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The People’s Hospital Tales from the surgeon's table

Chapter Six

The rise of specialisation

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Marilyn Cornish, operating suite theatre manager (second from left) and theatre staff in 1986 looking forward to moving from their cramped working conditions into four new operating theatres due to be completed the following year.

Western Health archives

The trend towards specialisation in surgery and the establishment of specialist surgical units gathered pace in the 1980s, fuelled by advances in surgical techniques, medical technology and a growing patient population.

In 1986 the surgery division’s general surgery units restructured. A specialist vascular surgery unit was set up and the number of general surgical units was reduced from five to three, with three general surgeons in each unit.

Two years later, under the Cain government’s overhaul of health services in the western suburbs, surgeons gained more opportunities to enhance their skills and specialist interests as the hospital expanded its medical teaching, nursing training, health research facilities and community health education and support programs.

Under Professor Thomas’s leadership of the Department of Surgery, three specialist units were created - breast endocrine, colorectal and upper gastrointestinal.

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Benefits for patients

Specialisation enabled surgeons to practice procedures more often, refine their techniques and keep up with the latest research and medical advances in their field of expertise. Their improved skills led to better patient care, according to Joseph Epstein, who was chairman of the senior medical staff in 1994.

“Specialisation and volume counts,” he said. “If you want something done to you, you go to the person who does it often. If you’re a patient, you’re better off. The patient data shows outcomes are better.

One of the inevitable and unavoidable consequences is that you get the ‘grey man’ syndrome – the staff are not as eccentric or colourful as they were in the past but we’re doing better overall.”

The move to specialisation affected every medical service in the hospital. John Mathew was a general physician at Footscray from 1970 for about 30 years. During that era, the medical, surgical, paediatrics and obstetrics division were located together at Footscray hospital.

“There’s an old joke that if you want something done, you get a surgeon and if you want to know what’s going on you get a physician,” Dr Mathew said. “Of course, it’s much more specialised now. I’m a general physician but you don’t find too many general physicians in the city unless they’re old like me. Now people are trained as cardiologists, neurologists or renal physicians.”

The Internal Medical Society of Australia and New Zealand, a peak professional organisation representing physicians, still has general physicians among its membership. But Dr Mathew said general physicians were a dwindling minority who “often come from country towns and the periphery and include old buzzards like me”.

He completed specialist training in diabetes but prefers the diagnostic challenges of general medicine. “If somebody comes in and says, ‘I’ve got diabetes,’ there’s no diagnostic challenge in that. It’s a challenge to get them to start exercising and watching their food . . . So I prefer to be a general physician with an interest in diabetes rather than only seeing diabetic patients.”

Surgeons in 2006 performing lap band surgery, a relatively new procedure to reduce the size of an obese patient’s stomach.

Surgeons in 2006 performing lap band surgery, a relatively new procedure to reduce the size of an obese patient’s stomach.

Western Health archives

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Tensions erupt

Specialisation occasionally led to professional tensions between surgeons and other medical staff. Vascular surgery was one of the areas where such tensions erupted.

Vascular surgeon Barry Beiles joined Footscray Hospital in 1995. As head of the vascular unit from 2002-2012, he witnessed dramatic changes in the relationship between vascular surgeons and radiologists, at a national and local level.

Traditionally radiologists were responsible for carrying out non-interventional procedures such as using stents or balloons to dilate an artery. However, by 2002 surgeons throughout Australia started using these procedures instead of performing open surgery on a patient, due to technological advances in aortic stents and other endoluminal diagnostic and therapeutic vascular procedures and devices.

When vascular surgeons decided to do their own angiography, radiologists became annoyed that surgeons were encroaching on their professional territory and poaching their patients. “They (radiologists) were making it very hard for us to get access to their angio suites on a regular basis,” Mr Beiles said. “They had to carefully vet all of our cases and decide how many we would be allocated to do.

“It eventually reached a head for several reasons. There was the issue of what would happen to the patient if a rupture occurred. And aneurysms that required a stent graft were put in as Category 1 patients, which meant you had to treat them within 30 days of them being put on the hospital’s waiting list, otherwise the hospital had to pay $50,000 penalties. The waiting lists started to blow out beyond the 30-day period. That gave the hospital another incentive to iron things out and get us to work together.”

The dispute was resolved in a round table meeting between the hospital’s vascular surgeons, radiologists and management.

“Our relationship became harmonious,” Mr Beiles said. “Everyone realised that we needed each other . . . It’s now accepted that vascular surgeons are independent and have their own laboratories in private practice so they’re not dependent on access to radiology suites. That’s been the case for the past 10 years or more.”

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Bringing surgeons into the tent of preventative medicine

Specialisation in other areas forged closer ties between the hospital’s surgical units and its medical units, according to Mr Beiles. The introduction of specialist services, such as the hospital’s diabetic foot service, the endocrine unit and the renal unit have brought surgeons into the process of patient care at an earlier stage, involving them in a more proactive, multi-disciplinary approach to preventative health care.

The vascular surgeons have a ward round meeting each week with the renal unit staff to discuss patient treatment options. They are also in constant communication with the endocrine unit, with surgeons seeing the unit’s patients on request.

“Patient outcomes are better with a collaborative approach,” Mr Beiles said. “Many years ago people with infected diabetic feet might be missed and could lie around and lose precious time and lose limbs because diagnosis was delayed while their other conditions were dealt with.

“Close collaboration between our units is now a regular occurrence. It means that we are very focused on time critical patient conditions. So the diabetic infected foot, to us, is an emergency. We’re not missing those and getting patients with advanced disease that makes the leg unsalvageable. We’re able to save more legs this way.

“We’re not getting delayed referrals. As soon as a diabetic patient hits the ward, we’re notified that there is a diabetic patient in the endocrine unit with a foot problem.”

General surgeon Trevor Jones replaced Professor Thomas as head of the Department of Surgery when Professor Thomas left in 2000 to take up an appointment at Peter MacCallum Hospital.

Mr Jones was one of the hospital’s most influential and legendary surgeons. He held senior leadership roles as a clinician and surgical teacher for 37 years at Footscray, until his retirement in 2014 at the age of 70.

During his career Mr Jones mentored and trained more than 600 surgical registrars and interns.

Mr Sayed-Hassen was a registrar at Footscray under Mr Jones’ tutelage. He is now the Director of General Surgery, at Eastern Health. “Trevor Jones is one of the greatest teachers of surgery I have ever worked with,” Mr Sayed-Hassen said. “As a surgical teacher, I have modelled myself on him.

“A big population of currently serving Melbourne and indeed, Victorian, surgeons would have been influenced by Trevor in one way or another,” he said.

The successive generations of surgeons trained by Mr Jones now work in many different specialty fields of surgery: orthopaedic, paediatric, upper GI, general surgery, breast, endocrine, hepatobiliary, ENT, colorectal, and trauma.

Mr Jones said the rise of specialisation over his long career had obvious advantages for patients and surgeons. But it also posed problems for the profession and hospitals: as surgeons are narrowing their focus, many are losing their broader skill set as general surgeons.

Some surgeons had become so specialised in a particular area that hospitals were having difficulty managing their emergency caseloads, according to Mr Jones.

“If you’re rostered to work in the emergency surgery department, you are supposed to look after every patient that comes in,” he said.

“There are some surgeons who feel unhappy about having to do some of the general surgical problems, including simple procedures such as taking a gall bladder out. My attitude to these fellas is that if they’re unhappy about doing these things, they should go and get trained, because surgeons employed at this hospital and all other hospitals are employed as general surgeons.”

Mr Jones said some younger surgeons at some hospitals had refused to go on the emergency surgery roster, which created a bigger workload for their colleagues. It was a problem that hospitals and Colleges of Surgeons were grappling with worldwide.

Mr Jones said if the problem remained unchecked, costs would spiral as hospitals increased the number of surgeons on call.

“To reduce this to absurdity, rather than having to pay one surgeon on call, we are eventually going to have to employ a colorectal surgeon, an upper GI surgeon and endocrine surgeon, which is just ridiculous,” he said. “We haven’t reached that point yet but it’s heading in that direction.

“This is a generational issue and an industry-wide problem. Younger surgeons will say, ‘I trained to become a specialist’. My attitude was to tell them, ‘You’re general surgeons, get on with it’. But that isn’t the prevailing attitude among hospital administrations, it’s a reflection of my age.

“The best surgeons I’ve ever worked with are general surgeons – one in Wangaratta and one in Port Moresby. They could do everything: hip replacements, removing cerebral tumours, opening chests, repairing hearts as well as doing all the orthopaedics and the general surgery.”

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How Footscray played a pioneering role in emergency medicine

In 1980 the hospital’s management team wanted to recruit a casualty supervisor to run the casualty department. They chose one of the hospital’s surgeons, Joseph Epstein, to do the job.

Director of Accident and Emergency Joe Epstein in 1983, getting to know one of the hospital’s smaller patients.

Director of Accident and Emergency Joe Epstein in 1983, getting to know one of the hospital’s smaller patients.

Western Health archives

“As soon as I took on the job, I became aware that right around Australia and around the world, there were a group of people – ex-surgeons, anaesthetists, physicians – in a similar position to me running understaffed emergency departments where junior staff were seeing patients,” said Mr Epstein, now a senior consultant at the hospital’s emergency department. “It was around the wrong way – the most inexperienced staff were seeing the sickest, most complex patients.”

Most patients in casualty had chronic vascular and degenerative diseases, respiratory diseases and cardio vascular disease. Many were injured in industrial accidents.

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A new type of doctor

The hospital’s management was also concerned about a nationwide trend showing casualty (emergency) departments swamped with people seeking treatment, especially after hours. “There is a growing feeling throughout Australia, that a new type of doctor, the Accident and Emergency Consultant, will have to emerge if departments are to keep pace with the ever growing field of emergency medicine,” Dr Peter McCleave, the hospital’s medical superintendent wrote in the hospital’s 1984 annual report.

While running the hospital’s casualty department, Mr Epstein became involved with a core group of emergency physicians in Australia who wanted to improve standards and training in emergency medicine. After three years of discussions with Australia’s main medical colleges, the group decided to set up a separate medical college, the Australasian College for Emergency Medicine.

Mr Epstein was one of the 74 Fellows who founded the College in 1984. Several years later he was appointed as the College’s second president and helped lead a national and international campaign to have emergency medicine recognised as a principal specialty.

“I was pursuing international stature for emergency medicine because we were arguing with the National Specialist Qualifications Advisory Committee about getting specialty recognition for emergency medicine in Australia and New Zealand,” he said.

Footscray’s medical director, Dr Mary Stannard and its executive director, Ian Wolstencroft, supported his efforts to establish emergency medicine as a specialty.

“One critical year when we were setting up the International Federation for Emergency Medicine, I was going backwards and forwards between Australia and the United States garnering support for the idea,” Mr Epstein said. “Ian Wolstencroft said, ‘You can go and we’ll pay for it’.

“Mary Stannard and Ian Wolstencroft were far-sighted and were more supportive than most hospitals, of their emergency department. Part of the reason that I had some persuasive power at the hospital was because I was a surgeon.

“I leveraged my surgical credentials throughout the time we were pursuing recognition for emergency medicine. I had the confidence to do that because of the influence that Footscray’s surgical environment in the ‘60s had on me.”

In 1991 the Australasian College for Emergency Medicine became one of the four founding members of the International Federation for Emergency Medicine. Mr Epstein, as College president, was the Australian signatory to the foundation’s charter, along with the presidents of the other three founding members: the American College of Emergency Physicians, the British Association of Emergency Medicine and the Canadian Association of Emergency Physicians.

Two years later the College, under Mr Epstein’s leadership, obtained principal specialty recognition for emergency medicine in Australia.

A/Prof Epstein said the successful campaign was one of the highlights of his career.

His involvement with Footscray Hospital has spanned more than 50 years, starting from his first experiences as an undergraduate medical student in 1961. As the hospital’s director of emergency medicine, he went on to establish a specialist emergency medicine research centre at Sunshine Hospital supported by Melbourne University.

In 2001 the Joseph Epstein Centre for Emergency Medicine Research was opened by the state health minister, The Hon John Thwaites. Named in honour of A/Prof Epstein’s contribution to emergency medicine, the centre was the first of its kind in Australia, catering for research at Footscray and Sunshine hospital emergency departments. Professor Anne-Marie Kelly was appointed as the centre’s first research professor in emergency medicine.

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Thoracic surgery – changes in patient illnesses

Simon Knight joined the thoracic surgery unit in 1991, working with senior surgeon Peter Clarke. Mr Clarke was an early adopter of technology. In the 1990s he embraced the use of video assisted thorascopic surgery (VATS) and ran one of Australia’s first VATS education courses training surgeons to use the technology.

Since the 1990s, the profile of patients being treated for lung cancer and malignancies of the chest, lungs and oesophagus has changed dramatically, according to Mr Knight.

Male cigarette smokers were traditionally by far the largest group of lung cancer patients treated by the unit’s surgeons. Their numbers have dropped markedly over the past 20 years because smoking rates among men have been declining steadily. But lung cancer in women has been rising.

The unit now treats almost equal numbers of men and women with lung or other types of thoracic cancer.

“Lung cancer among women has continued to rise. We think it’s partly because women, especially young women, feel they are immune from the effects of cigarette smoking, whereas the rate of cigarette smoking among men, especially young men, has dropped precipitously. The rate of smoking in school age young women is remarkably high.”

Thoracic surgeons and their colleagues in respiratory medicine and oncology have traditionally had a close professional working relationship because each group is usually involved in discussing a patient’s treatment options once a diagnosis has been made.

Historically thoracic surgery matured as a discipline in the 1920s when physicians were swamped by the scourge of patients dying from tuberculosis. From about 2005 onwards the historical links between surgeons and physicians have evolved into a multidisciplinary approach to lung cancer.

“We’ve always had a close association with our colleagues in respiratory medicine and in oncology but one of the biggest changes in the last 10 years has been the formalisation of that previously informal arrangement through the establishment of multi-disciplinary clinics and multi-disciplinary meetings,” Mr Knight said.

The unit’s patient caseload includes people suffering from the deadly industrial disease mesothelioama - an incurable lung disease caused by exposure to asbestos in manufacturing of building materials and in shipbuilding.

Asbestos products were commonly used as building materials until the latter part of the 20th century. The use of asbestos has been banned in Australia since the end of 2003.

The disease’s symptoms take up to 20 years to appear, with the number of sufferers in Victoria predicted to peak in 2020.

Workers such as plumbers, electricians and builders as well as family members who breathed in the deadly asbestos dust on their relatives’ work clothes are being treated at the unit.

“Mesothelioma, sadly is a disease where we’ve tried many things but we can’t surgically do a lot to change the course of the disease,” Mr Knight said.

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