Sunday, October 01, 2006

A rare open admission of public hospital failure in Costa Rica

The news site quoted below usually touts the great work done by the Cuban medical system and is very supportive of Castro, Hugo Chazez in Venezuela and Evo Moralis in Bolivia. There has been no reference, however, to the recent outbreak of dengue in epidemic proportions in Cuba nor to the inability of the medical system there to control it. If you aren't familiar with this problem (you won't read about it in the MSM) Cuba Net has a good report here

The emergency room at the San Juan de Dios hospital had to be closed for some eight hours yesterday as hospital staff and doctors could not cope with the quantity of patients requiring medical attention. The announcement was made shortly after 12 noon, asking people not to go the downtown hospital emergency room as they would accept patients until 8:00pm. Hospital officials and officials of the Caja Costarricense de Seguro Social (CCSS) made the decision to close off the emergency facility to allow medical staff to catch up on existing cases. Hospital officials said that they had some 50 patients in the emergency ward when only 18 beds were available.

Those requiring attention were being asked to visit other facilities like the Calderon Guardia Hospital and Hospital Mexico. Patients being transferred by ambulance were being sent to San Rafael de Alajuela and Vicente de Paul, Heredia facilities.

Rosa Climent, medical chief for the CCSS, said that yesterday's crisis is just one chapter more at the San Juan de Dios. Just a little over a month, medical authorities complained of the shortage of 16 anesthesiologists which has resulted in the waiting list for surgeries to grow to more than 8,000. In addition, unofficial reports have been floating that the hospital is lacking some 400 beds, equipment that does not work, flooded floors, cracked walls and four areas closed off due to collapses in the construction.

Climent said that the CCSS is working on a "Master Plan" to address all the problems at the hospital, in the hopes of bettering conditions, both for the medical staff and patients. To achieve their end, Climent said that hey will seek the support of the Organizacion Panamericana de la Salud (Panamerican health organization).

The San Juan de Dios hospital is one of the most important medical facilities located in the middle of downtown San Jose


Dodgy doctors working in Australia but governments don't care

Comment below by John P Collins, dean of education at the Royal Australasian College of Surgeons

During the recent inquiry on skills recognition by the federal parliament, evidence was presented to the Migration Committee reflecting concerns about the lack of proper assessment of overseas-trained doctors, and of surgeons in particular. The question that immediately arises is whether the Australian public should be concerned about standards of surgical care provided by surgeons trained overseas? And, what processes, in any, are in place to ensure all surgeons working in Australian hospitals are properly assessed and up to requirements? The first answer is - not usually, and rarely when the existing systems of assessment in place for this purpose in Australia are applied.

The Royal Australasian College of Surgeons is responsible for the training of all surgeons who train in Australia and New Zealand. Those in its programs must undertake comprehensive education and training, gain wide surgical experience and undergo repeated assessments to ensure they have reached the uniform standard required to practise surgery without supervision.

No one would disagree that there must be in place an equally robust process which assesses the competence of overseas-trained surgeons who wish to work in Australia and New Zealand. These surgeons vary enormously in their level of training and experience and include those who are outstanding and occasionally leaders in their field, as well as those who may have had minimal, or indeed no, formal training. There is an established national assessment process available in Australia which is endorsed by the Australian Medical Council, the different medical colleges and the state registration boards. The colleges have worked on streamlining their processes and now have agreed timelines within which they must complete the process.

For surgeons, the process is initiated when an individual first applies to the Australian Medical Council, which ensures the submitted documentation is in order and verifies whether the applicant has bona fide qualifications. Already this year this rigorous process has screened out two applicants whose documentation did not stack up and who never got to practise in Australia. The application is then forwarded to the College of Surgeons, where assessment includes checking for level of training, experience and assessment, recency of practice and documented evidence of "good standing" from the formal registration authorities in the country of their origin. This is followed by a structured interview. A decision is made as to whether an applicant is either "substantially comparable", "partially comparable" or "not comparable" to an Australian-trained surgeon.

Those who are substantially comparable are required to undertake a period of supervision in their new post, usually over one year, and those considered partially comparable must undertake a period of upskilling and complete the college's exit examination. Those who are not comparable must sit the Australian Medical Council registration examination if they wish to remain in Australia, following which they can apply for surgical training in the same manner as all Australian-trained medical graduates. For those who wish to work in positions designated as "area of need", a decision is made as to whether the applicant has the competencies required to undertake the specific post for which they have applied.

The real worry lies in the number of doctors appointed into surgical positions without any such assessment taking place, because state and territory registration boards are using their discretionary power to grant registration - often due to pressure to fill a longstanding vacant hospital post. Of equal concern is that many of these doctors have no proper supervision in their local workplace. No one is certain how many such appointments have or are being made, but this college regularly receives applications from people who have been in posts for some considerable time. Furthermore there seems to be no local pressure on these surgeons from either their employers or registration boards to apply for formal assessment.

There is often an ongoing tension between the need for safety and standards and the supply of surgical care. However, the recent experience in Queensland clearly demonstrates the danger of bypassing the established assessment processes. A somewhat controversial issue surrounds the requirement for all appointed overseas-trained surgeons to work under supervision for a defined period, usually not less than one year. The federal inquiry was told this is an imposition, as many have already worked as specialists elsewhere and the requirement may impact on specialist recruitment. This rhetoric needs to be balanced by the reality that not all doctors who appear competent on paper and at interview are actually competent once they are in the local workplace.

Overseas-trained surgeons hail from many different countries, with widely divergent cultures and health systems. Once appointed in Australia they require a period to learn local hospital systems, establish support networks and confirm both to themselves, their colleagues and their employers that they can work in what is often a very different environment to the one which they have previously worked in.

There are many anecdotes of overseas-trained surgeons who have benefited greatly by a period of supervision and upskilling, some of whom have been enabled through this process to realise their career aspirations and provide a lasting contribution to the Australian community. Inevitably there also are some practitioners who have been found wanting in different ways. It is vital that these people are quickly identified and a process put in place to ensure patient care is not compromised.

The availability of appropriate local supervisors is also a real issue, particularly in rural or remote areas. The college would prefer overseas surgeons appointed into such positions to first work for a short period in a major hospital where they can be properly supervised, learn how the healthcare system works and establish their networks. The federal government does provide some financial assistance for such a program, but it is rather limited and does not meet the identified needs.

The Productivity Commission has recommended the introduction of a national accreditation board for the assessment of overseas-trained doctors, but it remains unclear what this new bureaucracy will entail. It is to be hoped that the experience and credibility gained by the Australian Medical Council will not simply be dismantled. We are not struggling with the absence of a robust, agreed assessment system - but with the fact it is not always applied. Surely this must be made mandatory.

The Royal Australasian College of Surgeons is very supportive of overseas-trained surgeons. We recognise their importance as part of the surgical workforce and the substantial contribution they make to the healthcare of Australians. At the same time one of the most fundamental roles of the college since its inception 80 years ago has been to ensure that safety and standards of surgical care are foremost at all times. The college will continue to advocate for these issues, not only from its own trainees but for all who practise surgery in both Australia and New Zealand.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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