Controversial Ideas in Medicine

House of God by Samuel Shem is full of many sorry truths of hospital medicine, of General Medicine in particular. One of those is the art of the "buff" and "turf". No-one wants extra work. It is an eternal rule of human nature (unless you are a workaholic such as myself and find work somehow interesting, exciting or, heaven forbid - fun). And it is true that being in hospital for too long is bad for patients. The "buff" is the polishing up of the patient so that they are as healthy as you can get them from your point of view. The "turf" is the act of sending them to another medical team, to rehab or home or to a nursing home. And you want to do this in such a way that they don't "bounce" - otherwise known as a failed discharge. On the whole this can be an effective system. Certainly it is the kind of system that everyone seems to like - administrators, consultants, registrars, residents and the patients themselves. Less work, less costs, less time in hospital- you can see the advantages right there. Sadly though this leads to the very predictable problem wherein no-one wants patients unless somehow the rules state they can't be discharged or turfed. Usually the "buff" is very incomplete at this stage. Because we are all just focussed on the turf. So we have some 75 year old patient with an uncomplicated heart attack being admitted under general medicine rather than cardiology because she has a urinary tract infection as well. Or no-one has bothered to check liver function tests and someone with ascending cholangitis ends up on general surgery instead of gastroenterology. Or neurosurgery takes a patient who "definitely has an acute disc prolapse" because overnight no-one wants to argue with the emergency registrar who wants to get patients out of a full emergency department and they turn out to have septic arthritis. It is well documented that admitting patients under the appropriate speciality unit leads to significantly improved outcomes - in particular coronary care units and acute stroke units are cited as examples. It leads to shorter hospital stay, lower complication rates and marked improvements in morbidity and mortality. This is relevant to both speciality and general units, I feel. Often general medicine is better for complex or geriatric patients because rehabilitation and multiple referrals are streamlined, while speciality units can be very focussed- and can miss multisystem disorders. Perhaps what will happen in the futures is that we will have speciality multisystem units- those dealing with "metabolic syndrome and smoking diseases", those dealing with disorders of immunity and infections and such-like. Either way, appropriate unit protocols can be a way of reducing fighting over rejecting patients. It certainly simplifies the process of admission. Another thing that must be done is reducing bed pressures and simplifying routine task management for junior doctors. It is high (and unnecessary) workloads and often very unfair bed concerns that mean the "buff" is not complete. And so they bounce.

I had a fairly disjointed argument on the weekend with a would-be future political type. The crux of this segment was as follows: Him: "The states' power should be preserved because Australia is a federation of independent countries" Me: "But how exactly are Victorians benefited by keeping everything separate?" Him: "They should be separate as a safeguard to the federal government and because of history" Me: "But how does that benefit people?!" &c&c Australia is an odd country. It's one of the least population dense countries and continents in the world. 20 million people most of whom live in cities scattered along the coastline. A huge amount of empty space in which people do actually live, here and there. A great whopping big desert that we try and farm. Mostly developed and first world with one of the highest life expectancies  and best healthcare systems in the world... unless you live in a very remote Australia or are Indigenous. The biggest barriers to healthcare in Australia then?

• Geography
• Race/Indigenous status

Let me explain. There are country towns with a population of 300 which are inland and where the nearest tertiary hospital is greater than 5 hours away. By helicopter. Other towns with a population of 30,000 which have the biggest hospital by road for hours and are very strained. There are towns which are remote or even not that remote but where the closest big centre is in another state. Or where half the town is on one side of the state border and the other on the other side. This is problematic for many obvious reasons. Airlifting trauma patients is difficult. It is difficult to get patients from one state hospital system to another. There are funding issues. Doctors have to ... get this... apply for registration in both states (and pay an exorbitant fee) in order to perform the practicalities of working in a border town. The federal system in Australia is impractical precisely because of the size and geography of the country. Rather than facilitating healthcare in disadvantaged areas by tailoring policy it results in an ad hoc patchwork system where interhospital transfer (something crucial in remote areas where services are difficult to access) is exquisitely painful to organise and results in avoidable delays in getting sick patients appropriate care. The states and their laws are divided by history and accident rather than logic or relevance to modern Australia and its issues. As far as I can tell it only offers disadvantages to its citizens in its current incarnation. Perhaps in a much smaller and more highly populated country the state system would make more sense because it would just be a matter of there existing a protocolled system for treating and transferring patients. However, when you have little choice where to go and what to do and time is critical... it is inefficient, bureaucratic, and furthermore harmful. Conclusion: Whatever you do, just don't get sick in Broken Hill. Or chased by drunk guys because you're a drag queen from Sydney. Whatever.