Is there a crisis in the NSW Public Hospital system?

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I recently reviewed the file of a patient in a NSW public hospital. He was an elderly man who presented in a confused state. He was a chronic alcoholic with long-term, alcohol-related brain damage. His life involved going to his local club to eat two meals a day, and drinking himself into a stupor every night. He was single. During a lengthy hospital stay, he had one visit from a drinking mate. The likelihood he could rehabilitate from alcohol dependence was very slim. He eventually died in hospital, from complications of his alcoholism. However he did not die before he had many thousands of dollars spent on him. Cerebral CT scans, cerebral MRI and MRA, EEG and dozens of blood tests were all used to diagnose the cause of his confused state. The conclusion: alcoholic brain damage. Irreversible. One junior doctor who performed a thorough medical history and examination early in the course of the man’s admission picked the diagnosis immediately. In a bygone era this man would have been admitted to hospital for a few days – his case managed with a minimum of tests by an experienced and confident physician with no need to consult other specialists – been given some thiamine, good nutritious meals, general nursing care and allowed to go home to start drinking again. His GP would have been asked to keep an eye on him. He may or may not have died at home before too long. Instead, this man was seen by innumerable specialists and allied health practitioners, he even spent time in ICU. He became the subject of a ‘mortality review’, resulting in hours of senior medical and nursing time spent picking over the bones of the case. Was something done wrong? Was his death preventable? Was someone to blame? Was there a need to form a sub-committee from the policy sub-committee of the clinical review committee to develop policy on how to prevent death in hopeless alcoholics with irreversible brain damage? Not to mention how to prevent the media hearing about it? All human life should be respected. Alcoholism and brain damage are not undeserving of high quality medical and nursing care. However, endless investigation by numerous consulting practitioners is neither good medicine, nor respectful to the patient. Somewhere along the way, we have become lost. We have forgotten what we are trying to achieve. We have lost confidence in our clinical judgement. We are terrified of being sued. We cannot rely on politicians to defend us. The public hospital system has been taken over by administrators, who although hard-working and well-intentioned, are often non-clinical professionals and who are bullied by media-shy bureaucrats. Media management has taken precedence over patient management, so this overly defensive and inappropriate scenario is repeated in NSW Public Hospitals many times over every day. I’m sure it’s not restricted to NSW. I have been privileged to be involved in the training of medical students and junior doctors for twelve years now. These are some of the brightest, most accomplished and hard-working people in our society. The vast majority are empathic, and altruistic. Unfortunately, my observation is that these latter qualities gradually evaporate from doctors as they progress through the hierarchy. I have an uneasy, growing suspicion that this is less a result of the usual blameworthy factors of long working hours, demanding bosses, and difficult postgraduate specialist exams, and more from despair about an increasingly unrealistic, litigious general public who are constantly being misled by an irresponsible media. Anyone who has been in a position to be interviewed or quoted by the powerful tabloid newspapers will understand the inaccuracy contained within many of their articles. Few television news or current affairs programs allow enough time for informed or intelligent exploration of medico-political issues. Doctors in general are not media savvy people. We are losing the battle to win back the confidence of the general public. Why aren’t doctors filling key political positions? Can you imagine a non-lawyer being made Attorney General? Why then is it acceptable for federal and state health ministers, and chief bureaucrats, to have no background in health? How can they judge whether they are receiving sensible advice? Why would one appoint a former Federal President of the AMA as the Federal Education Minister rather than as the Health Minister? How many people are employed by the Federal government to look at health workforce planning? I suspect a significant number. How can the people responsible for determining the number of doctors and nurses we need in our society have messed it all up so spectacularly ten or so years ago? Our affluent society is registering more overseas trained doctors per year (many from countries with a desperate need for their skills) than we are locally trained doctors. It suits politicians to talk tough when it comes to finding someone to blame for mishaps in public hospitals, but there is an eerie silence when it comes to accepting responsibility for the lack of staff available to cover an emergency department. It does not require a genius to predict that increasing numbers of female and mature-aged medical students will result in more doctors looking to work part-time in the future. The public hospital system still manages an enormous amount of fantastic work. I care for an eighteen year old man who may well have died in any other health system in the world. He presented to a metropolitan hospital with a rare and fulminant multi-system autoimmune disease. He was diagnosed promptly and appropriate treatment instituted. He was transferred to a tertiary ICU in a timely fashion. He was desperately ill with multi-system failure for many weeks and almost died several times. He was afforded every technology and new treatment available, at no cost to his family. He now leads a normal life maintained by expensive drugs that his local hospital provides to him for a nominal fee. This case illustrates why I continue to work in the Public Hospital system. It is easy to criticize governments and health departments for the current situation in our public hospitals, and for the most part justified, but as a profession we need to step up and do something about it. Doctors need to start thinking more broadly about the way they practise. Every time the decision is made to perform an MRI scan, to put a 90 year old on life support, to aggressively treat a bed-bound, incontinent, demented nursing home resident in a public hospital with expensive antibiotics for a chest infection, the consequences have to be considered. Thinking about the opportunity cost when we practise defensive medicine needs to become part of what we do. There are limited resources. It is time we stopped squandering so many of them. Senior clinicians need to find a voice. We need to learn to use the media better to get messages to the public. We need to be accessible to the media, and prepared to challenge every ill-informed and damaging health story that gets dragged out to sell newspapers. We need to defy the administrators and politicians who bully public hospital doctors into staying silent, or expect us to recite carefully worded scripts prepared by public relations experts. We need true community participation in public hospitals. Having a ‘community member’ on every committee in the hospital does not mean the community is involved. Many of these ‘community members’ are political party branch members unlikely to speak out against their political masters. The wider community needs to become engaged in informed debate about how health resources are used, and about the limitations of the system. Doctors and legal professionals need to liaise in a productive way to avoid the scenario like that of the Health Care Complaints Commission, where no doctor is in a senior position in the organization – established to investigate complaints against doctors and hospitals. Why, as a profession, would we entrust a group of people who wouldn’t know a scalpel from a bedpan to investigate serious complaints about the quality of patient care? Can you imagine the legal profession allowing a group of doctors to perform an enquiry into the judicial system? Most importantly of all, senior doctors need to rediscover their clinical confidence and set a better example for junior colleagues. The majority of clinical decisions are not that difficult for a senior clinician, and don’t need a consult from a super sub-specialist. Patients need doctors, not technicians, when it comes to decisions about their care. The value of non-procedural medical specialities needs to be recognised. Doctors need to feel safe to make courageous decisions about trying new treatments when they are being made with the patient’s welfare as the sole criterion. We cannot keep our eyes on the ball if we are constantly glancing back over our shoulders. Evidence based medicine is important. It’s here to stay. Common sense and compassion in clinical medicine urgently needs to make a comeback.

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