Australia, July 02, 2005
Adam Cresswell
Weekend Australian
RIGHT now is not a great time to be an overseas-trained
doctor in Australia. Following the furore over Queensland's
so-called "Dr Death", Jayant Patel, some
patients are turning away from other foreign-trained
doctors, even though there is no evidence they
are sub-standard.
The results of the audit of Patel's work, released
by the Queensland Government this week, show Patel
to have been much less of a monster than his diabolical
moniker suggested.
Initially associated – and by implication, blamed
– for the deaths of 87 patients, the audit shows
that he contributed to the deaths of just eight patients,
four of whom were terminally ill. He contributed to
adverse outcomes in 24 cases, and possibly another
22, and his patient management was unreasonable in
15 cases and possibly another 20.
But it's still a bad enough record, and one that
raises questions over whether there are adequate systems
in place in Australia to check up on doctors and hospitals,
and whether they are clear and transparent –
transparent not just to the public, but to the profession
itself.
Nor are these issues confined to Queensland. Questions
have been raised in Western Australia, where an unidentified
surgeon recorded 48 deaths among his patients in two
and a half years.
The cases are quite different but there are common
threads in the issues they raise. What systems are
in place to detect and put a stop to rogue doctors,
or poor hospital practices? Do they work? Is it clear
to the profession and the public who should be doing
what?
Most experts agree the answers to these questions
are not all reassuring.
The Patel case is unique for the doctor's deception:
as the Queensland Medical Board's report to state
Health Minister Gordon Nuttall makes clear, Patel
lied in his application for registration (denying
registrations elsewhere had ever been restricted or
cancelled), and removing an attachment from one document
that revealed disciplinary action taken against him.
The board – which in April hurriedly launched
an audit of the credentials of all its 1670 other
"special purpose" or overseas-trained doctors
after the Patel allegations became public – has
accepted responsibility for failing to spot the missing
document.
But the other routine safety check that should have
applied in the Patel case – a referral to the
Australian Medical Council and thence the Royal Australasian
College of Surgeons for assessment – did not
happen.
Normally, in Queensland, a doctor who wants to practise
as a surgeon must register specifically as a surgeon
– a process that would require him or her to
be assessed by the RACS, the arbiter of standards
for surgeons in Australia and New Zealand.
RACS executive director of surgical affairs John
Quinn said Patel's application to the medical board
was not as a surgeon, but as a medical officer, a
much more junior doctor often only a few years out
of medical school. After being appointed in this non-specialist
capacity, he was then deemed by Queensland Health
to be a surgeon, without reference to the college
or the AMC, and later appointed director of surgery
at Bundaberg Hospital.
Had the referral to the AMC and RACS happened, Quinn
says Patel would have had to submit to a period of
formal clinical supervision and reporting, which would
have picked up the problems much sooner.
Bob Wells, a first assistant secretary in the federal
Health Department until last year and now director
of health policy and planning at the Australian National
University, said the "pivotal role" given
to the medical colleges should give the public confidence
that the system was working well, but in this case
it appeared the RACS had been bypassed.
That's less likely to happen in future: the Beattie
Government this week announced a major overhaul of
the way overseas-trained doctors are accredited.
Instead of Queensland Health having the power to
declare an "area of need" – a special
status that allows for faster tracking of OTD applications
– this role would now go to the Office of Health
Practitioner Registration Boards. This avoids the
conflict with Queensland Health's role to ensure hospitals
have enough doctors.
In future, overseas medical boards must send certification
direct to the medical board (removing the opportunity
for documents to be removed), incoming doctors must
pass an exam from July 2006, and most will be supervised
for one to threee months, receiving extra training
if required. They will also have to pass the AMC exams,
or gain fellowship of an Australian college within
four years of their initial registration.
The Queensland Medical Board, which had been pushing
for these reforms in its report on the Patel case,
is also in talks with other state boards and the commonwealth
in an attempt to standardise this approach in all
jurisdictions.
Wells says the "increasing shortage"of
doctors has created the pressure for doctors to be
brought into the country quickly. A report recently
issued by the Queensland Government confirms how bad
this picture is: the number of doctors in the state
per 100,000 people decreased from 236 in 1997 to 220
in 2002. This week's audit of Patel's work criticised
not just the doctor but also the standards of Bundaberg
Hospital itself, where "amongst the medical staff,
there was general acceptance of mediocrity of performance".
This raises wider issues, many of which are also
relevant to the case in WA of the unnamed surgeon
linked to 48 patient deaths.
While that seems a high figure, many doctors –
anaesthetists, assisting surgeons, and so on –
would have been involved in many of the 48 cases,
making it impossible to say whose fault, if anyone's,
any of the deaths were.
More importantly, the deaths are recorded if they
happen within 30 days of surgery, and could be due
to any cause – and could merely reflect the patient's
poor prognosis or a deterioration in their condition
post-surgery. It could also reflect the fact that
the surgeon was working in a very high-risk area,
or was a well-regarded surgeon who attracted the most
difficult cases.
An RACS committee conducting the audit in WA is investigating
the case, but in the meantime Quinn says the deaths
could be due to what is known as "system failures"
– for example, a delay in obtaining a crucial
scan or test due to rostering schedules of relevant
staff. In such cases a death might be linked to a
particular surgeon even though he or she bore no responsibility
for the patient's death.
Director-general of WA Health Neale Fong admits he
does not know who the surgeon is, but says he is nonetheless
satisfied "there is not another Patel out there"
because of the other checks and balances in place.
These include the fact that every major hospital
has mortality and morbidity committees, and all surgical
deaths are scrutinised by two independent clinicians
for issues of concern.
However, WA is addressing another area of concern.
The WA surgeon came to light as part of a state-wide
audit of surgical mortality conducted by the RACS
in partnership with the WA Government. The surgeon
declined to voluntarily provide reports on his mortality
rates – a situation Fong says will not be allowed
in future.
Co-operation with surgical audits was already a condition
of employment for all new staff doctors, and the condition
would now be progressively introduced for existing
staff as contracts came up for renewal, he said.
RACS president Russell Stitz says the surgical audit
program is now being rolled out nationally, and should
bring big improvements in patient care – as achieved
by a similar program in Scotland – by identifying
quality issues in the bigger picture. For example,
this might mean routinely ensuring patients were given
drugs before surgery to reduce the risk of blood clots.
What Fong, Stitz, Wells and many others oppose is
the publication of "league tables" –
data that ranks individual doctors according to their
surgical outcomes, including the numbers of their
patients who die.
Wells says that far from helping the public, such
information would probably be misleading. "I'm
not particularly in favour of league tables –
particularly for things like surgery, if there are
problems it won't always be the surgeon, it's because
they perform as a team. It could be a whole lot of
factors. And some surgeons tend to do more difficult
work than other surgeons, either because of where
they practise or the type of procedure they do. It's
a bit hard to convey all those subtleties in a simple
league table . . . I think therefore it's a bit misleading
for the public."
