Monday Message Board

It’s time for the Monday message board, where you are invited to post your thoughts on any topic. Civilised discussion and no coarse language please.

Reader Mark Upcher has suggested that this item be moved to the weekend, when readers might have a bit more free time. In the spirit of free competition, I plan to run both for a while. The weekend board might be a better one for longish, more reflective, pieces.

31 thoughts on “Monday Message Board

  1. I said I would post something about my experiences at the hands of industrial relations once proceedings weren’t hanging over me. Actually, since I am desperate with my back to the wall, I’m still looking for other legal avenues but I may have to resort to my media contacts and stop using legal channels. It’s just that the AIRC has refused leave to appeal.

    I think I’m justified in giving people a couple of highlights on what I was appealing against, which the AIRC thinks didn’t amount to anything. I just won’t give any individual names.

    Early on a clique of Blood Service senior management got me alone in a room in other premises for an ambush, by telling me that the meeting was to discuss training. I became suspicious and contacted mt lawyer about this. In the original decision the Commissioner said that that showed I was reaching for my lawyer from an early stage, that this was evidence against me since it showed my lack of trust from an early stage since the evidence showed I consulted my lawyer just because I was to be interviewed by a clique of senior managers! (Mind you, what the Blood Service did to Leo Raffoul led to Justice Munro saying he wouldn’t be surprised if that sort of HR meant that “litigational neurosis” occurred more widely in
    the Blood Service.)

    Well, anyway, even if that reasoning was sound, it wasn’t even based on the facts. The Commissioner had edited the evidence, which was an email to my lawyer embedding another email to colleagues from a few days before. The Commissioner left out the earlier part. What the evidence actually showed was that as soon as I heard about the meeting I told my colleagues I would be away, and nothing more. I only contacted my lawyer when I heard that my immediate superior had had a similar ambush meeting which had given him a hard time and one of the clique gave me an oral instruction not to return to work after the meeting, telling me she had been directed not to put the instruction in writing. It was all that together
    that struck me as ominous enough to need lawyer help, and the timing of the emails proves that I did not reach for my lawyer just because I had been summoned to a meeting – though I don’t see how just asking for advice makes me a paranoid.

    The Commissioner edited the evidence and the Full Bench thought it was reasonable for him to do that.

    Here’s another thing where the Commissioner got the evidence wrong. The Blood Service were busily engaged in selecting and distorting evidence against me so they could go through the motions of a fair dismissal process. They screwed up with the final dismissal, putting through my final pay on 28.7.03 and calling the purported final review on the 29.7.03 by mistake. This made it easy to show that it was a farce – or should have. During the hearings I corrected the date, the Blood Service witnesses agreed with the correction, and exhibits supported it too. I thought it was plain sailing.

    Then the Blood Service lawyers simply misrepresented it in submissions, pointing at the dates on their paperwork and claiming that the dismissal had been on 28.7.03 just because they had planned for it to be then. The Commissioner accepted that and wouldn’t accept the evidence and exhibits he had been shown. And the Full Bench wouldn’t accept that when the Commissioner ignored the evidence, this was a ground for appeal – they said he was reasonably entitled to do that.

    There are a great many other things I could say. These are just two isolated things that stand by themselves, where I don’t have to bring out seemingly minor items and put two and two together (like the way the Blood Service processes were ignored by not having director level involvement in my dismissal, and the Commissioner made out that I was talking about my immediate superior – not that he was there either). These are the glaringly obvious things where what was under the AIRC‘s nose should have told them the Blood Service was up to no good.

    Apart from a personal whinge, and apart from the fact that if it could happen to me it could happen to anyone else under such “justice”, what does it matter in the larger scheme of things? Because the Blood Service clique jumped on me for asking about the new blood management computer system, Progesa, which looked iffy even then. Little birds tell me that everything with the new computer system is about to hit the roof, RMIT and NAB fashion, when it could so easily have been avoided. The clique’s response was purging people who hadn’t even reached the level of dissent, who were only doing our duty by looking into what was coming up. When Australia’s infrastructure is handled by sitting on the lid, agency costs rule
    and we don’t get what we need from such essential services. The recent blood shortages owe much to having to dump supplies in NSW because of computer system problems, and we can expect more if things aren’t put right before going live.

    Don’t believe me? Check the Leo Raffoul material if you just don’t believe the Blood Service could ever be anything but good guys (though it was just a capturing clique that gave me trouble). Or wait for Progesa to hit the fan – government departments are getting critical consultant reports even now. If you think the AIRC has to have got things right, just check the easy part of the evidence that I cited above. I can refer people to my former lawyer if you want to see for yourselves (“former” because the clique ran me out of funds and I had to start representing myself).

    Oh, and if you think my keeping going this long instead of settling shows I am unreasonable, consider this. The clique were always quietly going to pick up the phone and rubbish me, for their own self protection, so I would never work again unless I could somehow head that off. I couldn’t accept promises except from people who acted in good faith – and I had seen too much of them in action to be sweet talked into trusting that without an external guarantee. I wouldn’t even be able to warn people about Progesa if I had signed the small print they offered.

  2. I wanted to comment on the front page headlines in today’s Age newspaper (subscription only) which again raise the issue of excess demand for elective medical surgery.

    Excess demands in economics normally indicate underpricing of a resource but in the present case it seems to me that the excess demand is driven partly at least by the AMA which restricts the supply of doctors and ultimately the supply of surgeons.

    Generally I do not support using immigration as a way of addressing skill shortages in our economy but in this case there might be a need for an exception, particularly for specialists and surgeons. In addition the absurdly high entry standards and restrictions on medical training that limit the supply of graduates from the universities need to be addressed.

    The AMA and other interest groups like to push the ‘supplier creates demand’ line that, with more doctors there will be overservicing. But this is easily addressed by abandoning the foolish objective of seeking to maintain bulk-billing and instead seeing co-payments as a way of limiting moral hazard in supplying health services.

  3. Harry, the story in the Age is about waiting times for elective surgery in public hospitals.

    Bulk billing is a method of paying doctors for services provided to patients in the doctors surgeries. Maybe bulk billing creates a moral hazard problen, maybe it doesn’t, but forcing patients to make a payment when seeing a doctor outside a hospital is going to do nothing to reduce waiting lists for elective surgery in hospitals.

    And it’s not in the least obvious that simply allowing foreign trained surgeons to practice is going to help either. You could bring in thousands of surgeons, but if there are no more operating theatres or hospital beds or nurses that won’t help at all.

  4. You misunderstood my point Milton. I was asserting only that the supply of doctors should be increased to bring about an eventual increase in the supply of surgeons.

    The argument against this is that increasing the supply of GPs, those who do not become surgeons or specialists, will boost overservicing because of supplier-induced demand in the GP market. My argument was that this can be offset with co-payments eliminating the moral hazard..

    I was not asserting that increasing co-payments in itself will increase the supply of surgeons. It clearly will not.

    Is it clear that the constraint on elective surgery is facilities rather than surgeons? If so then facilities also need to be ungraded. But I would be suprised if this is the whole story — specialists and surgeons have long waiting lists simply because of the queue of patients.

  5. Another issue to consider in importing doctors, and nurses for that matter, is the deleterious effect on the sending countries. They’re often developing nations, and their investments in training medical personnel are disproportionately higher than for Western nations. Their need for those personnel is also higher.

    So I think medical problems can and should be addressed by enhanced training. In particular, there should be greater access for rural students who might return to shortage areas in the bush, and there probably should be graduated access for nurses who are interested.

    PM Lawrence, were the Blood Service’s grounds based on your criticism of the new computer system? If so, that’s alarming.

  6. By the way Milton there is some evidence that it is surgeon numbers as well as facilities which are creating the waiting lists. Total employment in specialist medical practice (a large fraction of which are surgeons) fell from 51,477 to 45,046 in the nine years to 2004. (Australia’s Health, 2004, p.294).

    It is true that hospital bed numbers have grown more slowly than population but this data is ambiguous because of increases in same day care and provision of treatment in the home.

    The data on waiting times is out of date but figures for 2001/02 suggest a median waiting time for elective surgery of 27 days. Figures across the States suggested between 3.6% (Qld, SA)-9.0% (Tas)of patients waited more than one year. On average something less than 5% of all patients waited over one year.

  7. 2002-03 data is avaialble at http://www.aihw.gov.au/publications/hse/ahs02-03/index.html. Not much change as compared to 2001-02. Median wait was 28 days ie 1 month. 4.0% waited more than year. The 4.0% who waited more than a year is about 21,000 and they are the serious problem. 518,000 were treated from the waiting lists for elective surgery in 2002-03. In total 6.7 million treated by hospitals (4.1 million public hosp, 2.6 million private hosp). The 21,000 is a small percentage of total workload. They could be treated in no time at all if necessary, but as soon as they were treated, the doctors would add another 20,000 to the waiting lists. The government has no real control on who is put on the waiting lists.

  8. I don’t know anything about the statistics on waiting times for elective surgery in SA but a couple of cases I’m aware of suggest statistics be damned. My 32yr old cash strapped nephew, back from OS recently had cruciate ligament damage to his knee playing sport. Being a chef he couldn’t work and had to shell out $900 for a MRI scan privately to ascertain the damage(or wait 6 months for public scan) An op was required but he was told a 12 months wait. He is borrowing the $3000 from mum to have it done privately in order to get back to work.

    A similar story with the young son of friends of my younger sister. He apparently would have to wait 12 months for ear operations to correct a chronic problem(eustacian tubes I think). Just one small problem though. If they did, he would in all likelihood be permanently deaf. A tax refund and Howard’s family cheque has saved the day apparently.

    I guess you could argue there is some sense in making people queue for a year.

  9. The cost of staffing facilities for surgery is at least part of the explanation in my experience. In public hospitals that I have worked in as a nurse, while day surgery places have increased, (largely because the profit to the doctor is huge and the cost per patient to the hospital is low) places for surgery requiring overnight admission are far more constrained.

    The problem of surgery places has been addressed to some extent by changes in patient management over the last 5 – 10 years. Where patients stayed two or three days post-op, nowadays post-op stays are much more closely managed. But this change in management is a one off and cannot be improved. The number of readmissions starts to increase drastically.

    Long or complicated surgery e.g. knee replacements etc. are really a function of hospital staffing levels.( i.e. nursing and ancillary staff) rather than surgeons. The surgeons profit is lower and the hospital costs are higher.

    But I’m only speaking anecdotally here, suffice it to say that the usual AMA bluster about waiting lists usually disguises a far more complex situation.

    As to the shortage of qualified surgeons – the medical profession has been accused of restricting these numbers for quite some time, in particular orthopaedic surgeons. In response to these criticisms they have appeared to have cleaned up their act in recent years.

  10. Observa said
    He apparently would have to wait 12 months for ear operations to correct a chronic problem(eustacian tubes I think). Just one small problem though. If they did, he would in all likelihood be permanently deaf.

    If it really was a eustachian tube problem which they corrected by grommets, then this illustrates the problem. Such problems frequently go away with just antibiotic treatment, and there is still great debate as to whether grommets do actually improve the situation as compared to just medical treatment. But surgeons will scare people into the grommet operation by saying there is a probability of the child going deaf if they don’t operate. This increases the surgeon’s income, but doesn’t necessarily increase the welfare of the child.
    Now this case may not have been a grommet operation, so what I’m saying would not apply in this case, but the literature has many examples where the surgeon has recommended and done operations where it is not clinically justifiable.

  11. observa – i don’t know any of the actual details of your case but the deafness claim doesn’t ring entirely true.

    If the op was for grommets then it is now clearly sub optimal treatment. Even though many surgeons will recommend (based on the old maxim if the only tool you know how to use is a hammer every problem will look like a nail) the evidence in most cases is overwhelmingly *against* grommets.

  12. You could be right about the grommets thingy as I only had that 2nd hand. The nephew’s case is accurate and in any case the other does concur with his quoted waiting time. I must confess I found it hard to believe that an op that would prevent deafness in a child wouldn’t have absolute priority. Still, leaving a productive 32 yr old out of the workforce for a year did seem a bit of a worry. In that respect my 85 yr old father wasn’t that impressed with Labor’s Medicare Gold promise for over 75s. He would have happily deferred his place in a queue to his 32 yr old grandson under similar circumstances. He wisely maintains his private health cover as usual.

  13. Interestingly enough with the cases I mention not seeming to square with the stats on waiting times for elective surgery, perhaps the medicos are indulging in a bit of prospective queue shortening here. They might be giving those patients who they think can ultimately rustle up the cash to go private, the news they think will get them to do so.

  14. The cruciate ligament story by observa accords with many I have heard and illustrates the bloodymindedness of the orthopedic surgeons. They hate the public system and will do whatever they can to build up the private system by, among other things, using their patients as pawns ie if their patients need to suffer by lingering on a waiting list so as to break the system, they will make that sacrifice. They also have very definitely decided to restrict their numbers so as to increase their income and their power. Others such as general surgeons are now more public minded with regard to number of specialists, but not the orthopods. I can see no way to break their power in the short term. I suspect it will be a war of attrition. But I do think the orthopods are a special case.

  15. observa I didn’t say much because I didn’t want to be thought of as having a go at you personally, but all your cases above don’t square with what I know with regard to various ops and in particular MRI.

    One of the big problems with health is that the customer rarely has perfect information to make good decisions. Even if they know how the system works the customer will often be sick or worried and unable to optimise their treatment options. And that is an important point, there are always s options not just one course. There will be options of type of treatment, options of opinions, options of treatment centres, options of payment etc. There will be trade offs too.

    I am always wary of anecdotes because in more cases than not they leave out crucial bits of information. Waiting lists will vary between hospitals for procedures. Specialists are rarely the best person to advise on total health care. A good GP who knows how the system works is vital to balance the self interest of the procedural specialists and advocate and interpret for optimal solutions for patients.

    With the case of ‘Glue ear’ (eustacian tubes) it is extremely unlikely that deafness will result, even if untreated. There is some debate that there *may* be some slowing down of speech development in the first 18 months but that is not agreed on at all. The most common treatment recommended is ‘watchful waiting’. However watchful waiting doesn’t provide the income an operation for grommets does and does not use the surgical expertise that surgeons know. Patients and particularly parents will very very often prefer “heroic active interventions” that go wrong or offer little real improvement but provide the colour and mystery of surgery, hospital, “best surgeon in state”, than a gentle incremental approach with oversight by the GP and parents with very little active intervention over 18 months.

  16. They put a grommet in my left ear about seven years back, and I’ve been deaf in that ear ever since. Perhaps kiddies’ eardrums grow back nice’n’flexible. I suspect old buggers like me grow ’em back like wood. The bugger who stuck it in shoulda known that, and I’m not about to forgive him.

  17. Re unsavoury comments about orthopedic surgeons.

    Let’s assume the health system, especially the public part, is dysfunctional in some areas. That, at least, is a widely held belief. How do highly skilled and intelligent “doers” respond when they have to work in that environment? They do the best they can, and may move to where their efforts are appreciated. Private hospitals reward them (orthopods) with accomodation, facilities, instruments and attractive schedules, if they are good. The private insurance industry (that both sides of the chamber agree is desirable, so no more debate!) rewards them a fee structure of their liking.

    On the other side of the coin, did anyone see the story about the new anti-cancer wonder drug on 7.30 report? Three oncologists, including Prof Coates of the Cancer Council, waxing enthusiasm about the results of an experimental drug in *one* person in a clinical trial. Coates even spouted the golden glib from the pharmaceutical industry’s propaganda machine – like, goodness me, it takes well over *US1bn* to get a new drug on the shelf in today’s money. Er, that’s based on highly secret internal data is it, Alan, and it was verified by who? Oh, a ‘research’ outfit funded by pharma! Well, that explains why drugs are so expensive, doesn’t it?

    The questions not put to the 3 oncologists include – what are the financial links between yourselves, your employers, and the pharmaceutical company sponsoring the trial? Do you have shares in pharma? Who paid for your last trip to the annual oncology conference in Hawaii?

  18. rob – everything is different in that area for older people. Young kids actually push the grommets out as they grow. Have you had some further checkups with a few reputable Ear and Ear people? Was the grommet because of glue? Don’t give up. Maybe your ear is just blocked with glue. [that will be $164 please – credit card is ok – pay receptionist on the way out – you got private insurance?]

    johnG /saint EVERYBODY hates orthopaedic surgeons. orthopod jokes always get a laugh. most specialists, but not all, treat GPs like shit. Case study: How would you like to be a hospital manager who suddenly finds your orthopods who do 200 knees a year are now, without notice, insisting on using a new u beaut knee replacement that costs $5,000 more than the old one. Same operation now costs you and EXTRA $1m a year, not budgeted for, not discussed.

  19. I was offered the grommet thing but got suspicious because the surgeon was Just So Rude. Second opinion clobbered it real fast.

    However, Rob, if someone talks to you about hearing aids, do pay attention. Here the terrain really stinks; in Victoria at least we have Vicdeaf, which is run by the deaf community (sort of) in the public interest.

    But you will still take a pounding in your wallet. End of digression.

  20. PM
    What you have described is almost text book bullying – where it gets down to arguments which others have difficulty following and where those in positions of power and authority misrepresent information, where small things are made into a major case against you it is hard not to be crushed.

    There has been some work done on bullying in the workplace over recent years but it is still far from understood. Sometimes it is even thought to be leadership. Bullying in the playground is far better understood.

    When you look at our political system the bullying is very open and often quite damaging. Look how many pollies lead dysfunctional lives. If you look at much of what passes for political discourse then it is often reduced to name calling and abuse – attacking the person not the issue – although there are politicians who are truly evil.

    This may not help much especially as you are unable to get on with life – this is often how bullying pans out. Read up on bullying – you will probably be surprised at how it resonates – then you may find ways to deal with it.

  21. Don’t get me wrong about orthopods. They are one of the most hard-working and competent groups of people I have ever come across. But they are remarkable in the consistency of their ideological position. It would be fascinating to do a sociological/psychological study of them. In Australia they all know each other and are ‘tight’ as a group. (They would of course argue there are lots of differences between them, but I would argue their similarities way outweigh their differences). Of course they have legitimate beefs with the public system -everyone does; but their ideological commitment to the private system means they are difficult to negotiate with. It will take a new generation of orthopods and more women before they change.

  22. johng – I think its also a lot more than the private thing. The main critiscism of orthopods is that they only see bones (and surgical solutions) not humans or diseases or drug interactions or falls prevention or ….
    This has enormous impacts on the type of health care people get from orthopods.

  23. I agree its not just their commitment to the private system that distinguishes them from us mere mortals. They do tend to see the body as a machine, and they are excellent mechanics. And if a narrow focus on being technically correct is what is necessary to produce a good knee job, I am happy to live with a poor bedside manner. Bruce Shepherd ( an orthopedic surgeon who was once head of AMA) epitomised for me the mechanical focus of orthopods when he said that no orthopedic surgeon worth his salt can go past a hardware store without going in to check out the latest gizmos.

  24. Guys you are right on the point, dont lose it. The surgeons monopoly is a disgrace, it leads to enormous waiting lists and unbelievable incomes for the specialists. People’s health is now suffering because of the ridiculous shortages.

    The ACCC has been going on for years about the surgeons, and the surgeons consistently thumb their noses. Because people don’t usually pay directly the surgeon’s costs, they dont feel the incredible price pressure being brought to bear, but they do have to cop the incredible waiting periods.

    Just about everyone else has to play by the rules economically, so now its time for the medical profession, which thinks it can set its own fees for ever, to finally have to open up to let more people in.

  25. On a more basic level (and perhaps not sound economic argument) I can’t imagine anyone wanting surgery because it’s available.
    Surely the overwhelming majority of Australians avoid surgery if not necessary because of a healthy distaste of needles and scalpels.
    And for those masochists who don’t, surely the GP is most often the first port of call, where they could be diverted to a more appropriate medical treatment.
    Are some commenters really suggesting that more people will *want* surgery if more surgeons are available? Isn’t surgery a necessity, not a desire, for most? Don’t long waiting lists then imply undersupply rather than a justifiable avoidance of overdemand?

  26. (There might be an argument that a certain class of sadistic GP and surgeon might cooperate to cause an unnecessary increase in surgery. I dearly hope that that sort of medical professional is a close to insignificant minority.)

  27. Francis, I still don’t see it.
    I think there’s a natural human tendency to avoid surgery – for the sake of avoiding associated fears, pain and complications. I don’t see the same incentive to avoid sheet metal products.
    And nearly all surgery involves a referral from a GP or similar professional – who probably have a greater interest (perhaps in part selfish, because of financial benefit) in early intervention at least, and perhaps as a consequence population health.

  28. Tony Healy and Jill Rush –

    I was planning on giving a full reply to your questions in the following week’s Monday Message Board, but it’s not up yet. Maybe this evening or tomorrow morning then. Watch this space.

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