Dr Jayant Patel: Butcher of Bundaberg Hostpital

050420jayant_patel.jpg

Writing my column I try to follow a fairly standard formula editors seem to really want this of commenting on topical events. Sometimes I find this preoccupation with what’s happening now really frustrating. It means that things at least in journalism are not assessed on their quality or their ‘relevance’ to our lives considered broadly, but rather their relevance to the matters of the hour.

Then again, there’s not much point in grizzling about it. It’s a matter as ever in life of trying to fit the substance to the form. The rules give you pretty wide latitude when you follow them properly, so you just stay on the lookout for ‘hooks’ which are opportunities to develop the themes you want to.

This week’s column was on the rogue doctor Jayant Patel who fled the country having performed disastrous operations in Bundaberg hospital leaving death and destruction in his wake. A lot of the focus of discussion was on how officials should have detected his shonky credentials. He left his previous port of call Oregon State in the US having been disciplined, something which he unsurprising left off his papers when he presented them to Queensland officials. The political excitement has tended to focus on this aspect, though the larger scandal is how he could have practiced for so badly for so long without being stopped.

This is despite various nurses’ complaints, (and I read in one of the news stories the gallows humour of another doctor who said things to Patel like “who are you planning to kill today”). The column argues that we could use the scandal to try to improve information and management systems in hospitals and sets out some examples of how this has been done elsewhere.

Readers will notice a quick reference to Japanese led systems of manufacturing production. I got excited about the Japanese production system when I first encountered it in the mid 1980s. I hope to post or ‘column’ on this in future, but suffice it to say as an intro to the piece, that I regard these new developments in management going variously by titles such as Total Quality Management, the Toyota production system (or ‘Kan Ban’) and ‘lean production’ as matters of considerable significance.

Adam Smith would have been interested in them, their significance in the progress of humanity and in how they can be brought to account in improving our lives. But they are of little interest to economists except as rightward shifts in the supply curve. Sad but true.

Click here for the column or read below for a slightly updated version and one that will survive the Courier Mail’s removing it from their public website.
_________________________________________________________________
Lets turn Dr Patel’s outrage into better hospitals

Dr Jayant Patel, butcher of Bundaberg, was a foreigner. What a relief! It gives us a nice distant target for our horror and outrage. Memo to ourselves: Foreigners can be sneaky and we should check their credentials better. Case closed.

But, though we could and should have prevented Dr Patel’s rampage altogether by checking his credentials (like we do with vets!), the bigger scandal is that internal systems didn’t detect his rampage within a few months if not weeks.

Finding and punishing the Dr Patels of this world is just fine with me. But it would be a whole lot better literally more than ten times better if we also used their outrages to radically improve hospital quality control.

Better information systems are the start. In the early 1990s experts in the New York State hospital system meticulously built a clinical database of cardiac by-pass surgery. All events were ‘risk rated’ so that outcomes were related to operations’ ‘degree of difficulty’.

It turned out that 27 surgeons who only occasionally performed cardiac surgery were performing poorly. They were moved out of cardiac heart surgery to specialise and so improve their own performance elsewhere. A win-win.

One well-regarded hospital had mysteriously high mortality rates for emergency heart patients. The data revealed the anomaly and some simple detective work discovered the cause which was remedied with new procedures. The change has saved around 11 lives a year since. The whole system saw a 41 percent decline in mortality rates over three years.

In Australia, a quite different program based on similar principles yielded similar benefits at the Wimmera Base Hospital in Horsham Victoria.

The Royal Commission should not shy away from holding responsible those who might have stopped Dr Patel’s long before he fled. Yet examples New York State’s experience shows that this is a side show compared with improving the performance of the systems under which all the well motivated members of our health professions work.

Some of the most successful initiatives have been surprisingly similar to the techniques the Japanese introduced into manufacturing in the 1970s and 80s. Firms like Toyota dramatically ramped up their productivity around a cluster of simple but subtly revolutionary ideas, based ultimately on the idea that they were not making things so much as structuring a system in which people controlled and constantly revised and optimised the complex system of which they were a part.

Central principles included:

1. When given the choice and appropriate encouragement, people prefer to work well rather than to shirk.

2. Given that complex systems are difficult to manage with surveillance from above, setting people to work and solve problems in teams helps unleash creativity and makes bad behaviour more difficult because well motivated groups police their own members.

3. In this context, fear and punishment must be driven out of the workplace, so that people can be motivated to identify and fix problems instead of watching their back and passing the buck.

4. Systems particularly systems of control and information should be built not so much to assist management direct or maintain surveillance of workers, but to assist teams of workers to improve the quality of their work.

In the American State of Utah similar principles appear to have dramatically improved the clinical quality of their hospital system. They drive out fear by encouraging practitioners to report all adverse incidents within 48 hours in return for immunity from legal liability for negligence.

The culture of safety that this engenders generates far more information about adverse events to be analysed and encourages professionals constantly to improve and optimise their own systems and performance.

The Utah system is predicated on the idea that well over 90% of adverse events arise from systems that can be improved rather than from individual idiosyncrasies and inadequacies lets face we all have those!

So this system reduces errors far more effectively than a punitive approach based on identifying individual wrongdoing. Indeed, it turns out to be much better at detecting rogues. Not only do generally lower accident rates and better information systems mean that rogues stand out like a politician at Gallipoli on Anzac Day. But there’s also a virulent culture of identifying problems and fixing them.

And, just as the Japanese discovered building cars, better quality needn’t cost money. Getting it ‘right first time’ saves squillions in rework and all the disruption that goes with it. It also facilitates constant improvement further down the production line.

If we’d had such a system in Bundaberg we’d have prevented most or all of the outrages of the Dr Patels. But we’d also prevent over ten times more problems arising from mundane errors by well intentioned and well credentialled professionals working in systems that could be improved out of sight.

Building such a system would be the most fitting monument to the victims alive and dead of the butcher of Bundaberg.

Published as “What a feeling system change evokes” in the Courier Mail on 27th April 27, 2005

This entry was posted in Uncategorized. Bookmark the permalink.
Subscribe
Notify of
guest
21 Comments
Oldest
Newest Most Voted
Inline Feedbacks
View all comments
Jason Soon
Jason Soon
2022 years ago

“Adam Smith would have been interested in them, their significance in the progress of humanity and in how they can be brought to account in improving our lives. But they are of little interest to economists except as rightward shifts in the supply curve. Sad but true.”

Actually, Paul Milgrom has published a lot on the economics of manufacturing though some of his papers are fairly heavygoing mathematically – see his website
http://www.milgrom.net/index.html

then go to ‘Published articles’ and ‘Economics of manufacturing’

observa
observa
2022 years ago

Your points about the quality control of Japanese firms like Toyota are very valid here. The Japanese miracle was largely a result of TQ management. They were not great technical innovators but largely copiers of technology. What they learned was that if the first and 100,000th vehicle off the line were equal in high quality, the world would beat a path to your door in preference to the risk of Monday morning lemons.

Perhaps the Dr Death scenario presents some other peculiar problems for TQ management. Firstly hospitals work in shifts with rotation of staff and concomitant lags in peer judgement. Secondly professionals are supposed to be just that and it can be slow to dawn on independent professionals and hierarchical underlings(nurses) that some are not professional. Thirdly, to what extent did his peers feel uncomfortable about pointing the finger, due to racial PC concerns?

The lag in outing a medical professional whose outcomes were measurable in an obvious physiological way, says something about the difficulties in assessing professionals with mental and psychological outcomes. So much for Cornelia Rau conspiracy theories in this regard.

Tony Healy
Tony Healy
2022 years ago

I think the appeals to “quality management” systems miss the point. Dr Patel was head of surgery and, while the facts are not fully in at this stage, some of the allegations suggest he used his authority to frustrate the workings of the system. A Courier Mail (13 Apr 2005) story reports that problems were flagged by senior hospital staff within a couple of months of Dr Patel’s arrival.

“Highly experienced medical staff questioned what made him tick. ‘He would come in on weekends and on days off and look around trying to find a patient to operate on,’ one said. ‘There were nurses literally hiding the patients from him or standing over the patients to prevent him getting to them.’

http://www.thecouriermail.news.com.au/common/story_page/0,5936,12837697%255E3102,00.html

Francis Xavier Holden
2022 years ago

There’s no doubt that these no fault continuos improvement techniques improve safety and health outcomes. They do however need (reasonably) sophisticated statistical backup to be successful, this in turn needs reasonable numbers and most importantly systems.

From memory Patel had performed (not very well) at least one leg amputation at Bundaberg. My guess is Patel did only 1 (one) leg amputation at Bundaberg – not enough to suggest a trend.

Now I’d suggest, to be objective, that you’d need at least 5 or 6 of Patel’s amputations to see any sort of trend in competence.

I’d also suggest that no one in their right mind would be doing amputations at Bundaberg.

I’d also suggest that the good citizens of Bundaberg would be *extremly* proud that their hospital would be doing “big city” operations locally like amputations.

From memory the College of Obs & Gyny suggests AT LEAST 30 deliveries a year should be the minimum to continue to service births by their members. Most people would agree that a GP doing births should stick to the same standards. However try telling this to the small rural town people and populist politicians trying to keep their hospital doing everything under the sun. Never mind that most of them will travel to the larger regional hospital 20 minutes away for their births or that they can travel 20 minutes to the regional centre for groceries and sport 2 or 3 times a week, it will still be *too far* to travel for that twice a year specialist appointment or surgery.

Patel could only happen in rural and regional australia where unrealistic notions of entitlement to care, that can only sensibly and safely, be delivered under high volume regimes, remain unchallenged and even worse, supported by unthinking populist politicians and empty headed activists.

Tony Healy
Tony Healy
2022 years ago

FXH, on the contrary, all the reports suggest medical staff were concerned that Dr Patel was retaining complicated procedures at Bundaberg, in contradiction to previous practice and against the professional judegement of staff at the hospital. I suspect those locals who were patients would have shared these views.

Country people are not stupid.

woodsy
woodsy
2022 years ago

“In the American State of Utah similar principles appear to have dramatically improved the clinical quality of their hospital system. They drive out fear by encouraging practitioners to report all adverse incidents within 48 hours in return for immunity from legal liability for negligence.

The culture of safety that this engenders generates far more information about adverse events to be analysed and encourages professionals constantly to improve and optimise their own systems and performance.”

Was it not this system that was used to reduce medical litigation at hospitals in the state ? Plaintiffs are usually paid out without costly defence of doctors based on information about adverse events and subsequent risk management.

kerry bullemore
2022 years ago

Hello,

I think we are Justified to whine about this disaster, which people are responsible for. Bigger than the Granville train disaster, worse than the Grafton Bus crash. Peter Beattie does not want to hear a thing about the matter. He calls the Opposition whiners and Fans of Dr Patel, however Peter offered him a new contract and Paul Neville Liberal MP Bundaberg has not, said a word, before, during or after.

Naturally the Opposition stuck their heads in the sand and scurried away from Headmaster Beattie.

I had been very disappointed at the attack which was allowed to occur toward alleged “whistle blower”

kerry bullemore
2022 years ago

Hello,

I think we are Justified to whine about this disaster, which people are responsible for. Bigger than the Granville train disaster, worse than the Grafton Bus crash. Peter Beattie does not want to hear a thing about the matter. He calls the Opposition whiners and Fans of Dr Patel, however Peter offered him a new contract and Paul Neville Liberal MP Bundaberg has not, said a word, before, during or after.

Naturally the Opposition stuck their heads in the sand and scurried away from Headmaster Beattie.

I had been very disappointed at the attack which was allowed to occur toward alleged “whistle blower”

kerry bullemore
2022 years ago

Hello,

I think we are Justified to whine about this disaster, which people are responsible for. Bigger than the Granville train disaster, worse than the Grafton Bus crash. Peter Beattie does not want to hear a thing about the matter. He calls the Opposition whiners and Fans of Dr Patel, however Peter offered him a new contract and Paul Neville Liberal MP Bundaberg has not, said a word, before, during or after.

Naturally the Opposition stuck their heads in the sand and scurried away from Headmaster Beattie.

I had been very disappointed at the attack which was allowed to occur toward alleged “whistle blower”

jack
jack
2022 years ago

Dr Jayant Patel (Dr Death) is a real butcher, he is a murderer!!! He should serve life in prison, or serve the death penalty. Dr Patel, being a professional of such nature (surgeon) and highly qualified, it was his intention to kill and take the lives of those patients he treated. Given the circumstances in his cases, he deliberatly wanted to kill his patients and he did so indirectly by using his own profession as a scapegoet.

Dr Jayant Patel, is fortunate to be gifted to become a doctor and be highly recognised in his working days, but instead of taking the opportunity to treat patients and cure them and do a service to people and the community (which not many people have the qualifications/capacity of doing), he intentionally misuses his power and takes the lives of most of his treated patients, whenever he finds the opportunity to do so. (Personal Comment)

jack
jack
2022 years ago

Dr Jayant Patel (Dr Death) is a real butcher, he is a murderer!!! He should serve life in prison, or serve the death penalty. Dr Patel, being a professional of such nature (surgeon) and highly qualified, it was his intention to kill and take the lives of those patients he treated. Given the circumstances in his cases, he deliberatly wanted to kill his patients and he did so indirectly by using his own profession as a scapegoet.

Dr Jayant Patel, is fortunate to be gifted to become a doctor and be highly recognised in his working days, but instead of taking the opportunity to treat patients and cure them and do a service to people and the community (which not many people have the qualifications/capacity of doing), he intentionally misuses his power and takes the lives of most of his treated patients, whenever he finds the opportunity to do so. (Personal Comment)

jack
jack
2022 years ago

Dr Jayant Patel (Dr Death) is a real butcher, he is a murderer!!! He should serve life in prison, or serve the death penalty. Dr Patel, being a professional of such nature (surgeon) and highly qualified, it was his intention to kill and take the lives of those patients he treated. Given the circumstances in his cases, he deliberatly wanted to kill his patients and he did so indirectly by using his own profession as a scapegoet.

Dr Jayant Patel, is fortunate to be gifted to become a doctor and be highly recognised in his working days, but instead of taking the opportunity to treat patients and cure them and do a service to people and the community (which not many people have the qualifications/capacity of doing), he intentionally misuses his power and takes the lives of most of his treated patients, whenever he finds the opportunity to do so. (Personal Comment)

Deb Roy
Deb Roy
2022 years ago

I liked your view. As an overseas trained doctor who has worked in Australia for 5 years, I believe I am in the position to make a few rational comments:
1.Dr Patel did his basic training in India (an MBBS) since then he trained in Surgery in the USA and was actually a director of surgery there.
2. I believe it is unfair to label all doctors from India as third rate as seems to be the case in the media.
3.It would be just as unfair to call all Australians, pedophiles or drug runners on the basis of a few arrested in India or Singapore.
4.Some of the finest doctors in the world, and now unit heads in the USA/UK are from and trained in India. (Dr.naresh trehan, Dr. Ram Gokal, Dr.Khalid Butt etc to name a few)
5. I have always believed that the Aussies were a fair set of people but here a “mob lynching ” attitude seems in place.
6. Finally I feel a set of surgeons would be in a better position to verify whether Dr.Patel was plain incompetent or a well meaning “surgical cowboy” who had a poor choice of patients needing surgery in a remote public hospital with very poor medical facilities

Dr. D.Roy
MD,DM,DNB,MRCP

Deb Roy
Deb Roy
2022 years ago

I liked your view. As an overseas trained doctor who has worked in Australia for 5 years, I believe I am in the position to make a few rational comments:
1.Dr Patel did his basic training in India (an MBBS) since then he trained in Surgery in the USA and was actually a director of surgery there.
2. I believe it is unfair to label all doctors from India as third rate as seems to be the case in the media.
3.It would be just as unfair to call all Australians, pedophiles or drug runners on the basis of a few arrested in India or Singapore.
4.Some of the finest doctors in the world, and now unit heads in the USA/UK are from and trained in India. (Dr.naresh trehan, Dr. Ram Gokal, Dr.Khalid Butt etc to name a few)
5. I have always believed that the Aussies were a fair set of people but here a “mob lynching ” attitude seems in place.
6. Finally I feel a set of surgeons would be in a better position to verify whether Dr.Patel was plain incompetent or a well meaning “surgical cowboy” who had a poor choice of patients needing surgery in a remote public hospital with very poor medical facilities

Dr. D.Roy
MD,DM,DNB,MRCP

Lynda
2022 years ago

I live in Bundaberg and have observed the public Patel debates from the beginning. I also have personal experience of the Bundaberg Hospital, as a patient, and relative of a patient. It is far from ‘remote’ as Dr Roy suggests, nor have I heard that it has very poor medical facilities. Ive commenced a web log in which there are a number of my observations. If you want to check it out you’re very welcome. Please go back through the June archives as well as the entries since then. In case the address dosn’t show up as a link, it is http://spaces.msn.com/members/LyndasRetreat

Raj
Raj
2022 years ago

I would have to agree with Dr. D. Roy on all points specifically point 6. It is easy to soak in a number like 200 related deaths, or the media magic number of 87 which Dr. Patel is associated with. In fact, the audit team has attributed 8 deaths to an “unnaceptable” level of treatment. As a percentage, that is 6/10 of 1 % of all patients he treated while in Australia. All of a sudden, the statistics are not as conclusive in terms of labelling him as a murderer or neglegent or anything else. Though he appears neglegent, a murderer is a bold comment to make given the facts. That determination should be made by qualified medical personell rather than speculative web surfers.

Raj
Raj
2022 years ago

I would have to agree with Dr. D. Roy on all points specifically point 6. It is easy to soak in a number like 200 related deaths, or the media magic number of 87 which Dr. Patel is associated with. In fact, the audit team has attributed 8 deaths to an “unnaceptable” level of treatment. As a percentage, that is 6/10 of 1 % of all patients he treated while in Australia. All of a sudden, the statistics are not as conclusive in terms of labelling him as a murderer or neglegent or anything else. Though he appears neglegent, a murderer is a bold comment to make given the facts. That determination should be made by qualified medical personell rather than speculative web surfers.

Raj
Raj
2022 years ago

I would have to agree with Dr. D. Roy on all points specifically point 6. It is easy to soak in a number like 200 related deaths, or the media magic number of 87 which Dr. Patel is associated with. In fact, the audit team has attributed 8 deaths to an “unnaceptable” level of treatment. As a percentage, that is 6/10 of 1 % of all patients he treated while in Australia. All of a sudden, the statistics are not as conclusive in terms of labelling him as a murderer or neglegent or anything else. Though he appears neglegent, a murderer is a bold comment to make given the facts. That determination should be made by qualified medical personell rather than speculative web surfers.

Dr. D O'Neill
Dr. D O'Neill
2022 years ago

I used to work for over the last 1 1/2 years at the Base Hospital in Bundaberg as an overseas trained doctor. Amongst now unbearable working condition (lack of staff, racism towards my fellow colleages from India & Asia…) and constant doctor-bashing by the media I left Australia a couple of weeks ago and returned to my home country. Before my departure I wrote a letter to the editor of the only exisitng newspaper in town which was actually recommended to me to do so by the acting Director of Medical Services at the Base. In this letter I shared my thoughts about the scandal from an insider point of view. Nevertheless part of my letter was not printed in full and also altered in an inappropriate and misleading way. It shows once again that the media appears to be more interested in selling a “shocking” story than in practising serious journalism. I really feel very sorry for my overseas fellow doctors who stayed behind in Australia and decided to continue their daily fight for their credibility. I assume that with new assessment criteria for foreign doctors (English and clinical knowledge test, higher registration fees,…) less Western doctors (e.g. Europeans) will take on an assigment in down under, especially for a short term.

trackback

[…] aside: Nicholas Gruen has also discussed this issue in a couple of opeds. He provides several examples in which better information has raised performance. The oped […]

V Greentree
V Greentree
11 years ago

Can somebody compare Dr Patel’ case with 5 death (including three children)due culvert failure on Pacific Hwy under the jurisdiction of Gosford City Council NSW?

It appears Engineers in Australia treat it as part of allowed risk management and next time they try to reduce deaths if the can. Applying science seriously is not their concern. They wait for failure to make improvement?