Chairman's Report

Introduction

Upon reflection, 2016 was a difficult time and a catalyst for positive change in both organisations. The change process is ongoing and already we can see an improvement in the financial position of RHMS. However, secured contracts with the relevant HHS’s must be finalised to ensure we have continued stability and evolution.

There continues to be opportunities to manage and deliver projects under the CQ Rural Health umbrella. The board need to consider the value of these projects to the longer term vision of the organisation. However, it is evident that the organisation is trusted and respected and can be relied upon to deliver projects and services in a responsible and sustainable manner.

CQ Rural Health

Constitution Review

The sub- committee met in early December 2016 and continued their review of the constitution. This process has taken on a new level of importance given the recent AGM that saw the organisation become unconstitutional. The sub-committee will finalise their recommendations and report to the board at the face to face meeting in March 2017.

Rural Health Management Services

Negotiations with the Hospital Health Services

The period over December and early January has been a quieter time within the organisation with relation to negotiations. We have recently received a letter from the Wide Bay Hospital and Health Service which presents a slightly different model for our consideration. No correspondence has been received from Mackay or Central Queensland Hospital and Health Services as yet.

Eye to the Future

The board and organisation need to be aware of the various reviews, such as the Commonwealth Medicare Review, that may impact rural general practice viability and delivery. The organisation need to position themselves to be sustainable in the areas that rely upon them.

In conclusion, I am looking forward to a progressive 2017, that will see our organisation having a solid base; with the ability to flourish. Thank you for your commitment to the organisation and for bringing your expertise to the table.

 

Yours sincerely

Mike Belonogoff

CQRH Happenings

It’s two months into 2017 and already we have filled our little office with yet more warm bodies. Deb Louis and Deirdre Fagan-Pagliano have joined the Admin Team. Deb is part of the casual Admin pool while Deirdre has started working on the new service mapping project in Gladstone (among other things). Ben Lederhose, our casual IT consultant, is also starting a school-based traineeship with us this month. For people who work exclusively with computers we are a surprisingly un-tech-savvy lot so it will be great to have him around every Wednesday.

With so many new employees, office space is getting tight. We have explored (independent of the CEO or the board) a couple of new options. It’s tough finding a space that will fit us all and be as cost-effective as our current location. However, we think we may have found the perfect one. Now to get it past Sandra and the Board!

 

Integrated Allied Health in Rural Communities—Project Update

Unfortunately the role of Project Officer is now vacant as Ellen has resigned from the position. However, things are going pretty well. Donna (pictured), the Project Admin Officer, has stepped up to handle most of the work load, while Sandra has taken over the responsibilities associated with leading the Project. Admin Staff in the office have also been working with Donna to keep the Project going as smoothly as possible.

The Primary Data has been collected and collated and has been presented to the  three main committees (which are made up of representatives of the projects main stakeholder groups). There is the Steering Committee, The Allied Health Reference Group and the Community Reference Group.

However, there is still a lot of data to collect. One major obstacle is the lack of willing parties to complete surveys (you know who you are!). These surveys are essential for us to better understand current service funding, patient eligibility and other potential funding sources, as well as how community members feel about the services they are currently receiving.

To access the Patient Audit Survey please click here. For the patient audit survey we are aiming to capture a one week window of your normal clinic in the Banana Shire.  The week we would like to capture is anytime during 1 November to 31 December 2016.

For a copy of the Patient Audit Survey or the Patient Satisfaction Survey, please email Donna at donna.johnson@cqrdgp.com.au.

An exciting development within the project are the three Allied Health Assistant scholarships which have been awarded to successful applicants Rowie White, Trudy List and Danielle Beezley. The development of the role of Allied Health Assistant is well supported to improve services across multiple sectors. We wish aspiring AHA’s well with their training.

 

If you would like to know more about the project, or you wish to be involved, please don’t hesitate to contact us on 07 4992 1040 or email Donna at donna.johnson@cqrdgp.com.au.

 

CPD Update – Emerald

Early in February Dr Hany Aziz (MBDS) presented to about 30 health professionals on the topic Oral Health and Human Health Well-being.

Speech pathologist, dieticians, child health nurses and dentists, from as far away as Middelemount, were among the audience present to learn about the oral and human health.

Dr Aziz practices in Mackay and Moranbah and sees many patients from the Central Highlands region.  Speech pathologist and CQRDGP board member Louisa Backus said, “this CPD event was well supported and had excellent clinical content, and provided an opportunity to network across the health sector.”

Dr Aziz  recently made headlines for his unique approach to managing patient anxiety in the dental surgery.  Dr Aziz has introduced a therapy dog into his waiting room to ease anxiety and replace potential negative experiences associated with the dentist with a more positive one.

The next CQ Rural Health CPD event scheduled for Emerald is Black Lung Update on Tuesday March 7 at the Maraboon Tavern.  Contact Emma McCullagh at emma.mccullagh@cqrdgp.com.au for more details.

 

Dr Takasei Morioka and his wife, a qualified nurse, Chiaki  Morioka, spent three weeks in February visiting the Central Queensland region.  They are visiting from Japan and were keen to get a taste of rural medicine in Australia.  Their visit has included observer ships at  Central Highlands Health,  Belman Medical, Emerald hospital, Clermont Surgery, Theodore Medical and Woorabinda. They have also enjoyed visits to an irrigation farm and cotton picking, a mine tour, Minerva Hills National Park, the Fairbairn Dam and the Gemfields.

Japan is launching their rural generalist program at the WONCA conference in Cairns later on this year. The Early Bird registration has been extended to February 28th, so hurry! For more details about WONCA, please visit http://www.globalfamilydoctor.com/.

 

CPD Update – Biloela

On Saturday February 18 CQ Rural Health partnered with the Central Qld, Wide Bay and Sunshine Coast PHN to present the first Banana Shire Education Day.  About 23 health professionals, including GP’s, nurses, practice staff, allied health and medical students attended.

Ten presenters spoke on various topics including Health Pathways, Allied Health Services, Mental Health, Medico Legal, Exercise is Medicine, My Health Record as well as an interactive simulation on Emergency situations in general practice.

The day was a huge hit with everyone happy with the informative and interactive sessions, as well as opportunities to meet and network with fellow health professionals in the Banana Shire.

Keep a look out for upcoming Education Days in North Burnett as well as another Banana Shire Education Day later in 2017.

 

College puzzled by 'unjustified' cannabis guidelines

Australia’s first cannabis prescribing guidelines have been met with bewilderment, described as mysterious, unjustified, and unsupported by evidence.

The 29-page document from the Queensland health department, made public on Australia Day, provides guidance on sourcing, doses and regimens.

The guidelines focus on treatment of drug-resistant epilepsy in children, and symptom control in palliative care, chemotherapy and multiple sclerosis.

Yet a puzzled Dr Evan Ackermann (pictured), chair of the RACGP’s Expert Committee on Quality Care, says they have “no justification in evidence”.

It is unclear who the authors are, let alone how they came up with the recommendations, he says.

“This is very contrary and unusual that the government supplies a clinical guideline without any sort of justification.”

The document stresses that cannabis should not be prescribed as a first-line therapy for any condition, and only when the usual standard of care has been ineffective or produced intolerable side effects.

It says medicine containing tetrahydrocannabinol should not be prescribed to patients who:

  • Are aged under 25;
  • Have a personal history of psychosis or concurrent mood or anxiety disorder;
  • Are pregnant or planning to be pregnant;
  • Have an active substance use disorder; or
  • Have unstable cardiovascular disease.

Doses should be increased slowly, preferably weekly, until a satisfactory dose is reached, the guidelines say.

Queensland Minister for Health Cameron Dick says the guidelines will give doctors clarity on medical cannabis and the confidence to consider its use as part of treatment plans.

States across the country have eased regulations on medicinal cannabis, and Prime Minister Malcolm Turnbull recently declared it a therapeutic option for doctors.

The RACGP remains concerned that governments are moving too quickly given the lack of a robust evidence base on efficacy and harms.

Under the Queensland guidelines, prescribers will be required to submit a report every three months to the state’s Medicinal Cannabis Unit discussing symptom control, adverse events and aberrant behaviour.

They stress that treating doctors should “take full responsibility for the use of [medicinal cannabis] as with any other unapproved therapeutic good”.

Sativex, for spasticity associated with multiple sclerosis, is the only cannabis-related product that presently approved by the TGA.

Follow the link to access the Queensland Clinical Guidelines: https://www.health.qld.gov.au/__data/assets/pdf_file/0023/634163/med-cannabis-clinical-guide.pdf

Rachel Worsley and AAP, Australian Doctor, 27 January 2017

Medical cannabis approved, but concerns remain

The Federal Government has approved the sale of medical marijuana via GPs, but several issues remain for prescribers, patients and other stakeholders.

Medicinal cannabis could be available under the new scheme in as little as eight weeks.

“It’s a space that is moving fairly rapidly now. There is a strong advocacy from patient and community groups for improved access and the Government has responded to this with the recent announcement,” says Dr Scott Smid, a senior lecturer in pharmacology at the University of Adelaide.

“This is not without reason, for there is building anecdotal evidence of the effectiveness of medicinal cannabis for various conditions, but I see a critical next step as being to address more research into just how effective medicinal cannabis is and under which therapeutic context(s).

“It is cited as being effective in conditions ranging from epilepsy to neuropathic pain, arthritis and inflammatory bowel disease, but the clinical studies are either very few or ongoing and it will be the outcomes of these that medical practitioners ultimately look towards for guidance.”

He says that it is critical, to ensure that the use of medicinal cannabis is safe and effectively targeted in the community, that it obtain acceptance within the medical community, whose benchmark reference point will be the evidence from clinical trials. “Even in terms of basic research there is so much we still don’t know about the bioactive components that make up the cannabis plant. We know a bit about THC, but even the pharmacology of another major cannabinoid, cannabidiol is still emerging,” says Dr Smid.

“Even in terms of basic research there is so much we still don’t know about the bioactive components that make up the cannabis plant. We know a bit about THC, but even the pharmacology of another major cannabinoid, cannabidiol is still emerging,” says Dr Smid.

“Add to that the 60-odd other cannabinoids and hundreds of plant terpenes and it becomes a tricky puzzle to tease out what works and where in the body, or even the added complexity of how they may all work together in the so-called ‘entourage effect’ to provide a potential therapeutic benefit.”

He says the vast scope for further research is exciting, “as cannabinoids may reveal new insights into the biological basis of disease, for example some types of epilepsy, as well as open up new targets and avenues for disease treatment.

“This last point is one that may also ensure the longer term sustainability of the fledgling medicinal cannabis industry in Australia, in terms of providing new markets. So I see both the clinical and preclinical research as critical to informing the safe and effective use of medicinal cannabis in Australia.”

Dr David Caldicott, an emergency consultant and senior clinical lecturer in medicine at the Australian National University, says it is possible that the move could make life easier for patients in two months’ time.

However, “there is very little information available to the medical profession about the strains being grown, and the intended formulation.

“The special access schemes in place to allow prescribing remain opaque and cumbersome. We are regularly advised by the (Australian) authorities that Australia is evolving as the best practice leader in this space. The global evidence remains overwhelmingly to the contrary.

“It is clear that there are conditions for which medicinal cannabis has benefit, and should be made immediately available, as it is clear that there are conditions for which much more work is needed. Dithering because of political indecision, the tensions between Big Green and Big Pharma, and concerns regarding any threat to the Tasmanian opium market provides no reassurance to patients, nor security to the Australian public at large.”

And Associate Professor David Allsop from the University of Sydney says the announcement is a welcome step, but some “potential flash points” remain.

“In having a local supply on hand, the timeline and costs of a patient getting access to medical cannabis products will be greatly streamlined,” he says.

“Prior to this change, patients have faced a lengthy process of navigating federal and state level permissions and import permits, and overseas suppliers needing to organise export permits – all at significant financial and time cost to the patient.

“These sourcing issues will now be dealt with in a faster more efficient manner,” explains A/Prof Allsop.

“There are some potential flash points that need to be considered also, such as whether allowing bulk importation and storage from overseas will in any way interfere with the Federal Government’s November 2016 legislation, designed to encourage local Australian companies to establish growing and manufacturing operations for medical cannabis here in Australia.

“It could be that allowing overseas importation lends significant competition to these emerging enterprises making it difficult to justify business models to investors.

“The announcement also does not solve an issue installed by the Federal Government in November 2016, when access to medical cannabis was removed from the Category A route of the TGA’s Special Access Scheme.

“Cannabis is the only scheduled drug to have been excluded from this route of access – meaning that terminally ill patients cannot gain ready access in the timeframes appropriate to their dire situation, despite being arguably one of the patient groups most likely to benefit.

“It also doesn’t change the fact that in order to gain access, a doctor still needs to make the application, but most doctors either do not know how to apply, do not have the required training or expertise to apply, or are politically or philosophically against supporting a medical cannabis application.”

Meanwhile, Medlab Clinical Limited has completed its final steps to start Australia’s first clinical trial using cannabis for oncology patients suffering intractable pain.

Medlab says it supports the Government’s initiative and also shares medical community concerns around safeguards and evidence based prescribing of cannabis products.

Medan Haggan, Australian Journal of Pharmacy, 22 February 2017

Your guide to the clamour for cannabis

The mystical Chinese Emperor and herbalist Shen Neng, who lived more than 4000 years ago, is believed to be among the first healers to prescribe marijuana tea as therapy for ailments such as gout, rheumatism, malaria and, perhaps surprisingly, poor memory.

According to legend, Shen Neng experimented on himself and could see into his own stomach to observe the effects of the cannabis on his body.1

Meanwhile, in India, the hemp plant was revered for religious and spiritual properties and as a panacea for dysentery and sunstroke. In medieval Europe, cannabis was used to treat tumours, coughs and jaundice.

Cannabis use dates back as far as 8000BC. Yet the evidence for its pharmaceutical efficacy remains as grey as the contents of Shen Neng’s stomach.

Nevertheless, in February 2016, the Australian government amended the Narcotic Drugs Act, allowing the supply of suitable medicinal cannabis products for the management of painful and chronic conditions. In the following months, states and territories drafted laws governing the prescription and supply of medicinal cannabis.

Are we rushing into this?

In the aftermath of this flurry of activity there has been widespread confusion and scepticism among doctors. Many question whether the cart has been put before the horse; whether legislative change has been driven by the passionate campaigns of patients and advocacy groups rather than evidence-based medicine.

“Cannabis has been around for a very long time and it is amazing that we still don’t know what to do about it,” says GP Dr Simon Holliday, a NSW addiction medicine physician and chair of the RACGP’s pain management network.

“Rhetoric-based policy causes trouble. We did the same thing with opiates.

“People said opiates are good for terminal cancer, then it became: why not use it to treat chronic pain? We are at risk of doing the same thing with cannabis.

“It might well be that doctors will be the appointed group to make decisions about whether someone’s cannabis use is appropriate or not, whether they are using it to feel better or to feel a whole lot better.”

Although the new legislation may give the impression that it’s as simple as a doctor dashing off a script for medicinal cannabis, getting the script filled is a different story.

If the drug contains delta-9 tetrahydrocannabinol (THC), it will be a Schedule 8 product and require approval from a state health department as well as the TGA. If it is a cannabidiol (CBD), it will be in Schedule 4.

The doctor does not require an application for authority, but to get the script filled, TGA approval must be sought.

Another way of viewing the legislation, of course, is that it is necessary to progress scientific research into a drug that is already used for therapeutic purposes by various patient groups.

Potential for treating epilepsy 

Dr John Lawson, a paediatric neurologist at the Sydney Children’s Hospital, is at the helm of a trial of medicinal cannabis for the management of seizures in children with epilepsy.

Of the 60 or so cannabinoids in the cannabis plant that are being studied for medicinal purposes, the ones showing most promise are THC and CBD.

A 2014 systematic review2 of cannabis for neurological conditions showed that oral THC, and the THC plus CBD oromucosal spray nabiximols (Sativex, developed by GW Pharmaceuticals, UK), each has modest efficacy for patient-reported but not objective measures of spasticity in multiple sclerosis. There was insufficient information to gauge efficacy in epilepsy, the authors found.

The drug being used in the NSW trial, Epidiolex (a GW Pharmaceuticals product candidate) is a medicinal grade liquid which is 98% CBD, something Dr Lawson says holds both promise and risk.

“We understand the risks of THC; there is no way you could trial a THC drug in children,” he says.

“We are giving this [CBD] drug to sometimes very young children without great knowledge of long-term side effects. If it works they have to take it for potentially the rest of their lives.”

Many of the proposed indications for medicinal cannabis rely on THC as the active ingredient although it is the source of the most concerning side-effects.

When it comes to epilepsy and seizures, it’s a different picture. Dr Lawson says animal models have shown that, although THC might worsen epileptic seizures, CBD could be protective.

“There is not really a simple way of putting it but if you ask me about any epilepsy drug we don’t really know how it works,” he says.

“In the case of cannabis, this is also because there has not been much research because it has been illegal.”

Promise for patients on chemotherapy

Associate Professor Peter Grimison, from the University of Sydney and Chris O’Brien Lifehouse, a Sydney cancer hospital, is leading another of the NSW studies, the largest randomised controlled trial (RCT) in the world of medicinal cannabis for prevention of nausea and vomiting in patients undergoing chemotherapy.

The drug being used is an oral capsule, a 1:1 mix of THC and CBD developed by a Canadian company.

The trial builds on a small Spanish study which found that a spray form of cannabis medicine containing THC and CBD in equal amounts (not routinely available in Australia) led to a 50% reduction in the number of chemotherapy patients experiencing nausea and vomiting.

Professor Grimison, a medical oncologist, says there is some evidence that the CBD counteracts the hallucinogenic and anxiety-provoking properties of THC.

Although there are many potential uses for medicinal cannabis, the jury is still out on its optimum formulation, safety and long-term side-effects.

“There is lots of anecdotal evidence from people who smoke cannabis or take an oil but there is not the evidence we need yet,” Professor Grimison says.

“One of the problems with the existing research is that it is very old and before modern anti-emetics.

“Another issue is that the available forms of illegal cannabis are high in THC and tolerance is often poor.”

Professor Grimison says that since patients in the trial will take the drug only for the duration of a course of chemotherapy, the long-term effects of THC are not as much of a concern.

Where the long-term effects are concerning, is in the use of cannabis for pain management in a non-palliative context.

Will cannabis help in chronic pain?

Pain specialist Dr Chris Hayes, director of the Hunter Integrated Pain Service, NSW, says there is little evidence in favour of medicinal cannabis to manage chronic pain.

The most recent systematic review3 recommends against cannabis products for pain management based on lack of evidence and the fear of substantial harms.

“Chronic pain is obviously the bigger market [for medicinal cannabis] and where the financial vested interests are angled,” Dr Hayes says.

“Then you get into a discussion about the harms, and these are substantial, although they may be less of a concern in a palliative care phase.

“If we are going to put a medicinal label on the front of a cannabis product it needs to go through normal RCT pathways and the balance of benefit and harm.

“As we do this in the chronic, non-cancer pain setting, it doesn’t stack up. We need to be cautious because a lot of the community advocacy is not cautious.”

When it comes to pain relief, Dr Hayes says animal studies indicate that any potential benefit of medicinal cannabis depends on the THC component.

“You cannot get the analgesia until the rat is stoned and lying at the bottom of the cage,” he says.

“Certainly in a pain context the two seem to be inseparable.”

The potential for abuse

Dr Hayes, who is also Dean of the Australian and New Zealand College of Anaesthetists’ Faculty of Pain Medicine, says it is important that medicinal cannabis does not travel the same path of misuse and abuse as opioids for chronic pain management.

“Our approach in a multi-disciplinary pain service is to stop medications and transition to a self-managed approach.

“We do see a lot of people already on cannabis for chronic pain and they always define a really poorly functioning group.”

Dr Holliday agrees that aside from permitting compassionate access for patients with terminal cancer, Australia needs to tread carefully to avoid “opening the floodgates to a drug that we know has many, many harms”.

“In my drug and alcohol clinic we see ubiquitous cannabis use; inevitably [these patients] are doing poorly in their relationships and their life.

“Rarely do they say they are using because I like to get stoned. They are saying ‘I am using it to sleep or because I am stressed’.”

Something as simple as a GP writing a script for medicinal cannabis to be filled at the local pharmacy is likely to occur within the next decade, Dr Lawson says.

That’s why the Australian legislation and accompanying research into medicinal grade products is important.

He says it is essential to avoid a situation such as that in the US, where non-medicinal grade cannabis can be legally obtained in many states for a wide range of conditions.

“The American system is a complete disaster: in those states where it is legal they have qualifying conditions which are not necessarily evidence-based.”

“Someone might come in and say they have a bad back, the doctor gives them a letter and they can go to a dispensary [but] the cannabis they are buying is not medicinal grade.

“The key principle is that this is a drug and, no matter what people say about its magical powers, it should be treated the same as any other drug.”

References:

  1. Understanding Marijuana: A New Look at the Scientific Evidence. Mitch Earleywine, Oxford University Press, 2002. Page 10.
  2. Neurology 2014; 82(17): 1556–63.
  3. Can Fam Physician 2015; 61(8):e372–81.

 

Emily Dunn, Medical Observer, 7 February 2017

Medicinal cannabis medications: the key points

EXPLAINER

The main ingredients in cannabis being targeted for medical purposes are delta 9-tetrahydrocannabinol (THC) and cannabidiol (CBD).

THC produces a ‘high’ and has also been used to treat symptoms such as nausea, pain and muscle spasticity. CBD has no psychoactive properties, and has been used to treat inflammatory disorders and epilepsy.

Three main medicinal-grade cannabinoid products have been developed pharmaceutically and approved for use overseas.

[Medical Cannabis: Do doctors have enough information to prescribe?]

Dronabinol and nabilone are both synthetic forms of THC indicated for chemotherapy-induced nausea and vomiting. Neither is on the Australian Register of Therapeutic Goods (ARTG).

Nabiximols (Sativex, Novartis) is a chemically pure 50:50 mixture of TCH and CBD. Nabiximols is the only cannabis-derived product on the ARTG and is indicated for spasticity in multiple sclerosis.

Currently there is little evidence from randomised controlled trials for its efficacy in palliative care medicine. Recent trials have not shown significant pain relief in patients with advanced cancer.

A trial in NSW is testing the efficacy of nabiximols for anorexia in patients with advanced cancer. The Australian and New Zealand College of Anaesthetists’ Faculty of Pain Medicine statement regarding its use notes the college “does not endorse the use of cannabinoids in chronic non-cancer pain until such time as a clear therapeutic role for them is identified in the scientific literature”.

The Clinical Oncology Society of Australia and the Cancer Council Australia have advised that: “There is no current evidence that cannabis or cannabinoids are effective at inhibiting tumour growth or to treat or cure cancer in humans. In addition, there is no current evidence that cannabis or cannabinoids reduce risk or prevent cancer occurrence or promote good health.”

 

Fact check: Are bulk-billing rates falling, or at record levels?

Dr Thomas Longden and Associate Professor Kees Van Gool, Australian Doctor, 10 February 2017

“Falling bulk-billing rates …” – Labor leader Bill Shorten, address to the National Press Club, Canberra, January 31, 2017.

“Bulk-billing is at record levels …” – Prime Minister Malcolm Turnbull, address to the National Press Club, Canberra, February 1, 2017.

In speeches delivered 24 hours apart, Labor leader Bill Shorten and Prime Minister Malcolm Turnbull made conflicting claims about the state of bulk-billing rates in Australia.

A bulk-billed consultation occurs when the fee charged by the doctor or medical provider is equal to the benefit paid by Medicare – leaving zero out-of-pocket cost to the patient. The percentage of Medicare-funded consultations that are bulk-billed is referred to as the bulk-billing rates. These rates are widely seen as a proxy indicator of the accessibility of Medicare-funded health care.

Shorten said that bulk-billing rates are falling. The next day, Turnbull stood at the same lectern and said bulk-billing rates are at record levels.

Who was right?

Checking the sources
When asked for sources to support his statement, a spokesperson for Bill Shorten said:

“The government’s figures show that from June to September 2016 the bulk-billing rate for non-referred attendances fell from 84.6% to 84.1%.”

The spokesperson added:

“Through an information request through the Parliamentary Budget Office, we know that for item 23 – a standard GP consultation – we also know the bulk-billing rate is falling: from 82.81% in April 2016 to 82.38% in May 2016 to 81.97% in June 2016. This trend continues as is reflected in the rate falling for all non-referred attendances from June to September.”

The Conversation has independently verified those figures, which are not publicly available.

A spokesperson for Malcolm Turnbull told The Conversation that:

“The headline bulk-billing rate of 85.1% for GP services is the official bulk-billing figure for 2015-16. This is the highest bulk-billing rate for GP services since 1984-85 (when Medicare started) – ie: record levels.

“The headline bulk-billing rate of 78.2% for all Medicare services is the official bulk-billing figure for 2015-16. This is the highest bulk-billing rate for Total Medicare services since 1984-85 (when Medicare started) ie: again, record levels … the bulk-billing rate has been reported on a consistent basis under all governments since 1984-85.”

You can read the full responses from Shorten and Turnbull here.

Same source, different statistics

Both Shorten and Turnbull’s statements are supported by the Department of Health’s Medicare Statistics – but Shorten has quoted quarterly statistics while Turnbull has quoted annual figures.

They are also both looking at slightly different categories within the Medicare bulk-billing data collected by the Department of Health.

Overall, however, neither politicians’ sound bite provide a complete picture on what’s happening with bulk-billing in Australia.

Yearly data on bulk-billing rates show record highs

The chart below shows the annual bulk-billing statistics for the financial years from 1984-85 to 2015-16. It shows the bulk-billing rate for all Medicare claims combined and selected services – not just GP visits.

* Includes Pathology Episode Initiation and Pathology Tests

Source: Annual Medicare Statistics Get the data

For overall Medicare claims (the red line), the bulk-billing rate in 2015-16 reached 78.2%. As correctly stated by Turnbull, this is an all-time high within the annual statistics.

Annual bulk-billing levels were also at record highs last financial year for non-referred GP attendances (which, by and large, means going to see your GP), pathology services and diagnostic imaging.

However, the bulk-billing rate for specialist services (the black line) in 2015-16 was at 30.2%, still below the record level set in 1995-96 of 32.5%.

So, technically, Turnbull is right to say bulk-billing rates are at record highs – as long as you use annual statistics and ignore the most recent data for the July to September 2016 quarter.

But quarterly data show bulk-billing rates fell in the third quarter of 2016
Quarterly statistics on bulk-billing rates are shown in the chart below.

* Includes Pathology Episode Initiation and Pathology Tests

Source: Quarterly Medicare Statistics Get the data

As you can see, drilling down to the quarterly data reveals that bulk-billing rates fell in the third quarter of 2016.

For total Medicare claims (the red line), bulk-billing rates fell by 1.1% in between the June and September 2016 quarters. But it is worth noting that it fell from the highest bulk-billing rates on record (78.7%).

The fall between June and September 2016 is the 11th biggest quarterly decrease (in percentage terms) since Medicare’s inception. But while it was a relatively large drop in bulk-billing, it is still within the range of quarterly variability that we’ve seen historically.

For non-referred GP attendances (the blue line), the September quarter data shows a 0.6% fall in bulk-billing rates compared to June 2016. For pathology services (the orange line), the bulk-billing rate fell by 1.7% in the September quarter which is in addition to a 0.23% fall in the June quarter.

So, technically, Shorten is correct to say that the latest data show a fall in the bulk-billing rate – but he has zeroed in on a very recent fall that is within the range of normal variability. This recent drop doesn’t tell us much about the overall trend.

There is considerable variation in the quarterly bulk-billing rate. This makes it difficult, at this stage, to say anything certain about whether bulk-billing rates will continue to fall as part of a downward trend, or whether the latest quarterly decline is just an anomaly.

Longer-term trends trump quarterly data

The Department of Health is set to release the December quarter data later this month. This much anticipated release will give further insights into whether a downward trend in bulk-billing rates is emerging or whether the last quarter was a blip.

The figures for the last quarter of 2016 are likely to attract considerable attention as policymakers will be eager to learn whether the Medicare indexation freeze is having an effect on bulk-billing rates.

The freeze has been in place since 2014 and is set to continue until 2020. In effect, that means that the Medicare contribution to each health care service has not changed for the last three years.

Others have argued that this will put pressure on doctor’s ability to bulk-bill.

Note that there was substantial negative bulk-billing growth in the period after the last Medicare indexation freeze and this did impact the annual level of bulk-billing.

What bulk-billing rates don’t tell us

One of the fundamental aims of Medicare is to improve access to care. Bulk-billing rates serve as an important proxy on how Medicare is performing with respect to allowing people of all income groups to access health care.

However, there are significant limitations. Bulk-billing rates cannot tell you, for example, whether bulk-billing services are fairly distributed across income groups or people in high health care need.

And headline bulk-billing rates do not reveal out-of-pocket costs for those patients who are not bulk-billed.

For example, for people who were not bulk-billed (almost 70% of specialist consultations) the average patient co-payment for a specialist consultation was $72 (as shown in Table 1.5a in the quarterly Department of Health statistics).

So any discussion of health care access needs to go beyond one simple headline measure.

Verdict

Technically, Shorten and Turnbull were both right – but their quotes don’t tell the whole story.

Shorten’s statement that we are seeing “falling bulk-billing rates” is correct if you look at the most recent quarterly statistics for total Medicare bulk-billing claims. But that fall was within the range of variation that we observe every quarter. Furthermore, one quarter of data is not enough to be making such generalised statements on total Medicare bulk-billing rates.

As Shorten’s full response notes, there has also been a fall for three consecutive quarters in bulk-billing for GP visits lasting less than 20 minutes. However, this data is not publicly available so we can’t say for sure that there’s a trend in this particular item.

Turnbull’s statement that “bulk-billing is at record levels” is correct if you look at the yearly statistics, though it doesn’t factor in the decrease in bulk-billing in the third quarter of last year.

It is too early to say whether the recent quarterly fall in total Medicare bulk-billing rates was an anomaly or perhaps signals a broader trend. Data due for release within the next week will tell us more about the true state of bulk-billing in Australia.

Dr Thomas Longden and Associate Professor Kees Van Gool, Australian Doctor, 10 February 2017

Primary's bulk-billing profits take a nosedive

Profits from bulk-billing patients at one of Australia’s biggest GP corporates have taken a dive.

Primary Health Care reports profits fell by 36% for its bulk-billing medical centres — dropping from $42 million in the second half of 2015 to $27 million in the second half of last year.

The company, which boasts 71 medical clinics nationwide, is attributing the fall to weaker than expected GP recruitment.

According to its half-year report released on Wednesday, it managed to attract 61 new GPs in the second half of last year.

The recruitment drive has been partly fuelled by the need to make up for its GPs opting to work fewer hours.

Writing in the company’s report, managing director Peter Gregg (pictured) claimed the company’s overall financial position was strong despite a 69% drop in profit across the business, which includes pathology and imaging.

The half-yearly figures show profit fell to $21.1 million in the second half of 2016, down from $67.6 over the same period in 2015.

But the ongoing Medicare freeze is making it harder to attract GPs and grow revenue, he said.

“Primary’s progress in ramping up recruitment has been slower than expected but pleasingly the recruitment pipeline is improving and retention continues to be strong,” he said.

“While it will take time to improve Primary’s reputation with GPs, Primary is committed to establishing its medical centres as a preferred brand for [doctors] and staff to practise, and for patients to trust.”

In recent years, Primary has shifted away from offering big up-front payments — which historically hit as much as $500,000 — to what it describes as more flexible arrangements where doctors take a bigger slice of the Medicare revenue they generate.

The move followed the government’s decision to tax the payments at a higher rate because it deemed them inducements rather than payments for doctors’ practices.

And in a highly symbolic move for a company founded on universal bulk-billing, Primary also recently launched a new private-billing division named Health & Co.

According to today’s report, it lost about $800,000 in start-up costs.

It emerged last week that Primary had gone into “partnership” with former AMA president Associate Professor Kerryn Phelps, with her two Sydney-based practices signing up with Health & Co.

Her clinics charge $400 for an initial 60-minute consult and $100 for subsequent consults lasting up to 15 minutes.

The new business will be operated separately and represents a significant departure from Primary’s bulk-billing model, Mr Gregg said.

“Primary’s aim is to deliver quality health services and growth to shareholders by becoming the preferred place for healthcare practitioners and employees to practise and for patients to visit,” he said.

“Today’s Primary has a strengthened balance sheet and improved free cash flow, allowing us to invest in the initiatives that will shape our future.

“Notwithstanding near‐term government policy concerns, the demand for front‐line health services continues to grow driven by an ageing population and an increase in chronic disease.”

Medical Observer, 16 February 2017

Greg Hunt vows to be a 'health minister for GPs'

Australia’s new Minister for Health has vowed to “re-establish the value, the role and importance of GPs”.

Greg Hunt was appointed to the portfolio by Prime Minister Malcolm Turnbull on Wednesday morning following the resignation of Sussan Ley.

Mr Hunt immediately took to the airwaves to declare the importance of general practice to the future of Australia’s healthcare.

“I want to re-establish that value, their role, their importance, their trust in the community,” Mr Hunt told reporters.

“I am biased towards nurses, as the son of a nurse and as the husband of a nurse, I am biased to the nurses and our volunteers and our allied health workers.

“But I do, again, want to repeat that for GPs, I want to be their health minister.”

The government has been urged to ditch the Medicare freeze.

Mr Hunt, who would not be drawn on future policy options, said: “Medicare is the fundamental underpinning of Australia’s health system.”

“I have, and we have, a rock solid commitment to the future of Medicare. It is simply indispensable and fundamental to our health care system.”

Mr Hunt will bring strong policy, analytical and communication skills to the complex portfolio, Mr Turnbull says.

“During his time as the environment minister, he demonstrated an ability to grapple with extremely complex policy issues and engage a very diverse range of stakeholders and interest groups, including state and territory governments.”

Gier O’Rourke, Australian Doctor, 18 January 2017              

Vaccine rates shoot up under 'no jab no pay'

The ‘no jab no pay’ policy has boosted child vaccination by more than a percentage point in just a year, new health department figures show.

In that time, 198,056 kids under the age of five who were not properly vaccinated have now met government immunisation requirements.

The new data show 93.4% of one-year-olds are now fully covered, an increase of 1.1% on a year ago, but that figure drops to just 93.2% by age five.

However, coverage in some areas remains patchy, with more than 20% of kids failing to meet requirements in the Gold Coast hinterland and central Adelaide.

Related News:

Parents of 142,793 unvaccinated children have had welfare payments slashed under the scheme.

They represent about 5.5% of parents who have lost Child Care Benefit, Child Care Rebate and Family Tax Benefit Part A supplement payments worth up to $15,000 since 1 January last year, when the policy was introduced.

Despite the boost, Australians remain among the least vaccinated people in the developed world, behind countries like Mexico and Estonia.

OECD league tables show Australia languishing near the bottom of the ladder, at 31st out of 36 developed countries for measles coverage, and three points behind the UK on DTP shots.

Health Minister Greg Hunt told Channel 9’s Weekend Today the patchy results show the government has more to do, despite a significant lift in vaccination rates.

“We’re going to keep pushing very hard but, with almost 200,000 new children, vaccination rates are increasing both within families that are covered by government benefits and across the board,” he said.

“So that’s an important step, but very clearly you need to have your kids covered for measles, mumps, rubella, whooping cough.”

The scheme is estimated to save the government around $500 million a year in welfare payments, while only $26 million has been allocated for incentives to convince hesitant parents.

Some vaccination experts have criticised the legislation for unfairly burdening disadvantaged families.

Writing in the Journal of Paediatrics and Child Health last month, Associate Professor Julie Leask, from the University of Sydney, and Dr Margie Danchin, from the Murdoch Childrens Research Institute, said vaccine objectors account for only 1.8% of the eligible population.

On the other hand, more than 6% of parents are failing to immunise their kids due to entrenched problems like disadvantage, lack of access or cultural barriers, the researchers said.

Geir O’Rourke, Australian Doctor, 20 February 2017

Why the college's PLAN is arbitrary and unhelpful

The new triennium is here and the RACGP wants GPs to start 2017 by uniting us in synchronised dry retching.

As if we didn’t have enough of that with the US election results.

By now, as you may have guessed, I’m referring to the introduction of PLAN (Prescribed Lengthy Asinine Nonsense).

In weathering this intellectual insult, I admit that I am at a particular disadvantage.

Related: Goodbye RACGP, your PLAN has got me going

My Master’s degree in epidemiology from the University of California ruined forever my ability to tolerate the methodologies of amateurs.

It looks to me like some gifted GPs and their mercenary IT slaves figured that anyone can produce an acceptable questionnaire.

No need to consult those who might bring a deeper understanding to bear on the task. Push the mouse around a bit and fill in the boxes. What could be so hard?

Well comrades, think of it this way. How would you react to an invitation to perform some backyard neurosurgery?

You know a scalpel from a stethoscope, don’t you? The patio table is surely sturdy enough for the job, and there is a little hole in the middle for the blood to drain through.

From far enough away in La La Land, neurosurgery looks straightforward, and so does questionnaire drafting. After all, you’re an experienced speaker of the English language, aren’t you?

This is the problem with people trying to perform technical skills outside of their field.

Along with whatever their degree is, seems to come the unspoken licence to attempt anything, and to do it with supreme confidence.

They feel free to have a go because their diploma confirms that they are educated. All those reliability and validity worries about questionnaires (go ahead, look ’em up) — how important can that crap possibly be?

Here’s the point: is there any meaning in your data?

Related: Are ‘self-reflecting’ GPs ditching RACGP for ACRRM?

Do your respondents share any common understanding of what is being asked, or have you so confused the task that 1000 people will each have their own take on it?

Frankly, this RACGP exercise is totally arbitrary and unhelpful in assisting GPs to identify their educational needs.

I could write a textbook on the PLAN questionnaire. In it, I could list and analyse all the classic errors.

Apply the anaesthesia before the cutting starts — that sort of thing.

I’m willing to skip over the software bugs that I’ve already alerted them to.

Let’s focus on another sin: asking people to consider a large list of issues and to characterise their opinion of them with a single score.

It’s akin to regarding your experience with extra virgin versus other olive oil, while taking into consideration your view on Commonwealth taxation, in light of the relative temperaments of yaks and oxen, would you say you were 1) extremely satisfied, 2) not fussed, 3) resigned, 4) disappointed, or 5) disgusted with things as they stand.

But nothing is totally bad. Just as the comedians found that Trump was good for their business, PLAN has been good for mine.

At least I got a story out of it.

Dr Pam Rachootin, Medical Observer, 16 February 2017

Aspiring GPs slugged with $700 in fees

Application fees for GP training programs will rise from nil to $700 when the RACGP and ACRRM take over candidate selection this year.

The job is being handed back to the colleges by the federal health department, which has run things since the General Practice Education and Training organisation was scrapped in December 2014.

The RACGP says it will charge a non-refundable application fee of $725 – enough, it says, to cover its own costs, but not enough to turn a profit. The ACRRM will charge $700.

Of the 1500 spaces available, the RACGP will select 1350 candidates and the ACRRM 150.

If the fees had been in place last year, the 2277 applicants would have shelled out more than $1.5 million, collectively.

The handover will bring general practice in line with other specialties, in which colleges select their training candidates, says assistant health minister Dr David Gillespie.

He adds the charging of an application fee is standard practice.

The Royal Australasian College of Surgeons charges a $770 application fee.

RACGP president Dr Bastian Seidel says the college will aim to increase the proportion of registrars passing its fellowship.

“The RACGP has advocated that the selection process should focus on the potential for candidates to achieve fellowship.

“The RACGP’s strong relationship with the department of health has been critical in securing the move of selection across to the profession.”

He says capability and professionalism will be core components of a “robust and transparent” process. A guide for applicants is coming in the next month.

ACRRM president Associate Professor Ruth Stewart says the handover is a key step towards the government’s promised rural training pipeline.

“It is fitting that in the college’s 20th anniversary year, we reach a milestone that the college has been calling for since the AGPT’s inception,” she said.

The AGPT involves 3-4 years of full-time registrar training, half of which occurs in rural areas.

Antony Scholefield, Medical Observer, 31 January 2017

GP in $12 million settlement over migraine drug

A Canberra woman who claimed that overprescribing of the migraine drug methysergide (Deseril) caused her stroke has settled a case against a GP, neurologist and hospital for $12 million.

The woman alleged that doctors had breached their duty of care by leaving her on the vasoconstrictor drug without a break for four years.

Because of its propensity to cause fibrosis and vasoconstriction, methysergide is not recommended for continuous use, and the product information advises a four-week ‘drug holiday’ every six months.

In a case heard in the ACT Supreme Court, the woman claimed a severe stroke in 2011 could have been avoided if she had been given “Deseril holidays”.

The woman alleged she been taking the drug for migraine prevention since the late 1990s, and her original neurologist had ensured she had regular breaks of four weeks every five months to reduce the risks from the drug.

However, when this specialist retired, she was referred to a new neurologist.

The woman alleged her prescription for methysergide was then continued without any breaks for four years.

She alleged her GP and the hospital failed to pick up on the possibility that methysergide may have been the cause of vascular warning signs such as blurry vision, dizziness, pounding in the ears and weak limbs.

She claimed her GP referred her to an optometrist rather than the neurologist, and that she was still prescribed methysergide after she had a severe stroke that left her hospitalised for almost a year in 2011.

While the hospital and the doctors denied most of the claims, an out-of-court settlement comprising $4.5 million from each doctor and $3 million from the hospital was agreed on.

ACT Health, named as a defendant due to the allegations against the hospital, confirmed that the settlement was on the basis that it was not an admission of liability.

According to NPS MedicineWise, methysergide is the most effective of all the migraine prevention medicines, but is now only reserved for severe and resistant cases because of its serious potential to cause retroperitoneal fibrosis and cardiac valvulopathy.

The drug has been withdrawn in many countries due to its potential toxicity, and in Australia the TGA has warned that methysergide may still cause fibrosis even when used with drug holidays.

Antony Scholefield, Medical Observer, 17 February 2017

How to avoid legal traps around clinical photos

Images are part of the medical record and are subject to the same security protocols.

You have left your busy rural general practice on Friday afternoon and are some hours’ drive away when you get a text message from your registrar, with some photos attached. One of your patients has just arrived at the practice with a nasty steam burn to her arm. The registrar is concerned this could be a full thickness, circumferential burn and therefore the patient may require a higher level of care than can be provided at the local hospital. She wants your opinion before contacting the relevant burns unit in the city.

Second opinion

Using a clinical image to get a second opinion can be a very effective strategy. It happens frequently in hospitals, and is also increasingly being used in GP practices. Before you get out your smartphone though, it’s important to make sure you have appropriate processes and safeguards in place.

What is a clinical image?

Clinical images, whether in the form of photos, videos or audio recordings, all amount to ‘health information’ for the purposes of privacy legislation. A clinical image may be of the patient’s body, such as an injury, skin lesion or bodily fluid, or an image of a pathology report or diagnostic image.

A clinical image is part of the medical record and is subject to the same collection, maintenance, retention and security requirements as all other parts of the medical record. Even in Australian jurisdictions where legislation does not prescribe retention of medical records for seven years, ‘good medical practice’ may be seen in line with these requirements.

Clinical images with smartphones

There are various laws and guidelines that govern how personal and sensitive health information can be collected, disclosed, stored and secured. While the law does not specifically preclude using smartphones to capture clinical images, there are some particular issues with using personal phones such that it may be preferable to have a practice camera or phone if you are taking images regularly.

There are certain procedures and processes you need to follow to ensure that a patient’s privacy and confidentiality is not breached in the context of clinical images. Although not raised by this scenario, if you are working in a hospital, you also need to follow any relevant hospital policies that cover the use of smartphones.

Depending on the circumstances, use of clinical images by private doctors may be regulated by the Privacy Act 1988, state-based health records and privacy legislation, the Health Practitioner Regulation National Law Act 2009, the Medical Board of Australia’s advertising guidelines and the Medical Board’s Good Medical Practice: A Code of Conduct for Doctors in Australia.

Related: The pitfalls of taking clinical photos on your phone

The Privacy Act

In this case, to comply with the Privacy Act, the registrar must obtain the patient’s consent to take the photograph. She should explain to the patient the purpose for taking the photo, how she intends to use it, and who is likely to see it.

She should document the patient’s verbal consent relating to the clinical photograph in the patient’s medical record, or check if the practice requires written consent. And check any relevant practice policies to guide her in how she uses the clinical image.

Both you and the registrar need to consider the security of the image on your respective smartphones. While images are on your device, you must take reasonable steps to prevent unauthorised access — for example, security codes, passwords and remote-erasing capability are likely to be considered reasonable steps.

As soon as possible, the image should be incorporated into the patient’s medical record, with a note about the consultation and diagnosis. Once images are securely stored in the patient’s health record, they should be immediately deleted from the mobile device. Ensure you have disabled any automatic processes that would upload images to a social network or backup site.

What would be an appropriate use of the photograph?

It would be appropriate to use a clinical image of the burn to facilitate treatment for the patient and to assist with the patient’s clinical management. It may also be appropriate to use clinical images and other information for writing case reports and educative purposes if the patient provides their specific consent for this purpose.

Although not raised by this scenario, posting to social media is rarely appropriate.

Safeguarding Images

  • Clinical images, including photographs taken on your personal smartphone, form part of the medical record and are subject to the same requirements as all other parts of the medical record.
  • Make sure you have the patient’s consent to capture a clinical image and that the consent is documented in the medical record.
  • You should review practice or hospital protocols to understand how to remove the image from your phone and upload it to medical records.
  • If using your personal smartphone, consider your settings to make sure you protect the image with strong security settings.
  • Do not post clinical photographs to social media or share them in ways not contemplated in the consent process regardless of privacy settings.

Ms Josephine Montgomery, Medical Observer, 20 February 2017

What I learned from one of general practice’s wisest men

I buried a dear friend recently, or more accurately I cremated him. But that part comes at the end of this tale and we are still at the beginning.

In 1983, after responding to an advertisement from an accredited training practice in Inverell in Northern NSW, I attended the mandatory briefing session with the Family Medicine Program in Sydney.

There I was told how lucky I was because the practice principal and supervisor, Dr Keith Whish, was “probably the best GP supervisor in Australia … no, make that the best GP in Australia”.

I drove for eight hours with my wife and infant son, and met the person who was to become the most significant professional mentor in my life.

Over the next seven years, Keith was much more than a supervisor and partner — he was a mentor, surrogate parent, counsellor, confessor and protector, a role that he undertook for dozens of GP trainees over 30 years.

As a mentor, Keith suffered our mistakes, our overconfidence (and even arrogance), our bouts of self-doubt and our occasional tantrums with equanimity and grace. He was ever supportive and ever reliable — helping us to maintain our equilibrium in the challenging environment of rural medical practice.

He taught us that to be good doctors, we had to meet the physical, emotional and spiritual needs of our patients, and to do that effectively, we had to make sure our own health was intact.

For someone with such a commanding presence, indeed gravitas, he was the most gentle of instructors.

He modelled experiential learning before the academics wrote about it, by giving clear, supportive feedback and helping us to reflect on each new situation we encountered.

There are many things I learned from Keith about the art of medicine that I still quote to those who are new to clinical practice.

  • On understanding patients and their complex needs: “So what else is happening in their life at the moment?”
  • On balancing your life and your work: “The first thing that you do when you return from a holiday is to start planning your next one.”
  • On making mistakes: “The patients who could sue you, never do; the patients who should thank you, sometimes sue you.”
  • On the future: “One day we’ll all have computers in our consulting rooms” (this, in 1984).

Along with his wife Philippa, also a doctor, Keith taught us the essential value of community and his development of future generations of doctors reflected a broader community role.

During the 1960s, he and Philippa developed one of the first practical assistance programs for Aboriginal people in NSW, with a focus on adequate housing, education and access to healthcare.

Keith also led the establishment of community development programs including the McLean retirement village, now regarded as a model for effective aged care, and the establishment of local parkland and reserve programs around Inverell.

Keith epitomised the quintessential values of a good human being — understated determination, passion and commitment to others.

The purpose of this reflective piece is to remind us that the very real problems we face each day in our practices are neither new nor insurmountable.

Dr Keith Whish taught me that by keeping my life in balance I could truly enjoy a long career, without succumbing to the burnout and cynicism that can result from the challenges of frontline clinical practice.

He also taught me that beyond simply surviving, you can actually make the world a better place.

Keith and Philippa spent the last year and a half of his life in Sydney, as their health problems became too much to manage at home in Inverell. This gave me a new opportunity to spend time with my dear friend and mentor.

Following Keith’s death I was asked to officiate at his funeral, which included operating the crematorium console that moved both curtains and coffin.

For the umpteenth time in my life I channelled the gifts that Keith had given me, thinking “I have been a rural GP, and I was trained by the best of them. I can do this.” Keith would have been chuckling.

Vale Keith, and thank you.

“You cannot teach a man anything; you can only help him find it within himself” — Galileo Galilee.

Professor Simon Willcock, Medical Observer, 18 January 2017

I saved a life—but what came later was far more challenging

I saved a life the other day. As you do.

Another notch in the belt. Another grateful customer.

It’s a calling, really. It’s a heavy load, but still, that’s what we do.

From a certain angle, if the light is right, you can just about see my halo.

As a particularly prominent American might now say, hands outstretched: “Believe me. Believe me. You are gonna be saying, ‘Dr Jon, you are just giving us too many miracles’.”

I saved a life. Apparently.

This is what happened: a patient came to see the nurse about a vaccination and mentioned, en passant, that he’d had very bad indigestion for two days. Very bad. Different to his normal indigestion.

Now, the nurse (a complete brainiac, by the way) smelt a rat.

She got the patient on a couch, called the good doctor and — hey presto! — he had an excellent story for myocardial ischaemia.

He had an ECG (normal) and some aspirin, nitrates, IV line, and the local paramedics were carting him off before you could say ‘long consultation’.

Later in the day, we heard he was in coronary care and that I had “saved his life”.

Later that day I went to the nursing home to see a demented patient who was crawling about the floor and had taken to doing a bit of poo-inspired art, if you get my drift.

This lady had been a high school teacher. She had raised a family. She now had a rotten and demeaning disease, and the question was whether this behaviour was a further tumble in the cascade of dementia, or a delirium.

Was she in pain? Constipated (unlikely)? Toxic? Did she have a subdural or a UTI?

If so, what was to be done? How were we to find out? Get an MSU? Good luck. Do a brain CT? Transfer her to the local A&E for assessment? If not, what care would help her?

It took a lot of time.

Phone calls to family, a review of her Advanced Care Directive, talks with the nursing staff, a review of her medication, an attempt at some form of examination, and formation of some sort of plan (she didn’t go to A&E).

There was no phone call of congratulations for that visit. No machines that go bing. No IV lines. No room crowded with GP, nurse, patient, family members and paramedics firing questions.

I was grateful for the thanks from the family of the bloke with chest pain, and so was our nurse, the true lifesaver. (Hats off to you, Ingrid!)

But I know which bit of medicine I found harder and more confounding.

It’s a funny old thing, medicine.

Dr Jon Fogarty, Medical Observer, 27 January 2017

Yes, most med students are posh. But what's the alternative?

A few years ago, I read an article titled ‘You know you’re from Brisbane when …’.

Top of the list: “Your first question to people is, ‘What school did you go to?’”.

As a Brisbanite, I cringed reading this. I’ve often started conversations with that question, even when I moved down to Melbourne to attend medical school.

Then again, it probably wasn’t the most ridiculous ice-breaker on the first day of university.

And what I learned from asking that question was that certain schools had quite a presence in our medical course. Names such as Bialik, Scotch and Methodist Ladies’ College came up over and over again. Students from state schools were uncommon, and those from non-selective-entry state schools were downright rare.

One of the first friends I made was a girl from Adelaide. We sat together in our first tutorial. The topic was gastroenteritis, and before delving into the pathophysiology of it all, the tutor wisely set some context.

Related: From riches to riches: The effect of affluent medical students on patients

He said: “Gastroenteritis is one of the leading causes of deaths of children in the developing world. And it can be prevented so easily, with some clean water.”

My new friend asked, very innocently, “So why don’t we just give clean water to everyone?”.

She said this holding a $3 bottle of water. I wanted to slap the Evian out of her hand. Wisely, I didn’t, and after the tutorial ended, she walked back to the apartment that her parents had purchased for her.

I walked away wearing the sandals I had superglued together that morning. It’s not that I couldn’t afford new ones — it’s just that I was compelled to avoid having to pay for a new pair.

Frugality was, and still is, hardwired into my system.

Suffice it to say that living in India until I was eight years old had exposed me to some unsavoury truths about scarcity and inequality. These things have a way of staying with you, even in more privileged times.

While it was frustrating to see someone so oblivious to the world around them, it was entirely understandable. It’s simple — she didn’t know. She hadn’t seen poverty, let alone experienced it.

I think our medical school did a good job of filling this knowledge gap. We were educated about the state of the world, the social determinants of health and how health itself affects prosperity.

Sometimes we read about it in books, at other times it was through placements in outreach health services or persuasive speakers, all with a view to open our eyes.

But let’s be honest … hearing about people’s hardship is no substitute for observing it first hand. And observing something is no comparison to experiencing it.

So perhaps it’s no surprise that a University of WA study recently revealed that it’s doctors from disadvantaged backgrounds who are more likely to work in disadvantaged communities themselves.1

And when we consider the shortage of doctors in disadvantaged areas, it would seem like a pretty direct solution to train more doctors who hail from a disadvantaged background.

Simple, right?

Yet, every instinct within me is opposed to this.

The meritocratic selection of medical students is something utterly necessary. Doctors must be intelligent, and the smarter the better.

Having quotas for people of certain backgrounds is quite literally a double standard; it just replaces one injustice with another. But this is just my instinct.

For would it really be such a huge compromise to lower UAI thresholds from 99-odd, down to say, 95, for a few students if it resulted in more medical students from disadvantaged communities?

Although deceptively simple, the question lies at the crux of the decades-long argument of affirmative action/positive discrimination policy.

However, for us as a society, the larger question is, what is the real aim of medical school?

Is it to produce the best doctors or to improve the health of society?

The two might seem to go hand-in-hand, but the maldistribution of doctors in disadvantaged areas demonstrates they can be competing notions.

If a positive discrimination policy to train doctors from more disadvantaged backgrounds is ever put in place, you would hope it works.

It’s a gamble — arguably a wise one, but there are no guarantees.

People can surprise you.

As I was writing this article, I decided to Google my old friend from that medical school tutorial.

Turns out, Ms Evian now practices medicine in an outer metropolitan, lower-income suburb.

And here I sit, in a private-billing clinic in Melbourne CBD, with superglue in my shoes.

Dr Vyom Sharma, Medical Observer, 16 February 2017

Medical Must-See: Cockroach in cranium

Known for its ability to survive in the harshest environments, the cockroach can now add human skull to the list.

Doctors in Chennai, India, were shocked to discover a live, fully grown cockroach sitting on the base of their patient’s skull during a nasal endoscopy.

The 42-year-old woman believed the insect had crawled into her nostril the previous night while she was sleeping, according to a report in the New Indian Express.

“I could not explain the feeling, but I was sure it was some insect. There was a tingling, crawling sensation,” she said. “Whenever it moved, it gave me a burning sensation in my eyes.”

She was referred to the ENT department at the Stanley Medical College Hospital after multiple physicians failed to find the cause of her discomfort.

On further investigation, doctors found that the roach had scuttled as far up as the ethmoid bone, between her eyes. More shocking still, it was alive.

“This is the first such case I have seen in my three decades of practice,” Dr M Shankar, head of ENT, told the newspaper.

But with forceps and suction apparatus, they were able to successfully remove the insect.

“If left inside, it would have died before long and the patient would have developed infection, which would have spread to the brain,” Dr Shankar said.

To see a video of the cockroach being extracted follow this link: http://www.australiandoctor.com.au/news/latest-news/medical-must-see-cockroach-in-cranium

Sophie Attwood, Australian Doctor, 10 February 2017

'Poo pill' paves the way for faecal transplants

US researchers have come up with a way of taking the ‘ick’ factor out of faecal transplants, which are remarkably effective in treating refractory Clostridium difficile infection.

Using freeze-dried faecal microbiota, they have developed a capsule that can be taken orally, which could ultimately replace the uncomfortable and potentially messy techniques for faecal transplant, such as colonoscopy, enemas or nasogastric tube.

The freeze-drying technique preserves the viability of faecal mirobes and allows ease of encapsulation for transfer to the colon, according to researchers from the University of  Minnesota.

In their study, they trialled their pill in 49 patients with recurrent C. difficile who had failed at least one course of antibiotics.

Overall, 88% of patients were cured of their infection by taking 2-3 capsules in a single dose, with success defined as two months without C. difficile recurrence.

Success rates were around the same as found in clinical trials using colonoscopy, the researchers said, although the effect of the treatment was somewhat delayed.

No preparation was needed for the capsule therapy other than fasting for several hours beforehand and waiting at least two days after discontinuation of antibiotics.

Around one-third of patients experienced irregular bowel movement, bloating and flatulence in the weeks following the transplant.

The study also found greater microbial diversity after treatment compared with before.

A ‘poo pill’ has been seen as something of a Holy Grail in faecal microbiota transplant research, given the practical difficulties of delivering faecal microbiota via the rectum.

Hugo Wilcken, Australian Doctor, 17 February 2017

Medical Directions: Timely News for Australian Practice Managers

February 2017

Changes to Bulk Bill Claims

Bulk Bill Webclaims can be accessed via Health Professional Online Services (HPOS). Webclaims are usually paid within 48 hours of submission in HPOS, and all types of MBS eligible services can be claimed this way. Practices can also view details about GPs’ provider numbers, create new provider locations and update bank details … read more.

 

Handbook for General Practitioners

Continuing professional development (CPD) for general practitioners includes a range of activities to maintain, develop, update and enhance knowledge, skills and performance to ensure that they deliver appropriate and safe care. To assist your GPs the RACGP has published a new Handbook for General Practitioners for the new 2017-19 triennium.

 

News for Aged Care Providers Now Available

An online news stream, with an email subscription service, to help stay up-to-date with changes to aged care is now available by subscribing via the Department of Human Services … read more. This service gives important information about aged care payments, services and updates about aged care reforms.

 

Flexible Working Arrangements

Did you know that your employees have the right to request flexible working arrangements – this can be requested for a variety of reasons including: if they have worked for you for 12 months or more; and if they are caring for a child who is school aged or younger. For more more information and a full list of instances where an employee can request flexible working times visit the Fair Work website.

 

Medical Benefits Schedule (MBS) Online

The 1 February 2017 MBS files (XML, DOC, PDF, ZIP) can be downloaded from the 1 February 2017 downloads page.

A summary of changes is available on the February 2017 Latest News page

 

Find more information at http://www.medicaldirections.com.au/

Dealing with vaginismus

Managing women who have difficulties with intercourse due to vaginismus can be a challenge.

You watch carefully as Brooke comes into your surgery. She is accompanied by her partner, James, who shakes hands vigorously with you. In contrast, Brooke fails to make eye contact and sits nervously.

When you ask how you can help them, James looks at Brooke and asks her if she wants to say anything. Brooke starts to become embarrassed and begins to cry, and James tells you they are here because they have never had intercourse.

They have been trying since their marriage 18 months previously, and they are feeling upset and frustrated.

James begins to sound angry when describing the situation, and tells you he can’t understand why Brooke has taken so long to see you. He has come with her to make sure she attends the consultation.

This may be one scenario in the presentation of vaginismus or genitopelvic pain disorder in general practice.

This disorder is a new diagnostic subcategory within female sexual dysfunction as defined in the DSM-5 in 2015. It represents the fusion of dyspareunia and vaginismus into one single diagnostic entity.

Vaginismus has been previously defined as involuntary spasm of the musculature in the outer third of the vagina, which interferes with penetration of the vagina and causes personal distress.

The coupling of vaginismus with dyspareunia into one diagnostic category is based on the conclusion that they cannot be reliably differentiated clinically.

The other criteria required for a diagnosis of genitopelvic pain disorder include that the symptoms: are present for a minimum of six months; are present for 75-100% of the time; cause significant distress; and cannot be explained by any non-sexual mental disorder, relationship issues or other significant stressors.

There is now a perception of genitopelvic pain disorder as a spectrum disorder that goes from dyspareunia to vaginismus.

The symptoms may be primary, as in Brooke’s situation, where the symptoms have preceded intercourse, or they may be secondary, where there has been previous sexual experience. In general, treatment of primary symptoms is more difficult than that of secondary symptoms. If secondary symptoms are present, it is more common to find a predisposing cause.

Clinical symptoms

  • Recurrent difficulties with vaginal penetration during intercourse
  • Marked vulvovaginal or pelvic pain during intercourse or penetration attempts
  • Marked fear or anxiety about pain in anticipation of, during, or as a result of vaginal penetration
  • Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.

This includes other penetration difficulties or inability, such as tampon use, finger penetration and difficulty with gynaecological examinations.

In Brooke and James’ situation, it is important to assess the possible underlying causes of their problem. A careful history and examination is necessary.

History-taking is often difficult in this situation, as it is well documented that doctors are often uncomfortable when taking a sexual history.

We may feel we do not have the specific skills to ask personal or sexual questions, and we do not want to appear intrusive.

It may be difficult to ask appropriate questions when a partner is present, and we may feel inadequate if there is anything disclosed that is uncomfortable for us, such as a history of sexual abuse.

Lack of time in a busy general practice is another important factor in failing to ask questions that will provide important clinical information.

In all cases, it is important to explain the nature of questions and ask permission for doing so.

Useful questions
Some questions that may be useful include:

  • Have you or your partner tried inserting a finger into your vagina?
  • Have you tried using a tampon?
  • Was it a surprise to you that it was so painful/difficult?
  • What happens when you try to have intercourse?
  • Have you had any unpleasant sexual experiences in the past?
  • Is the pain always present? Does it change from time to time?
  • What sort of relationship did your parents have?
  • Do you have particular religious or cultural beliefs around intercourse that you feel may have influenced your experiences?
  • Any history of recurrent UTIs/back spasm?
  • Are you a generally anxious person? Do you try to relax yourself in other ways prior to intercourse?

Examination should be performed sensitively and with permission. It may require a second visit when there is more time, and the patient is prepared, or it may be important to assess the integrity of the genital area at this visit as this will indicate the direction for further treatment.

We need to exclude physical causes for the genitopelvic pain disorder, which may include the following.

Physical causes

  • Pelvic floor muscle dysfunction (vaginismus)
  • Vulvodynia, vestibulodynia
  • Imperforate hymen, hymen- al bands
  • Infections
  • Trauma (eg, previous surgery, episiotomy, injury)
  • Menopause
  • Pelvic pathology (eg, endometriosis, ovarian cyst).

If a clinical cause is evident from the examination, then clearly treating this is a first priority.

With Brooke, a single-digit pelvic examination is just possible, and you notice significant tightness.

Brooke appears highly anxious about pain with the examination and it is necessary to proceed slowly, with assurances that she can ask you to stop at any time.

Bimanual examination is normal. You decide not to insert a speculum at this visit as it will clearly be difficult. There is no discharge evident on inspection and as Brooke’s history indicates she has never had intercourse, it should not be necessary to perform an STI screen.

If it is possible to perform a low vaginal swab this may be helpful to exclude vulvovaginal candida.

You are aware from your examination that there is a moderate degree of vaginismus present that may require further treatment. Occasionally, treatment of the underlying physical cause may mean the vaginismus will settle spontaneously, but it is common for it to persist even with successful treatment outcome of the physical symptoms.

Treatment of vaginismus usually involves the use of vaginal trainers/dilators and biofeedback techniques to allow women to engage in a desensitisation program, regardless of the aetiology.

The regular use of trainers of increasing sizes is a graded desensitisation technique that is generally successful. Demonstrating their use in the surgery is helpful, as many of these women will be avoidant of self-touch and any genital sensation.

The use of vaginal trainers is well within the domain of general practice. The kits can be purchased by the patient over the internet, and the GP can monitor progress regularly, say once a month, to ensure the patient continues to progress.

Vaginal trainers

  • Demonstrate the use of vaginal trainers with pelvic floor relaxation techniques
  • Size will depend on bimanual examination
  • Choose smaller size so it is comfortable and successful.
  • Stress using a trainer must be done daily
  • Then introduce partners to trainers if they are willing
  • Encourage the patient to use sexual arousal to help with larger sizes
  • Stress that progress may be slow with larger sizes
  • Always stay positive even if progress is slow.

Brooke embraces the use of vaginal trainers as she feels she needs to demonstrate to James that she is willing to try.

However, after an initial positive start, review at two months shows she has dropped back her practice and is feeling disheartened. This may alert you to the need to deal with psychological factors as well.

You may decide to ask further questions regarding psychosocial issues.

Psychological causes

  • Previous trauma (eg, past history of sexual abuse, sexual assault)
  • Anticipation of pain
  • Relationship issues
  • Negative psychological constructs around sexual activity (eg, different cultural/religious perspectives)
  • Other female sexual dysfunctions (eg, low libido)
  • Comorbid psychological diagnoses (eg, anxiety, depression)
  • Sexual aversion disorder.

There are now several studies acknowledging the need for a multidisciplinary team in treating genitopelvic pain disorder.

In Brooke’s case, there are physical and psychological components to her presentation, and the possible beginnings of relationship issues with James.

It is important to prevent negative cognitions from being magnified. Some women with this disorder will sexually catastrophise any genital touch or sexual act and this will impact on their partner as well.

Partners commonly feel rejected and may require help to reframe this as a chronic pain disorder rather than a sexual problem.

It is important for the doctor to emphasise what a couple can engage in sexually in a positive way, rather than what causes repeated pain. All too often couples persist in engaging in painful sexual activity where outercourse options may provide a welcome relief from the downward spiral of negative and painful experiences.

Should referral be necessary, the GP is the person most suited to find the appropriate specialist. These may include a gynaecologist, a vulval dermatologist, a sexual health physician, a pelvic floor physiotherapist, a psychologist or a pain specialist.

As with other chronic pain disorders, women may require a team of health professionals to assist in the long-term management of symptoms. All too often women with genitopelvic pain disorder report feeling disheartened and unheard, and that it is ‘all in their head’.

Studies report it is important the GP remains interested and concerned as they are integral in coordinating care.

Dr Lesley Yee, Australian Doctor, 2 February 2017

Daily Happiness: 13 Simple Ways to Find it in Your Life

Happiness.

When you think about it then you may often think of the future in some way. The dream vacation coming up, the promotion you are working towards, the baby that is on the way or the sixth date with someone new in your life.

But happiness can also be found in the small things of a regular day.

So today look for it there. Take just a few minutes and apply one of the tips below and see how it brightens your day.

 

(1) One minute of appreciation.

Take a minute, sit down and just reflect on what you appreciate and love about your partner. Or a friend or family member. Or yourself. This will fill you with gratitude and redirect your focus to the positive side of things.

(2) Express your appreciation.

Tell the partner, family member or friend what you came up with. It will brighten his or her day. And as his or her face lights up with a big smile you’ll feel happier too because emotions are contagious.

(3) Take 5 minutes to see how you can help someone out.

Offer some practical help, some good advice, look something up for him or her, be encouraging and supportive or just lend a listening ear.

(4) Slow down for 3 minutes.

Walk and move slower for just these few minutes. Let your thoughts slow down. Use the 3 minutes to enjoy what is happening all around you. Truly take it in with all your senses.

There is much simple wonder we miss each day because we are so preoccupied with our thoughts and plans for the future.

After those 3 minutes are up, continue at the slower pace if you like.

(5) Be the smile you want to see in your world.

Smile more towards the people you meet and you’ll get more smiles back. You’ll feel better. They will too.

And they will probably smile more towards the other people they meet that day. So don’t wait for other people to smile more, be the smile you want to see in your world instead.

(6) Make someone else happy.

Don’t stop at just smiles.

  • Give someone a big hug.
  • Give him or her a small or a bigger gift of some kind.
  • Cook their favourite food if they have had a bad day.

 

(7) Start your day with setting a low bar for happiness.

As you open your eyes and wake up to a new day tell yourself:

“Today I will have a low bar for happiness”.

I have been using this one for quite some time now and it makes the regular day happier. I take fewer things for granted – like my food, the weather, the small gestures in my world and the small moments – and often pause to appreciate them more.

And it does not make me passive action-wise. Instead it makes me feel more inspired, motivated and inner resistance decreases. And so I get more of importance done.

(8) Be the day you want to see.

Don’t wait for someone else to create the day you want to have. Instead, get the ball rolling yourself.

Take action and take the first small step or steps forward:

  • Arrange an evening down at the pub or a picnic in the spring grass.
  • Set up a movie night when the rain is pouring down.
  • Take a walk or a run in the early morning to get your energy levels for the day and week up.

 

(9) Say yes to something new.

Something you haven’t eaten before. A new song or album. A new author or movie. A new sport. A new way to work or through your town.

By actively going outside of what is normal for you or your comfort zone you’ll discover new, wonderful things in life quite often.

This will bring happiness into your life and if you develop this habit then in my experience it will be easier to move outside of your comfort zone in bigger ways too.

(10) Say no to a should.

The shoulds in life can really drag that happiness and energy down and make everything feel like heavy work.

But do you have to do all of those shoulds on your to-do list? Or are you maybe stuck in a rut and are doing some of those things just out of old habit?

Ask yourself one of my favorite questions: Will this matter in 5 years? Or even 5 weeks?

By zooming out like this you make it easier to see the true value of doing something. To see it for what it really is. And so your questioning makes it easier to simply relax and to say no to doing something because you realize that it isn’t that important anyway.

(11) Take a 2 minute laugh-break.

Few things will so simply bring happiness and relieve stress as laughing. So:

  • Revisit one or two of those small video clips that always makes you laugh or smile.
  • Head over to your favourite funny comic online or in your bookshelf.
  • Listen a bit to a podcast or standup show that you know you find funny.

 

(12) Do what you deep down think is the right thing.

Instead of letting quick and judgmental words come of your mouth be understanding.

Instead of snacking on some candy eat a fruit or drink a glass of water.

When an impulse inside of you wants you do something that you know deep down isn’t right for you then pause. Be still for a few moments. The impulse will pass. And you can more easily choose to take the action you think is right in this situation.

Then appreciate that you did the right thing, give yourself a pat on the back and see how good it all feels. Continue to do this and you’ll help yourself to build a stronger self-esteem.

(13) Stand still for a minute, close your eyes and just enjoy the spring sun.

I did it yesterday and it was wonderful. This one may however work best if you have had a cold winter filled with grey skies for the last few months.

Henrik Edberg, The Positivity Blog

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