease the wound infection risk. From the near-parallel slope of the lines in Figure 2, it would appear that the difference between the two groups is due to some factor that occurs early in the admission, most likely through decreasing exposure to hospital microbial flora on the night before surgery, resulting in a shift of the curve to the right. Our study design was a prospective, sequential, before-and-after comparison. Randomised controlled trials are generally considered to be the reference standard for evaluating new treatments. However, when the intervention is a coordinated system of care involving a "culture change" in an organisation, there may be a "Hawthorne effect" -- that is, behaviour changes due to an awareness of being in a study -- and leakage of elements of the "culture change" into the control group, thus reducing the power of a randomised controlled trial.20 Our sequential enrolment of patients more closely mimics the situation in hospital when a surgical service is re-engineered, and makes the study results more relevant. Our study had the active collaboration of the hospital administration, and hospital policy was revised at the start of the treatment phase to require all elective surgery patients to be admitted through the Perioperative Unit. The surgeons and operating theatre location and organisation were unchanged, although junior medical staff were rotated. There was no change in antibiotic prophylaxis or hospital infection control policies, thereby minimising any differences in enrolment patterns and other factors between the two arms of the trial. Our patient satisfaction survey suggested that patients were more satisfied with a shorter length of stay combined with the appropriate support after hospital discharge. A previous study in which surgical patients were not similarly supported after early hospital discharge found patients to be less satisfied with the treatment.21 We have demonstrated that changes in the organisation of elective surgery can produce improved health outcomes and patient satisfaction. This does not mean that any reduction in length of stay results in improved outcomes, but that reduced in-hospital support may be replaced with carefully planned and supervised preadmission assessment, education and postdischarge care, without detriment to the quality of patient care. Acknowledgements We would like to acknowledge the invaluable assistance of the staff of Post Acute Care Services, the Perioperative Unit, and the Departments of Surgery and Anaesthetics, without whose help this study would not have been possible. This study was supported by a grant from the Commonwealth Department of Health and Family Services Hospital Access Program. References Sawyer RB. General surgeons in the world of gatekeepers. Am J Surg 1995; 170: 528-531. Maxwell RJ. Why rationing is on the agenda. Br Med Bull 1995; 51: 761-768. Hoare J. Medicine for managers: day surgery. Health Services Management 1992; June: 12-14. Maddern GJ. The changing pattern of surgery [editorial]. Br J Surg 1996; 83: 145-146. Speer TL. With an eye to the future. Hospitals and Health Networks 1996; 70: 43. Barkun JS, Barkun AN, Sampalis JS, et al. Randomised controlled trial of laparoscopic versus mini cholecystectomy. Lancet 1992; 340: 1116-1119. Stoker ME, Vose J, O'Mara P, Maini BS. Laparoscopic cholecystectomy: a clinical and financial analysis of 280 operations. Arch Surg 1992; 127: 589-595. Adler MW, Waller JJ, Creese A, Thorne SC. Randomised controlled trial of early discharge for inguinal hernia and varicose veins. J Epidemiol Community Health 1978; 32: 136-142. Ruckley CV, Cuthbertson C, Fenwick N, et al. Day care after operations for hernia or varicose veins: a controlled trial. Br J Surg 1978; 65: 456-459. Russell IT, Devlin HB, Fell M, et al. Day case surgery for hernias and haemorrhoids: a clinical, social and economic evaluation. Lancet 1977; 1: 844-847. Hill S, Draper M. The role of patient satisfaction surveys in a national approach to hospital quality management. Canberra: AGPS, 1995. Kerridge R, Lee A, Latchford E, et al. The perioperative system: a new approach to managing elective surgery. Anaesth Intens Care 1995; 23: 591-596. Centers for Disease Control and Prevention, US Department of Health and Human Services. National Nosocomial Infections Surveillance Manual. Atlanta, Ga: USDHHS, May 1994. SPSS for Windows [computer program], version 6.0. Chicago: SPSS Inc, 1993. Kahan E, Carel RS, Hart J. Comparison of two pre-admission testing methods for elective surgery patients. Isr J Med Sci 1991; 27: 141-144. Ayliffe GAJ. Surveys of nosocomial infections. Med J Aust 1988; 149: 571-572. Hardy KJ, Miller H, Fletcher DR, et al. An evaluation of laparoscopic versus open cholecystectomy. Med J Aust 1994; 160: 58-62. Freeman J, McGowan JE. Differential risks of nosocomial infection. Am J Med 1981; 70: 915-918. Cruse PJE, foord R. The epidemiology of wound infection: a 10-year prospective study of 62,939 wounds. Surg Clin North Am 1980; 60: 27-40. Bouchet C, Guillemin F, Briancon S. Nonspecific effects in longitudinal studies: impact on quality of life measures. J Clin Epidemiol 1996; 49: 15-20. Michaels JA, Reece-Smith H, Faber RG. Case control study of patient satisfaction with day-case and inpatient inguinal hernia repair. J R Coll Surg Edinb 1992; 37: 99-100. (Received 5 Jun 1997, accepted 18 May 1998) Authors' details Prince of Wales Hospital, Sydney, NSW. Gideon A Caplan, MB BS, FRACP, Director, Post Acute Care Services. Ann Brown, RN, Nurse Manager, Post Acute Care Services. Philip J Crowe, MB BS, FRACS, Surgeon, Department of Surgery. Su-Jen Yap, MB BS, FANZCA, Director, Perioperative Unit, Prince of Wales Hospital. South Eastern Sydney Area Health Service, Sydney, NSW. Shaune Noble, BHA, MPH, Health Services Development Unit. Reprints: Dr GA Caplan, Director, Post Acute Care Services, Prince of Wales Hospital, Randwick, NSW 2031. E-mail: G. CaplanATunsw.edu.au - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Gideon A Caplan · Ann Brown · Philip J Crowe · Su-Jen Yap · Shaune Noble

The stress of metropolitan general practice Peter L Schattner and Greg J Coman MJA 1998; 169: 133-137 For editorial comment, see Douglas & Sibthorpe Abstract - Introduction - Methods - Results - Sex differences - Discussion - Acknowledgements - References - Authors' details - - ©MJA1998 Abstract Objective: To identify the work-related stressors of Australian metropolitan general practitioners (GPs). Design and setting: A descriptive postal survey of metropolitan GPs from all States and Territories selected at random from the Health Insurance Commission database. Participants: 296 of 464 GPs (64%) surveyed in June 1996; 67% were male; 87% worked full-time (more than 6 sessions per week). Main outcome measures: Frequency and severity of work stresssors in general practice; overall feelings of stress at work in the past 12 months; effects of the stressors on work satisfaction; contribution of work stress to overall life stress; responses to the 12-item General Health Questionnaire (GHQ) as potential correlates of occupational stress. Results: "Time pressure to see patients" was the most frequently reported stressor. Threat of litigation was perceived as the most severe stressor. Of the top 10 severe stressors, seven were also in the top 10 for stressor frequency. Work was the major stressor in GPs' lives. The GHQ scores did not correlate significantly with major stress outcome measures, but 12.8% of GPs had scores indicative of severe psychiatric disturbance. Fifty per cent of respondents had considered leaving their current workplace and 53% had considered abandoning general practice because of occupational stress. GPs working 6 or more sessions per week were more likely to be moderately or severely stressed than those working part-time (P < 0.02, Fisher's exact test). Those who had considered leaving their current workplace or careers were also more likely to be moderately or severely stressed (P < 0.0001, Fisher's exact test). Conclusions: The most frequent and relatively severe stressful events in general practice involved time pressures. There are implications for government, which, through remuneration policies, might influence GPs to work at a rate beyond their capacity to cope. Strategies are required to manage or prevent stress in metropolitan GPs. Introduction Stress has been defined as a response to challenging events.1 It is usually thought of as "distress" or an inability to cope with an external factor (the "stressor"). In the workplace it is generally referred to as occupational stress. Australian and international studies suggest that general practice is a stressful occupation.2-7 The extent to which GPs feel stressed by various aspects of their occupation may affect the quality of patient care and may also affect practitioners' health. Health problems experienced by GPs include alcohol and drug abuse,8-10 marital disruption and divorce,3,11,12 anxiety,3,13 burnout,14 depression,15 as well as suicide and attempted suicide.16,17 The specific characteristics that make general practice so stressful are largely unknown, although anecdotal evidence would suggest that time and financial issues are major stress factors for Australian GPs. In our study we aimed to identify the sources, frequency and severity of occupational stress experienced by metropolitan GPs; the importance of occupational stress compared with other life stressors; the effects of the work stressors on GPs' job satisfaction; and the possible effects of these stressors on GPs' psychological health. Rural GPs were not included, as factors such as isolation and difficulty in obtaining locum relief suggest this group should be studied separately.18 Methods General practitioner recruitment and survey distribution A list of 500 potential survey participants was obtained from the Health Insurance Commission database of the Commonwealth Department of Human Services and Health (now the Department of Health and Family Services). Potential participants were randomly selected from the population of GPs in all States and Territories who had capital city practices only and more than 1500 consultations annually (the number generally accepted by the General Practice Evaluation Programme as the definition of "active" GPs). The Department advised that potential participants had not recently been surveyed through this database. Questionnaires were mailed to all 500 GPs in June 1996. Non-respondents to the first mailout were sent a second questionnaire in July 1996, and non-respondents to this prompter were telephoned to request their participation in August 1996. Survey instrument We used a four-part questionnaire to collect data on:(1) GPs' demographic and practice information. (2) The frequency and severity of potentially stressful events in general practice, using a 28-item list developed from an extensive literature review which included validated stress-screening instruments,4,5,6,18 and input from a Melbourne-based GP focus group. A four-point Likert-like scale was used, with 3 representing "frequently, at least weekly"; 2, "occasionally, at least monthly"; 1, "rarely, a few times a year"; and 0, "does not occur". Another four-point Likert-like scale, with 3 representing "severe stress"; 2, "moderate stress"; 1, "mild stress"; and 0, "no stress", was used to assess stress severity for each item. (3) The effects of stressors on GPs' job satisfaction, including asking them to (a) indicate on a four-point scale (from 0 = none to 4 = severe) their overall work stress levels in the previous 12 months; (b) rank six aspects of general practice in order of contribution to work stress levels, from 1 for the greatest contribution to 6 for the least; (c) distinguish between stressors related to job content (ie, clinical duties) and job context (ie, environmental and organisational factors) (see Box 1); (d) rank six potential sources of life stress in order from 1 for the greatest source of stress to 6 for the least stressful. (4) The 12-item General Health Questionnaire (GHQ),19 used to determine the presence of psychiatric disturbance, anxiety or depression as potential correlates of occupational stress. GHQ items have four response options, which were scored 0, 0, 1 or 1. This provides a GHQ score range from 0 to 12. Using this method, scores of less than four represent negligible psychiatric disturbance, scores between four and eight suggest moderate disturbance, and scores greater than eight indicate severe psychiatric disturbance. Data entry and analysis Data were computer-coded and analysed using the Statistical Package for the Social Sciences for Windows.20 Analyses included cross-tabulations of stress outcome measures with the demographic data shown in Box 2. Non-parametric tests were used to test for significant differences at the P = 0.05 level. Potential work stressors were ranked in order of reported frequency and severity. Ethical approval Ethical approval was granted by the Monash University Standing Committee on Ethics in Research on Humans. Results Characteristics of respondents Of the 500 questionnaires mailed, 36 were returned unopened; 296 of the remaining 464 GPs participated (response rate, 64%). Box 2 shows their demographic characteristics, which are similar to the demographic profile of Australian metropolitan general practice.21 General practice stressors Frequency of general practice stressors The most frequent stressors were related to perceived lack of time. "Time pressure to see patients", "phone interruptions during consultations" and "too much work to do in a limited time" were ranked 1, 3 and 4, respectively, in frequency, with "paperwork" the second most frequent stressor (Box 3). Severity of general practice stressors The threat of litigation (actual involvement in litigation proceedings was not an item), although perceived as one of the most stressful events in general practice, was reported relatively infrequently. However, seven of the 10 most stressful events (Box 4) were also in the top 10 for frequency. The GPs appeared to experience a number of stressors which were perceived as mild to moderate, but which occurred frequently. The mean ratings for the three most severe stressors -- "threat of litigation", "too much work to do in a limited time" and "earning enough money in general practice" -- were between "mild" and "moderate". Effects of stress Overall work stress The Figure shows that most GPs (273/296; 92%) reported some feelings of stress, with 241 (81%) labelling it "mild" or "moderate" and 32 (10.8%) "severe". When asked about levels of stress in the past 12 months, 121 (41%) of GPs said they had increased, 118 (40%) said they had stayed the same, and 33 (11%) said they had decreased. Fifty per cent of GPs surveyed had considered leaving their current workplace, and 157 (53%) had considered abandoning general practice because of occupational stress. Factors associated with high overall work stress levels When the GPs' reported experience of work stress was cross-tabulated with the demographic variables reported in Box 2, the only significant association was that GPs working six or more sessions per week were more likely to be moderately or severely stressed than those working part-time (P < 0.02, Fisher's exact test). Those who had considered leaving their current workplace or abandoning their careers were also more likely to be moderately or severely stressed (P < 0.0001, Fisher's exact test). Six major causes of occupational stress Of the six most stressful aspects of general practice high workload was rated worst, followed, in descending order, by economic factors (income, running a business) and "medicopolitical" factors (involvement with professional associations, government pressures). Clinical factors and the effect of work on outside life were rated fourth and fifth, respectively, and the physical working environment was considered the dimension which contributed the least to the stresses of general practice (Box 5). These rankings were based on the means of rank scores; the first two items ranked significantly ahead of the other factors (P < 0.05). Sixty per cent of the GPs said that their experience of stress arose mainly from "job context" rather than from "job content". Comparisons with other life stresses Work was the major source of overall stress in GPs' lives, followed closely by financial concerns (Box 6). General Health Questionnaire data The 12-item GHQ was used to assess respondents' levels of psychiatric morbidity, especially depression and anxiety. The mean GHQ score was 3.01 (95% confidence interval, 2.66-3.35), suggesting that, on average, GPs experience low levels of psychiatric disturbance. However, almost a third (30.7%) of respondents recorded GHQ scores of 4 or more and 38 (12.8%) recorded scores of 8 or more, suggesting that many GPs are clinically depressed, anxious, or experiencing other psychiatric symptoms. The responses to three GHQ questions were of concern. These were Item 5 ("Have you recently felt constantly under strain?"), to which 7.1% responded "much more than usual"; Item 9 ("Have you recently been feeling unhappy and depressed?"), to which 5.1% responded "much more than usual"; and Item 11 ("Have you recently been thinking of yourself as a worthwhile person?"), to which 6.1% responded "not at all". Box 7 shows that, while significant, correlations between GHQ scores and the stress measures were not high. The highest correlation (0.53) was with GPs' overall perception of stress in the past 12 months. Sex differences There were small but statistically insignificant differences in the responses of men and women. Discussion Our study indicates that, while the worst stressors in general practice are perceived to be of only mild to moderate severity, many occur frequently. The study cannot determine whether there is a cumulative effect, in which a series of minor frustrations leads to a pervasive level of significant stress in GPs, but this may be an explanation as to why so many GPs have considered leaving their practices or abandoning general practice altogether. Apart from the threat of litigation, work overload issues, such as time pressure to see patients, phone interruptions and too much work to do in a limited time, were the most common stressors for GPs. Both GPs and their patients have been reported to be dissatisfied with the amount of time spent in consultations.4,7,22-25 Time pressure may be a reason for patients' reporting that GPs are not listening to what they are saying and not explaining things to them properly.26 Effects of time constraints on GPs may include irritability, frustration and, possibly, mistakes in diagnosis and treatment.4 Practice administration issues, which have not been traditionally taught to undergraduates, were rated as causing much more stress than issues of clinical competence. This may add to the pressure of high patient loads. The intrusion of work on family life was a significant stressor. Presumably, GPs would be less stressed if work did not impinge on family time or if they could see more of their family by working fewer hours. Although our list of potential sources of life stress was not exhaustive, we have not found a similar ranking attempt in the other stress studies reviewed. It would be interesting to see how this group of GPs compares with other occupational groups and the community at large in this regard. Concerns about remuneration and other financial concerns, such as the cost of practice overheads, were considered to be among the most frequent and severe stressors in this study (although they were not rated as highly as some might expect). This should be of interest to governments, which continue to emphasise cost-cutting in healthcare expenditure. It is of concern that almost a third of the respondents (91; 30.7%) had GHQ scores of 4 or more, suggesting moderate psychiatric disturbance, and that 38 (12.8%) scored 8 or more, suggesting severe disturbance. To some extent this is an independent finding; work stress cannot be blamed entirely for the presence of psychiatric disturbance in GPs, although it is likely to be a contributing factor. Our 64% response rate and the similarity of our sample's demographic profile to that of Australian metropolitan general practice21 suggest that the survey results are generalisable to urban GPs. It is possible that highly stressed GPs are under-represented because they were too stressed to comply with yet another demand on their time (the completion of a questionnaire). General practice may be no more or less stressful than many other "caring professions".4 However, the specific stressors highlighted in this study do suggest that government, healthcare policymakers, organisers of vocational training and GPs themselves should be aware of the high levels of stress experienced by doctors who choose this vocation, and steps should be taken to institute stress prevention and management. Acknowledgements Our thanks to the administrative staff at the Department of Community Medicine and General Practice at Monash University, as well as Dr Lynne Ham and Dr Chris Peterson for their expert advice on occupational stress, and Dr Con Tsalamandris for statistical analysis. This project was funded by a grant from the General Practice Evaluation Program of the Department of Human Services and Health. References Selye H. The stress of life. New York: McGraw Hill, 1976. Mawardi B. Satisfactions, dissatisfactions and causes of stress in medical practice. JAMA 1979; 241: 1483-1486. Roeske N. Stress and the physician. Psychiatr Ann 1981; 11: 245-258. Porter A, Howie J, Levinson A. Stress and the general practitioner. In: Payne R, Firth-Cozens J, editors. Stress in health professionals. Chichester: Wiley, 1987: 45-70. Makin P, Rout U, Cooper C. Job satisfaction and occupational stress among general practitioners -- a pilot study. J R Coll Gen Pract 1988; 38: 303-306. Sutherland V, Cooper C. Job stress, satisfaction and mental health among general practitioners before and after introduction of new contract. BMJ 1992; 304: 1545-1548. Sutherland V, Cooper C. Identifying distress among general practitioners: predictors of psychological ill health and job dissatisfaction. Soc Sci Med 1993; 37: 575-581. Ball J. Alcohol and drug use and related problems in the medical profession. Aust Drug Alcohol Rev 1986; 5: 29-32. Baldwin D, Hughes P, Conrad S, et al. Substance abuse among senior medical students. JAMA 1991; 265: 2074-2078. Serry N, Bloch S, Ball R, Anderson K. Drug and alcohol abuse by doctors. Med J Aust 1994; 160: 402-407. Bird H. The physician's marriage: joys and sorrows: life transition points. Facets 1979; Summer: 18-20. Miles J, Krell R, Lin T. The doctor's wife: mental illness and marital pattern. Int J Psychiatry Med 1975; 6: 481-487. Cramond W. Anxiety in medical practice: the doctor's own anxiety. Aust N Z J Psychiatry 1969; 3: 324-328. Lemkau J, Purdy R, Rafferty J, Rudisill J. Correlates of burnout among family practice residents. J Med Educ 1988; 63: 682-691. Smith M, Andrasik F, Quinn S. Stressors and psychological symptoms of family practice residents and spouses. J Med Educ 1988; 63: 397-405. Craig A, Pitts F. Suicide by physicians. Dis Nerv Syst 1968; 219: 763-772. Steppacher R, Mausner J. Suicide in male and female physicians. JAMA 1974; 228: 323-328. Dua J. Development of a scale to assess occupational stress in rural general practitioners. Int J Stress Manage 1996; 3: 117-128. Goldberg D, Williams P. Manual of the General Health Questionnaire. Windsor (UK): Nfer-Nelson, 1988. Statistical Package for the Social Sciences [computer program] release 6.0. SPSS, Chicago, Ill, USA, 1996. Commonwealth Department of Health and Human Services. General practice in Australia: 1996. Canberra: AGPS, 1996. Cartwright A, Anderson R. General practice revisited. London: Tavistock, 1981. Bates E. Doctors and their spouses speak: stress in medical practice. Sociol Health Illness 1982; 4: 25-39. Richardson IM, Howie J, Durno D, et al. A study of general practitioner consultations in North-East Scotland. J R Coll Gen Pract 1973; 23: 132-142. Brooks M, Stewart-Weeks M. Integrating consumer views about quality in general practice. Canberra: Consumers' Health Forum of Australia, 1996. Myerson S. Doctors' methods of dealing with "on going" stress in general practice. Med Sci Res 1991; 19: 267-269. (Received 7 Oct 1997, accepted 31 Mar 1998) Authors' details Department of Community Medicine and General Practice, Monash University, Melbourne, VIC Peter L Schattner, MMed BS, FRACGP, Director, Research Unit; Greg J Coman, GradDipAppPsych, MSc, Psychologist. Reprints will not be available from the authors. Correspondence: Dr P L Schattner, Department of Community Medicine and General Practice, Monash University, 867 Centre Road, East Bentleigh, Melbourne, VIC 3165. E-mail: peter.schattnerATmed.monash.edu.au - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Peter L Schattner · Greg J Coman

Fundamental reform of hours worked by junior doctors is required It has long been recognised that the rites of passage for junior doctors in public hospitals require extended hours of work with inadequate provision for rest and recovery. Not only are the junior doctors on a very demanding learning curve, but, at the same time, they are required to establish effective working relationships with patients, families and senior colleagues, and deal with the complexity of the modern hospital administration. Add to this a stressful workplace environment and, at times, the necessity to make critical decisions within a limited time frame and you have a situation no other professional group would be prepared to tolerate. Yet the research1 indicates that this is the situation most doctors face at the beginning of their careers. While Olson and Ambrogetti2 in this issue of the Journal present some criticisms of the methods of such research, there is considerable evidence to support the view that junior doctors' hours of work are, at times, excessive.3 The most recent Australian survey, undertaken as part of the current AMA Safe Hours Project, has produced further evidence to support this view.4 Why is this practice, which exerts a very heavy personal toll on the health and work performance of doctors, allowed to persist? No doubt there are respected members of the medical profession who argue that it is an essential component of the "toughening up" process. Clearly the hospital environment and the professional medical work ethic contribute to the excessive hours of work so ingrained in the hospital culture. The depth of this tradition was demonstrated recently in New York, where amendments to the Health Code5 were introduced in 1989 following the death of Libby Zion in a New York hospital. The circumstances of this unfortunate event are outlined by Nocera and Khursandi6 in this issue of the Journal. Libby's father, Sidney Zion, a newspaper columnist, was instrumental in launching a successful campaign restricting the hours of work of junior doctors working in hospital emergency departments. However, recent reports in the New York Times7 indicate there are still a large number of hospitals flouting this law. While legislative reform is one part of the solution, there is clearly a need to look at the attitudes which continue to support the practice. Until recently, little attention was given to the statutory responsibility of the employer to provide a safe system of work for doctors employed in hospitals.8 Currently, under occupational health and safety laws, there is increased emphasis on employers undertaking a hazard identification approach, followed by risk assessment and the application of risk controls. Applying this approach to the work regimen of junior doctors will present particular challenges to hospital administrators. An added consideration is the increasing recognition of the extent to which latent organisational failures may contribute by creating the circumstances leading to mishap.9 A hospital administration which fails to identify hazards and assess risks arising from extended hours of doctors' work could be in breach of a duty of care owed to doctors. Further, permitting a doctor to carry out duties while so fatigued that a patient's safety is endangered could be a breach of duty owed to the patient. The comments of the acting coroner in the recent inquest into the death of a New Zealand woman, the innocent party in a car crash, reinforce the importance of addressing the issue of fatigue.10 The patient survived the accident, but died following a mishap while in hospital. A significant issue for the coroner was the extent to which the fatigue of one of her doctors may have played a part in her demise. The coroner remarked that there was a growing level of concern, both nationally and internationally, over the hours of work of doctors in hospitals, and suggested that the medical professional bodies address the issue of extended periods of work. The hospital work practices of junior doctors appear to be common to many countries. Although the weekly hours worked by doctors in training are variable, it is reasonable to conclude that these routinely exceed 55 hours per week in many European countries.11 While the European Union originally excluded doctors in training from its 1993 Directive on Working Time,12 the Union's Council of Ministers indicated more recently that the directive should also apply to doctors in training.13 In 1990, the United Kingdom adopted an agreement, the New Deal, to phase in reduced hours for junior doctors.14 In March 1996, the AMA Federal Council adopted a policy to promote a safer workplace for junior doctors and patients in public hospitals.15 Part of the strategy involves the development of a national code of practice for the hours of work and rostering arrangements of junior doctors employed in hospitals. The Commonwealth Department of Health and Family Services has provided financial assistance to undertake a number of research projects to support the development of this national code. A draft of the code should be available for public comment in June/July 1998, to be followed by a national symposium in November 1998. Undoubtedly the major challenge is the professional medical culture, which, while it recognises the hazards and risks of excessive hours of work, appears to lack the collective will to resolve the problem. Nocera and Khursandi raise the question "Can the medical profession afford to let the courts decide what is reasonable?". In the absence of the medical profession's commitment to support fundamental reform of hours worked by junior doctors, where else can the victims turn? Gerry Holmes Manager, Occupational Health and Safety University of Wollongong Legal Advisor AMA Steering Committee, Safe Hours Project Swan, N. Juniors' Hours: International Overview. BMJ 1990; 301: 830-832. Olson LG, Ambrogetti A. Working harder -- working dangerously. Fatigue and performance in hospitals. Med J Aust 1998; 168: 614-616. Williamson A. The effects of workload and long hours of work on medical officers. Sydney: National Institute of Occupational Health and Safety (WorkSafe Australia), 1995. Australian Medical Association (AMA). Systems of work and overview of current arrangements. Canberra: Australian Medical Association, 1998. In press. New York State Health Code (10 NYCRR 405.4). New York: Department of Health, 1989. Nocera A, Khursandi DS. Doctors' working hours: can the medical profession afford to let the courts decide what is reasonable? Med J Aust 1998; 168: 616-618. Fein EB. Flouting law, hospitals overwork novice doctors. New York Times, 14 December 1997; 1. Holmes G. Hospital medical officers: hours of work and workloads, A strategic approach to occupational health and safety. Canberra: Australian Medical Association, 1995. Department of Transport. Investigation into the Kings Cross Underground Fire. London: HMSO, 1998. Coroner's Court. In the matter of the death of Patricia Margaret Ross. Rotorua, New Zealand: 15-17 October 1997; 18-20. Permanent Working Group of European Junior Hospital Doctors. Working conditions for doctors in training. Conference Proceedings, Executive Summary. Brussels: European Union Publications Office, December 1995. European Union. Directive on Working Time, 93/104. Brussels: European Union Publications Office, 1993. European Union. Sectors and activities excluded from working time directive. Brussels: European Union Publications Office, 1997. NHS Management Executive. Hours of work of doctors in training: guidance on regional task forces. London: Department of Health; 1991. Federal Council, Australian Medical Association. Executive minutes, 1-2 March 1996. Canberra: Australian Medical Association; 1996. Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia ".

Gerry Holmes

Fatigue and performance in hospitals Patients in hospital don't stop requiring medical care at night. That means either overtime or shift work for somebody. "Somebody" is usually a junior doctor. The early postgraduate years are not easy -- the problems of professional responsibility, study and combining a career and a personal life are difficult enough, but to these challenges are added hours of work that society does not expect of any other occupational group. The routine 50- hour shifts of not so long ago have, we believe, disappeared, but hospital doctors still commonly work long hours and unreasonable shifts. What impact this has had in our hospitals -- how it contributes to mistakes, suicides, drop-outs and divorces -- is unknown. However, fatigue undoubtedly impairs professional performance, learning and quality of life. For legal, educational and humanitarian reasons, hospitals need to do whatever can be done to limit excessive hours of work. A physiological, not an industrial, problem How many hours are "excessive"? We do not know. It depends on what we are trying to achieve, and the answer will be different if we want to maximise teaching and learning than if we just want to avoid disastrous errors. How many hours are doctors working? We do not know that either. Most data derive from retrospective self-reports, which is obviously unsatisfactory, and concern average hours per week, which is not the issue. The issue is the existence of any work weeks that do not allow adequate recovery between shifts or which impose excessive periods of continuous work. The Association of American Medical Colleges has suggested that residents should not work more than 80 hours per week averaged over four weeks.1 This approach is irrational -- it is like saying you are fit to drive at any time if your blood alcohol level averaged over four weeks is less than 0.05%. We have practically no data on the frequency with which doctors work exceptionally long hours. Hospitals may have data on rostered hours, but this is only a portion of the total hours worked, and the information is not entirely accurate. Rosters change because swaps are unregulated, and unrostered overtime is usually not included in hospital estimates of hours worked. Time sheets would be a better source of data, but their use raises confidentiality problems, and they miss unpaid overtime. Unrostered overtime, whether obligatory or self-imposed, is unregulated and mostly unrecorded because the pressure to work and not complain is overwhelming. The only accurate source of data on total hours worked would be direct observation, and no such study has been done. It is critical that this is seen not as an industrial issue but as a physiological problem. An 80-hour work week including 40 hours of unpaid overtime and no days off, however unacceptable industrially, could be acceptable physiologically if the worker had eight hours' sleep between shifts. A 24-hour shift at double-time with paid meal breaks is not acceptable physiologically, however attractive it may be to a junior doctor with a mortgage. Imposing a 24-hour shift once a year because all the other medical staff are off sick may not be unfair, but it is unsafe. The body clock keeps ticking at night Humans have a marked circadian preference for sleep at night and, even under optimal conditions, being awake at night is associated with impaired performance. When long hours and sleep deprivation are added to the circadian problem, the performance deficit is exacerbated. The effects of fatigue on performance are well defined.2 Concentration, data processing and short-term memory are impaired. The variability of performance increases, so that normal performance alternates with periods of poor work, and astute decisions are mixed with lapses of judgement. Performance declines sharply as the duration of a task increases, and fatigued workers sacrifice accuracy to speed. Fatigue causes less performance decrement in workers with more control over their work because they can schedule non- urgent tasks for periods when they are at their best. Doctors will thus cope better than staff with less job flexibility, such as nurses. Effort can compensate for fatigue, but as fatigue worsens the ability to summon an effort of concentration declines and the time for which it can be maintained shortens. Performance in crises, however, is preserved until fatigue is extreme. Mistakes caused by fatigue are most likely to occur during routine tasks and tasks which require sustained vigilance, especially when the factors that trigger an effort of concentration (such as an obviously ill patient) are absent. Fatigue mistakes characteristically involve failure to recognise the existence of a serious problem. Giving the wrong antibiotic to a patient recognised as having sepsis is not a typical fatigue mistake, but failing to recognise sepsis at all is. For this reason fatigue-related errors of judgement are difficult to prevent and often disastrous. Are doctors seriously impaired by fatigue? We are not sure. Some studies have found performance decrements attributable to fatigue,3 but others have not.4 The methodological issues that make most existing studies of limited use are twofold. Firstly, the psychometric tests usually used to assess fatigue have never been shown to predict real-life medical performance.2Secondly, many studies use unrealistic definitions of fatigue. In one often-quoted study of junior doctors with work weeks of 100 hours, "fatigued" was defined as less than four hours' sleep in 24 hours, and "rested" as more than four hours' sleep in 24 hours.4 It is little wonder that no difference was discernible between the "fatigued" and "rested" doctors! Doctors and army officers are the only occupational groups reported to be unaffected by fatigue,2 but this is generally regarded as an artefact of methodology.2,5 A "healthy worker effect" is a possible explanation (people who need a lot of sleep don't last very long as surgical registrars or army cadets), but not needing a lot of sleep is hardly the best basis for choosing doctors. Willingness to work when fatigued is widely seen as "professional". This view goes back to acts of genuine heroism in wars and epidemics and to some of the noblest traditions of medicine. But the diurnal rhythm of alertness and the drive to sleep are basic physiological processes, and commitment does not affect physiology. Heroic workloads are out of place in the routine organisation of the urban teaching hospital. Many doctors, junior and senior, voluntarily undertake long hours of work for reasons of money, professional advancement or altruism. Neither money nor seniority is an antidote to fatigue, however, and fatigue is no less damaging to performance when it is incurred voluntarily. It is just as inappropriate for a consultant surgeon to perform emergency operations all night and a routine list the next morning as it is for a junior doctor to be forced to stay at work to assist. Hospitals must not only stop forcing staff to work dangerous hours, they must also prevent them choosing to do so. Hours ain't hours Given that night work is inevitable, and that it inevitably impairs performance and quality of life, it seems obvious to insist on the use of minimally damaging patterns of shift work. The reality in hospitals is different: a number of practices known to cause particularly severe impairment are common. The most obvious suspicion about shifts is true: long ones are worse than short ones.6 Data from a number of occupational groups suggest that eight-hour night shifts are optimal and that 12-hour night shifts are acceptable only if workloads are light. Night shifts longer than 12 hours, and daytime shifts longer than 16 hours, have consistently been found to be associated with reduced productivity and more accidents.6 It is also important to note that the later the night shift ends, the less sleep is obtained that day.7 Even when the night shift has officially ended, casual extension of night shifts into the morning for hand-over rounds and morning report is common. In addition, libraries and medical administration offices rarely have opening hours that allow night workers access without intruding on their sleep time. Physiological adaptation to night work is largely a myth8 and there is no reason to extend periods of night work in the hope that adaptation will occur. For intellectually demanding tasks, short periods of night work (one or two shifts) are better tolerated than longer periods because the accumulated sleep deficit is less. It is easy to demonstrate that the progressive sleep loss of a seven-night roster causes a progressive rise in accidents and a fall in productivity.9 Sleep deficits cannot be repaired immediately. Night-shift workers seldom sleep more than five or six hours in each 24- hour period, so that after seven nights the accumulated sleep deficit is 15 to 20 hours. At least 48 hours off duty are usually needed to recover this deficit,7,10and rosters that require workers to go from night shifts to day or afternoon shifts with no break are dangerous. The pattern of long work days followed by nights interrupted by calls is regarded as normal by the medical profession. These calls are, at best, simple telephone calls. At worst, they may entail returning to the hospital several times a night. Few other workers do this, and data on its long-term effects are entirely lacking. Being on-call impairs sleep even when there are no calls,11 and as five or six hours' uninterrupted sleep is needed to avoid performance decrement10 perpetual or frequent on-call work is probably damaging. Solving the problem We have very little of the knowledge that we need to understand fatigue in medical work. Studies are required to determine whether there is a serious problem of fatigue-related impairment of performance in some or all Australian hospitals. Such studies need to focus on how learning and quality of life, as well as professional performance, are affected by fatigue. Junior doctors are not the only ones affected by fatigue, and senior staff also need to be studied. We need controlled trials to determine optimal work schedules and to test countermeasures to fatigue (eg, benzodiazepines to assist daytime sleep, and bright light and caffeine for stimulation). We do know enough, however, to eliminate the worst abuses of the human sleep-wake cycle, and we need to see a shift by both hospital employers and the medical profession towards addressing this issue. References Executive Council, Association of American Medical Colleges. Resident supervision and hours: recommendations of the Association of American Medical Colleges. J Med Educ 1988; 63: 417-426. Dinges DF, Kribbs NB. Performing while sleepy: effects of experimentally induced sleepiness. In: Monk TH, editor. Sleep, sleepiness and performance. Chichester: Wiley, 1991: 97-128. Rubin R, Orris P, Lau SL, et al. Neurobehavioural effects of the on-call experience in housestaff physicians. J Occup Med 1991; 33: 13-18. Deaconson TF, O'Hair DP, Levy NW, et al. Sleep deprivation and resident performance. JAMA 1989; 260: 1721-1727. Leung L, Becker CE. Sleep deprivation and house staff performance. J Occup Med 1992; 34: 1153-1160. Rosa RR. Extended work shifts and excessive fatigue. J Sleep Res 1995; 4 (Suppl 2): 51-56. Kecklund G, kerstedt T. Effects of timing of shifts on sleepiness and sleep duration. J Sleep Res 1995; 4 (Suppl 2): 47-50. Dahlgren K. Long-term adjustment of circadian rhythms to a rotating shiftwork schedule. Scand J Work Environ Health 1981; 7: 141-151. Knauth P. Speed and direction of shift rotation. J Sleep Res 1995; 4 (Suppl 2): 41-46. Carskadon M, Roth T. Sleep restriction. In: Monk TH, editor. Sleep, sleepiness and performance. Chichester Wiley, 1991: 155-167. Torsvall L, Akerstedt T. Disturbed sleep while being on call. An EEG study of apprehension in ships engineers. Sleep 1988; 11: 35-38. Authors' details Sleep Disorders Centre, Royal Newcastle Hospital, Newcastle, NSW. Leslie G Olson, FRACP, Sleep and Respiratory Physician. Department of Medicine, University of Newcastle, Newcastle, NSW. Antonio Ambrogetti, MD, FRACP, Sleep and Respiratory Physician. Reprints will not be available from the authors. Correspondence: Dr L G Olson, Department of Medicine, University of Newcastle, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, NSW 2310. Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>".

Leslie G Olson · Antonio Ambrogetti

General internal medicine in Australia and New Zealand -- a renaissance A new society challenges potentially excessive subspecialisation MJA 1998; 168: 104-105 Last year in Auckland the Internal Medicine Society of Australia and New Zealand (IMSANZ) arose from the merger of the Australian Society of Consultant Physicians in General Medicine and the Internal Medicine Society of New Zealand. The new society, with 400 Australian and 100 New Zealand members, is now the regional voice of consultative general medicine. Its birth coincides with the renaissance of this discipline in Canada, the United States and Europe. Hospitals, health care managers and funders are reconsidering the likely benefits to both quality and efficiency of health care when medical services are provided by a team in which the "breadth" skills of generalists complement the "depth" skills of subspecialists.1 Outcomes of care Who achieves better outcomes -- general or subspecialty physicians? There are two relevant Australian studies, both in tertiary hospitals. One was not completed because of lack of enthusiasm by busy clinicians and doubts about the value of consensus evaluation following case note audit.2 The second, a randomised study, showed no differences between general medical and specialist geriatric care in acutely ill patients older than 70.3 Although comparisons with the US are problematic because "general" in the US includes primary care as well as consultative general medicine, US subspecialists have better outcomes for the care of rheumatoid disease and myocardial infarction,1 while for hypertension and non-insulin-dependent diabetes outcomes for generalists and specialists are similar.4 However, specialists consume more resources.5 Health care costs In the US, swelling numbers of physician subspecialists reportedly increase health care costs, unmatched by proportional outcome benefits.6 Excessive subspecialisation may lead to economic blow-out, especially in the uncapped, fee-for-service private sector. With "managed care" to contain costs, there is a resurgence of training and career opportunities for generalists.7,8 Is there too much subspecialisation in Australia and New Zealand? In Australian capital cities, subspecialisation, especially in procedural subspecialties, may be excessive. Of 2611 Australian consultant physicians in adult medicine in 1995, only 399 described themselves as "general", compared with 371 cardiologists and 286 gastroenterologists.9 In State capitals in the period 1988-1995 physician numbers (excluding paediatricians) increased from 1729 to 2146, while general physician numbers dropped from 412 to 281.9 In 1996, of 552 Australian advanced trainees of the Royal Australasian College of Physicians (excluding those in paediatrics), only 42 (8%) were in general medicine, with 84 in cardiology and 51 in gastroenterology. However, in New Zealand, 25% of the trainees were generalists. Despite the subspecialisation in Australia's biggest cities, there are shortages of consultant physicians in country areas. Up to 50 additional consultant physicians are needed in provincial and rural Queensland alone.10 Most would need to be generalists. Why do tertiary hospitals need general medical units? Tertiary practice, now dominated by technology and procedures, is becoming organisationally and financially based on discrete episodes of care involving single diagnoses. In this climate, the general medical unit may be seen by some as unnecessary; three teaching hospitals in Sydney as well as the Canberra Hospital, ACT, now have no such units. Compartmentalisation of care by medical specialty means that significant comorbidities and patient concerns unrelated to the particular specialty are easily overlooked, misdiagnosed or inappropriately managed. Gains in efficiency through greater throughput of patients with similar problems may be offset by more consultations and unnecessary investigation. Further, the continuity of care is disrupted. Generalists, with skills in managing undifferentiated problems and conditions that cross subspecialty barriers and an awareness of both the psychosocial and the biological aspects of illness, offer "whole person" patient care and can act as advocates for the patient.11 While many subspecialists practise in a similar way, general units are needed to provide training positions and role models for both basic and advanced training in general medicine. The generalists' integrated view of patients is an absolute requirement for undergraduate and early postgraduate education in a setting where illness is not arbitrarily framed by such overlapping criteria as age (e.g., geriatrics), organ system (e.g., cardiology), pathological process (e.g., oncology), aetiology (e.g., infectious disease) and treatment goal (e.g., palliative care). New agenda for general internal medicine General internal medicine has the breadth and the capacity to embrace new challenges. Generalists can continue to learn from experienced subspecialists and can acquire both the knowledge and procedural skills that might be necessary in particular city or rural, hospital or office settings. They can also lead the way, as in North America,12 in clinical epidemiology and decision-making, ethics, clinical informatics, health technology assessment, clinical audit, and health service research. General physicians can act with other colleagues (e.g., in general practice, surgery, emergency medicine, psychiatry, geriatrics) to help integrate medical care and provide an overview of medical management that may be lost with exclusive specialty care.13 Barriers to the realisation of this new agenda include negative perceptions of generalists by some influential subspecialists in hospitals, by professional societies and by patient support groups; difficulties faced by general trainees in competing for coveted subspecialty training positions;14 and competition among institutional units for limited resources under casemix funding. Lack of confidence and leadership among generalists themselves may set up internal barriers. While the need for subspecialisation in consultative physician practice is recognised and supported, it seems the pendulum has swung too far. Our health care systems stand to benefit from a more vigorous contribution by well-trained and committed general physicians. For a winning team, we need outstanding players -- some with specialised talents and others who are versatile.1 Ian A Scott Director General Medicine Princess Alexandra Hospital, Brisbane, QLD Peter B Greenberg Director General Medical Services North Western Health Care Network, Melbourne, VIC Nash DB, Nash IS. Building the best team. Ann Intern Med 1997; 127: 72-73. Douglas RM, Blood A. Evaluation and peer review of the role of specialist and general medical units in a teaching hospital. Aust N Z J Med 1978; 8: 337-343. Harris RD, Henschke PJ, Popplewell PY, et al. A randomised study of outcomes in a defined group of ill elderly patients managed in a geriatric assessment unit or a general medical unit. Aust N Z J Med 1991; 21: 230-234. Greenfield S, Rogers W, Mangotich M, et al. Outcomes of patients with hypertension and non-insulin-dependent diabetes mellitus treated by different systems and specialties. Results from the medical outcomes study. JAMA 1995; 274: 1436-1444. Welch WP, Miller ME, Welch HG, et al. Geographic variation in expenditures for physician services in the United States. N Engl J Med 1993; 328: 621-627. Schroeder SA, Sandy LG. Specialty distribution of US physicians -- the invisible driver of health care costs. N Engl J Med 1993; 328: 961-963. Wartman SA. Managed care and its effect on residency training in internal medicine. Arch Intern Med 1994; 154: 2539-2544. Weiner JP. Forecasting the effects of health reform on US physician workforce requirement. Evidence from HMO staffing patterns. JAMA 1994; 272: 220-230. Dent O. The Royal Australasian College of Physicians Clinical Workforce in Internal Medicine and Paediatrics in Australia 1988 and 1995. Fellowship Affairs 1989; 8: 9-20, and 1997; 16: 17-30. Hadfield C. Rural manpower in Queensland -- a start to tackling the problem? IMSANZ Newsletter June 1997: 6-7. Guidelines for members and advanced trainees in general medicine, 1997. Sydney: Internal Medicine Society of Australia and New Zealand, 1997. Greenbeck MR. Educating physicians for the 21st century. Acad Med 1995; 70: 179-185. Ward JD. The hospital general physician in the 1990s. J R Coll Physicians Lond 1996; 30: 209-210. Smith BJ, Darzins P, Heller RF. RACP Survey of advanced trainees' job aspirations: the fate of those who pass the clinical exam of the RACP. Fellowship Affairs 1993; 12: 31-33. Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Ian A Scott · Peter B Greenberg

Medical planning for the Sydney 2000 Olympic and Paralympic Games Your country will need you MJA 1997; 167: 593-594 - - - ©MJA1997 Introduction Planning for an Olympic Games is in one sense unique. It involves deploying resources (human, logistic and material) on a scale almost unprecedented in peacetime. This is for a transient spectacle that rarely returns to the same country, an event equivalent to holding 28 World Championships simultaneously in one city. It is incumbent on planners for the Sydney 2000 Olympic Games to draw on the wealth of experience already available, both in Australia and other countries. This includes at least 18 scientific manuscripts published (or in press) on activities of the Medical Program at the 1996 Atlanta Olympics;1-19 three of these articles1-3 appear in this issue of the Journal (see Brennan et al., Eaton et al., and Keim and Williams). The International Olympic Committee (IOC) has entrusted the task of staging the Sydney 2000 Olympic Games to the Sydney Organising Committee for the Olympic Games (SOCOG), together with the New South Wales (NSW) Government and the City of Sydney. SOCOG's Medical Program is responsible for facilitating the health and wellbeing not only of the members of the Olympic Family (athletes, officials, administrators, staff and volunteers), but also of hundreds of thousands of spectators at the 35 competition venues. The NSW Department of Health, in collaboration with SOCOG, will administer services relating to public health, medical disaster planning, hospitals and health care interpreters. The Ambulance Service of NSW and St John Ambulance are also key participants. Under the aegis of the IOC Medical Commission, SOCOG, through the Chief Medical Officer, is also responsible for administering both the IOC's doping control program, as well as the gender verification program for women competitors. The Olympic Games are centre-stage for scrutinising the abuse of illegal performance-enhancing drugs, and Australia has a proud record to maintain in the fight against doping. The Australian Sports Drug Agency (ASDA) conducts over 3000 tests annually, either in competition or unannounced. ASDA will provide some training services for the extra personnel needed for the Games. Sydney is also fortunate in already having the Australian Sports Drug Testing Laboratory (ASDTL), the first such facility in the southern hemisphere with IOC accreditation. In conjunction with Sports Medicine Australia, SOCOG will help to organise the 5th IOC Congress on Sport Sciences, to be held in Sydney in November 1999. The Olympic Games provide the opportunity for elite sports medicine research. SOCOG will facilitate a series of biomechanics research projects to be carried out at the Games under the auspices of the IOC Medical Commission. Such projects serve to illustrate that performance can be enhanced by means other than doping. What personnel and resources are needed? We anticipate that planning and implementing the Sydney 2000 Olympic Games Medical Program will require about 4500 volunteers from a variety of health care backgrounds to supplement the handful of salaried SOCOG staff. We also envisage that much of the equipment and consumables will be made available through donation or sponsorship. Volunteers will need not only to have first-rate professional skills, but to be able to work in newly assembled teams in an exciting, if at times stressful and unfamiliar, environment. We hope that many who volunteer for the Olympic Games will also assist at the less "glamorous" Paralympic Games. This large and extraordinary event will involve over 4000 athletes with disabilities participating over 10 days of elite competition. Those who give their time to work with the Paralympic Games will be rewarded with a unique and inspirational experience. From 1998 to 2000, a series of "test events" will be held to evaluate venues and logistics, albeit on a small scale. We plan to begin the call for Medical Program volunteers in mid 1998, with the support of the relevant professional colleges, societies, associations and health authorities. What lessons can we learn from previous Olympic Games? Although many aspects of Olympic medical programs remain constant, operational and logistic factors may vary substantially. For example, compared with Atlanta, Sydney enjoys much closer collaboration between the organising committee and government and also between the Olympic and Paralympic organising committees. Hospital and ambulance services in Atlanta were provided via a series of private hospitals, one of which (Crawford Long Hospital) was chosen for athlete care (as described by Keim and Williams,3). In Sydney, a single State-run ambulance service and designated public hospitals will be involved. Surprisingly for such a large event, in Atlanta there were only 306 ambulance transfers and fewer than 70 hospital admissions from Olympic venues (and similar numbers in Barcelona in 1992). However, the potential impact of the Games on the provision of normal hospital and ambulance services needs to be, and is being, considered during planning. Another major difference between Atlanta and Sydney is the Olympic Village Polyclinic. This will provide general and sports medical care for up to a month for the 15 300 Village residents (athletes and team officials) plus several thousand SOCOG support staff (equivalent to the population of a medium-sized country town). In Atlanta, the Polyclinic was housed in the Student Health Center of the Georgia Institute of Technology together with an adjacent Sports Performance Centre, as the Village used campus dormitories for accommodation (see Eaton et al.,2). In contrast, in Sydney all Polyclinic services will be in one building. We will not have the luxury of a dedicated health care facility, as the Polyclinic is destined to become a primary school for the new Sydney suburb of Newington. This poses interesting challenges in design and fit-out which need to be addressed in detail now. The operational aspects of public health programs, emergency medical care and disaster preparedness in Atlanta are well summarised by Brennan et al.1). We face similar organisational challenges in Sydney, except for the lower likelihood of heat-related illnesses, as our Games will be held in spring. We must prepare for the possibility of a disaster (natural or man-made) either within a venue or outside (as happened in Atlanta, with the Centennial Park bombing, and more recently in Israel, at the Maccabiah Games, where a bridge used by competitors collapsed). The Medical Program in Atlanta was well run, thanks to careful planning, good management and the selfless involvement of thousands of volunteers. Sydney has considerable expertise in medical management of mass gatherings (e.g., the annual City-to-Surf run and the 1988 Bicentennial celebrations). Preparations for the Sydney 2000 Olympic Games began even before the successful bid was announced in 1993, and detailed operational planning is now well under way. In cooperation with government, in consultation with a variety of agencies and individuals, and hopefully with the enthusiastic support of health care professionals from Sydney and throughout Australia, we will achieve the same success at both the Olympic and Paralympic Games in 2000. Daniel Stiel Chief Medical Officer Patsy Trethowan Manager Medical Program Nicki Vance Manager Doping Control Program Sydney Organising Committee for the Olympic Games Brennan RJ, Keim ME, Sharp TW, et al. Medical and public health services at the 1996 Atlanta Olympic Games: an overview. Med J Aust 1997; 167: 595-598. Eaton SB, Woodfin BA, Askew JL, et al. The Polyclinic at the 1996 Atlanta Olympic Village. Med J Aust 1997; 167: 599-602. Keim ME, Williams D. Hospital use by Olympic athletes during the 1996 Atlanta Olympic Games. Med J Aust 1997; 167: 602-605. Anderson GV Jr, Feliciano DV. The Centennial Olympic Park bombing: Grady's response. J Med Assoc Ga 1997; 86: 42-46. Cantwell JD. Role of the cardiologist in the 1996 Olympic Games. Am J Cardiol 1995; 75: 1081-1082. Cantwell JD, James B. Connolly; First modern Olympic champion. J Med Assoc Ga 1995; 84: 41-45. Cantwell JD. An explosion in Centennial Olympic Park! Atlanta Med 1996; 70: 41-43. Cantwell JD. The five Olympic passions in sports and medicine. Atlanta Med 1996; 70: 43-44. Cantwell JD. The Olympic medical experience: an overview. J Med Assoc Ga 1997; 86: 13-14. Cantwell JD. Cardiovascular events in the 1996 Olympic Games. Am J Cardiol. In press. Cohen RW. Doping control in the '96 Olympics. J Med Assoc Ga 1997; 86: 33-36. Elsas LJ, Hayes RP, Muralidharan K. Gender verification at the centennial Olympic games. J Med Assoc Ga 1997; 86: 50-54. Henderson JM. The Olympics in Columbus: a first and a legacy. J Med Assoc Ga 1997; 86: 37-40. Mulherin WB. Soccer at Sanford. J Med Assoc Ga 1997; 86: 25-27. Nettles JL. Reflections on the Olympics: the memories linger. J Med Assoc Ga 1997; 86: 18-19. Sparling PB. Environmental conditions during the 1996 Olympic Games: a brief follow-up report. Clin J Sport Med. 1997; 7: 159-161. Wilkes JS, et al. The Olympic medical experience: venue and command center perspective. J Med Assoc Ga 1997; 86: 47-49. Woodfin BA, Eaton SB, Askew JL. Medical care at the 1996 Olympic Village. J Med Assoc Ga 1997; 86: 15-17. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Daniel Stiel · Patsy Trethowan · Nicki Vance

Funding Australia's health and medical research A commitment to improving health through high quality research MJA 1997; 167: 608-609 In 1996, the National Health and Medical Research Council's research expenditure was approximately $142 million.1 According to official estimates, this is about a quarter of Australia's total outlay on health research.2 With this level of expenditure, it is reasonable to ask what we gain from this investment. In this issue of the Journal, Bourke and Butler show that in 1995 Australian research provided about 2.5% of new knowledge in medicine and the health sciences (Australian research produced 18390 publications, which were cited over 88000 times), a contribution that has strengthened in recent years.3 This is tangible evidence of our commitment to improving the health of people not only in Australia but in other countries. In one sense, this health research commitment is similar to our other international commitments, such as preserving world heritage areas or reducing emissions of gases causing ozone depletion. Apart from this international contribution to knowledge and new discoveries to improve health, research also benefits Australia itself. For example, health care practitioners with research training are of key importance in ensuring that Australian clinical practice is effective and of high quality because they can access, sift and digest new research findings here and elsewhere. Researchers active in public health are needed to provide informed advice on the benefits and costs of proposed public health measures; for example, the detection and prevention of cancer and cardiovascular disease. The strong base of Australian medical research is also helping to build our biotechnology industry. Finally, and less tangibly, Australians derive satisfaction and pride through the achievements of their health researchers, just as they are proud of high achievers in sport and the arts. The NHMRC now provides research funds across the spectrum of health and medical science via a single Research Committee formed in 1997 by a merger of the Medical Research Committee and the Public Health Research and Development Committee. As the largest single provider of peer-reviewed health research funds for the public good, the NHMRC has the responsibility of ensuring that Australia's health research effort is of high quality: the Research Committee provides funds on the basis of excellence (as judged by peer review), strives for fair, open and competitive processes, considers funding applications in all areas relevant to health, and attempts to ensure that research findings are translated into better health and health care delivery. Health research is conducted mainly in universities, hospitals and medical research institutes (Box 1, above). About 30% of total NHMRC research support is provided to medical research institutes, about half of which is via block funding to five institutes. Box 2 shows the support won by institutes receiving over $1 million, those which are block funded, and the proportion of institute funding going to each State (for institutes receiving over $100 000). NHMRC funding to the major universities is shown in Box 3. The Government provides additional support for hospital and university research via salaries for researchers doing academic or clinical research as part of their teaching and clinical duties, but this does not occur for all research institutes. The institutes also play a valuable role in gaining additional support for health research from private corporations and individuals. The report by Bourke and Butler3 shows that the medical research institutes produce some of our most highly regarded research. Ten of the 12 most cited Australian biomedical research articles are associated with institutes, and the overall citation rate for publications from institutes is impressively high: medical research institutes publish about 13% of all Australian health research articles, and these account for about 21% of the total citations of Australian health research. Underfunding the institutes would jeopardise this high quality output. Bourke and Butler comment that their results raise issues of the efficacy of block funding,3 but stress that conclusions about funding methods require further bibliometric studies. The NHMRC's Research Committee is actively reviewing all aspects of research support, including issues in block funding, such as how best to review institutes and how to increase competition between institutes. Some will argue that the data of Bourke and Butler show that substantial, longer term research support (e.g., block funding) is required in order to achieve the highest impact research. Others will point to examples such as St Vincent's Institute for Medical Research in Melbourne to argue that institutes can achieve outstanding publication results without block funding. The NHMRC supports a pluralistic system because the aims of health research extend well beyond quality research publication. It currently supports three-year project grants (about 48% of the current total NHMRC funding), and five-year program grants (9% of total NHMRC funding) and block grants (13% of total NHMRC funding) to provide for longer term research commitments. New researchers are supported via scholarships and postdoctoral awards (about 9% of funding), and outstanding individuals are supported by Fellowships (11% of funding, exclusive of Fellows on Programs and at block-funded institutes). Nothing in science or medicine is immune to change. The NHMRC's research support system must accord with the ways in which research is currently conducted and be relevant to contemporary health needs. One exciting plan for the triennium 1997-1999 is the introduction of multidisciplinary Health Research Networks in important health areas. This scheme will involve researchers at different locations working collaboratively on research in areas of major health importance. Part of the aim is to capitalise on the merger of the Medical Research Committee and the Public Health Research and Development Committee by creating teams of biomedical, clinical and public health researchers. The Networks will focus on effective delivery of health care or prevention. They will thus be integrated research teams (as in the NHMRC Program Grants Scheme), but multisite and multidisciplinary. Interestingly, Bourke and Butler's article3 shows that research collaborations, both local and international, are growing strongly. The NHMRC-sponsored Networks scheme acknowledges this trend and will help to build new collaborations. Bibliometric data are important for monitoring Australian research. We also need better indicators of the other outcomes of research (such as discoveries which benefit health or reduce health costs, better-informed medical and public health decision making, a vibrant biotechnology industry, and new generations of trained researchers in all areas) so that we can assure the Australian community that its financial investment in health and medical research is well placed. Warwick P Anderson Professor and Chairman, Research Committee (Public Health and Medical) National Health and Medical Research Council, Canberra, ACT National Health and Medical Research Council. 1996 Annual Report. Canberra: AGPS, 1997. Australian Institute of Health and Welfare. Health Expenditure Bulletin No 13, July 1997. Bourke PF, Butler L. Mapping Australia's basic research in the medical and health sciences. Med J Aust 1997; 167: 610-613. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Warwick P Anderson

Doctors and healthcare reform To influence their own destiny, doctors need to participate in the design and management of healthcare reforms that are targeting value for money MJA 1997; 167: 184-185 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - Register to be notified of new articles by e-mail - - ©MJA1997 Healthcare systems all over the world are undergoing substantial change as governments look for ways to constrain what appear to be inexorable cost increases while simultaneously searching for ways to increase value for money. Change is never easy, but the more that individuals participate in planning and implementing change, the more comfortable they feel with these changes. In the past, doctors probably felt they had a significant influence over their immediate work environment. However, this is changing, and, as Perkins et al. report in this issue of the Journal, there is a low level of congruence between the personal goals of individual medical specialists and organisational goals.1 Importantly, the medical specialists are less enthusiastic about their work since the introduction of healthcare system changes that involved resource restrictions and splitting the roles of purchasers and providers (although Perkins et al. did not control for other variables, such as salaries and promotion). the medical profession needs to recognise the legitimacy of funders' and purchasers' concerns about cost increases and value for money While Perkins et al. did not address differences in responses in relation to individual specialists' organisational roles, they did find that specialists in the United Kingdom reported a greater influence on management than their Australian and New Zealand counterparts; this may reflect the greater role for United Kingdom specialists as clinical managers. The study sample in New South Wales (whence the Australian sample was drawn) consisted mainly of visiting medical staff from one Area Health Service, and previous research has shown that visiting specialists identify less with an organisation than physicians who have adopted a managerial role, such as divisional directors.2 Of interest, in terms of health service reform, New South Wales was in a period of relative health policy stability at the time of the survey; nevertheless, the specialists reported decreased enthusiasm for their work. Perkins et al. show that medical specialists would like to influence the "management" of their healthcare organisations, but they have been unsuccessful at this, either because management is unwilling to be influenced, or the attempts at influence are ineffective. At the hospital level, attempts to ensure a greater clinician role in management may involve, as Perkins et al. and their respondents point out, a heavy but rewarding workload. Strategies to enhance clinician influence on policy directions in the wider environment are more difficult to devise. Managed care is the current "bogey" of the medical profession: the profession's current strategy is to run what the health insurance funds deride as a "managed scare" campaign. Governmental and funder concerns about the costs of care and about value for money keep managed care on the agenda in Australia, and political campaigns will not make these concerns disappear. What is needed is a more sophisticated response -- one that addresses the concerns of funders in a way that does not increase feelings of alienation in doctors. With such a response, the medical profession might unpack the many contemporary meanings of managed care and differentiate those elements which have some benefit (e.g., providing feedback to doctors about comparative practice matters) from those which would have a deleterious impact on the Australian health care system (e.g., imposing outdated or rigid treatment protocols). Any policy alternative to managed care must address the need to improve technical efficiency and value for money (technical and allocative efficiency) in the healthcare sector. The key way to address hospital technical efficiency issues is through casemix funding, paying hospitals on the basis of benchmark performance rather than on the basis of history or political influence. Increasing value for money relies on changing the behaviours of providers through funding and education strategies. The 1997 Budget strategy of limiting additions to the Medicare Schedule to cost-effective interventions is a step in the right direction. Providers will also need assistance in implementing best-practice approaches to care -- this can be done through the introduction of local guidelines to influence behaviour. Local guidelines should not be seen as idiosyncratic approaches based on the conventional wisdom of local providers, but rather should be based on the best available evidence,3,4 building on nationally established guidelines where these exist.5 Local guidelines can be supplemented by care paths or clinical pathways to reduce provider variation and lower costs. Care paths also have the benefit of defining appropriate practice and providing a framework for evaluation. The alternative to managed care thus requires a twofold approach: Improve the technical efficiency of healthcare provision; and Encourage and provide incentives for the adoption of local guidelines to influence practice patterns, to ensure effective and efficient care. Unfortunately, local strategies for behaviour change seem to have had limited success.6,7 Even when professional organisations support guidelines for cost-effective care, such guidelines cannot always be implemented, for reasons such as the strongly held beliefs of individual doctors in maintaining their own professional autonomy.8 However, local norms can influence practice,9 through peer pressure and systematic quality assessment processes. In addition, information given to doctors about resource consumption for specific conditions seems to play a part in reducing hospital costs,10 by, for instance, providing feedback to referring physicians about the costs and benefits of ordering particular diagnostic tests. For healthcare providers collectively, it would probably be more politically attractive to be able to influence their own destiny rather than have it determined without their professional involvement. A corollary to this is that the medical profession (and the other health professions) must be given the opportunity to engage in the reform process. To diminish the sense of alienation identified by Perkins et al., the medical profession needs to recognise the legitimacy of funders' and purchasers' concerns about cost increases and value for money. We need to develop strategies that respond to these needs in ways that do not undermine professional values or lead to alienation and loss of morale. Stephen J Duckett Professor of Health Policy; Dean, Faculty of Health Sciences La Trobe University, Melbourne, VIC. Perkins RJ, Petrie KJ, Alley PG, et al. Health services reform: the perceptions of medical specialists in Australia (New South Wales), the United Kindom and New Zealand. Med J Aust 1997; 167: 201-204. Abernethy MA, Stoelwinder JU. Goal orientations and the use of budgeting information: A comparison between physicians and non-physicians in public teaching hospitals. In: Butler JRG, Doessel DP, editors. Proceedings of the Eighth Australian Conference of Health Economists. Sydney: Australian Studies in Health Services Administration, 1987: 67-92. Grimshaw J, Freemantle N, Wallace S, et al. Developing and implementing clinical practice guidelines. Qual Health Care 1995; 4: 55-64. Eccles M, Clapp Z, Grimshaw J, et al. Developing valid guidelines: methodological and procedural issues from the North of England evidence-based guideline development project. Qual Health Care 1996; 5: 44-50. Smallwood RA, Lapsley HM. Clinical practice guidelines: to what end? Med J Aust 1997; 166: 592-595. Eisenberg JM. Doctors' decisions and the cost of medical care. Ann Arbor: Health Administration Press, 1986. Mittman BS, Siu AL. Changing provider behavior: Applying research on outcomes and effectiveness in health care. In: Shortell SM, Reinhardt UE, editors. Improving health policy and management: nine critical research issues for the 1990s. Ann Arbor: Health Administration Press, 1992: 195-226. Rappolt SG. Clinical guidelines and the fate of medical autonomy in Ontario. Soc Sci Med 1997; 44: 977-987. Westert GP. Variation in use of hospital care: an empirical and theoretical analysis of differences in the duration of hospital stay. Assen/Maastricht: Van Gorcum, 1992. Conrad D, Wickizer T, Maynard C, et al. Managing care, incentives and information: An exploratory look inside the "Black Box" of hospital efficiency. Health Serv Res 1996; 31: 235-259. To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Stephen J Duckett

Health service reform: the perceptions of medical specialists in Australia (New South Wales), the United Kingdom and New Zealand Rod J Perkins, Keith J Petrie, Patrick G Alley, Peter C Barnes, Malcolm M Fisher and Peter J Hatfield For editorial comment see Duckett Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Results - Discussion - Disclaimer of conflict of interest - References - Authors' details - - ©MJA1997 Abstract Objective: To examine the effect of recent healthcare service changes (including significant resource constraint and a greater role for the non-medical manager) in the United Kingdom, Australia and New Zealand on medical specialists' perceptions of their healthcare organisation goals and service delivery, and their enthusiasm for their work. Design: Postal questionnaire survey, answered anonymously. Participants and setting: Medical specialists employed either part- or full-time in two United Kingdom National Health Service Trusts (one acute, one mental health/community service), an Australian Area Health Service and a New Zealand Crown Health Enterprise in 1995. Main outcome measures: Participants' rating of their knowledge of employers' organisational goals, ability to influence management, perceptions of changes in resources and service availability since 1990 and changes in enthusiasm for their work over the past four years. Results: 369 of 521 eligible specialists responded (71%); by country -- United Kingdom, 123/186 (66%); New Zealand, 123/160 (77%); Australia, 123/175 (70%). New Zealand specialists were less aware of their employers' organisational goals and had less congruence between these and their own personal goals than United Kingdom or Australian specialists (P < 0.05). Interest in influencing central management was similar in the three countries, but Australian specialists felt management was less likely to follow their advice compared with United Kingdom specialists (P < 0.05). New Zealand specialists perceived that waiting times for non-urgent patients were currently longer than in 1990 compared to United Kingdom specialists (P = 0.02). In all three countries, inpatient beds were perceived to be less available than in 1990, but less so in New Zealand. The ease of replacing equipment was better in New Zealand than in Australia and the United Kingdom (P = 0.00001). More than 50% of participants in all three countries (183/361; 50.7%) reported that their enthusiasm for their work had decreased in the past four years. Conclusion: The effects of health service reforms seem to have reduced enthusiasm for work among medical specialists in Australia, the United Kingdom and New Zealand. MJA 1997; 167: 201-204 Introduction In recent years, Australia, New Zealand and the United Kingdom have seen major structural changes in the way health services are funded and managed (Box 1), and these changes have altered relationships between doctors and managers.1,2 Whether the new structures deliver better services to populations -- in terms of cost, quality and access -- is currently debated, but little information is available on the impact of these changes on the working lives of specialists in hospital settings.3,4 We set out to determine whether the healthcare changes affected specialists' attitudes towards their work and practice. We assessed their perceptions of their current influence on central management, whether their enthusiasm for involvement in healthcare delivery had changed since the changes were instituted, and whether they believed that availability of resources and services to their patients had changed. Methods Participants In 1995 we mailed questionnaires to 521 specialists (individuals holding College postgraduate qualifications) employed full-time or part-time in two United Kingdom National Health Service Trusts (Salford Royal Hospitals and Newcastle City Health), a New Zealand Crown Health Enterprise (Capital Coast Health, Wellington) and an Australian Area Health Service (staff specialists or visiting medical officers in the Northern Sydney Area Health Service, New South Wales). Specialists from two National Health Service Trusts were surveyed to ensure that all specialties were represented from each country. The questionnaire (to be answered anonymously) was mailed with a covering letter from a senior colleague within their organisation. A second questionnaire was sent to all specialists approximately six weeks after the first (as we did not know who replied to the first mailout, we had to send everyone a second). Questionnaire Participants were asked to rate, on seven-point Likert scales: Their knowledge of their employer's goals, the congruence between what they like doing in their work and what their employer wants them to do, their interest in influencing hospital or service management, and the extent to which their advice is noted or acted upon. The time spent per week in hospital management meetings (from less than one hour to more than six hours), on a scale of less than one hour, one to two hours, two to three hours, etc. Their perception of changes in resource availability and service over the past four years; specifically, waiting time for non-urgent patients, availability of beds, and condition and ease of equipment replacement. They were also asked to rate whether their enthusiasm for their work had increased, stayed the same, or decreased. Open-ended questions (e.g., "If your enthusiasm for your work has changed in the past four years, please state why.") invited the participants to comment on the changes. Statistical analysis The results were analysed using the Statistical Package for the Social Sciences (SPSS) for Windows.5 Non-parametric tests were used to analyse the time spent in management meetings. Differences between specialists in the three countries were assessed using one-way analysis of variance and post-hoc Tukey B tests. Differences in the specialists' enthusiasm for work were evaluated using a contingency table and the chi-squared statistic. Results Three hundred and sixty-nine replies were received after the two mailings (overall response rate, 71%). By country, response rates were: United Kingdom, 123/186 (66.0%), Australia, 123/175 (70%) and New Zealand, 123/160 (77%). Twenty-four percent of the specialists were aged under 40 years, 35% were 40-49, 23% were 50-59 and 19% were 60 years or older. Women made up 19% of the total sample and were equally represented in the three countries (chi-squared = 2.92; df = 3; P = 0.23). There were more full-time specialists in the United Kingdom (56 full-time, 27 part-time) than in New Zealand (33 and 58) and Australia (40 and 47) (chi-squared = 17.53; df = 2; P = 0.0001). Time in management meetings There was no difference between New Zealand and Australian participants in the amount of time spent in meetings about hospital or service matters (median for both, less than one hour per week; Mann-Whitney U test = 6950.5; P = 0.18). United Kingdom specialists spent significantly more time in these meetings (median, one to two hours) compared to either New Zealand (Mann-Whitney U test = 5652.5; P = 0.0007) or Australian specialists (Mann-Whitney U test = 5652.5; P = 0.0007). This effect also held when answers for full-time staff only were examined. Knowledge of organisational goals and influence on management New Zealand specialists were significantly less aware of their health care organisation's goals than specialists in the United Kingdom and Australia, and New Zealand specialists had significantly less congruence between their personal goals and those of the organisation (Box 2). Specialists in the three countries were equally keen to influence management, but Australian participants felt their advice was less likely to be followed. Perceptions of changes in resources and availability of services since 1990 New Zealand specialists felt that waiting time for non-urgent patients was longer than in 1990 compared with their United Kingdom colleagues (Box 3). Beds were perceived to be relatively less available than in 1990 in all three countries, with availability much worse in Australia and the United Kingdom. There was no difference in specialists' perception of equipment condition across countries; most considered this to be fair to moderate. New Zealand specialists felt that equipment replacement was much easier than before 1990 compared with their counterparts in Australia or the United Kingdom. Enthusiasm for work The Figure shows that 50.7% of specialists in the three countries (183 of the 361 who answered the question) reported decreased work enthusiasm over the past four years. The decrease in the United Kingdom was smaller than that in either Australia or New Zealand, but with this size sample no between-country differences were demonstrated (chi-squared = 4.6; df = 2; P = 0.10). Responses to open-ended questions The specialists' comments reflected a divergence between their perceptions of adequate clinical practice and the requirements imposed by the healthcare service reforms (see Box 4). Discussion We found that more than half of hospital specialists in all three countries had decreased enthusiasm for their work in the past four years, coinciding with a greater role of non-medical managers and more restrictions on resources in the secondary (hospital) care sector. The responses to the open-ended questions were consistent with this finding. While all specialists acknowledged resource contraints, in the open-ended questions Australian and New Zealand specialists were more critical of their healthcare organisations than were the United Kingdom specialists. However, the consequent involvement of the United Kingdom specialists may result in a heavy workload: "Sometimes the clinical work and admin work is overwhelming, but on good days it's great. Sometimes I worry if I can keep this level of activity up in the long term" [United Kingdom specialist]. The management structures in the employing organisations are such that specialists in the United Kingdom Trusts, particularly at Salford Royal, seem to be more involved in the organisation and management of their services than are Australian and New Zealand specialists. In this Trust, there were 26 clinical directorates, and more than 30% (26/79) of all specialists were clinical directors; although this position implies extensive involvement in management, the clinical director may not be the manager of the service. A similar organisational structure did not exist in the Northern Sydney Area Health Service. At Capital Coast Health (New Zealand) only one of the three general managers was a medical specialist, and none of the departmental managers were clinicians. This may explain why there appears to be greater enthusiasm for work among the United Kingdom specialists and a greater acceptance of resource difficulties (i.e., although they perceived greater resource difficulties, they did not have less enthusiasm for work than their Australian and New Zealand counterparts). This involvement in management may also explain why United Kingdom specialists spend more time in committee work -- a level of involvement that is significant for their employer. On average, the United Kingdom specialists spent one hour more per week in management meetings than their Australian and New Zealand counterparts, and, given the standard working week of 40 hours, our study would suggest that a United Kingdom Trust employing 120 specialists could expect to receive an additional three full-time-equivalents of time commitment to management issues from those specialists compared with their Australian and New Zealand counterparts. The results of our study show that for many hospital specialists health service reform has come at a "cost" -- a loss of enthusiasm for their work. Specialists' involvement in the management of their hospitals or services seems to be related to higher levels of enthusiasm, even when resource constraints may make it difficult for them to perform their duties properly. Our study suggests that the greater involvement of doctors in management is working to the advantage of the United Kingdom specialists and their employers. This could provide lessons for Australian and New Zealand healthcare systems that have values and structures in common with the organisations employing the Australian and New Zealand specialists in this study. Disclaimer of conflict of interest The authors declare no conflict of interest. References Hunter DJ. Doctors as managers: Poachers turned gamekeepers? Soc Sci Med 1992; 35: 557-566. Scrivens E. The management of clinicians in the National Health Service. Soc Policy Admin 1988; 22: 22-34. Ham C. Health care reform; learning from international experience. Milton Keynes: Open University Press, 1997. Ham C. Reforming the New Zealand health reforms. Big bang gives way to incrementalism as competition is abandoned [editorial]. BMJ 1997; 314: 1844. SPSS: Statistical package for the social sciences for Windows [computer program], version 6.1. Chicago, Ill: SPSS Inc, 1995. (Received 28 Oct 1996, accepted 13 March 1997) Authors' details University of Auckland, Auckland, New Zealand. Rod J Perkins, BDS, MHA, Senior Lecturer in Health Management; Keith J Petrie, MA, PhD, Associate Professor in Health Psychology; Patrick G Alley, MB ChB, FRACS, Associate Professor, Department of Surgery. Royal Salford NHS Trust, Salford, United Kingdom. Peter C Barnes, MB ChB, FRCP, Physician and Clinical Director. Royal North Shore Hospital, Sydney, New South Wales, Australia. Malcolm M Fisher, MD, FFICANZCA, Clinical Professor, University of Sydney. Wellington Hospital, Wellington, New Zealand. Peter J Hatfield, MB ChB, FRACP, Renal Physician. Reprints: Dr R J Perkins, Senior Lecturer in Health Management, University of Auckland, Private Bag 92019, Auckland, New Zealand. E-mail: r.perkins@auckland.ac.nz ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Rod J Perkins · Keith J Petrie · Patrick G Alley · Peter C Barnes · Malcolm M Fisher · Peter J Hatfield

A model for the management of self-poisoning Ian M Whyte, Andrew H Dawson, Nicholas A Buckley, Gregory L Carter and Catherine M Levey Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Service structure - Philosophy and strategies - Nursing perspective - Psychiatric perspective - Medical perspective - Outcomes and resource use - Discussion - Acknowledgements - References - Authors' details - ©MJA1997 Abstract Objective: To describe the development and activity of a multidisciplinary service to manage self-poisoning. Design: Descriptive, comparative study with prospective data collection. Setting: Regional toxicology treatment centre in the Hunter area of New South Wales (NSW) with primary and secondary referral service to 385 000 people and tertiary referral service to a further 100 000. Patients: All patients (1987-1995) with poisoning or envenomation presenting to the Hunter Area Toxicology Service (HATS). Main outcome measures: Average length of stay for HATS compared with national and NSW hospitals; mortality data for HATS compared with NSW. Results: Average length of stay for HATS was 0.53-1.22 days shorter than for all Australian hospitals, potentially saving 518 bed-days, valued at $468 000 per year. Average length of stay was 0.94-3.39 days shorter than for all NSW hospitals, saving 1470 bed-days at $1.4 million per year. Inpatient mortality (0.2%; 95% confidence interval, 0.0-1.1) was not significantly different from NSW (0.5%; 95% CI, 0.2-0.8). Standardised mortality ratios showed no greater all-cause suicide mortality. Conclusions: In our centralised model for managing self-poisoning, all toxicology patients in an area health service are diverted to one hospital, where all patients with deliberate self-poisoning are admitted under the one multidisciplinary team, and all receive psychiatric assessment. This model has substantially reduced bed stay, with considerable savings to the Hunter Area Health Service manifested as an increase in beds available for other purposes. MJA 1997; 167: 142-146 Introduction Estimates of admissions for deliberate self-poisoning vary from 1%1 up to 5%2 of public hospital admissions. More than 50% of these admissions occur between 6 pm and 2 am.3 Deliberate self-poisoning (including carbon monoxide) is the cause of death in 42% of suicides.4 With a few exceptions, deliberate self-poisoning is managed on an ad-hoc basis in Australian hospitals. Commonly, the patient is managed in the emergency department and, if required, admission occurs under the general physician of the day or under the specialty which best corresponds to the patient's toxicological problem. Other models include medical management for most patients occurring entirely within the emergency department/intensive care axis. In one centre, 30% of patients with deliberate self-poisoning were not formally admitted.5 In many centres, expertise in toxicology comes from outside the service providing the patient care (e.g., from Poisons Information Centres). In these models of management, not every patient with deliberate self-poisoning receives formal psychiatric assessment. Despite evidence that psychiatric intervention after parasuicide is worthwhile,6 psychiatric resources are commonly concentrated on those patients who require admission and those who have the most medically severe poisoning.7 However, significant suicidal risk is present for many patients with toxicologically "trivial" poisonings. Service structure In 1986 the Department of Clinical Pharmacology, then located at the Royal Newcastle Hospital, was requested to manage deliberate self-poisoning and other toxicology patients. The Hunter Area Toxicology Service (HATS) was established jointly by the Department of Clinical Toxicology and Pharmacology and the Department of Liaison Psychiatry in January 1987. The only increase in staff was one registrar position in clinical pharmacology. All deliberate self-poisoning patients are formally admitted under the HATS clinical toxicologist, who retains primary responsibility for care during the whole admission. A toxicology data collection form was developed which is also the formal admission record. The psychiatry team assess all patients with deliberate self-poisoning and, on request, other poisonings. Referral to the drug and alcohol service occurs as necessary. The patient is determined as medically fit for discharge by the toxicologist and the decision on appropriate discharge destination is made by the psychiatrist. Medical follow-up, when required, is the responsibility of the toxicologist. A relational database for collecting data on poisoned patients4 was written (by I M W) in late 1986. The complexity of this database has progressively increased and an extensive psychiatric component (written by G L C) became operational in January 1996. HATS was transferred to the Newcastle Mater Misericordiae Hospital in 1991 and took on an Area role (population, 385 000). All poisoning cases are transferred, either directly or after assessment at a closer hospital, to the Newcastle Mater Misericordiae Hospital unless they are too ill. If they are admitted to another hospital, they are admitted under the care of HATS. In practice, this relates to critically ill patients who are admitted to the intensive care unit at the presenting hospital under the care of the toxicologist from HATS, and discharged directly from that unit or transferred to the Newcastle Mater Misericordiae Hospital if they need more inpatient care after their intensive care stay. HATS provides a 24-hour telephone consulting service for the Upper and Lower Hunter Areas (population, 100 000) and a tertiary referral service when required. The clinical pathway for this managed care is shown in Figure 1. HATS medical management is provided by a full time equivalent clinical toxicologist (currently two clinical pharmacologists) and a registrar in clinical toxicology. The after hours service is provided by the two clinical pharmacologists with the addition of another clinical pharmacologist and a drug and alcohol specialist with an interest in toxicology. Every toxicology admission is seen by the medical team (at least once a day), seven days a week. HATS psychiatric care is provided by a psychiatrist, a psychiatry registrar and a clinical nurse consultant in psychiatry. An after hours service is provided by part of an area roster of psychiatry registrars and four to six "second on call" psychiatrists. Every deliberate self-poisoning admission is seen by the psychiatry team (at least once a day), seven days a week. Even when the patient is consciously or cognitively impaired, our practice is to begin the psychiatric assessment by obtaining a collateral history from family/friends and health care workers before proceeding with individual psychiatric assessment. If the patient presents with a toxicologically trivial poisoning after 5 pm or on weekends (which would allow discharge before the routine morning psychiatric review) then the psychiatric registrar on call will come in to do the assessment and decide on appropriate discharge destination. Philosophy and strategies HATS was established with the premise that deliberate self-poisoning is a presenting symptom for an underlying psychiatric disorder, personality disorder or psychosocial problem that requires assessment and intervention. A distinction is made between "drug overdose" (exposure to an amount of drug or toxin sufficient to cause harm) and the more inclusive term "deliberate self-poisoning", which also includes toxicologically trivial exposures. All admissions are formally discussed at a weekly multidisciplinary meeting where medical and psychiatric management is reviewed. When appropriate, individualised management plans are discussed for patients who have frequent presentations. Nursing perspective Nursing care of deliberate self-poisoning patients uses a combined medical and behavioural model. The staff recognise that patients with deliberate self-poisoning are entitled to a legitimate "sick role"8 and use a non-judgemental approach to patients and their relatives. Retention of patients for the full duration of treatment can be increased by emphasising the need for medical review and treating deliberate self-poisoning patients in a similar manner to other medical patients. In the acute phase of the admission, patients are kept in hospital pyjamas and their street clothes removed. Patients with catheters or intravenous cannulas often have these devices kept in situ until their mental state is assessed and their discharge destination is determined by the psychiatric team. The involvement of family and friends in helping to orientate and support the patient can lessen the nursing burden and improve compliance. Psychiatric perspective Psychiatric care of deliberate self-poisoning patients is aimed at maintaining the safety of the patient (and staff), enhancing compliance with decontamination and other medical treatment, psychological support, the initiation of treatment for specific indications (e.g., delirium, psychosis and relationship problems), and coordination of psychiatric follow-up. The incorporation of a psychiatry team in HATS allows for very early intervention in deliberate self-poisoning, in contrast to consulting the psychiatrist after completion of medical management. Medical perspective The primary aim in the treatment of poisoned patients is to reduce mortality and early and late morbidity. The secondary aim of treatment is to reduce hospital stay and use hospital resources efficiently. This is accomplished by an active education program9 focused on evidence-based management, good supportive care and actively discouraging punitive medical procedures. Outcomes and resource use The NSW Health Department Inpatient Statistics Collection uses average length of stay (with a minimum bed stay for a formal admission defined as one day). Examination of medical records data for patients with self-poisoning (ICD-9-CM10 codes E950-E959) admitted to the Royal Newcastle Hospital in 1985 and 1986 showed an average length of stay of 3.88 days. For 1987, when HATS began to operate, the average length of stay for this group of patients had decreased to 2.75 days and for 1988 to 1.4 days. In 1995 there were 736 admissions to HATS (see Box 1). The median (range) hospital stay is calculated because the data are not normally distributed. The lower quartile is at 10.5 hours and the upper quartile at 27.5 hours. The distribution of hospital stay for deliberate self-poisoning patients is shown in Figure 2. In 1994-1995, for all hospitals with an emergency department in the Greater Newcastle area, deliberate self-poisoning comprised 1.2% of medical admissions; most presented to Newcastle Mater Misericordiae Hospital, where they comprised 7.3% of medical admissions. Of the 520 deliberate self-poisoning admissions who received formal psychiatric assessment, 492 (94.6%) had had one or more formal diagnoses11 made of psychiatric disorder, personality disorder or other condition ("V" codes11). Average length of stay data for HATS compared with national data and all NSW public hospitals are shown in Boxes 2 and 3, respectively. Box 2 compares data derived from the HATS database for 1991-1994 with national data for 1992 (the most recent year available). Box 3 presents data from the NSW Health Department Inpatient Statistics Collection (1994-1995), and compares deliberate self-poisoning admissions to Newcastle Mater Misericordiae Hospital with the mean for all public hospitals in NSW. The data from Newcastle Mater Misericordiae Hospital in Box 3 are not derived from the HATS database, but rather from independent coding by the Medical Records Department of the Newcastle Mater Misericordiae Hospital according to ICD-9-CM.10 Both comparisons show a substantial reduction in bed stay for HATS. Since those patients not formally admitted at other hospitals are likely to be short stay presentations and thus not reported in the Inpatient Statistics Collection, we further analysed HATS data for 1993-1995. For all admissions average length of stay was 1.5 days; for all admissions with a hospital stay greater than 12 hours (72.6% of admissions) average length of stay was 1.69 days; for all admissions that required intensive care admission (16.8%), average length of stay was 2.59 days. There has been no evidence that reduced bed stay has compromised patient care, as mortality from deliberate self-poisoning during this period (1987-1995) has been 0.6% (24 deaths in 3856 deliberate self-poisoning admissions; 95% CI, 0.4-0.9). Most of these patients had an out-of-hospital cardiac arrest and death was inevitable on presentation.4 NSW Health Department data for 1992 (the most recent year for which death data are available) show 13 inpatient deaths in 2876 admissions in NSW (0.5%; 95% CI, 0.2-0.8). HATS data for 1992 show one inpatient death in 512 deliberate self-poisoning admissions (0.2%; 95% CI, 0.0-1.1). These proportions are not significantly different (chi-squared = 2.04; P = 0.36). Standardised mortality ratios for suicide in NSW show the Hunter Area has no greater all-cause suicide mortality.13 HATS' prospective data collection on all presentations in a defined population is a very powerful tool for observational research. We have been able to identify public health issues related to patterns of drug use,14,15 relative toxicity of drugs within classes16-18 and the impact of safety packaging of medications.19 The NSW Health Department, as part of its health outcomes strategy, has provided funds to HATS to develop the management model (and the database) so that it can be trialled at other centres in NSW. Discussion There are difficulties in comparing data collected by clinicians with a particular interest in a group of patients and national data derived from ICD-9 coding from all hospitals in Australia. The main difficulty is the potential for ascertainment bias. For example, it is possible the national data contain significant numbers of patients without true deliberate self-poisoning, who have a longer length of stay. This may make our comparisons less robust. However, the data for NMMH in Box 3 are the official data requested by the NSW Department of Health for inclusion in the NSW Inpatient Statistics Collection and are thus directly comparable to data from other NSW public hospitals. It could be argued that shorter length of stay in the Hunter is due to our policy of admitting all patients with deliberate self-poisoning regardless of severity. However, the greatest difference in average length of stay occurs in those patients with complications or comorbidities (Boxes 2 and 3), who require admission under any policy. Figure 2 shows that 90% of all our patients stay in hospital for less than 50 hours, which is less than the average length of stay for uncomplicated poisoning in NSW public hospitals (Box 3). In addition, HATS bed stay for all admissions (complicated and uncomplicated) after excluding those admitted for less than 12 hours (27.3% of presentations) is still shorter than the average length of stay for uncomplicated admissions to all NSW hospitals. The average length of stay for HATS admissions requiring intensive care is more than two days shorter than the average length of stay for all complicated admissions to NSW hospitals. The model of management of self-poisoning described in this article is, we believe, unique in Australia. The differences we have identified in this model are: all toxicology presentations in one Area Health Service are diverted (by ambulance services and emergency departments) to one hospital all deliberate self-poisoning presentations are admitted all admissions are to one team the team is multidisciplinary, with medical, psychiatric, drug and alcohol, and nursing participation all deliberate self-poisoning admissions receive psychiatric assessment a 24-hour service for management and advice is provided. We argue that all patients who present with deliberate self-poisoning should be admitted for several reasons: deliberate self-poisoning is a presenting symptom for another problem that requires assessment and intervention most deliberate self-poisoning admissions (94.6%) have a diagnosable psychiatric disorder, personality disorder or other psychiatric condition formal admission facilitates more efficient and effective assessment and management of both medical and psychiatric issues as more than half the presentations occur after hours, overnight admission is required to ensure adequate psychiatric assessment. This model has resulted in a substantial and significant reduction in bed stay, which increases beds available for other purposes in the Area. There are two ways of calculating the monetary cost if funding were on a diagnosis-related group (DRG) basis. The first is to multiply the bed-days saved by the DRG cost of a bed-day, as in Box 2 and Box 3. The second is to assume the saved beds will be occupied by patients attracting further DRG funding. Assigning a monetary value to this is not possible. It is clear, however, that based on DRG funding these saved bed-days are worth more to the Area than the cost of running the service. The reduction in bed stay has not been accompanied by a worsening in outcome, as defined by in-hospital mortality from deliberate self-poisoning or standardised mortality ratios for all-cause suicide. While the number of admissions to HATS in 1992 appears disproportionate, it is consistent with the proportion of admissions to other major hospitals1,2 and reflects our policy of admitting all patients who present with deliberate self-poisoning. It appears likely the Department of Health figures for admissions significantly underestimate the number of presentations for deliberate self-poisoning to NSW hospitals. If so, while the magnitude of the saving per admission may be uncertain, on a State-wide basis the potential savings from implementing our model are even greater. Without further data, determining the reasons for the shorter average length of stay is not possible, but anecdotal comparisons with other hospitals suggest the following possibilities: centralised, evidence-based management of specific poisonings resulting in earlier recognition of non-toxic or minimally toxic exposure more efficient gastrointestinal decontamination better management of significant toxic exposure more efficient use of psychiatric assessment, aftercare and discharge planning increased involvement of nursing staff in a multidisciplinary approach. Our current model of management has evolved using the skills and experience of those interested in poisoning in Newcastle. The only new position created was the registrar position in clinical pharmacology. We do not believe, however, that replicating the model or its outcomes is dependent on replicating our subspecialty mix. Nevertheless, the identification of a team to manage poisoning is crucial. In many health areas the emergency physicians may be the logical choice for such a team. This would require an extension of admitting rights into the general hospital or a collaborative venture with an identifiable medical team. A specific group of psychiatrists is also required. We believe that Area Health Services should consolidate acute toxicology services. A potential disadvantage of consolidation is loss of skills in the management of toxicological problems in other hospitals in the Area. This could be offset by making the service part of registrar and nursing training rotations. The advantages of consolidation include: individualising patient care continuity of care a better learning curve via greater experience training, education and research. The efficiencies of this model are a product of the reorganisation of largely existing resources to provide a multidisciplinary team approach to the management of poisoned patients. The provision of care is based on a philosophy that these patients are entitled to a legitimate sick role. The major stumbling block to establishing a similar dedicated service is in making the decision to reorganise existing services. As House et al. state, after reviewing services in the United Kingdom, "there is much to recommend in clinical diversity, but nothing to recommend [in] unplanned and incoordinated service provision".6 Acknowledgements We would like to acknowledge the support of nursing staff in the Intensive Care Unit, the Emergency Department and Ward 5E at the Newcastle Mater Misericordiae Hospital. The Hunter Area Toxicology Service has also received considerable support from the Mental Health Epidemiology Group (NSW Department of Health) and the Chief Executive Officer of the Hunter Area Health Service, Dr Timothy Smyth. Some of the later development of this service was supported by a NSW Health Department Health Outcomes grant and a grant from the Hunter Area Health Service. References Pond SM. Prescription for poisoning. Med J Aust 1995; 162: 174-175. McGrath J. A survey of deliberate self-poisoning. Med J Aust 1989; 150: 317-322. Buckley NA, Whyte IM, Dawson AH. There are days . . . and moons. Self-poisoning is not lunacy [letter]. Med J Aust 1993; 159: 786-789. Buckley NA, Whyte IM, Dawson AH, et al. Self-poisoning in Newcastle, 1987-1992. Med J Aust 1995; 162: 190-193. Davis AT, Kosky RJ. Attempted suicide in Adelaide and Perth: changing rates for males and females, 1971-1987. Med J Aust 1991; 154: 666-685. House A, Owens D, Storer D. Psycho-social intervention following attempted suicide: is there a case for better services? Int Rev Psychiatry 1992; 4: 15-22. Tengel E, Cook NG, Kreeger IS. Attempted suicide. London: Chapman & Hall, 1958. Parsons T. The social system. London: Routledge and Kegan Paul, 1951. Buckley NA, Dawson AH, Whyte IM. HyperTox -- a hypertext teaching program in toxicology. < http://www.ozemail.com.au/~ouad/toxi0002.html > > World Health Organisation: International Classification of Disease ICD-9. Clinical modification, 1978. Geneva: WHO, 1992. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994. Manual of resource items and their associated costs for use in submissions to the Pharmaceutical Benefits Advisory Committee involving economic analyses. Australian Government Publishing Service, Canberra, 1992. Stewart G, Chipps JA, Sayer G. Suicide mortality in NSW local government areas. NSW Public Health Bull 1995; 7: 1-10. Smith AJ, Whyte IM. New drugs for old: an issue for debate? Med J Aust 1988; 149: 581-582. Dawson AH, Whyte IM. Compound analgesics [letter]. Med J Aust 1990; 152: 334. Buckley NA, Dawson AH, Whyte IM, Henry DA. Greater toxicity in overdose of dothiepin than of other tricyclic antidepressants. Lancet 1994; 343: 159-162. Buckley NA, Dawson AH, Whyte IM, O'Connell DL. Relative toxicity of benzo diazepines in overdose. BMJ 1995; 310: 219-221. Buckley NA, Whyte IM, Dawson AH. Cardiotoxicity more common in thioridazine overdose than with other neuroleptics. J Toxicol Clin Toxicol 1995; 33: 199-204. Buckley NA, Newby DA, Dawson AH, Whyte IM. The effect of the introduction of safety packaging for carbamazepine on toxicity in overdose in adults. Pharmacoepidemiol Drug Safety 1995; 4: 351-354. (Received 26 Aug 1996, accepted 3 Apr 1997) Authors' details Newcastle Mater Misericordiae Hospital, Newcastle, NSW. Ian M Whyte, FRACP, Senior Staff Specialist and Director, Department of Clinical Toxicology and Pharmacology. Andrew H Dawson, FRCP, FRACP, Staff Specialist, Department of Clinical Toxicology and Pharmacology. Gregory L Carter, FRANZCP, Senior Staff Specialist, Department of Liaison Psychiatry. Catherine M Levey, RN, ICUCert, Clinical Nurse Specialist, Intensive Care Unit. Discipline of Clinical Pharmacology, University of Newcastle, Newcastle, NSW. Nicholas A Buckley, FRACP, Lecturer. Reprints: Dr I M Whyte, Department of Clinical Toxicology and Pharmacology, Newcastle Mater Misericordiae Hospital, Locked Bag 7, Hunter Regional Mail Centre, NSW 2310. E-mail: mdimw@cc.newcastle.edu.au ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Ian M Whyte · Andrew H Dawson · Nicholas A Buckley · Gregory L Carter · Cathterine M Levey

Sydney 2000: guarding against disasters Planning for the unexpected and practising responses is the critical task now MJA 1997; 166: 517-518 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - ©MJA1997 In this issue of the Journal, Nocera describes the consequences of a grenade explosion in a munitions factory that injured four women, two of them critically. The report is a reminder of the ingenious creativity of the human race in weapons and war, with its impetus to do as much harm as possible -- but it might also remind us that some major advances in care for trauma patients have been spawned by wars, particularly methods to decrease the time from injury to first aid and advanced resuscitation techniques. In the incident described by Nocera, the prompt response by emergency services was the key to the survival of the injured. The first ambulance arrived five minutes after the explosion, followed by two more in the next six minutes. As part of the controlled response, a helicopter was put on stand-by nine minutes after the accident and took off five minutes later, carrying universal donor (O Rh-negative) blood, a paramedic and an emergency medicine doctor. The obvious cooperation between all personnel involved -- including police, fire, ambulance officers and helicopter staff -- enabled appropriate deployment of resources, prompt triage and transportation (making allowances for peak hour traffic and matching the capabilities of the hospitals in the area with the patients' conditions). "it is too late to plan a response once a disaster occurs" On a more general note, the article prompts us to review our preparations for disasters in general. Sydney is hosting the Olympics and many other mass gatherings in 2000. What if something happens: explosion, fire or mass transport accident . . . ? Are we prepared? A disaster may be defined as "Any incident, involving large numbers of casualties, which overwhelms the capacity of available resources to cope with it."1 A disaster is, obviously, unexpected, but we might expect Murphy's Law to operate. The recent history of the Olympics includes the tragedies of Munich (1972) and Atlanta (1996). Disaster preparedness was part of our successful bid for the Games in 2000. The response plan was based on DISPLAN/MEDPLAN. MEDPLAN has now been superseded by HEALTHPLAN,2 which defines the command structure and standard operating procedures to be followed in a disaster by the New South Wales health services (ambulance, medical, mental health and public health). These disaster-response plans have been tested and refined through the challenges of bushfires, the Newcastle earthquake, bus crashes and mass gatherings such as visits by two Popes, Royalty and United States Presidents, at rock concerts,3 City to Surf runs and many other occasions. The New South Wales State Emergency and Rescue Management Act 1989 has required increased disaster planning and preparedness at local government, district, area health and State levels. Training and certification of selected health professionals and practical texts4 are now readily available. A glimpse of the complexity of the overall picture of disaster response is provided by the table of contents (10 pages) of the Commonwealth's Australian emergency manual: disaster medicine,5 which covers all aspects of disasters through to recovery. Both this manual and the New South Wales HealthPlan2 have been revised for 1997. Disaster planning brings forth apathy, denial, squabbles about resources, turf battles and many committees representing various disciplines creating camels,* as well as serious professionals trying to plan for "What if . . . ?". The Olympic Health and Medical Working Committee, with senior representatives from the Sydney Olympic Games Organising Committee, the NSW Department of Health and other agencies, is setting up the framework for events in 2000. There are several established principles in disaster planning: In disasters, do the greatest good for the greatest number (a reversal of the usual clinical emphasis on quality of care for the individual). This explains why any disaster scene has to be declared safe by fire officers, why police are in charge overall, why systems are set up to evacuate "walking wounded" before attention is given to the mortally injured. Both military and civilian experience has confirmed that in a disaster a rigid chain of command is essential (doctors, with their individualistic training and professional independence, are poor at this), and that personnel should perform tasks similar to their normal duties (e.g., that surgeons should continue in surgery and not be called upon to organise transport). Overall service command must be led by a controller off site . Each service must have liaison officers from all other major agencies involved. The biggest problem is always communication: this must be organised by those agencies with the relevant expertise and equipment. Emergency physicians are the appropriate controllers of the medical response to a disaster: ". . . they are familiar with the system and personnel providing care before hospitalization; they are practiced in rapid assessment, basic treatment, and triage; and they have a good working rapport with other specialists needed during the response."6 As Waeckerle states in an article on disaster planning, it is too late to plan a response once a disaster occurs.6 Disaster response will always be a team collaborative effort which must be planned and practised. As everybody's time and resources are short, we have to use tabletop exercises, mass gatherings and even expensive exercises with moulaged victims to practise to get it right well before 2000. Gordian W O Fulde Director, Emergency Department St Vincent's Hospital, Sydney A Senior Commander, NSW Healthplan . * "A camel is a horse designed by a committee and an elephant is a mouse built to military specifications" -- Caxton C Foster Ambrose G. Disaster medical planning. In: Fulde GWO, editor. Emergency medicine: the principles of practice. 2nd ed. Sydney: Maclennan and Petty, 1992: 13-19. NSW Healthplan . Functional area supporting plan to the NSW State Disaster Plan (NSW DISPLAN). Sydney: Department of Health, 1997. Fulde GW, Forster SL, Preisz P. Open air rock concert: an organised disaster. Med J Aust 1992; 157: 820-822. Hodgetts TJ, Mackway-Jones K, editors. Major incident medical management and support. The practical approach. London: BMJ Publishing, 1995. Australian emergency manual: disaster medicine. Canberra: Commonwealth Department of Human Services and Health, 1995. Waeckerle J. Disaster planning and response. N Engl J Med 1991; 324: 815-821. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Medical women and men are struggling with the problems of outdated work structures and geographic maldistribution Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia". - ©MJA1996 Recent Australian medical workforce data indicate dramatic changes in the structure and culture of medicine in this country. Women now comprise some 47% of general practitioners under 35 years of age; 1 men are working fewer hours and retiring earlier; 2 and the proportion of women doctors in the medical workforce is forecast to increase by 12% from the present level by the year 2025. 3 Reports, such as that of the (then) Department of Human Services and Health, 4 usually emphasise the particular needs of women doctors, including family responsibilities, child care and spousal career needs. Such conclusions imply that women alone have family responsibilities and ignore the reality that men, too, are making adjustments in these areas. Women have made huge efforts to accommodate work structures that were designed for male workers with invisible domestic support The influx of women into all areas of paid professional work has brought about a cultural revolution, one that challenges the traditionally invisible personal life of the worker. "He" is no longer regarded, implicitly, as a sexless, childless, work-driven automaton. Except perhaps in medicine, where expectations persist that "dedicated" doctors will be infinitely available to their patients and immune to fatigue. Consequently, exhausted and demoralised young doctors -- both men and women -- are retreating from oppressive hospital posts. 5 Changes are needed, including the provision of options -- available to both men and women -- such as job-sharing and permanent part-time work. 3 The challenge in the future may be to match the community's needs with working patterns for health professionals that are closer to reasonable working patterns in the general community. For all doctors to work around 40 hours per week (and why shouldn't we?) would require an increase in the medical workforce of about 15%. 3 But Government policy is moving in the opposite direction (e.g., the restrictions on provider numbers aimed at limiting new graduates from private medical practice). Indeed, a two-tiered system may be evolving, with a predominantly young and female "cottage industry" 5 of general practitioners -- supplemented by (chiefly female) paramedicals -- functioning as "gate-keepers", 2 referring patients to the male-dominated, high-technology (high-prestige, high-income) medical specialties. Women comprise only 12% of all private specialists. 1 They are best represented in dermatology (29%), psychiatry (24%), radiology (19%), pathology (17%) and anaesthetics (16%). 1 (Figures vary somewhat according to source [e.g., those of the Australian Institute of Health and Welfare are slightly different]. 6 ) These career choices may reflect the attraction of more flexible working hours in these specialties, but they may also reflect structural constraints, such as resistance to women doctors in other fields, rather than female predilections. The fact that surgery remains 96% male, 1 while anaesthetics has a relatively high female representation, suggests that Colleges play a significant role in facilitating (or impeding) the participation of women. Both surgery and anaesthetics are more technical than relational -- perhaps one training program is more "woman-friendly" than the other? The same question might be asked about training in obstetrics and gynaecology. Women represent only 11% of this specialty in Australia, 3 whereas they comprise 70% in France. 7 Structural impediments to the progress of women, such as the lack of part-time or job-sharing posts and inadequate mentorship of women trainees, must also be significant in hospitals and in academic institutions; in both these arenas the increasing influx of women (35% of all hospital doctors and 50% of all medical undergraduates) is not reflected in a corresponding "upward mobility". Mostly, the findings of the various reports available come as no surprise and accord very much with my personal experience of women in medicine and psychiatry. 8 One notable exception is the data on retirement. Based on the 1991 Census figures of the Australian Bureau of Statistics, it appears that, beyond the age of 65, half of male doctors continue to work, compared with a quarter of female doctors. 2 For me (born in 1943), these figures were counterintuitive, and a quick "straw poll" of my peers brought forth responses similar to mine. No-one in good health was thinking of retiring. The only sense I can make of these data is that they refer to an earlier generation (born in or before 1926 [i.e., those aged 65 or over in 1991]) that differs from subsequent generations. These early-retiring older women are likely to have had a more traditional type of marriage, an older husband and more children. They may feel obliged to retire when their (older) husbands do, rather than (as my peers seem to) regard the postchild phase of life as a new opportunity for increased career activity. My guess would be that the retirement age for later cohorts of older women will not differ so dramatically from that of their male peers, given the economic imperative for two incomes, as well as the rising divorce rates, which will result in more women doctors who are sole parents. Women have made huge efforts to accommodate work structures that were designed for male workers with invisible domestic support. Male doctors are beginning to make lifestyle changes too, perhaps to accommodate family needs. Work structures must be redesigned to accommodate these changes. The result will be a medical workforce that is more expensive, but less exhausted. Without this redesigning, a two-tiered and gender-stratified system of general practitioners and specialists may develop. However, neither of these scenarios deals with what most reports identify as the single most resistant medical workforce problem: geographic maldistribution. 2,3,9 The poor supply of doctors outside metropolitan areas is a major political issue. While even fewer women doctors than men may be willing to accept a rural placement (with women comprising only 12.7% of rural general practitioners, compared with 27% of metropolitan general practitioners 3 ), the issues involved are common to both. Neither women nor men are keen to work the longer hours of rural practice, where they must offer more complex medical services and practise without the support of colleagues, but where, as general practitioners, they gain no more overall remuneration than they would in the city. The professional needs of spouses pose another problem with rural placements. Both women and men may have spouses to consider, and this problem seems to impact more upon women doctors than on their male counterparts -- accommodating to spousal career needs is reported to be a significant restraint for women. 4 "Conscription" is not a pleasant word, and neither women nor men practitioners are likely to welcome moves in that direction, but the new policy of regulating provider numbers, if successfully implemented, seems likely to usher in just such a system. The desirability, indeed the necessity, for doctors to be granted the same privileges as those that exist in the workforce as a whole should not be construed as a gender issue. A 40-hour week and reasonable allowances for family needs and obligations are the entitlements of all workers -- they do not reflect the "special needs" of women doctors. Carolyn Quadrio Visiting Fellow, School of Psychiatry, University of New South Wales, Sydney, NSW. Australian Bureau of Statistics, Private Medical Practitioners Survey 1996. Canberra: ABS, 1996. (Australian Medical Association Document 325/1/96.) Conn W. Medical workforce participation: males and females 1981, 1986 and 1991. Labour Force Unit, Australian Institute of Health and Welfare. Canberra: AIHW 1995. Australian medical workforce benchmarks. Australian Medical Workforce Advisory Committee (AMWAC) report 1996. Sydney: AMWAC, 1996. (AMWAC used the statistics of the National Health Labour Force for 1994 6 to arrive at this estimate.) Women in the medical workforce: the changing gender profile and its implications. Canberra: Commonwealth Department of Human Services and Health, State Financing Branch (Discussion paper) December 1995. Douglas RM, Dickinson J, Rosenman S, Milne H. Too many or too few? Medical practice and general practice in Australia. National Centre for Epidemiology and Public Health, Australian National University. Canberra: National Capital Printing, 1991. (Discussion Paper No 5.) Australian Institute of Health and Welfare. Medical labour force 1994. Canberra: AGPS, August 1996. Kincaid-Smith P. Where are the women specialists? Australian Medicine 1995; Aug 21: 10. Quadrio C. Women in Australian and New Zealand Psychiatry: the fat lady sings. Australian and New Zealand Journal of Psychiatry 1991; 25: 95-110. Papers from 1995 Australian Medical Association Medical Workforce 2000 Summit. Canberra: Australian Medical Association, August 25-26, 1995.

Carolyn Quadrio

Ensuring quality in all phases of the pathology cycle Laboratories need to monitor and improve their procedures to ensure that they always deliver the correct test results for the correct patient to the correct doctor MJA1996; 165: 125-126. There is an unfortunate perception that pathology laboratories are only interested in performing tests, whereas, in reality, they are responsible for a cycle of activities which begin before and conclude after the actual testing. These activities include consultation between the clinician and pathologist, accurate identification of the patient and referring doctor, correct collection and storage of the specimen, timely and accurate delivery and readability of the result, and, if necessary, more consultation between the pathologist and the clinician. As a consequence of more than 30 years of the Royal Col lege of Pathologists of Australasia (RCPA) leading the provision of well-organised proficiency testing programs, and the advent of medical (pathology) laboratory accreditation with mandatory National Association of Testing Authorities-RCPA registration in 1986, 1 the quality of analysis in Australian laboratories is as good as, if not better than, that in most developed countries. However, it has been recognised that there are still significant problems with the activities that surround analysis in many laboratories. In this issue of the Journal, Khoury et al. ( page 128 ) present an insight into the extent of the problem. Although there were an equal number of laboratories which compared less than favourably with their peers in each of the analytical and transcription-error aspects of the study, the error rate would appear to be much higher in the latter. While some of the 14 laboratories they looked at had near-perfect records in transcribing patient details, median error rates for various elements of the data were in the order of 3%. One laboratory documented an overall transcription-error rate of nearly 40%. If these findings are extrapolated to all laboratory activity in Australia, errors must abound in alarming numbers. In a similar study of 417 laboratories (eight from Australia), Nakhleh and Zarbo 2 found deficiencies of identification and recording in 6% of surgical pathology requests. While neither of these studies addressed the question of whether such errors affect patient outcomes, there is indirect evidence that a minor, preventable systems error can have serious consequences. 3 The Quality in Australian Health Care Study 4 showed that a significant number of patient adverse events were related to system errors. These were often errors of omission related to investigations, such as failure to act upon results of findings, or failure to carry out indicated tests. In such cases it is likely that one health care worker's error of omission results from another's error of commission, such as the incorrect delivery of a report. It is likely that most errors occur because of system problems. Typical examples are poor staff training and non-existent work manuals. Inadequate computer systems with insufficient internal audit checks and poor or no access to the hospital Master Patient Index and ward information system are the bane of many laboratories' existence. Despite a belief that those in private practice are more skilled at the activities surrounding analysis, the article by Khoury et al. indicates that the problems are widespread in both public and private sectors. Where then does the remedy lie? The first step in rectifying this situation is to recognise and document that the problems exist. Pathology laboratories should recognise that their professional responsibility encompasses a whole cycle of events, starting with the requesting doctor initiating an investigation necessary for the management of a patient, right through to recognising the significance of the results for the management of the patient. Then, laboratories should be given, and accept, the authority and responsibility necessary to fulfil their professional obligations to both patient and clinician. Australian pathology laboratories have been slow to adopt total quality improvement processes. Unfortunately, there are even those who believe that too much money is already being spent on mandatory quality activities. This near-sighted stance ignores the significant costs to both patients and the community of preventable adverse events, not to mention potentially expensive medicolegal exposure. Without some mechanism for documenting the problems they experience or cause, laboratories are in no position to begin improving the quality of their services. An example of such documentation stipulating the requirements for laboratory quality systems has been provided by the International Standards Organisation. 5 Because so few laboratories monitor their pre- and post-analytical activities, there is little information from which to develop the necessary benchmarks. The College of American Pathologists has introduced "quality probes" programs to gather data from which realistic benchmarks may be re commended. These programs also document the features of laboratory operations and organisation that correlate with better quality outcomes. A good example of this is a study of wristband identification errors which showed that hospitals with the lowest error rate had systems where the pathology phlebotomists played a crucial role in monitoring wristband conformity to the required standard. 6 Such peer review techniques, which have delivered improvement in the quality of laboratory analysis, may bring about similar improvement in these other areas of laboratory operations. Another technique that has been productive in other procedural areas is incident monitoring. 7 It may very well yield fruitful results if applied to laboratory activities. There is obviously much scope for documenting, understanding and minimising the types of laboratory errors highlighted by Khoury et al. However, a systematic and co ordinated approach will be required from those involved in laboratory medicine to achieve the all-round quality of performance that clinicians and their patients should come to expect. Stewart J Bryant General Manager, SouthPath, St George Hospital Campus, Sydney, NSW Maynard JH. The regulation of medical laboratories in Australia. Clin Lab Med 1991; 11: 777-791. Nakhleh RE, Zarbo RJ. Surgical pathology specimen identification and accessioning. Arch Pathol Lab Med 1996; 120: 227-233. Craig JC, Knight JF, Smith GH. Communication breakdown: a preventable cause of acute renal failure in a newborn infant. Med J Aust 1996; 164: 663-664. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471. International Standards Organisation guide 25. General requirements for the competence of calibration and testing laboratories. 3rd Ed. Geneva: International Standards Organisation, 1990. Renner SW, Howanitz PJ, Bachner P. Wristband identification error reporting in 712 hospitals. A College of American Pathologists' Q-Probes Study of Quality Issues in Transfusion Practice. Arch Pathol Lab Med 1993; 117: 573-577. Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study. Errors, incidents and accidents in anaesthetic practice. Anaesth Intensive Care 1993; 21: 506-519. To top of article ©MJA; 1996 < URL: http://www.mja.com.au/> © 1996 Medical Journal of Australia.

Stewart J Bryant

Limited adverse occurrence screening: using medical record review to reduce hospital adverse patient events Alan M Wolff Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1997 Abstract Objectives: To determine whether continuous detection of adverse patient occurrences followed by analysis and medical intervention can alter the rate of adverse occurrences. Design and participants: 15 912 patients discharged from one hospital were reviewed in two stages. Medical records were screened retrospectively by medical records staff for one or more of eight general patient outcome criteria. Those that screened positive for the criteria were reviewed by one of four doctors. If an adverse occurrence was confirmed, further analysis and recommendations for action to prevent its recurrence were made at meetings of the four doctors, and forwarded to a committee of visiting medical officers who decided on the appropriate course of action. Setting: A rural base hospital in Horsham, Victoria, between July 1991 and June 1994. Main outcome measures: The rate and severity of adverse patient occurrences in each year. Results: 1465 records were screened positive for one or more criteria, and an adverse patient occurrence was confirmed in 155. 88 cases were determined to be minor or not preventable and further action (mostly by changes to hospital policies) was recommended for the remaining 67. Over the three years, the number of adverse occurrences fell from 69 (1.35% of all patient discharges in the first year) to 33 (0.58% of all patient discharges in the third year) ( P < 0.0001) and there was no significant change in severity. Conclusions: The rate of adverse patient occurrences can be significantly reduced by their continuous detection using retrospective screening in conjunction with review, analysis and action to prevent recurrences. MJA 1996; 164: 458-461 Introduction The objective of medical quality assurance programs is to improve the quality of care provided to patients. However, "quality medical care" has proved difficult to define, leading some programs to attempt to detect "disquality", or events that should not happen under optimal conditions.1 Quality, then, may be defined as the absence or lowering of the rate of adverse patient events or occurrences. Many preventable adverse patient events occur in hospitals. The Quality in Australian Health Care Study, which reviewed over 14 000 patient admissions in 28 hospitals in New South Wales and South Australia, found 16.6% involved an adverse event; half of these were assessed as highly preventable.2 The Harvard Medical Practice Study, a review of over 30 000 inpatient medical records from 51 acute-care hospitals in the United States, showed that adverse events occurred in 3.7% of hospitalisations and that many of these were the result of substandard care.3 Both these studies used methods that required substantial resources in time and money to detect adverse patient events, and neither looked at the effect of intervention in preventing recurrence of an adverse event. Limited adverse occurrence screening is a continuous process of retrospective screening and review of inpatient medical records to detect adverse patient occurrences.4 It is referred to as "limited" because only eight general patient outcome criteria are used. When an adverse occurrence is found, appropriate action is taken to prevent its recurrence and the success of the action is determined by ongoing monitoring.4 Thus, the quality assurance feedback loop is securely closed. This study was designed to determine whether limited adverse occurrence screening could reduce the number and rate of adverse occurrences and therefore improve the quality of patient care. Methods The study was undertaken at Wimmera Base Hospital in Horsham, 300 km north-west of Melbourne. There are 11 specialists and 14 general practitioners on the medical staff who treat between 5000 and 6000 inpatients per year. Four doctors were chosen by the Hospital Medical Staff Group to be medical reviewers and to form a Patient Care Committee. All doctors held dual positions in the hospital and had postgraduate clinical qualifications. They were a physician (also Director of Intensive Care), a surgeon (also Chairman of the Medical Staff Group), a general practitioner (also Director of Postgraduate Education) and the Medical Director (also Director of the Accident and Emergency Department). The medical records for all inpatients discharged between 1 July 1991 and 30 June 1994 were screened by medical records staff using eight general patient outcome criteria (Box 1, below). An adverse patient occurrence analysis form was attached to any medical record that met one or more of the criteria. The record was reviewed by the doctor allocated to that criterion, who evaluated the care given to determine if an adverse patient occurrence had arisen before or during admission, and then completed the form. Adverse occurrences for which patients had had previous admissions were excluded. 1: General patient outcome criteria used for screening of medical records Death. Return to operating theatre within 7 days. Transfer from general ward to intensive care unit. Unplanned readmission within 28 days of discharge. Cardiac arrest. Transfer to another acute-care facility. Length of stay greater than 35 days (reduced to 21 days in 1993-1994). Theatre booking cancelled. An adverse patient occurrence was defined as "an untoward patient event which, under optimal conditions, is not a natural consequence of the patient's disease or treatment".1 I have described the limited adverse occurrence screening method in detail in an earlier paper.4 Medical care was evaluated using a six-point scale,5 to help the reviewer decide whether an adverse patient occurrence was caused by medical management: 1 = little or no evidence, 2 = slight evidence, 3 = not likely (less than 50:50 odds but a close call), 4 = more likely than not (greater than 50:50 odds but a close call), 5 = strong evidence, 6 = virtually certain. A score of four or more on this scale was regarded as an adverse patient occurrence. Severity of adverse occurrences was graded on a seven-point scale:1 0 = minor severity, 1 = minor temporary, 2 = minor permanent, 3 = major temporary, 4 = major permanent, 5 = potential major or major continuing, 6 = death. The medical reviewer wrote brief notes about the case for the Patient Care Committee. Adverse occurrences were discussed at the Committee's bimonthly meetings and recommendations for further action relating to patient care were made and forwarded to the Medical Staff Group, which consisted of all visiting medical officers in the hospital and the Director of Medical Services. All data from the adverse patient occurrence analysis forms were entered into a database program developed from the Clipper Dbase Compiler software package.6 A chi-squared test was used for statistical analysis, and confidence intervals were calculated for odds ratios using standard methods.7 Results A total of 15 912 inpatients were discharged between 1 July 1991 and 30 June 1994. Using the eight general patient outcome criteria, 1465 records (9.21%) were screened positive for one or more criteria by medical records staff. The commonest criteria among these were unplanned readmission of a patient within 28 days of discharge (3.4% of all records screened) and transfer of a patient to another acute-care facility (2.8% of all records screened) (Box 2). A medical record was most likely to be subsequently confirmed as containing an adverse patient occurrence when it was selected by the criterion "return to operating theatre within seven days" (odds ratio = 3.98; 95% confidence interval, 2.15-7.37) (Box 2). After medical review, 155 records (0.97% of all records screened) were found to contain an adverse patient occurrence using the six-point scale (Box 3). Of these adverse occurrences, 45 were minor and 110 were major (Box 4). Of the 155 adverse patient occurrences confirmed on medical review, no further action was recommended by the Patient Care Committee in 88 cases (56.8%) (i.e., the adverse occurrence was considered to be not preventable or of minor significance). Recommended action for the other cases included changing the relevant hospital policy; presenting the case at a postgraduate meeting; undertaking a quality assurance program to investigate the adverse occurrence in detail; discussion with, or counselling of, the doctor involved; and, rarely, review of the doctor's clinical privileges or reporting the case to the hospital's insurers. Over the three-year period of the study, 66 recommendations were made by the Patient Care Committee and almost all were accepted by the Medical Staff Group and became hospital policy. Changes in hospital policies were both clinical and administrative. Clinical policy changes included restricting some drug prescribing; revised protocols for reporting vital signs; eliminating use of multidose drug vials; formulating guidelines regarding fitness for general anaesthesia; and developing protocols for managing patients with alcohol withdrawal, haematemesis and melaena, and for patients who have had a cerebrovascular accident or who require analgesia. Administrative policy changes included sending copies of referral letters when patients were transferred to other hospitals; sending private antenatal notes to the obstetric ward before the patient's confinement; redesigning the preadmission form to allow consent for procedures to be obtained in the consultant's room; and routinely including a copy of the death certificate in the medical record (if the patient had died in hospital). (Examples of the types of adverse occurrences, more detailed recommendations for further action and their subsequent reduction in incidence are given in an earlier paper.4) The adverse patient occurrences were grouped by year to determine whether the actions instigated had any effect on the subsequent rate of adverse occurrences. The rate of adverse patient occurrences fell from 69 in the first year (1.35% of all patient discharges in that year) to 33 in the third year (0.58% of all patient discharges in that year) (Box 4). The proportion of adverse occurrences fell significantly with time (chi-squared = 17.11; df = 2; P = 0.0002) and this trend was linear (chi-squared = 16.87; df = 1; P< 0.0001). When the severity rating of adverse events was divided into minor (severity score 0-2) and major (severity score 3-6), there was no significant change in the severity of adverse patient occurrences between the first, second and third years of the study (Box 4). Also, the proportion of adverse patient occurrences detected in each year by screening did not alter significantly over time for patient age, sex or insurance status (Box 5). The commonest major diagnostic categories, using the ICD-9 classification,8 in which patients had adverse occurrences were injury and poisoning, followed by digestive and circulatory disorders (Box 6, below). Patient characteristics such as sex and age did not change significantly during the three years of the study, but the proportion of inpatients privately insured fell from 26.6% to 24.3% (chi-squared = 10.24; df = 2; P< 0.01). Discussion Limited adverse occurrence screening has been shown to be effective in detecting approximately 50% of adverse patient occurrences,9 a much higher proportion than found by traditional medical quality assurance programs. This study has shown that it is also possible to subsequently reduce the number of adverse occurrences by more than 50% over a three-year period. These results indicate that use of a more complex and expensive screening system is not required to achieve a significant reduction in adverse occurrences. Adverse occurrence screening has been shown to be valid and reliable, with a high level of agreement between reviewers as to whether a patient has had an adverse occurrence.10 Although in this study each medical record was reviewed by only one doctor, other studies using a similar methodology and rating scale have shown high agreement.5 Limited adverse occurrence screening is efficient as it requires the review of the medical records of slightly less than 10% of all patients discharged, costs only 0.1% of an acute-care hospital's total budget, and is fast and accurate (false positive rate, 2.0%; false negative rate, 0.4%).9 In this study, 9.21% of medical records were screened positive for one or more of the eight general patient outcome criteria and an adverse occurrence was confirmed in 0.97%. Little or no clinical judgement was required in the screening process. This compares with a rate of 8.4% (confirmed in 0.73%) in a study using similar screening criteria in a medium-sized New South Wales hospital.11 In the Quality in Australian Health Care Study, potential adverse events were detected in 43.7% of the medical records on initial screening (a much higher rate than in other studies) using 18 criteria, some of which required clinical judgement.2 Adverse events were confirmed in 16.6%, although, unlike in this study, 49% of these occurred before the sample admission. An average rate of potential adverse events of 13.2% was found in a study of 146 Veterans Affairs Medical Centers in the United States that used nine screening criteria.12 There was considerable variation between centres, with a 25th percentile of 8.6% (confirmed in 1.7% of records) and a 75th percentile of 27.2% (confirmed in 7.9% of records). In the Harvard Medical Practice Study, potential adverse events were detected on initial screening in 25.9% of medical records using 18 screening criteria.13 Adverse events were confirmed in 0.2% to 7.9%, depending on hospital complexity and location, with the rate in rural hospitals being 1%.13 Limited adverse occurrence screening can be adapted to all sizes of hospital. It has recently been introduced into 10 small hospitals in central western Victoria by the Division of General Practice in that area working with the Monash University Centre for Rural Health in Moe, Victoria. In larger hospitals, limited adverse occurrence screening could be introduced on a departmental basis. The program could be enhanced by combining its retrospective medical record review with prospective critical incident reporting. In the United States, adverse occurrence screening and incident reporting both detected a substantial number of adverse events; however, there was less than a 50% overlap in the adverse events detected by each method when used concurrently.14 Thus, a program that simultaneously uses both methods may detect the largest pool of adverse occurrences for analysis and development of preventive strategies. Acknowledgements I wish to thank Mr Ian Campbell, Dr David Leembruggen and Dr Grant Phelps for their enthusiastic participation in the Patient Care Committee; Mrs Cathy Dooling, Chief Medical Records Administrator, and her staff, for their support with the screening program; Mr Kieran Loughran, Computer Systems Officer, for assistance with data collection; and Mrs Naomi Uytdehaag for preparing the manuscript. References Craddick JW, Bader B. Medical management analysis: a systematic approach to quality assurance and risk management. Auburn (CA): Joyce W. Craddick, 1983. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. N Engl J Med 1991; 324: 370-376. Wolff A. Limited adverse occurrence screening: a medical quality control system for medium sized hospitals. Med J Aust 1992; 156: 449-452. Hiatt HH, Barnes BA, Brennan TA, et al. A study of medical injury and medical malpractice: an overview. N Engl J Med 1989; 321: 480-484. Clipper [computer program]. Version 5.0. Los Angeles: Nantucket Corporation, 1990. Daly LE, Bourke GJ, McGilbray J. Interpretation and uses of medical statistics. Oxford: Blackwell Scientific Publications, 1991: 398-424. US Department of Health and Human Services. The international classification of diseases. 9th revision. Clinical modification (ICD-9-CM). 3rd ed. Bethesda, Md: DHHS, 1989. Wolff A. Limited adverse occurrence screening: an effective and efficient method of medical quality control. J Qual Clin Pract 1995; 15: 221-233. Panniers TL, Newland J. The adverse patient occurrence inventory: validity, reliability and implications. Qual Rev Bull 1986; 12: 311-315. Britton S. A hospitalwide outcome study. Aust Clin Rev 1991; 11: 132-135. Goldman R, Walder DJ. An initial assessment of the Veterans Affairs Occurrence Screening Program. Qual Rev Bull 1992; 18: 327-332. 13. Brennan TA, Herbert LE, Laird NM, et al. Hospital characteristics associated with adverse events and substandard care. JAMA 1991; 265: 3265-3269. 14. O'Neil AC, Petersen LA, Cook EF, et al. Physician reporting compared with medical record review to identify adverse medical events. Ann Intern Med 1993; 119: 370-376. (Received 2 Sep 1995, accepted 2 Feb 1996) Authors' details Wimmera Base Hospital, Horsham, VIC. Alan M Wolff, FRACGP, MBA, Director of Medical Services, and Director of the Accident and Emergency Department. Reprints: Dr A M Wolff, Medical Administration, Wimmera Base Hospital, Baillie Street, Horsham, VIC 3400. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Alan M wolff

The Professional Indemnity Review: what did it accomplish? Charlotta Blomberg In a previous article,* Richard Tjiong criticised the Professional Indemnity Review's specific recommendations for reform of professional indemnity insurance. But the Review covered many other issues, particularly to do with identifying, evaluating and reducing adverse outcomes of medical procedures. Charlotta Blomberg highlights some of the key findings (and failings) of the Review's Final Report. MJA 1996; 164: 502 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Introduction - New research into health outcomes - Preventing adverse outcomes - Litigation crisis? - Compensation schemes - Drawing together medicine and law - In conclusion ... - References - Authors' details - - ©MJA1997 Introduction The Review of Professional Indemnity Arrangements for Health Care Professionals (chaired by Fiona Tito) was established against a background of increasing litigation, or fear of litigation, among health care professionals (see Box). Its purpose was to report to the then Minister for Health, Housing and Community Services on: the arrangements for patients injured through health care negligence or misadventure; the means of funding these arrangements; any problems with these arrangements; and proposed solutions and recommendations on the feasibility, appropriateness and estimated costs and benefits of these proposals.11 The last duty remains largely unfulfilled in the Final Report. Despite 168 detailed recommendations for changes of varying degrees, there is little discussion of feasibility, appropriateness or, more importantly, estimated costs and benefits. New research into health outcomes The Review embarked upon a 41/2-year investigation of the health care system and produced 19 publications (listed in Appendix C of the Report) in addition to the Final Report. The Review looked at the incidence and nature of health care injuries, compensation and structured settlements for personal injuries, facilities for the disabled, professional indemnity arrangements, "defensive" medicine and informed consent, birthing issues and information guidelines for patients and providers. At the start of the Review there was no information on the nature and extent of adverse outcomes, no readily available information on the number and types of health-related compensation claims and little publicly available information on the business operations of the medical defence organisations. The Report argues that lack of information on the issues under review required several individual studies to obtain the information required for decision making. Therefore, a major part of the Review was information gathering. It commissioned the Quality in Australian Health Care Study, which investigated the nature and extent of injuries suffered by patients in Australian hospitals. The preliminary results of this study were released in June 1995 and provoked considerable media attention. After peer review, the results were recently published in the MJA.12 With this study and others, the Review produced the first detailed analysis of the system of compensation for personal injury resulting from health care in Australia. The Final Report attempts to tie this considerable research work together with far-reaching recommendations which, if implemented in full, would radically alter the delivery and funding of health care in Australia. Preventing adverse outcomes The Quality in Australian Health Care Study defined an adverse event as "an unintended injury to a patient which resulted in a temporary or permanent disability, prolonged length of stay or death, and which was caused by health care management not by the patient's underlying disease".11 Under this broad definition the study found that hospital-based care produced over 400 000 adverse outcomes, with an estimated 230 000 of these being preventable. As a result, a considerable part of the Final Report concentrates on proposals aimed at preventing adverse outcomes. The solutions proposed involve the development of clinical practice guidelines based on evidence gained through the Cochrane Collaboration (which focuses on evidence derived from randomised controlled trials, conducted around the world and collectively analysed at the Cochrane Centre, Oxford University, UK). Medical services will be assessed on their efficacy and cost effectiveness. The Review recommends review of current services under the Medicare Benefits Schedule to establish their efficaciousness and cost-effectiveness. Commonwealth funding for those that fail these tests should cease (see Report recommendations 16, 19, 23, 28, 29 and 33).11 The emphasis on the development of clinical practice guidelines appears to stem from one of the findings of the Quality in Australian Health Care Study that system errors account for 16% of all adverse outcomes, with 53% of these due to the absence of or failure to use a policy, protocol or plan.12 However, the Study also concluded that "half of all AEs [adverse events] are deemed to have low or no preventability" and that this should be remembered "to avoid an inappropriate presumption of culpability when things go wrong".12 The Review does not address the difficulties associated with implementing a guidelines-based system of health care. The cost or cost-effectiveness of implementing these recommendations is not discussed, and no mention is made of what is involved (such as time and resources) in evidence-based reviews. There appears to be an underlying assumption that, if evidence-based guidelines are developed and followed, adverse outcomes will, in the main, be prevented. This "cookbook" approach to medicine has been criticised elsewhere.13 Without further debate of the issues, the Final Report fails to convince that strict adherence to evidence-based practice guidelines will achieve perfect outcomes. Litigation crisis? In the Final Report, the issues of professional indemnity, negligence actions and adverse outcomes were described as surrounded by myths and assertions supported by little hard data. Much of the information relating to the "litigation crisis" was anecdotal: "evidence for a so-called claims crisis is scant", said the Report, concluding that a crisis mentality has been fostered by some medical defence organisations to deflect attention from their own "irresponsible financial management".11 Although an increase in the rate of incident reporting was noted, the Final Report held that this did not appear to be reflected in an increase in claims filed in courts. It did acknowledge that there is often a considerable time lag between the reporting of an incident and the filing of a claim in court, which may imply recognition that the crisis may yet eventuate. The Review has rightly identified a lack of readily available information on common law negligence cases. A database of common law personal injury cases would be a valuable tool for monitoring the nature and frequency of legal claims, patterns of claims, the frequency of settlement and the amounts of awards and settlements. Such a project would require Commonwealth-State cooperation, as common law matters fall outside the Commonwealth's jurisdiction. The Report cites the register currently operating in South Australia and the National Practitioner Data Bank in the United States as models, but does not estimate the amount or nominate the source for funding of such a project. It does recommend that such a register would provide "a positive quality link between the tort system and the [practitioner] registration system" (Report, pages 154-155).11 This proposal must be studied further. It could mean registration would be subject to the frequency or value of claims incurred each year. It could mean a type of peer review that may establish that common law negligence is not to be equated with medical negligence. Unfortunately, the Report is not clear on what is meant. Compensation schemes In relation to compensation for those who have suffered personal injury as a result of health care, the Review recommended against the introduction of a "no-fault" scheme of compensation. Such a scheme would remove the need to prove negligence (fault) to receive compensation; proof of injury would suffice. It was rejected on grounds of inequity. The public interest is served by those who cause injury paying compensation. A no-fault scheme would mean that the full burden of assistance for injured persons would fall on the community as a whole through increased taxes and an overall reduction in resources available to those suffering injury as a result of health care.11 While recognising that there is inequity between the allocation of resources for those with compensable injuries and those with non-compensable injuries, the Report suggests that the overall public interest would be better served by the retention of the current system. The Review did investigate means of compensation other than the current lump sum awards. In many cases these, although seemingly generous, have proved to be inadequate when taken over the lifetime of a severely disabled person. Structured or serial payments in the place of lump-sum awards were offered as a solution. This is an alternative worthy of further consideration as it may provide security of assistance for those with severe permanent disabilities and solve the problem of awards being dissipated, eventually leaving the injured party relying on the public system. Drawing together medicine and law The Review has made useful recommendations in relation to the medicolegal system. Incorporating the study of legal issues into the training for health care professionals (Report recommendation 8), introducing a system of peer support for health professionals involved in negligence litigation (recommendation 89) and accrediting specialist health negligence lawyers (recommendation 94) are all worthy of further investigation. Greater positive and cooperative interaction between law and medicine is a desirable goal. Both professions would benefit from greater understanding and appreciation of each other's workings. Often people injured during medical procedures say that their main reason for pursuing legal actions is to find out what went wrong.14 This suggests that many potential actions may be prevented through appropriate advice at an early stage. A key factor in this process is access to expert opinions. The Review recommends a college-based system of encouraging high quality health professionals to provide expert opinions in medicolegal cases (Report recommendation 98). This type of system, along with appropriate legal training for medical experts, has been under review by the Australian Medical Association since last year. The existence of a pool of peer-recognised medicolegal experts available to give advice to plaintiffs, defendants and even the court itself may well have a positive effect on reducing litigation and delays inherent in the current system. Judges are keenly aware of the delays and costs attaching to civil actions and actively consider means to speed up their progress. The public interest is not served by lengthy delays and costly litigation. In conclusion . . . it's inconclusive The Final Report of the Review has not lived up to its high expectations. It has identified and investigated issues and proposed recommendations which raise more questions than they answer. There is little real assessment of the financial effect of the recommendations or the impact on current medical practice. The focus is on providing information for more effective decision-making. The legacy of the Review will be even more extensive consultations and reviews to develop practical solutions to the problems it has identified. References Tjiong R. The American litigation crisis is already here. Australian Medicine, 5 June 1995: 4. Bailie RS, Douglas RM. The future role and operation of Australian general practice survey results. Canberra: National Centre for Epidemiology and Population Health, 1995. Komesaroff PA, Keaney MA, Niselle P, Dunn IM. Is there a medical litigation crisis? MJA 1996; 164: 178-182. Keaney MA. Is litigation increasing? MJA 1996; 164: 178-179. Rogers v Whitaker (1992) 175 CLR 479. Lowns v Woods, by his next friend the Protective Commissioner & Ors Court of Appeal (NSW), unreported, 5 February 1996. O'Shea v Sullivan & Macquarie Pathology Services Pty Ltd (1994) Aust Tort Reports 81-273. Talbot & Anor v Lusby (1995) unreported, Supreme Court of Queensland, 14 July 1995. Litigation fears increase health bill. Australian Doctor, 1 September 1995: 48. Breen v Williams (1994) 35 NSWLR 522. Review of Professional Indemnity Arrangements for Health Care Professionals [Tito F, chairman]. Final Report. Compensation and professional indemnity in health care. Canberra: Commonwealth Department of Human Services and Health, 1995. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. MJA 1995; 163: 458-471. Arnold P. The Tito Report -- medical practice re-invented. Australian Medicine, 19 February 1996: 6. Vincent C, Young M, Phillips A, et al. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet 1994; 343: 1609-1613.* See: Tjiong RTT. The Professional Indemnity Review. A lost opportunity for reform. MJA 1996; 164: 371-374. Authors' details Australian Medical Association, Canberra, ACT. Charlotta Blomberg, BA(Hons), LLB, Legal Advisor. Reprints: Ms Charlotta Blomberg, AMA, 42 Macquarie Street, Barton, ACT 2600. E-mail: cblombergATama.com.au ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Charlotta Blomberg