Chair’s Report: June 2017

Central Queensland Rural Health has had to adjust over the last financial year, adapting our practises in order to make the organisation financially sustainable. With June 30 just around the corner, I am proud to say that these efforts are paying off. CQRH is now in a good financial position and we are able to focus more attention on our core supportive and advocacy roles. We are also planning for our future with a number of renovations to the RHMS practices and a relocation of our office in Biloela to a location more suited to our needs.

We are working through our new constitution to reflect the changes in our organisation and membership, with consideration to the role of the organisation as a Health Promotion Deductible Gift Recipient and Tax Concession Charity. Maintaining our charitable status has enabled us to support rural communities and advocate on behalf of our members to achieve our vision of excellence and sustainability in rural health, something we are keen to continue.

We have given some consideration to the role of the organisation in direct service delivery. CQRH is currently the lead organisation in a consortium tender to provide Mental Health services in Central Queensland and Wide Bay. If we are successful this will give an additional focus for the organisation, one we were very familiar with as a Division of General Practice. This may mean our organisation will need to be restructured to in order to effectively deliver the required services.

Health Advocacy and Health Promotion are an important parts of CQRH’s mission and we currently have a number of advocacy and promotion roles in Central Queensland and beyond. We are currently;

  • working with local indigenous organisations and Central Queensland University to develop Indigenous Health Worker training locally.
  • developing the private rural nurse practitioner role within general practice.
  • developing the Go Rural Program for Banana Shire and Woorabinda with Health Workforce Queensland
  • working on integrated service planning within CQ and Wide Bay
  • developing University of Queensland Rural Health Hubs and Rural Intern programs for CQ and Wide Bay
  • working on a discussion paper to lobby for more effective funding of counselling services to allow a more responsive process in times of high community stress.

CQRH also has a number of representative roles in community organisations including Livewell Central Queensland, the PHN Clinical Council, the State Rural and Remote Clinical Network, the State Suicide Prevention Taskforce, Central Queensland University Health Education Development Group and, the State Rural Generalist Nurse Working Group. If there are any advocacy opportunities which you think CQRH should be a part of, including gaps in funding or services, please contact any of the board members, Sandra or myself or email us on admin@cqrdgp.com.au.

Health Promotion and Professional Education have been long been a part of our role. We continue to hold CPD events in both Emerald and Biloela, as well as our biennial Rural Health Weekend (scheduled for March 10 and 11 in 2018). However, there has been a noticeable increase in the delivery of CPD through the PHN so there is a question around the role of CQRH in this area in the future as we support the needs of our members. To help us in this, your input in this short survey would be invaluable.

On behalf of the Board and Staff, I want to thank you again for your continued support of our organisation. 

Kind Regards,

Michael Belonogoff

RHMS Progress Report

A strong performance financial year has given RHMS the opportunity to grow and reinvest in communities, practices, GPs and Staff. There are currently seven practices being managed. We have also been invited to manage a practice in Cloncurry, though there is nothing official on this yet. The Nebo Practice building continues to be managed by RHMS.

Baralaba

Baralaba continues to provide GP services to the local community, including regular clinics in Wowan. However, thanks to a new pharmacy opening its doors in the small town, the practice no longer has a drug dispensing responsibility. A new nurse, Sue Witten, and a new casual receptionist, Christine Ashton, have also recently started at the practice. As at July 1, there is a vacant GP position at the practice.

Biggenden

Biggenden will see major changes ahead as both Dr Geeth Weerasoriya and Dr Jotham Chickwakuri resign in August. However, the recruitment process has already begun and there are a few promising candidates. Staff have recently received immunisation and cold chain training and a new vaccine fridge, which has helped the practice provide flu vaccinations and Q Fever Clinics.

Clermont

This week was very exciting in Clermont, as the new Doctor, Joshua Dally, started work. This practice has been growing steadily for a while now, offering much needed services to the community. Unfortunately, space is limiting capacity to offer many of these services with Allied Health professionals often having to find alternative spaces to see their patients. This will not be the case much longer as RHMS is searching for a suitable demountable building to add to the current practice set up.

Eidsvold

More space is also necessary in the Eidsvold practice. Renovations are planned to turn the house next door to the current building into a three consult room practice, retaining the current space for Allied Health professionals and other visiting medical professionals.

Monto

Dr Vish will start in Monto in July as a permanent MSRPP. He will join Dr Rob Pickham and they will be joined by Dr Tom Battison in January 2018 who will work as the GMT Registrar with regular rotations to Eidsvold.

Mt Morgan

Mt Morgan has recently bought some much needed new equipment. The staff are particularly excited about the new rechargeable thermometer, and perhaps more importantly, their new ECG machine.

Rolleston

Rolleston has been steadily increasing the number of regular clinics, including Women’s Health clinics in Springsure. The community has also banded together to raise funds for a SolarScan which will be used in the practice.

 

Peer Visit Program

CQ Rural Health offers a GP Peer Visit Program. This is an educational and quality improvement program lead by Associate Professor Harry Jacobs. Harry was a Mackay GP for 32 years and has extensive experience in GP Vocational Training in NQ, in medical student education and assessment at the JCU Mackay Clinical School, as a GP accreditation surveyor for AGPAL, as an examiner for the RACGP Fellowship and extensive experience providing independent expert GP opinions for Avant, OHO and AHPRA.

The Peer Visit Program is designed to provide you, the rural GP with expert one-to-one feedback in a confidential manner on your day to day practice as well as discussion and advice about any clinical or professional issues which cause you concern.

The underlying principles of a visit are:

  • Confidentiality
  • Education – exam preparation, CPD
  • Peer Support
  • Risk Management of medico-legal issues

Competence is the possession of knowledge and skills i.e. what the practitioner knows, ‘knows how’ and can ‘show how’ to do.

Performance is the application of knowledge and skills i.e. what the practitioner actually ‘does’ in practice.

A site visit would be no more that one day and would involve:

  • Telephone contact prior to the visit to identify any issues or cases that might be a concern for the rural GP. This would be ideally in the week prior to the visit. 30-60 mins
  • Introduction & Interview. Discussion might include current education plans, exam preparation, supervision arrangements, educational needs assessment , clinical strengths and weaknesses, social and personal issues relevant to clinical performance, and career counseling. 30 mins.
  • Observed clinical practice – direct observation of consulting and procedural skills. Ideally 2-3 hours.
  • Medical record review – random inspection of documentation in clinical records. Ideally 1 hour
  • Case discussion. Cases to be discussed would be de-identified and principles of diagnosis and management would be discussed. Cases might be identified by the rural doctor, identified in the records review or might be hypothetical and developed to discuss fundamental principles. 1 hour
  • De-brief. Summary of the days work and outlining future plans. 30 mins

 

References.

Peer review. A safety and quality improvement initiative in a general practice Angela Rutherford AFP Volume 40, No.1, January/February 2011 Pages 30-32

http://www.racgp.org.au/afp/2011/januaryfebruary/peer-review-safety-and-quality-improvement-initiative/

Review by Peers. July 2010. Australian Commission on Safety and Quality in Healthcare.

https://www.safetyandquality.gov.au/wp-content/uploads/2012/01/37358-Review-by-Peers.pdf

 

Integrated Allied Health Services in Rural Communities: Project Report for May 2017

ALLIED HEALTH PLANNING  FOR EACH COMMUNITY IN THE BANANA SHIRE: 

Project Schedule:  30th June 2017

HUI Report completed and submitted.

Meetings between Wowan/Dululu Multi-Purpose Centre and CQ University, looking at Podiatry service to commence in Wowan early July 2017.

Moura community has identified Physiotherapy as a need, discussion have commenced looking at outreach options.

Education Qld representative engaged, Christina Rigo, Mental Health Coach for Central Qld Region.

Commissioning application sent to PHN for ‘top up’ support of Credentialed Diabetes Education and awaiting response.

 

ALLIED HEALTH ASSISTANT PLAN

Project Schedule:

Scholarships provided to 3 AHA’s who are now actively engaged in study, placements of 120hrs  confirmed or in consultation. Dual placements are being sought where maximised learning may be obtained for AHA student through this arrangement and/or more conducive to organisational capacity.

Second scholarship round was released on Wednesday 24th May 2017 closing date Friday 9th June 2017. Amendments to process will be made in response to learnings from first round.

Conversations held with CQU regarding feasibility of providing AHA Cert IV as EdQ shared Intellectual Property and able to be offered at any EdQ registered org. This would maximise local engagement and support as it reduces the need for students to travel to Gold Coast TAFE for face to face component

Clarification around supervision and clinical governance processes.  Each position will need to develop a local supervision plan and ensure there is a clinical governance policy in place for the allied health assistants.

 

FUNDING MAPPING

Current:

Analysis of Disaster Relief Funding eligibility criteria, distribution, effectiveness and limitations.

Analysis of counselling services funding options, application and eligibility criteria eg: process for EAS

Discussions held with Uniting Care Qld CEO Jason Reid re: counselling services within the region, suggested a focus group for further development in this space, volunteered personal engagement.

Qld Counsellors Association, Anna Olsen reports current advocacy regarding MBS eligibility for counsellors. Anna is eager to be engaged in ongoing discussions related to funding for counselling services and Disaster Relief funding reform submission.

ADEA (Australian Diabetes Educators Association) Professional Services Manager, Rachel Freeman contacted and eager to maintain connection with project team. Rachel has provided information on current funding options, keen to be engaged in ongoing consultation and be updated on any developments in this field.

Allied Health Audit data for the information reported in the Patient audit has been entered and a draft report has been prepared.  Opportunities will be identified to access alternative or complimentary funding for each discipline.

Ongoing:

Research on allied health service funding options. Development of a resource tool to assist clinicians to be aware of various funding options and the process for accessing these.

Sorting funding into AHP categories as information resource and flowchart for each discipline, and each funding source.

Mapping of service and funding options for use by practitioners and consumers

Investigation into options for a web based platform to support the development of this resource with the concept that it can also be provided as a paper based information package.

 

PROJECT REFERENCE GROUPS CONSULTATION:

ALLIED HEALTH REFERENCE GROUP – Ongoing now moved to bi-monthly meetings

Ongoing future planning and drafting of ideas for AHP services to be reviewed against data collected for each discipline, previous issues and concerns that are identified during consultation with clinicians and communities.

Submission made to PHN to subsidise Diabetes Educator services not covered by MBS

COMMUNITY REFERENCE GROUP

The second Community Reference Group meeting was held on the 3rd May 2017 in Moura.

Wowan identified Podiatry as priority.  Meetings between Wowan/Dululu Multi-Purpose Centre and CQUniversity, looking at Podiatry service to commence in Wowan early July 2017.

Moura identified Physiotherapy as priority, discussion have commenced looking at outreach options.

Meetings will be held with each community to continue the development of the community allied health plans.

 

TELEHEALTH: Project Schedule:  Telehealth mapping April 2017

Canvasing organisations and professionals use of telehealth

Researching different Telehealth apps used by AHPs and costs

Awaiting response from Telehealth Taskforce regarding request for support with appraisal of viability, resourcing and development of infrastructure for allied health service provision in Banana Shire

 

PROJECT EVALUATION

Evaluation

ICI Monthly Report to be completed by Steering Committee and submitted through smartsheet

 

A young GP explains: Why I’m taking the plunge into practice ownership

Are younger GPs really turning their backs on practice ownership? Dr Nicole Higgins, a Queensland GP who has just opened a new clinic in Mackay, explains why she is taking the plunge.

I’m at the stage of my career where I’m quite established. My children are 12, 10, and eight. So it was a good time for me to step out on my own. Also, I had wonderful mentorships, which helped me develop what I wanted to do. I am a medical educator by background, so I wanted to turn this into the best teaching practice it could be. And, finally, it was about having the freedom and creative control over running a practice.

Did you find it a daunting prospect when you started?

This is actually my second attempt. About five years ago, I looked at opening a practice. But it was at the time of the mining boom and I couldn’t get a premises. So this time I got the premises first. The biggest decision was making the decision to do it; that was the hardest bit.

Did you seek advice from a practice consultant?

No. Through my role as a medical educator, and through my networks, like GPs Down Under, I received wonderful support. On GPs Down Under we have about 4500 GPs and we can discuss all the day-to-day issues of running a medical practice. So if I had questions, I could put it out there to the hive and get some pretty instant feedback. Importantly, I could develop mentorships with practice owners — and that’s been the key.

What were your main issues about establishing your own practice?

The financial load, the work load and the impact on my work-life balance — because I’m raising a family. I think for women that’s probably the biggest issue. But there are positives. The building we’ve got is perfect. I’m also lucky because my husband is a tradesman, and he’s got mates at the footy club who are also tradesmen. And they’re all from the local community, so they’ve all been invested in it. Once you’re off and running, it’s just breathe, and hang on.

I really wanted a practice that was ‘non-clinical’, very welcoming and open. The furniture is eclectic and a little bit retro.

There’s a kids room; there’s a chandelier in the loo — in homage to my practice manager who said we should have a chandelier there because no one else would.

There are two nursing homes literally within scooter distance. We’re going to have a knitting circle for patients if they want to knit while they wait.

Do you think that younger GPs are avoiding practice ownership?

In my experience, there are a lot of younger GPs who are setting up their own practices. I’ve got two girlfriends who have set up practices in the past couple of years; one in Cairns, and one in Airlie Beach. Another friend has just set up in Townsville. There are lots of discussions online among younger doctors who would like to take up practice ownership but don’t know how.

Medical Observer, 30 June 2017

 

Medicare freeze to continue for 12 months

This is a budget of less than nothing for General Practice with the continuation of Medicare cuts.

The widespread rumours of the end of the rebate freeze this year all proved false.

Yes technically there is a thaw of sorts – indexation will be applied from July, but only to the GP bulk billing incentives.

You may expect the government to declare this a product of a concern to protect the poor and vulnerable, to ensure they can still access GP care.

But not even this government is that cynical.

A measure of its significance is that it will “cost” just $9 million during the coming financial year.

Rebates for actual GP standard consults will be lifted in line with indexation from July 2018 – along with the attendance items for specialist consults.

So patient rebates will be left to erode for another 12 months (ie the real terms cuts continue).

When it comes to items for specialist procedures and allied health services, they will only be indexed from July 2019.

The media release put out by Federal Health Minister Greg Hunt refers to a “partnership having been struck” with the nation’s doctors, its GPs and specialists.

But you could be forgiven for asking for written evidence of when and where doctors signed their names to this patnership.

GP groups should be disappointed but their words tonight about Treasurer Scott Morrison’s (pictured) budget seem up beat.

RACGP President Dr Bastian Seidel hailed the delayed thaw as a victory.

“The lifting of the freeze was exactly what the RACGP’s #youvebeentargeted campaign was aiming for,” he said.

“If we are serious about focusing on a preventative GP health care we need to end the inequality of GP Medicare rebates compared to other clinical specialties.”

To be fair to the government, if you look back at the words falling from their mouths in recent months, they have done no more than drop hints the freeze will end.

The truth is they let the media run with its speculations.

 

What is in the rest of the budget:

There is no crackdown on Medicare after hours funding.

The RACGP wanted the urgent items made GP only to curtail the boom in corporate after hours. That has not happened.

Health Care Homes roll out will be delayed.

The alleged funding revolution in GP care for chronic disease patients was meant to start in July.

The idea was that 200 practices would register patients in return for receiving block funding (capitation).

But now only 20 practices will become Health Care Homes in October. The other 180 practices – whoever they are, we still don’t know – will wait until December.

It’s a win for the RACGP. It called for the delay after having turned its back on the reform it is now warning GPs against.

The MBS Taskforce is a winner. When it was first launched, it was meant to spend a couple of years modernising the schedule – it is now here for the long haul.

It will get $44.3 million over three years to continue its existence.

And the crackdown on GP rents being paid by pathology corporates for co-location collection centres?

Its looks like it will go ahead – but how hardline the crackdown will be is unclear.

There is money – $18 million over four years  – for audits and compliance programs to ensure that GP practices are in line with the law.

From Australian Doctor’s understanding, the current law demands that no payments are made for rents that are above 20% of the so-called market value.

There is no detail in the budget papers explaining the impact on GP practice revenue this crackdown will have.

The Pharmacy Guild of Australia has secured a compensation package for its members, who have been affected by savings to the PBS.

The headline is that there will be $600 million over three years for pharmacists “to continue and expand existing community pharmacy programs”. This is money that has already been announced – money that has come from the 6th Community Pharmacy Agreement.

It is not clear from the budget papers what it means by “expansion”.

It has been suggested (again by the media rather than ministers) that it could include the roll out of in store diabetes checks – something that would cause alarm among GPs.

But presumably those programs will be left pharmacy sector to develop as it sees fit.

If you want to see the protection that pharmacy owners get from government that has not been extended to general practice, it’s worth looking at the fine print of the budget papers.

They say pharmacies will get paid $225 million to compensate for lower than expected script volumes.

The MyHealth Record is also something ministers don’t shy away from when it comes to funding.

It will become opt-out for all Australians (as previously reported). It will cost a further $380 million over two years. But the government claims it will save $305 million in efficiencies from its use.

The reaction from the AMA to tonight’s budget has, like the RACGP response, been measured.

President Dr Michael Gannon claimed the government has begun to win back some of the goodwill it lost after the 2014 bloodbath health budget.

“The AMA would have preferred to see the Medicare freeze lifted across the board from July [this year],” he said.

“But we acknowledge that the three-stage process will provide GPs and other specialists with certainty and security about their practices, and will help address rising out-of-pocket costs for patients.”

“Lifting the Medicare rebate freeze is overdue, but we welcome it.”

Paul Smith and Geir O’Rourke, Australian Doctor, 9 May 2017

Why the Budget leaves general practice out in the cold

ANALYSIS

No government will put money into general practice unless bulk-billing rates collapse.

This is the key principle that should be applied when looking through the debris of last night’s budget.

There is no immediate respite from the continued cuts to patient rebates for GP care.

What has emerged — contrary to the brave self-declarations of victory from the RACGP — is not an end to the specialty’s woes.

Indexation for bulk-billing incentives will be reintroduced this year at a cost to government coffers of just $9 million, according to the budget papers.

That probably wouldn’t cover the travel expense claims of the 22 pollies in the current cabinet.

The freeze on GP consultations remains for another 12 months.

(Note the wording. The thaw doesn’t cover things like GP care plans, just the consult items.)

As for items for specialist procedures and allied health services, they will be indexed from July 2019.

The AMA media release, under the headline ‘Farewell Freeze’, says the budget wins back “goodwill” for the government.

But this is the gratitude you offer an abusive partner when they decide to no longer hit you.

GPs probably think the domestic situation is a little more fraught because the budget, as we wrote on Australian Doctor, gives general practice less than nothing.

The government has only pledged to stop cutting the real terms value of Medicare rebates. The bringing back of indexation is not, as the government is attempting to argue, an “investment … to recognise and reward General Practitioners”. That is a laughable claim even if you make efforts to forget that indexation falls short of the inflation rate in the real world.

And the bigger, more fundamental question of how we are to properly fund general practice care still has no answer.

There are no proposals from the government itself. Nor are there any concrete proposals emanating from the GP groups, beyond a vague wish that one day, in the not-too-distant future, maybe the government will finally raise rebates beyond the peanuts supplied by indexation.

This stagnation in the political debate about funding is reason enough for concern given the way fee for service on the MBS is being left to wither.

The truth is that the government sleeps easy on Medicare.

It’s only likely to stir if bulk-billing rates begin to wobble as they once did under John Howard.

But as yet, there is no evidence they will.

Paul Smith, Medical Observer, 11 May 2017

RACGP chief defends budget pact with govt

The RACGP is denying bungling the numbers as it defends its controversial budget pact with the Federal Government.

Under the “compact”, unveiled on the night of the budget, the RACGP gives the government the green light to wait until July 2018 to lift the freeze on Medicare rebates for GP consultations.

Under the deal, the rebates will rise based on a government indexation formula.

However, the formula, which will lift a level B consult by around 55 cents, has long been criticised by doctor groups for being below the actual rate of CPI (see box below).

Despite this, RACGP president Dr Bastian Seidel (pictured) has defended the agreement.

Describing it as a major win, he said it ensured rebates would be reindexed in line with “wages and inflation” from July and secured an “ongoing guarantee of the same funding each year in real terms”.

“While this [guarantee] may seem like a step back to where we were before the big freeze, it’s a clear win for over 85% of Australians who receive preventative health services from their GPs each and every year,” Dr Seidel said in a media statement on Tuesday morning.

“Our agreement with the Australian Government to help strengthen Medicare recognises the essential role of GPs in a system that touches every Australian.”

The AMA made a similar deal with the government, without agreeing to how rebates will be indexed once the freeze is lifted.

But AMA vice president Dr Tony Bartone said: “If funding is less than CPI, then, by definition, it is not in real terms.”

On Monday, former AMA secretary general Dr Bill Coote warned it would add to the already heavy financial pressures on practices.

“The RACGP part of the ‘compact’ notes that indexation for these items will continue annually, on an ongoing basis, using the calculation which has formed the basis of indexation of MBS items by successive governments since 1995,” he wrote.

“This is the very formula that has led to the erosion of MBS fees, threatening the economic viability of many practices.”

Dr Seidel’s comments come amid growing anger among GPs about the college’s “memorandum of understanding” with the government.

But Dr Seidel is refusing to back down, saying the agreement is “unprecedented”.

“The compact is an unprecedented move by the RACGP to secure a planned strategy to addressing the challenges we face now and into the future,” Dr Seidel wrote in a message to college members.

“Whilst verbal agreements have previously been the norm in negotiations with government, the compact represents the first step towards formalising meaningful written agreement between the profession and government.”

But Dr Seidel also recognised the deal was not a perfect one for the profession. It should be seen as the first step, and not the end-point, he wrote.

“Our end-game is not just lifting of the freeze, but genuine and meaningful recognition of the value of general practice care.”

Gier O’Rourke, Australian Doctor, 16 May 2017

Pharmacies are agents of the government, says review panel

The King review panel believes community pharmacies are agents of government and should not be guaranteed undue profits for dispensing PBS medicines.

That’s the thinking behind the contentious suggestion of a flat dispensing fee of $9 to $11.50, in the panels interim report on pharmacy regulation and remuneration.

In a video discussing the report, panel chair Professor Stephen King says remuneration for dispensing should be business neutral.

“Appropriate remuneration for community pharmacy does not mean that any community pharmacy regardless of its efficiency of operations should make a profit,” he says.

“The remuneration for dispensing paid by government and consumer co-payments to community pharmacy should be based on the costs of dispensing for a best-practice pharmacy.”

Consumers should expect and receive certain minimum levels of service from all community pharmacies, says Professor King. “The payment made by any particular customer for a PBS-listed medicine should be the co-payment set by the government for that customer or the dispensed price for that medicine, whichever is the lower.” Pharmacies should not have discretion to either raise or lower that price.

But the panel also wants the government to address inflated wholesale costs and a more “flexible framework” of remuneration to allow pharmacies to adapt to changes in healthcare.

“The sustainability and viability of an effective community pharmacy sector is a key consideration for the review,” Professor King says.

Here’s how Professor King and his colleagues, Bill Scott and Jo Watson, have balanced medicine affordability with pharmacy viability:

Flat dispensing fee: The review panel was clear the $9 to $11.50 figure is based on limited data. It wants pharmacies to provide more data to determine a benchmark for efficient dispensing.  Importantly, the fee would be backed by measures to contain wholesale costs. Otherwise it would need to be bundled as a two-part tariff (see below).

Changes to CSO supply: The CSO payment is possibly leading to inflated wholesale prices, according to the review panel. It wants CSO payments to be scrapped.  The panel would also like to see the terms of trade offered to pharmacies varied according to the medicines costs. This would resolve cash flow issues caused by pharmacies having to pay suppliers for high cost medicines before they’ve been reimbursed by the government.  Another option would be for the government to undertake separate review of CSO arrangements, the panel says. Wholesalers would have to deliver medicines to pharmacies within 24 hours.

Cap on wholesale price of high-cost medicines:  The panel suggests a pharmacist pay a maximum of $700 to $1000 for medicines. The government would pay the remainder directly to the wholesaler.

Two-part dispensing tariff: If the government doesn’t impose an upper limit on pharmacies’ wholesale costs, a tariff should be added to the dispensing fee. This would vary according to the price of the medicine.

Price variation scrapped: Pharmacists could no longer vary the price of PBS medicines. Consumers would pay the same whichever pharmacy they choose.

$1 co-payment discount scrapped: This initiative has been inequitable with consumer in urban areas the main winners.

Funding for evidence-based health services: The government would have to pay pharmacists the same rate as other primary care health professionals offering the same service. The panel also raises the possibility of select pharmacies being paid for some programs. Funding would come from outside the PBS.

Rural pharmacy paintenance allowance: Pharmacies within the one 10 km area would have to compete for a single payment. This would be based on programs provided by the pharmacies as well as opening hours and location.

Community Pharmacy Agreement: The PSA and Consumer Health Forum would join the Pharmacy Guild at the negotiating table. Future agreements would also be restricted to remuneration for dispensing PBS medicines.

The review panel is accepting feedback on the interim report until 23 July before it presents its final report and recommendations to the government.

More Information:

Review of Pharmacy Remuneration and Regulation: interim report

Heather Saxena, Pharmacy News, 23 June 2017

Major shake-up for Guild in NSW

The fiercely contested election at the Pharmacy Guild’s NSW branch has resulted in a committee shake-up and a record number of women members.

Branch president Rick Samimi (pictured) was re-elected, but senior vice-president Phil Dibben and committee member George Mendria were ousted.

Women pharmacists now make up 40% of the committee — a massive turn around from a year ago.

Four women took up casual vacancies on the 15-member committee a few months before the election.  Their ranks have now been bolstered by two new members, Sally Sheehan and Karen Carter.

The election campaign was marred by a malicious and factually incorrect email from a no-name account that urged members not to vote for Mr Samimi.

But in a statement announcing the election results, Mr Samimi ignored the issue.

He instead “warmly” acknowledged the record number of women and thanked all candidates for their participation in the campaign.

“I urge all members to remain united behind the Guild and to convey ideas and feedback through the new branch committee members.”

The next stage of the elections, to elect office bearers, will start on 14 July.

Mr Samimi said he would make himself available for the branch president position.

The successful candidates (in alphabetical order):

  • Mario Barone
  • John Black
  • Catherine Bronger
  • Karen Carter
  • Caroline Diamantis
  • Greg Everett
  • David Heffernan
  • Paul Jones,
  • Feras Karem
  • Binh Luu
  • Judy Plunkett
  • Rick Samimi
  • Sally Sheehan
  • Adele Tahan
  • Richard Walsh

Heather Saxena, Pharmacy News, 27 June 2017

 

Patients ‘abandoned’ as ATAPS re-engineered

A GP says her patients are being “abandoned” as a scheme set up to provide mental health services to marginalised GP patients is re-engineered by primary health networks.

Dr Jane Ralls, a GP in Woodlands, WA, says dozens of her patients have benefitted from the Access to Allied Psychological Services (ATAPS) program since its introduction nearly 15 years ago.

But from next month, WA Primary Health Alliance, representing three WA PHNs, will replace the scheme with a stepped care service model.

Dr Ralls says some of her patients are being told by their psychologists that they only have one session left.

“I’m seeing very lovely beautiful people who are abandoned.

“Those patients of mine are either going to stop psychological treatment altogether or they are going to have to find the money somehow to pay the gap fees for psychologists [through the MBS] so that they can continue their therapy.”

Under ATAPS, GPs can refer patients from low socioeconomic or remote areas to psychologists for up to 12 sessions per calendar year, with a maximum of 18 if clinically indicated.

However, critics say the program has been plagued by bureaucracy and has failed to reach at-risk groups because of strict funding caps.

A 10 year evaluation of ATAPS found more than a million care sessions were delivered between July 2003 and December 2012, with an average of 5.2 per person.

Federal Government reforms, kicking in next month, will direct ATAPS funding to the 31 PHNs, which will be granted the freedom to allocate the money according to local need.

Some PHNs are expected to retain the ATAPS structure; others are planning to change the model.

For instance, the WA Primary Health Alliance will offer face-to-face, telephone and clinician-supported internet-based CBT treatments for patients aged 16 and over with mild-to-moderate anxiety.

Learne Durrington, the alliance’s CEO, says changes will address the uneven access to mental health support, where regional and rural patients often miss out.

“The type of support received will be determined by the person’s needs and they can get additional help or reduce the intensity of the support they receive as their mental health changes.”

Ms Durrington says GPs will be better off under the new system because they will be sent regular reports about their patients’ recovery process.

Rachel Woresley, Australian Doctor, 19 June 2017

GPs given new domestic violence reporting powers

Doctors will be given new powers to go against a patient’s wishes and refer them to support services if they suspect serious domestic violence.

The reforms are being introduced in NSW with the aim of ensuring victims get help, even if they fear going to the police to report abuse.

GPs will be expected to bring up any concerns with a patient before making a referral to the Safer Pathway program, which links health professionals with police, community services and education providers.

But if a doctor believes a patient to be “at threat” — based on their professional judgement and the Domestic Violence Safety Assessment Tool — they can make a referral without the patient’s consent or knowledge.

Some doctors are warning that it will destroy trust vulnerable people may have established with their GP.

University of Melbourne and Royal Women’s Hospital family violence prevention chair Professor Kelsey Hegarty (pictured) is concerned reporting could make victims resent GPs who breach their privacy.

“There may be some who benefit from this, but there will quite a large group of who will be pretty annoyed at getting a phone call after a GP has passed on their details without consent,” she says.

The GP academic says GPs face difficulties in identifying victims of serious domestic violence.

“Most domestic violence presentations involve psychological symptoms, not gunshot wounds.”

And doctors who make referrals without a patient’s consent or even knowledge could be taking more power out of the hands of survivors, Professor Hegarty says.

“General practice is built on the principle of patient consent and this would be a big leap to change.”

The NSW reforms will significantly increase GP reporting powers. But unlike the NT, it will not become mandatory for doctors to inform authorities of domestic violence affecting adults.

NSW Minister Pru Goward, whose portfolio covers the prevention of domestic violence, says victims are more likely to discuss their fears with GPs than police or other specialist services.

“Giving GPs the ability to refer patients to Safer Pathway means they can provide victims with support when they need it the most,” she says.

AMA NSW vice-president Dr Kean-Seng Lim says doctors may risk doing more harm than good by referring victims who aren’t ready to involve authorities into their lives.

“There could be safety risks associated with disclosing information without the victim’s consent,” he told the ABC.

“Often the sufferer of domestic violence is going to be in the best position to make a judgement as to their own safety,” he said.

More information:

What is the Safer Pathway program?

Domestic Violence Safety Assessment Tool

Geir O’Rourke, Australian Doctor, 8 May 2017

As a Psychiatrist, I’ve witnesses first-hand the dilemma of mandatory reporting

As more airtime is rightly being given to the issue of doctors’ mental health due to a spate of doctor suicides earlier this year, it would be remiss not to look at the current mandatory reporting system for impaired doctors.

To question whether the scheme is fit for purpose or whether it does, as is being claimed, have a serious impact on the mental health of doctors who are already in severe distress.

As a psychiatrist, I have a front row view of the dilemmas both mentally ill doctors and treating physicians face around the issue of treating and reporting impairment.

A few years ago the medical fraternity in Victoria was rocked by a number of suicides among junior doctors, and earlier this year a similar situation occurred in NSW.

When it comes to laws on mandatory reporting, in NSW the regulations sit under the section 151 of the Health Practitioner Regulation National Law. This states that if a registered doctor or student is found to be mentally ill and is detained as an involuntary patient in a mental health facility, the healthcare complaints commissioner, AHPRA and the relevant medical board must be notified.

Registration is often suspended as a result.

This procedure is borne out of a belief that the reported doctor poses a risk to the public—which may turn out to be the case, such as when they have no insight into their behaviour due to their mental illness.

But the doctor does not pose a risk to the public while being detained and unable to work. The real risk they pose is to themselves.

But by being mandated to report this to both bodies, regardless of the clinical context, treating psychiatrists applying the Mental Health Act in NSW are forced to breach patient confidentiality, regardless of the circumstances.

This leaves psychiatrists to grapple with the dilemma of reporting an unwell doctor, knowing this action has the capacity to destroy their career, or ignoring the clinical decision-making that would keep the doctor safe, and not treat under the Mental Health Act.

In both cases, where does the treating psychiatrist stand medicolegally, if that doctor goes on to commit suicide?

Many of these concerns are not new.

Pitfalls with the mandatory reporting of impaired doctors were flagged at the time of AHPRA’s implementation in 20101 and during the Senate inquiry into AHPRA and mandatory reporting in 2015.

These concerns in Australia resonate with those outlined in an internal review of the UK’s General Medical Council in 20142, which investigated cases of doctors who had committed suicide while under its ‘fitness to practice’ procedures between 2005 and 2013.

It found evidence that the impact of the GMC’s own investigation was actually a contributor in some of the 28 cases of doctors who suicided.

Of course, all doctors would agree that there needs to be a procedure and approach to managing doctors who are working whilst clearly impaired.

But what’s happening is a ‘scatter-gun’ approach and a ‘one-size fits all’ process for all doctors who are notified to AHPRA and their relevant medical boards.

A 2013 study3 of 18,907 formal patient complaints filed against doctors with health service ombudsmen (commissions) in Australia over an 11-year period demonstrated that just 3% of Australia’s medical workforce accounted for 49% of patient complaints, and tiny 1% accounted for one-quarter of all complaints.

Despite this though, every doctor notified to AHPRA is dealt with in exactly the same way at the time a complaint is lodged.

The complaint process has also been criticised for being lengthy and arduous, potentially placing doctors at risk of mental illness and suicide.

It places unnecessary pressure on the treating doctor who is trying to provide care for the notified doctor, bearing all the risk.

There is no compensation or support for writing reports for AHPRA and supporting reported doctors through multiple independent reviews.

Furthermore, another very recent study has demonstrated that the current mandatory reporting system has the capacity to be used in a vexatious manner4.

At present, AHPRA does not flag notifications that are found to be vexatious.

The initial handling of the complaint is performed by a non-health professional. And the way bad news is broken—via a letter with no notice or support—is a concern.

This may have been a factor in one of the suicides of a psychiatry registrar in Victoria in 2015

In addition, different states and territories handle complaints differently.

This forces some doctors to travel interstate away from family and supports to seek help for fear of being exposed or punished.

 

My recommendations

  1. AHPRA to adopt a position that protects patients but not at the expense of doctors’ safety;
  2. AHPRA to educate the health profession about what constitutes a mandatory report (currently too much misunderstanding about this);
  3. Establishment of a medical presence within the department who handles initial notifications to AHPRA;
  4. AHPRA to change the way they notify a doctor of a complaint in a humane way that mirrors any other profession and with the wellbeing of the reported doctor at the core;
  5. Investigation and amendment of section 151 of the Health Practitioner Regulation National Law (NSW) to remove obligation to report doctors to the HCCC and AHPRA for immediate suspension of registration if admitted involuntarily to a mental health facility;
  6. Peer support for doctors treating doctors who have been notified and investigated, rather than placing all risk onto the treating doctor; and
  7. Conclusion of Senate inquiry into AHPRA that commenced in 2015 and has stalled so lessons can be learnt and implemented.

 

Dr Helen Schultz, Medical Observer, 19 June 2017

‘Infatuated’ doctor suspended for failing to report registrar’s drug use

A senior neurosurgeon has been suspended for failing to report the illicit drug use of a registrar for whom he harboured near “infatuation”, and who later fatally overdosed on heroin.

The unnamed doctor developed an informal mentoring relationship with the registrar while they worked together at a Sydney hospital in 2012.

The NSW Civil and Administrative Tribunal was told the relationship soon developed into a “deep emotional bond” and that the neurosurgeon developed an emotional dependency on the registrar, which bordered on “unconditional infatuation”.

Both started taking the psychoactive drug GHB, ecstasy and cocaine while socialising outside work and on weekends, and they would turn up to work reporting insomnia and tiredness.

In early April 2013, the neurosurgeon attempted to wean the registrar off GHB by prescribing pregabalin. Later that month, the registrar was found dead from a heroin overdose.

The Health Care Complaints Commission brought six complaints against the neurosurgeon, including that he had failed to notify the hospital about his registrar’s drug habit.

The tribunal found AHPRA’s mandatory reporting laws did not directly apply because the neurosurgeon had discovered the drug use in the course of his personal relationship with the registrar, not as part of his practice as a doctor.

However, the tribunal said the neurosurgeon was still obliged to report his registrar under the Medical Board of Australia’s code of conduct because he had a primary duty to ensure his registrar was not putting patients at risk of harm.

“The tribunal is satisfied that the practitioner was so overcome with his affection for the registrar that he subverted his responsibility to notify the registrar’s superiors when there was a clear risk that patients could be exposed to potential harm,” the judgment stated.

“The tribunal considers such failure by the practitioner to so notify as egregious conduct, especially since the practitioner was a mentor of the registrar.”

The neurosurgeon was found guilty of four other counts of unsatisfactory professional conduct relating to inappropriate prescribing of drugs and failing to encourage his registrar to seek professional help.

He has been suspended for three months.

On return to work, the neurosurgeon will be subject to a range of conditions, including random urine testing and attendance at Narcotics Anonymous meetings.

Details of the case have been sent to NSW Health Minister Brad Hazzard amid concerns that the problem of recreational drug use by doctors may be more widespread than thought and could impact on patient care.

Rachel Worsley, Medical Observer, 30 June 2017

What needs to happen to build resilience and improve mental health among junior doctors

The contributing factors are complex and interacting. So what can we do?

Doctors experience higher levels of suicide and mental distress than their non-medical peers. A review of studies in the area found male doctors had a 26% higher risk of suicide, while female doctors had a 146% higher risk (more than double) than the general population.

And a recent survey, conducted by the mental health foundation beyondblue, confirmed there were higher rates of suicidal thoughts and psychological distress among doctors and medical students than in the general community.

But beyond the numbers are tragic stories of young individuals who lost their lives to suicide. In recent months, the suicide of four junior doctors in New South Wales has prompted the state government to investigate the issue. News reports have suggested at least 20 doctors took their own lives between 2007 and 2016 in NSW.

Family members have pointed to stress, “brutal expectations” and working hours as having had an impact on the doctors’ decisions to end their lives.

Are our medical students and junior doctors overworking? Can we identify underlying causes of mental distress and suicidal thoughts, as well as the warning signs? Can medical schools, hospital employers, supervisors, professional organisations and peers do more to prevent further tragedies?

 

A host of factors

Various inquiries and reviews have considered the above questions, in Australia and overseas. The conclusion is that it’s complex. Behind the phenomenon are a number of interacting factors.

There’s a legacy professional culture that can still view any admission of psychological distress as weakness or incompetence.

Doctors face long work hours in a pressured work environment. They experience anxiety about making mistakes that can have serious consequences.

Workplace bullying and harassment can also contribute. While this has most recently been highlighted among trainee surgeons, it probably extends well beyond surgical training.

And of course doctors have technical knowledge and access to the means to end life.

A lot has already been done to try to improve doctors’ mental health. For instance, progress has been made to reduce working hours. Prolonged shifts and continuous on-call rosters have been discontinued in most, if not all, health service rosters. This was at least in part in response to pressure from the Australian Medical Association (AMA) Safe Hours campaign, which outlined the risks to patients and practitioners of excessive hours worked and the need for breaks between shifts.

These recommendations have been incorporated into industrial agreements for hospital medical staff. These stipulate maximum working hours and mandatory periods of time off. However, 14-hour shifts and rosters that include one in three or four weekends without any reduction in weekday hours are not uncommon. There is considerable anecdotal evidence that some junior doctors are working more hours than they are rostered for.

Progress has been made in other areas too. Polices for better orientation of junior doctors in hospitals to explain supervision and avenues for support have been implemented. Other measures adopted include: education and mentoring programs in hospitals; supervisor training; blame-free reporting; assessment by external accreditors of health services’ and specialty colleges’ reporting and support arrangements; mental health first aid training for students; medical student guides; and confidential doctors’ health services.

But introduction of these initiatives has been patchy. The levels of support available in different hospitals are variable, and too often dependent on a few enthusiastic individuals. A systematic national approach would have much greater impact.

 

Medical graduates

One source of increasing stress for recent graduates, anecdotally, is the intense competition to get a job that will be their pathway to a specialist qualification. This pressure has its genesis in the dramatic boost to medical graduate numbers over the past 15 years.

Training beyond medical school is an intense period of four to nine years of work, on-the-job learning, study and examinations. By doubling the number of medical schools and almost tripling the number of medical graduates, Australia has severely increased competition in capital-city teaching hospitals (where, unfortunately, most of the training jobs for medical graduates remain based).

Ironically, the main reason for the boost in graduate numbers was the shortage of doctors in regional areas. An increasing number of young doctors (including those who trained in rural clinical schools or regional medical schools) feel that they have little choice but to apply for accredited metropolitan training posts.

They would be better off working and training from a home base in regional Australia, if only the specialist training pathways existed. Australia desperately needs to re-align this phase of medical training to better serve both regional communities and graduates.

 

Building resilience

There are core professional capabilities that should be taught and modelled throughout medical training. These include managing one’s own health needs, dealing with stress and fatigue, recognising and assisting distressed colleagues, and reporting bullying and harassment.

Medical schools and hospital employers could do better in finding ways to communicate with one other to protect more vulnerable graduates as they transition into the workforce.

We should also critically review our approaches to selecting students into medical school. Selection policies that promote greater diversity, place more emphasis on humanistic qualities (qualities that define who we are as human beings such as honesty, integrity, courage, self-awareness and wholeheartedness) rather than examination marks, and that include people with a positive orientation to risk and innovation may help to take the steam out of the pressure cooker. These approaches could also improve workforce outcomes in rural and under-served communities.

Beyond “resilience building”, there are important system challenges in how the nature of healthcare needs to be transformed into something that is more integrated, person-centred and community-based. This has particular implications for our larger institutions.

It turns out that finding “joy and meaning” in healthcare work is not only good for doctor well-being, it’s also safer for our patients. Teamwork, fun and personal fulfilment in caring for others are the essence of the joy of medicine.

Professor Richard Murray and Professor Brendan Crotty, Medical Observer, 25 May 2017

Doctor’s widow urges others not to suffer in silence

The wife of an overworked gastroenterologist who took his own life has gone public with a message that she wants doctors to talk more openly about suicide.

Dr Andrew Bryant (pictured above with his wife and daughter), who worked in public and private practice in Brisbane, was found dead in his office last week. He was 54 years old.

His wife, Susan Bryant, has released a letter that she wrote to friends and colleagues to highlight the circumstances of his death.

“I don’t want it to be a secret that Andrew committed suicide. If more people talked about what leads to suicide, if people didn’t talk about it as if it was shameful, if people understood how easily and quickly depression takes over, then there might be fewer deaths,” she wrote in an email that has been circulating on doctors’ social media forums.

Ms Bryant told Australian Doctor that her husband had no history of depression, but had been having trouble sleeping since February.

Dr Bryant started worrying excessively about practice finances and his heavy workload, but would not seek help, said Ms Bryant.

After Easter, he worked an unusually busy on-call roster at the public hospital while trying to keep up with his private patient list, she said..

His workload meant he began missing family dinners, including a birthday dinner for one of his sons, Nicholas.

“I was very concerned about him, tried to talk to him about my concerns, but he was very unresponsive,” she wrote.

Dr Bryant appeared exhausted, ‘flat’ and struggled to sleep. He felt more distressed than usual when a patient died.

He took his life the same week.

“In retrospect, the signs were all there. But I didn’t see it coming,” said Ms Bryant.

“He was a doctor, he was surrounded by health professional every day … and none of them saw it coming either.”

Ms Bryant said her husband’s former colleagues had contacted her expressing shock at the loss, including an anaesthetist who had worked with Dr Bryant the day before he died.

“They did the endoscopy list, they saw 10-15 patients together and he said Andrew worked as efficiently and as well as he always did, and he was just devastated he didn’t see anything,” she said.

Ms Bryant said her husband was a family man with a passion for travel, rugby, choir, concerts and sailing. He was deeply devoted to his four children and also had a commitment to military service.

He joined the army reserve while he was studying medicine and later became a RAAF medical officer.

“Medicine is such an unforgiving profession in terms of your own mental health.”

For support and information about suicide prevention, call Lifeline on 13 11 14.

Red flags for suicidal doctors

Rachel Worsley, Australian Doctor, 10 May 2017

Dropping out of specialist training was one of the best decisions I’ve made

A recent article in Medical Observer struck a chord with me. It talked about the high suicide rate amongst young doctors working in hospitals, and the stresses that all young hospital doctors face. The author also talked of the difficulties associated with ‘dropping out’ of specialist training.

Having successfully ‘dropped out’ of specialist training myself, I can’t help feeling – hoping – that my own story could serve as an encouragement to anybody finding themselves in a similar situation today.

I dropped out of specialist training—and it was one of the best decisions of my life.

I was a somewhat indifferent medical student, but performed surprisingly well once I graduated and entered the hospital system. I don’t know exactly why this was, but can say that I worked hard, and probably had above average communication skills.

My father was a medical specialist, and my parents were keen that I also become a specialist rather than a GP. Again, somewhat to my surprise, I found myself in a specialist training programme.

I got off to a good start. It felt exciting to be one of the ‘chosen few’, and my registrar in my first rotation was a terrific bloke who turned out to be a lifelong friend. Yes, the work was hard and the hours were long, but we were all in the same boat, and the camaraderie was strong. The first year flashed by fairly uneventfully.

Come the second year, however, the cracks were beginning to show. I was finding it increasingly difficult to avoid thinking about my future (a strategy that had worked pretty well for me up until then), and was aware that my colleagues were studying, while I was not.

Come the third year, I knew I was a ‘dead man walking’ as far as my specialist training was concerned. I had endured a clinical rotation that I had found extremely taxing, and I was unable to do any study at all. Many of my colleagues sat their first part examinations that year. I was under no pressure to do so, but I knew in my heart I could never pass it, no matter how long I managed to delay it.

My heart lay with writing and literature. I became a junior registrar myself, and remember reading large tracts of Don Quixote out loud to my resident. (I had just discovered it, and found it quite entrancing. I don’t think she did, though.)

There was a lot of talk from the consultants about how easy we had it, and how much tougher it had been in their day. I must confess I never really find this very intimidating.

It always seemed such a ridiculous way to think that I found it amusing, and even rather pathetic. We were doctors, after all. Shouldn’t we be working to relieve suffering rather than trying to glorify it? And where did patient care stand in all of this?

One of the great benefits of working at this particular hospital was that there was an end of year revue. I loved contributing sketches and songs. I wrote a parody of this line of thinking based on Monty Python’s “Four Yorkshiremen”. It went down well.

After a good deal of soul-searching, however, I realised that I had to leave at the end of the year. If I stayed for a fourth year it would all come to a head, and it would be very ugly. I was keen to leave on my own terms, though, if possible, so I waited until I had been offered a position for the following year, then resigned a week later.

Needless to say, this caused a good deal of consternation. My parents were very concerned. My colleagues were generally bemused and surprised, though I don’t recall much antipathy.

I was interviewed by a hospital administrator who was also a senior clinician. He seemed also somewhat puzzled and concerned, but did not communicate any animosity. When he asked me what I wanted to do with my life, I told him I wanted to write poetry for the environment movement. I must have sounded appallingly naïve, but he accepted my comments in good grace, and wished me well.

I am aware that the course my life took from there could not happen today. The year was 1983. Compulsory GP training had not commenced. (The Family Medicine Programme was in full swing, but it was optional.) This allowed a degree of freedom that I don’t think a person in similar circumstances would enjoy today.

My first move was to join the Franklin Blockade. I arrived at the tail end, when most of the drama was over, but I had a fascinating ten days in Tasmania nonetheless. Ironically, no one was interested in my poetry, but their ears pricked up when they discovered I was a doctor!

By a chain of events that I will not detail here, I found myself shortly after on the committee of Project Jonah (Save the Whale). For the next five years or so, I had a fascinating time involving myself in various political campaigns.

I was also instrumental in persuading the Victorian State Government to pass legislation banning the display of whales and dolphins in 1988, very possibly the first government in the world to do so.

The work was extremely taxing and entirely voluntary, but it was also exciting and rewarding. I continued to work part-time in general practice. My wife, a nurse, shared my enthusiasm and also took on much of the workload. Between the two of us, we managed to keep up with the mortgage payments on the house and generally keep the wolf from the door.

During this time I also stepped up my creative writing and embarked on a career as a performer in the folk scene. I got plenty of gigs, but the payment was minimal.

I eventually tired of the process of political lobbying. I resigned from Project Jonah and finally found the courage to address what I felt had always been my primary passion – writing poetry for children.

The payment for all of these activities is minimal or non-existent, but I do it because I love it. It gives my life much of its meaning.

Along the way, my medical career has also been varied and interesting. I have been involved in the treatment of alcoholics and IV drug users. I have worked with the Aboriginal community (including caring for Koori prisoners.) I have worked in a wide variety of suburbs, from the richer to the poorer, and in a variety of practices from the very small to the corporate. These experiences have given me insights into the human condition that it would be difficult to obtain any other way, and for that I am grateful.

So, how relevant is all of this for a young doctor struggling in a hospital today? In truth, I don’t know. I think the hours of work have improved a little. (I always found I felt a little odd by late Sunday afternoon on my hospital weekend shifts if I had been forced to work through the Saturday night.)

My sense is, though, that in most other ways life has become tougher for the hospital doctor. Intern positions are no longer guaranteed. There also seems to be more competition for specialist training places. The environment generally seems much leaner. I doubt if there are many hospitals that stage annual revues any more.

Of course, the GP Training Programme means that it would be very difficult (impossible?) for a young doctor to work part time as I did for many years, and sustain such an absorbing outside interest.

Has the GP Training Programme made better doctors? I hope so, and would like to think so. I have heard that methadone prescribers are getting harder to come by, though, and that disturbs me greatly.

Do I regret my decision to ‘drop out’ of specialist training? No way!

Was it one of the best decisions of my life? Absolutely!

Dr Stephen Whiteside, Medical Observer, 21 June 2017

8 reasons to grill parents about alternative therapies

Parents are using alternative practitioners as a parallel health service for their children without telling their GP, research shows.

A survey of 149 parents across Australia revealed high use of alternative products without the knowledge of the doctor.

Conducted via the website Bubhub, the survey revealed that in the previous year:

  1. Three out of four children have been taken to an alternative practitioner and 69% had been given alternative products;
  2. Alternative practitioners consulted included naturopath/herbalist (30%), chiropractor (18%), osteopath (15%), homeopath (12%) and TCM practitioner (8%);
  3. Children who visited alternative practitioners and used alternative therapies were less likely to be fully immunised;
  4. Alternative therapies were used most often for general wellbeing (66%), colds/flu (54%), nutritional supplements for fussy eater (25%), teething (23%), insomnia (16%) and constipation (14%);
  5. The most popular alternative products were vitamins and minerals (62%), herbal medicines (39%), essential oils (30%) and homeopathic remedies (12%);
  6. Most children had seen a GP in the last year but fewer than half of parents disclosed their use of alternative products to the doctor;
  7. Reasons for not disclosing alternative products use were “doctor did not ask” (50%), “doctor not knowledgeable about alternatives” (41%) and concern about a negative response from GP (28%); and
  8. Parents relied on family and friends and alternative practitioners for advice about alternative therapies, only 39% sought information from the GP.

The researchers say the link between low vaccine uptake and alternative product use is a concern, and deserves further investigation.

“This highlights the need to initiate conversations with parents about their child’s use of complementary and alternative medicine in order to ensure safe, co-ordinated patient care,’ they concluded.

Michael Woodhead, Medical Observer, 17 May 2017

 

Nursing tele-chemotherapy service bridges gap

Rural generalist nurses are administering chemotherapy under the supervision of specialist nurses as part of an innovative telehealth initiative in Queensland.

Since it was launched last year, the telehealth model has delivered chemotherapy to three patients at Hughenden Hospital, reducing the cost and inconvenience of patients regularly being forced to travel more than 370 kilometres for treatment at Townsville Hospital.

Under the tele-chemotherapy model, rural generalist nurses who received training to administer chemotherapy are overseen by chemotherapy-trained nurses via video link from the Townsville Cancer Centre.

The initiative has been such a success, it has been endorsed as a national model that is set to transform access to cancer clinical trials across the nation.

The Clinical Oncology Society of Australia (COSA) has endorsed the Australasian Tele-Trial Model which outlines a national framework to deliver clinical trials to patients living in remote and regional areas.

The framework was built on the model of care operating between Hughenden and Townsville Hospitals.

Speaking when the service was first launched, Professor Sabe Sabesan, Medical Oncology Director at Townsville Hospital and Health Service, said tele-chemotherapy could be delivered simply, safely and sustainably.

“We don’t take any shortcuts with telehealth. What we are now offering in Hughenden is a safe model of care that benefits both staff and patients,” he said.

“Modern technology has made it feasible for us to deliver this fairly significant service to a remote western community with a population of a tick over 1000 people, which is a significant achievement.”

Dr Sabesan said the tele-chemotherapy model will be adopted to deliver clinical trials in smaller satellite sites, increasing services for rural and remote patients while also tackling rare tumours – trials which have traditionally been difficult to undertake.

“Clinical trials, particularly for rare cancers, often struggle to attract suitable numbers of patients whose tumour fits the eligibility criteria to run a suitable trial,” he said.

“This model has the potential to make these potentially life-saving trials more readily available to people who previously had to overcome huge barriers to be involved.”

Since its launch, the service has received overwhelming community support with a range of local groups raising $20,000 for equipment, including a chemotherapy treatment chair, a nursing trolley for equipment as well as a blanket warmer.

The Prairie State School, which has a total of eight students, also raised $600 from a 14 kilometre bike ride to purchase a television, cushions, rugs, framed posters and plants to make the chemotherapy room more comfortable for patients.

The Hughenden Hospital is now planning a morning tea to officially open the service and thank the local community for its support.

Karen Keast, Health Times, 19 June 2017

Could pharmacists take over BP management from GPs?

Pharmacists are willing and able to take over blood pressure management from GPs, an Australian study shows.

In a proposed extension to their scope of practice, pharmacists with special training could confidently take on prescribing for patients with uncomplicated hypertension, according to a preliminary evaluation involving 30 pharmacists.

Such a move would relieve some of the burden of GPs and allow them to focus more on complex patients, say pharmacy researchers from the University of Technology, Sydney.

The researchers presented 30 accredited pharmacists with six clinical scenarios based on real-world patients with hypertension.

Most of the pharmacists’ recommendations for hypertension management, such as drug and dose selection, were rated highly for appropriateness by an expert panel of six doctors, including two GPs and two specialist cardiologists.

However, the pharmacists’ recommendations on assessment and monitoring of hypertensive patients were deemed inappropriate in up to two-thirds of the scenarios.

Pharmacists showed a high level of enthusiasm and confidence in their ability to manage hypertension, although their confidence in therapeutic recommendations declined markedly for patients with comorbidities such as chronic kidney disease.

Nevertheless, the researchers described the expert panel’s feedback overall as “extremely positive”.

“The study findings indicate that pharmacists who are accredited to conduct medication reviews would find a prescribing function useful within their current scope of practice and would be confident in executing this,” they noted.

The researchers said their findings highlighted the potential for pharmacists to optimise blood pressure control and provide “seamless care” for maintenance therapy and therapeutic adjustment in primary care patients.

“The delegation of simpler tasks to pharmacists would allow GPs to allocate time to the care of more complex patients, particularly in underresourced rural practices,” they suggested.

Although pharmacists in some jurisdictions in the US, UK and Canada have already obtained independent prescribing rights, the researchers suggested that a “supplementary prescriber” role may be the way forward for Australia.

Professor Nick Zwar a GP and Dean of Medicine at the University of Wollongong says he is unconvinced by the study findings, as they do not provide concrete evidence that even highly-trained pharmacists are ready to take on the role of prescribing.

Expanding the pharmacist’s scope in the area of hypertension management will require a framework for role definition and communication between primary care doctors and the pharmacist, Professor Zwar tells Australian Doctor.

“And the lack of trust [between pharmacists and GPs] is a real barrier,” he adds.

However Professor Zwar says there is potential for pharmacists to work collaboratively with GPs, particularly on improving medication adherence.

“There’s definitely evidence that pharmacists can improve blood pressure control in people with known hypertension, but it hasn’t happened yet in the Australian context,” he says.

“We haven’t really worked out yet what that would look like in Australia and how to do it in a way that’s collaborative between the GP and pharmacist.

Jocelyn Wright, Australian Doctor, 31 May 2017

Paramedics inch closer to 2018 national registration

Paramedic registration could come into force for Australia’s 13,000 paramedics on September 1, 2018.

As Australian paramedics prepare to become the 15th health profession to be regulated under the Australian Health Practitioner Regulation Agency (AHPRA), New Zealand’s paramedic workforce is also taking steps towards paramedic registration.

Peter Jurkovsky, a Paramedics Australasia director and chair of the National Registration Working Group, said paramedic registration will work to safeguard the public, protecting the title of ‘paramedic’.

“You won’t be able to use the title ‘paramedic’ unless you are qualified and accredited and registered to practice as a paramedic, and it will create certainly increased safety measures for the public in terms of making sure that people have got qualifications and skills to practice as a paramedic in the field,” he said.

“There are many examples of people practising and calling themselves paramedics, which you can do – anyone can go and call themselves a paramedic and offer their services today and it’s not illegal.

“Whereas, as of the first of September next year, that will certainly be illegal and people can be prosecuted for that.”

The first appointments for the inaugural Paramedicine Board of Australia closed in May. Once the National Board is appointed, it will develop registration, education and accreditation standards, as well as a code of conduct.

As part of the move towards national registration, paramedics will be required to pay an annual registration fee and an initial fee for background checks, and provide proof of their qualifications and recent work history.

Once national registration is implemented, paramedics in all states except New South Wales will be required to have completed a degree qualification in paramedicine.

Mr Jurkovsky said ‘grandparenting’ provisions, outlined in the legislation, have been designed to enable the existing paramedic workforce to gain registration under the National Scheme.

To gain registration, paramedics must have practised paramedicine for at least five of the past 10 years, while they must also be able to satisfy the Board of their competency to practise paramedicine.

“The ‘grandparenting’ provisions are a really important area of the legislation because there’s many paramedics in Australia who operate quite successfully – they are intensive care paramedics, critical care, advanced life support paramedics, who have not got a degree qualification but work as accredited and credentialled paramedics within ambulance services.”

Mr Jurkovsky, a former paramedic and senior lecturer in paramedicine who now practises as a lawyer, said the move to national registration reflects the evolution of paramedic training to a university sector with undergraduate and postgraduate degrees, and the increasing professionalism of the workforce in the past two decades.

“I think working closely with certainly nurses and doctors and different health professions, paramedics are now recognised as a high level health profession, whereas the stretcher bearer, ambulance driver role of years gone by is long gone.”

The step towards national registration will improve workforce mobility across Australian states and territory jurisdictions and countries such as the United Kingdom, where paramedic registration already exists.

It will also enhance the skills and expertise of the profession, requiring paramedics to meet annual continuing professional development requirements.

In New Zealand, the nation’s chapter of Paramedics Australasia is inviting New Zealand’s 1000 paramedics to comment in an online survey, on the workforce’s move towards registration and regulation.

Karen Keast, Health Times, 16 June 2017

There is a discordance between guidelines and what patients and GPs need

Technology can improve patient care, says nephrologist Associate Professor Ivor Katz, who shares examples of how GPs can use virtual consultations with tertiary specialists. Ivor is senior staff specialist, consultant nephrologist, at The St George Hospital and a conjoint associate professor at the University of NSW.

I’ve Been Reading

About novel health systems to manage chronic diseases and improving links between patients, GPs and tertiary specialists. The Economist ran an article about an Israeli app that uses a mobile phone camera for clinical-grade urine analysis. Taking this level of technology to the GP and patient is where we have to go!

 

I’ve Been Researching

The role of virtual medical consultation (VMC) in health systems. Having shown VMC is safe and has a role in healthcare, we plan to investigate the role of a chronic kidney disease (CKD) clinical nurse consultant in VMC. I’m investigating existing algorithms which calculate risk of developing advanced CKD and seeing if they have value to determine disease progression. For more info, click here.

 

Two Interesting Cases

These cases enrolled on our web-based VMC program demonstrated its value. One was a 41-year-old patient with hypertension and albuminuria. Her GP used VMC to get both a nephrologist and endocrinologist opinion as she was refusing treatment. The program facilitated drug therapy and confirmed type 2 diabetes. All investigations were arranged virtually i.e. echocardiogram and 24-hour ambulatory blood pressure measurement. The other case was a woman, aged 88, referred with decline in renal function against a backdrop of previous bladder cancer. Despite being known to a urologist and oncologist, the GP elected to use the quick VMC consult online. An obstructive uropathy was recognised and direct inpatient referral and stents arranged, relieving the acute issue.

 

A Thorn in my Side

There is a discordance between guidelines and what patients and GPs need. Analysis of referrals to our outpatient clinic showed 33% of referrals met Kidney Health Australia guidelines and 45% returned to their GP within six months. This does not mean patients did not need to be seen. However, it might mean the GP is not confident to manage certain problems on their own. Many patients could be managed virtually, allowing more time on transplant and dialysis patients.

 

What Challenges Me

More clearly understanding the ‘grey zone’ patients and when to refer! And so being able to recognise which patient needs greater focus so disease progression is reduced and resources better used. Improving guidelines to more closely reflect patient and doctor needs.

 

I’ve Been Thinking

How patients can be more involved in their care through technology. How we can maximise technology to best help those furthest from health care and who most need it.

Associate Professor Ivor Katz, Medical Observer, 16 May 2017

What to do when a patient requests a backdated referral

GPs often feel caught in the middle when a patient requests a backdated referral.

It is a busy afternoon and a patient phones you asking for a referral for a follow-up specialist appointment she attended a month earlier. You had initially referred her to the specialist but that referral had expired.

The patient is at the Medicare office trying to claim a rebate for the specialist visit, and explains that Medicare will not pay a claim for the specialist consultation because the referral was out of date.

Can you help the patient by backdating a referral?

GPs often feel caught in the middle when this scenario arises. They can feel an obligation to help their patient who will otherwise be left out of pocket without a current referral.

However, there is no leeway in this situation. It is unlawful to backdate a referral and GPs should not agree to such requests. Under the provisions in the Commonwealth Health Insurance Act, stiff penalties can apply for making false or misleading statements in relation to Medicare. This can also lead to disciplinary action from AHPRA.

Further, backdating referrals can result in Medicare declining to pay Medicare benefits or requiring repayment of benefits if they have been paid incorrectly.

Valid referrals

A valid referral is required before a specialist can itemise the consultation so the patient is eligible for Medicare benefits.

To be valid, a referral must be: in writing; signed and dated by the referring doctor; in date when the patient sees the specialist; and received before or at the time of the specialist consultation. Referrals from a GP to a specialist are valid for 12 months unless otherwise specified. If the specialist refers on to another specialist, the specialist referral is only valid for three months.

If a patient’s condition needs continuing care and management by a specialist or consultant physician, GPs can write a referral valid for longer than 12 months. An indefinite referral to the specialist or consultant physician can be provided where appropriate. However, if a patient on an indefinite referral has a new or unrelated condition, the GP must issue a new referral for that condition, even for the same specialist.

In some situations, provisions are made for Medicare benefits to be paid if a referral has been lost, stolen or destroyed. In those cases, the patient must declare to the specialist that a referral was completed by a referring practitioner, but was not delivered to the specialist because it was lost, stolen or destroyed. The patient must be able to provide the specialist with the name of the referring practitioner and their practice address or provider number.

There are also situations where referrals are not necessary, such as pre-anaesthetic consultations, emergencies and referrals of private patients in hospital.

Risk management strategies

GPs can introduce risk management strategies in a bid to avoid requests for backdated referrals from patients:

  • Ensure all practice staff and patients understand why a valid referral is important, and what constitutes a valid referral. It is important to note that the usual 12-month period for referral validity starts at the time when the specialist first sees the patient, and not when the initial referral is dated.
  • Reception staff should be trained and equipped to politely push back requests from patients for backdated referrals. Remember it is often not the patient’s fault that the referral is out-of-date.
  • When referring patients to a specialist, emphasise why a valid referral is important and the period it is valid for, if they are having ongoing care from the specialist. If it aligns with your practice policy, let patients know that if their referral is out of date they can call on the day of a specialist appointment to request a referral that can be sent directly to the specialist.
  • You may wish to have a notice displayed in your waiting room about referrals, which may remind patients about requesting an updated referral if theirs may be out of date.
  • In the interests of working together for the benefit of patients, good communication between GP and specialist is crucial. Consider a courtesy call to the specialist rooms, reminding them that requests for backdated referrals will be refused and are unlawful. Encourage them to call your rooms on the day of the follow-up appointment and inform them of your practice referral policy.

Key Points

  • GPs should never agree to requests to backdate a specialist referral.
  • Ensure all practice staff know backdated referrals will not be provided to patients under any circumstances.
  • Introduce strategies to educate patients about the importance of having a valid referral before visiting a specialist.

More information

The RACGP’s Standards for General Practices (4th edition) provides guidelines on writing referrals to specialists.

Related Opinion: Why referrals shouldn’t be mandated by Medicare

 

Dr Walid Jammal and Andrew Vanderford, Medical Observer, 16 May 2017

1 in 4 may be wrong dose of DOACS

One in four patients discharged from hospital on direct-acting oral anticoagulants (DOACs) are likely taking the wrong dose, a Victorian study suggests.

A review of 316 patients discharged in 2016 from a hospital at Eastern Health in Melbourne, revealed 27% were on a DOAC dose that was not appropriate for their weight, renal function, age or indication.

Consultant neurologist Dr Philip Choi, who led the study, said most of the patients were under-dosed.

“We suspect our patient cohort is quite elderly in general, with probably borderline renal function that can fluctuate, and I think there may be an ultra-cautious approach in prescribing,” he told Australian Doctor.

Some patients would have come into hospital on an incorrect dose prescribed by their GP, while others had the wrong dose prescribed by hospital specialists, he said.

DOACS had been marketed as not requiring monitoring, in contrast to warfarin, and this had possibly led to some complacency about their prescribing, he said.

Getting the correct dose required knowledge of the patient’s weight, age and renal function, as well as looking up the product information for the DOAC, said Dr Choi.

Another complicating factor was that the three DOACs —dabigatran, rivaroxaban and apixaban — had slightly different dosing requirements.

“For warfarin, age, weight and renal function don’t come into the equation at all, but for these medicines, these three key bits of information are what you need,” he said.

“This [study] highlights the fact that these medicines are not as easy to prescribe as we think.”

Dr Choi recommended that patients in their 80s underwent a review of their DOAC dose after six months, to check that renal function or weight had not changed significantly.

The findings were presented this month at the Royal Australasian College of Physicians congress in Melbourne.

Clare Pain, Australian Doctor, 15 May 2017

What we can learn from the rise and fall of Tamiflu

Oseltamivir (Tamiflu, Roche) has been downgraded by the World Health Organization (WHO) in the biennial review of its list of essential medicines.

A WHO expert committee removed Tamiflu from its list of “core” medicines, relegating it to the “complementary” list, a category used for drugs with consistently higher costs or less attractive cost-effectiveness.

This represents the latest blow to a drug whose sales hit $4 billion in 2009, riding on the back of worldwide stockpiling during the swine flu pandemic.

The spectacular rise and slow fall of Tamiflu is a cautionary tale worth remembering, if only to protect us from ourselves, the next time the public stampedes to pour money into the coffers of private industry.

Don’t forget; among the newspaper headlines screaming at politicians to stockpile Tamiflu in 2009, there was no shortage of doctors’ voices criticising any delay in access to the drug. Plenty of public health advocates—nearly all those with any influence—got it wrong, and we front-line clinicians were swept along.

The Tamiflu provided free to my Aboriginal health clinic provided the only opportunity in my entire career to stride out into my waiting room, spectacularly arrayed in gown, gloves and mask, to administer a drug to people who were mildly unwell with a fever. For two months I felt like I was on the set of the film, Contagion.

As it turns out, for my patients who did indeed have swine flu, the drug I so dramatically administered would have shortened their symptoms by just half a day, and not done a thing to prevent either complications or hospitalisation.

We only know the extent of our mistake thanks to the dogged persistence of a few Cochrane reviewers, and the support of the BMJ. These folk noticed an anomaly that had eluded governments all around the globe, whose advisers were allowed to divert hundreds of millions of dollars from other public programs.

Professor Chris del Mar, one of the Cochrane reviewers, explained on ABC’s Catalyst program: “When we did the initial analysis, it was straightforward. We just looked at published data…the drug reduces complications…easy.”

But he soon became worried that the data may have been cherry-picked (the majority of trials were fully funded by Tamiflu manufacturer Roche), and that there may also be unfavourable results which hadn’t been published.

The Cochrane reviewers asked Roche for its unpublished trials, and that is where the trouble started.

BMJ Editor-in-Chief Fiona Godlee described the process as “a really lengthy cat and mouse, Alice-in-Wonderland, bizarre experience of trying to get data on a drug which governments around the world were busy buying, stockpiling and spending billions of dollars on.”

It took an extraordinary four years of legal and public pressure (and ongoing Tamiflu sales) before Roche was finally forced to release the less favourable information, which turned out to be the majority of data ever collected on the drug.

Dr Godlee was unimpressed by the effort it took. “I think it’s very hard to explain why this behaviour by the pharmaceutical industry in suppressing data over many years is not considered as misconduct.”

That was the beginning of the end of Tamiflu’s golden run.

New analyses undermined the primary justification for stockpiling—a reduction in complications and hospitalisations—and the current WHO downgrading is the latest reminder of the folly of the 2009 international spending frenzy.

That money is long gone now, and the only thing it earned us was a valuable lesson.

This story is worth re-telling, so that next time the stampede begins, more of us are willing to look beyond the emotive calls to spend up big.

We must insist on close examination of the evidence, and our right to see all of it before buying the product.

Justin Coleman, Medical Observer, 21 June 2017

GP suspended after encouraging clay wrapping therapy

A GP has been suspended for one year after encouraging a child with metastatic hepatoblastoma to avoid chemotherapy in favour of alternative therapies.

Dr Alastair Marcus Nuttall saw 10-year-old Tamar Stitt, and her parents Trevor and Arely, in his Perth practice in September 2009, two months after the child was diagnosed.

In the 45-minute consultation, the parents told Dr Nuttall they were planning to fly to El Salvador, as doctors from the Princess Margaret Hospital had applied to the courts for a mandatory chemotherapy treatment order.

While in El Salvador, they planned to wrap Tamar in clay as part of a therapy that would extract toxins from her body.

Dr Nuttall reviewed the results of a recent ultrasound and said the child’s tumour had shrunk since the last scan.

“Whatever you are doing, keep doing it,” he said, referring to the alternative therapies.

Tamar died in El Salvador, about two months after the consult with Dr Nuttall.

The WA State Administrative Tribunal in April found Dr Nuttall guilty of professional misconduct for failing to contact doctors at the hospital about Tamar’s treatment and for encouraging the use of alternative therapies.

In a separate judgement handed down this week, the tribunal said the penalty imposed on Dr Nuttall had to send a message of general deterrence to other doctors who supported alternative therapies.

But the tribunal said that Dr Nuttall’s conduct relates to “an isolated and highly unusual consultation, the circumstances of which are unlikely to be faced by him again”.

Since the consultation happened nearly eight years ago, Dr Nuttall had not been reported for any other breaches.

The tribunal concluded that on balance, Dr Nuttall poses a low risk of future misconduct.

However, the seriousness of Dr Nuttall’s conduct means he should be reprimanded and suspended for 12 months starting from next month, it said.

The Medical Board of Australia had pushed for a cancellation of Dr Nuttall’s registration and a three-year ban before he could reapply, while he argued for a three-month suspension.

More information: State Administrative Tribunal findings

Rachel Worsley, Australian Doctor, 21 June 2017

Good isn’t enough, GPs need to be nice too

I’ve no doubt my old mate Steve is a good doctor, but whether he is a ‘nice’ doctor is a moot point.

Having once shared a house with him, I know him to be thoughtful, bright and absolutely dedicated to his vocation.

But he’s also taciturn and can be embarrassingly blunt to those who don’t know him well.

I’m sure I’d be in safe hands if Steve was my treating doctor, but a new report from the UK suggests that he might get a low-quality rating from many patients using the National Health Service feedback system.

Published in the BMJ Open journal, the report analyses almost a quarter of a million comments left by patients — mostly about GPs — via the NHS Choices portal.

It finds that patients are overwhelmingly positive about their healthcare experiences and rate doctors highly (87% positive) in terms of technical competence.

GPs and their staff also rate well for communication skills (77% positive) but really fall down the rankings when it comes to interpersonal skills (44% positive experience) and in terms of their systems and organisation (41% satisfaction).

What this means in practice is that some patients love their GP clinics for simple things, such as knowing their name and not being afraid to smile and have a joke with patients (“which goes a long way to helping relieve nerves”, commented one patient).

Unsurprisingly, patients also appreciate GPs who have a good ‘bedside manner’ and take the time to listen and explain things. The flipside to this is that many patients say the doctor and/or their staff appear dismissive, lack courtesy and don’t appear willing to listen.

“I find them so rude, and their lethargic attitude annoys me”, said one patient.

But even when doctors and staff were ‘nice’, their practices were negatively rated because of poor appointment booking systems, long waiting times or frustrating telephone answering experiences.

“Great doctors, great facilities but awful appointment service and opening hours!” was one comment.

Dr Gavin Brookes, a primary care researcher from the University of Nottingham, who co-authored the report, said it revealed that doctors and patients had different standards on quality of care.

While doctors might tick all the boxes on technical standards, communications skills and “shared decision-making”, they could still fall down on the “soft” interpersonal skills.

“Such skills might be developed more effectively through greater opportunity for hands-on human engagement,” he wrote.

But even Dr Brookes acknowledged that the daunting financial and time pressures GPs faced might have a lot to do with the perceived poor interpersonal skills and clunky practice systems.

Michael Woodhead, Medical Observer, 12 May 2017

GPs out of the loop on patient suicide risk

Family members know a lot about a close relative’s suicide risk, but they are not passing this information on to GPs, say researchers.

A review of 74 suicides in NSW and Queensland that involved contact with GPs found one in four families spoke to a doctor about suicide warning signs shortly before the patient’s death.

The warning signs included people suddenly changing their will, disposing of possessions, stock-piling pills and feelings of hopelessness.

“Even in cases involving people with recent suicidal behaviour, there was no communication between health professionals and next-of-kin in 62% of cases,” said lead researcher Professor Brian Draper, a psychiatrist at the University of NSW.

He suggested GPs explore ways to reach out to family members if the doctor had concerns about their patient’s suicide risk.

“[GPs] could start off by getting permission of the person to contact their family. People are quite open to the idea of contacting other family members, as long as they are informed,” he told Australian Doctor.

If the patient refused consent, GPs might need to weigh up the need for contacting the family without permission if they felt the person was at imminent risk of suicide, he added.

“That might be a big judgement call. In those situations, the GP will probably have to decide to involve the mental health crisis team to help this person.”

Dr Jane Ralls, a GP in WA with an interest in mental health, said she would always try to gain patient permission to contact family members if she had concerns about their suicide risk.

“But if I’m seeing a patient who’s very distressed and I happen to see a close relative in another consultation, I often raise the issues as an aside and just see what comes up,” she said.

Dr Vered Gordon, a GP with the Black Dog Institute, said she encouraged her patients to bring in a family member or support person to consultations so they could discuss ground rules about when it was appropriate to contact family members.

“It makes everyone more comfortable about what to do. You’ll more likely to have good communication between everybody so you can keep the person safe and well.”

Professor Draper presented the study at the Royal Australian and New Zealand College of Psychiatrists Congress last week.

For support and information about suicide prevention, call Lifeline on 13 11 14

Rachel Worsley, Australian Doctor, 9 May 2017

Let’s be honest, our letters are bad too

I sit here disappointedly staring at the one-page transfer summary I have been sent for a new patient, and wonder whether they really have been diagnosed with hypertension seven times and whether they still are on that anti-biotic from 2006.

GPs consistently complain about the poor level of communication coming from the hospital sector. But in truth, our communication to other clinicians is not much better.

Inter-doctor communication is a much-bemoaned issue.

As GPs, one of our favourite pastimes is to complain about hospital discharge summaries — or we would, if we had one.

But have a conversation with any local ED consultant, and they will also complain bitterly about the “terrible” quality of GP letters and the “atrocious” patient summary health sheets.

They lament that GP letters often lack basic vital signs, that the summaries are unreliable, or worse, that patients often present to the department with neither.

And I believe this.

A proud general practice liaison officer I know told me they were shown a random collection of de-identified GP referral letters for an upcoming hospital clinic, after trying to defend her profession’s letter writing skills to a group of specialist colleagues.

Expecting something better, they were embarrassed to see that the quality was mostly poor and left the meeting with a new-found respect for the challenges hospital specialists face.

Communication between GPs is just as bad. Getting a new patient’s notes is a mixed affair of either one page, 300 pages or even none because the doctor has retired and left for Tahiti.

Chasing previous specialist letters and investigation results is often frustrating and tedious. It all makes caring for a new patient far more complicated than it should be.

Yet, we seem to stuck in limbo-land on how to resolve the issue once and for all.

Neither GPs nor other specialists are keen — or have the time or energy — to make a committed move to solve this issue.

But maybe it’s time for GPs to break the stalemate, put aside our excuses, undergo some painful self-reflection and clean up our own backyard.

I say this because communication is critical to everything we do.

We hold ourselves up as the gold standard in high-quality communication, skills that we use daily to build rapport and educate our patients.

Unfortunately, these skills do not always translate to good communication with our medical colleagues.

And the only way to improve on this is to listen to feedback.

Yes, we need to seek and act on feedback from our hospital colleagues — something that happens very rarely at present.

Currently, you could be sending poor-quality letters to the hospital for many years, but assume what you’re doing is sufficient as you’ve never been told otherwise.

Unfortunately, some GPs may take such feedback as a personal affront.

However, without some form of feedback improvement is unlikely.

It’s like throwing darts in the dark but never knowing if you hit the target.

Do you keep throwing it the same way?

Of course, mutual respect is required in all communications.

For example, a discharge summary with one line that says ‘GP to chase the results of XYZ’ is rude, particularly if the GP has absolutely no idea why XYZ was ordered or has no access to the results.

Conversely, GP letters that say certain investigations have been completed, without including a copy of these investigations, is equally inappropriate and need to be improved.

If we made more effort to send our colleagues a useful document — such as a list of latest results, specialist letters, details about any chronic disease management plans and an up-to-date medication list — wouldn’t it make everyone’s lives easier? The extra time we save because a colleague sent us a great transfer, we could use in writing our own great transfer details to another colleague.

We can all carry on making the same old arguments that we are underfunded, that patients come in with too many problems, or that we don’t have time, etc.

However, while I think these are valid points, it is time to put aside our excuses.

There are many examples of great GPs who do keep their records up-to-date and write detailed appropriate letters. If they can do it with the same limitations that we all share, shouldn’t we all aspire to this ideal?

Dr Bob Park, Medical Observer, 17 May 2017

GPs to receive referrals from paramedics

Paramedics in NSW have been given powers to write referrals and ring GPs to discuss patients during call-outs.

Under new protocols designed to keep low-acuity patients out of hospital EDs, NSW Ambulance has informed local GP practices to expect up to two referrals a day from its paramedics.

When referring a patient, paramedics will ring and ask to speak to directly to their GP.

Over the phone, GPs will be provided with a brief summary of the patient’s condition and asked if they are willing to accept the patient.

If no GP is available to speak over the phone, the paramedic will instead give the patient a letter describing their condition to pass on to the GP at a later date.

The new powers will not mean risky patients are dumped at GP offices for treatment, said Cynthia Stanton, general manager for primary care advancement and integration at the Northern Sydney Primary Health Network.

“This is about low-acuity patients. If it wasn’t safe to leave that patient at home, they wouldn’t,” she said.

“One of the biggest challenges we hear consistently with GPs is the lack of information they get from other parts of the health system, so anything that improves communication is always going to be received well.”

Ms Stanton said use of the new powers has been limited in the Primary Health Network area, but GPs are being told to expect more.

The system has been introduced as part of NSW Ambulance’s new ‘P5 transfer protocol’, which, for the first time, gives paramedics the choice of treating a patient themselves and not transferring them to a hospital.

In a letter to GPs last month, NSW Ambulance said the changes would “benefit and streamline patient care through greater collaboration with local healthcare providers, primarily the patients’ GP”.

It added that the new powers were designed in response to the increasing demands on ambulance resources to attend triple zero cases for patients with non-emergency medical or minor injury presentations.

Geir O’Rourke, Australian Doctor, 21 June 2017

Transvaginal mesh: another device scandal?

In his previous working life, crossbench Senator Derryn Hinch was a controversial tabloid journalist, who delighted in the nickname ‘the Human Headline’.

During his long media career the Human Headline learnt a thing or two about how to catch the attention of the Australian public.

Last year, he stood up in Parliament and attempted to link the thalidomide scandal with a fresh medical controversy.

“I am about to put a four-letter word into the same category as thalidomide — a word that is not crippling babies but has crippled thousands of mothers both here and overseas,” he told the Senate. “That four-letter word is mesh, transvaginal mesh.”

 

Simpler and less invasive
The use of transvaginal mesh in urogynaecological surgery has become a vexed issue. When device manufacturers saw that surgeons were using surgical mesh products abdominally to treat stress urinary incontinence and pelvic organ prolapse, they started to develop specific vaginal mesh products. They were approved for use in urinary stress incontinence by the US Food and Drug Administration (FDA) in 1996 and six years later for the treatment of pelvic organ prolapse (POP).

The devices were credited with making the procedures simpler and less invasive. Uptake, particularly in the US, was significant,  but over the past decade, reports of complications have increased, with some women suffering agonising chronic pain, nerve damage, bleeding and infection, with mesh erosion cutting through the vaginal wall and sometimes perforating nearby organs.

In Australia, the issue has surfaced in the public domain, largely as a result of the lobby group founded by Caz Chisholm, a WA woman who had two mesh implant procedures for stress incontinence in 2014. The Australian Pelvic Mesh Support Group now has over 200 members and is active on social media. It was this group that brought their stories to the attention of Senator Hinch.

In February, this lobbying effort resulted in the establishment of a Senate inquiry to examine the issue. It is likely that a stream of medical experts will be called to Canberra to provide their expert views on this highly charged topic.

Warnings and complications
The FDA first issued an alert about the devices and their potentially serious complications in 2008. It was another three years before the FDA undertook new research in an attempt to discover what was happening.

Trawling through the Manufacturer and User Device Experience database, the FDA compared two, three-year periods — 2005-07 and 2008-10 — and discovered there had been a fivefold increase in medical device reports associated with POP repairs using transvaginal meshes.

This triggered a second FDA alert, which led to at least eight mesh devices being removed from the market.

Class actions were rapidly initiated in jurisdictions around the world. An American litigant named Linda Gross was awarded over $11 million in a case against Johnson and Johnson. After her mesh surgery went wrong, she required 18 subsequent operations. The case is currently being appealed by Johnson and Johnson.

Last year, the FDA changed its classification of transvaginal mesh to repair POP from ‘moderate-risk device’ to ‘high-risk device’.

Media reports have focused largely on the device itself as failing, but there are important qualifiers. RANZCOG says it is critical to distinguish between the use of transvaginal mesh for POP and its use for stress urinary incontinence.

“They should be viewed very differently,” says Dr Martin Ritossa, RANZCOG spokesman and Adelaide gynaecologist.

“Transvaginal mesh for treatment of urinary incontinence has been well researched and has been used in hundreds of thousands of women around the world and has been proven to be safe and effective and probably the best treatment we have for urinary incontinence.

“Transvaginal mesh for prolapse isn’t quite as well researched, does have some advantages over traditional repairs but also has increased complications.”

The reason for the different outcomes, he says, is partly because more mesh is used in POP.

“It will be under strain, and that strain is going to cause wear and tear. In urinary incontinence, you put a thin tape underneath the urethra … We don’t really understand how it works, but we think it supports the urethra. The tape is like a sling underneath the urethra, supporting it.”

Like a trampoline
With POP, a layer of mesh between the skin and the bladder or bowel is attached to ligaments.

“It’s a bit like a trampoline. The mesh is a bit like the mat of a trampoline, and the springs hold it up — attachments to ligaments,” Dr Ritossa says.

The alarm that has now surfaced about the use of the mesh for POP could and should have been avoided, according to Dr Christopher Maher (pictured left), one of Australia’s senior urogynaecologists, who works at the Royal Brisbane and Women’s Hospital.

He refers to the problems that often emerge with new medical devices, particularly in surgery. The way the uptake of the new technology — fuelled by a big company’s marketing budget and the recruitment of key opinion leaders — so often moves beyond the evidence base for their efficacy and safety.

The main problem with transvaginal meshes when they came to the market for treating POP, was they were deemed to be safe, based on “substantially equivalent” products used in the treatment of hernias and incontinence. Because these products had already been approved for use by the FDA, they ended up in a fast-track approval process, with no requirement on makers to conduct studies on patents. So the evidential hole was filled by something else.

“From the launch of transvaginal mesh kits in 2002 and until [2011]”, wrote Dr Maher in a 2013 paper titled ‘The transvaginal mesh decade’, “these products were aggressively marketed to clinicians by the manufacturers on the basis of FDA clearance”.

He said there was very little guidance given to clinicians about how or when to use these products by their relevant colleges. The primary educators of clinicians were the companies that manufactured them.

“Companies ran educational courses, cadaver demonstrations of relevant anatomy, surgical demonstrations and surgical mentoring programs to facilitate product utilisation by clinicians. Products were also promoted to primary health providers and to the general public.

“This scenario is completely unsatisfactory for all pelvic floor clinicians who have failed to demand a satisfactory level of guidance regarding the safety and efficacy of a product prior to its utilisation,” Dr Maher argued.

“As a group, our collective unfounded enthusiasm for transvaginal meshes resulted in loss of trust from women,” he wrote of his fellow surgeons. We cannot, in good faith, vouch for the safety or efficacy of any of the currently available transvaginal meshes.”

No central registry
In Australia, there are a number of questions to be answered. First, no one quite knows just how many Australian women have been affected as there is no central registry recording the number of mesh procedures undertaken.

The estimation is that as many as 100,000 Australian women have been given a transvaginal mesh implant. The lack of robust data, therefore, makes it difficult to know how many have suffered complications. Consumer health advocate Health Issues Centre says it could be as low as 1% or as high as 30%.

The TGA is more conservative. As of April this year, the agency says it has received 205 adverse event reports about transvaginal meshes, involving 277 patients (one report can refer to more than one patient), which suggests that if 100,000 devices have been implanted since 2000, 0.2% of cases have gone wrong.

For the defence
Amid the media reports, FDA warnings, speeches to Parliament, and news of legal action, anecdotal evidence suggests there has been a dramatic fall in the use of transvaginal meshes.

However, the procedure does have its defenders, and there are fears that the adverse publicity will see the demise of an intervention that still holds out the prospect of genuine therapeutic benefits.

Dr Vivien Wong and Dr Ka Lai Shek, from the Sydney Medical School Nepean, claim “the discussion surrounding the use of transvaginal mesh has been dominated by emotion rather than science”.

The problem has been not simply the devices themselves and bullish marketing, but also inadequate surgical techniques and what they say is poor patient selection.

“It is depressing to see the demise of a surgical option precisely at a time when we are finally starting to understand the risks and benefits of that option in individual patients”, they wrote this year in the Australian and New Zealand Journal of Obstetrics and Gynaecology.1

Proceed with caution
The call from RANZCOG is not about ditching the procedure. Its message is one of caution.

“For prolapse, our advice would be to try conservative measures and native tissue repair first,” says Dr Ritossa. “For anyone, considering a mesh procedure make sure their surgeon is experienced and well trained and recognised for performing that procedure.

“You could ask your surgeon what training they’ve done and how many procedures they’ve done. You could get a second opinion about whether that procedure is right for you and whether that person is the right person to be doing the operation.”

The Senate inquiry starts taking submissions on 31 May and will be wide ranging in its scope. It will look into the role of financial or other incentives provided to medical practitioners to promote the uptake of transvaginal meshes. It will also examine the role of the TGA, which according to Senator Hinch, has been too slow in voicing its warnings and has failed to protect women.

Court cases also loom. Shine Lawyers is representing 450 Australian women in a class action against the mesh manufacturer Johnson and Johnson. It is expected to go before the Federal Court in the middle of the year.

And as often seen in the past, when the media has its headlines, the lawyers their legal cases and patients have been harmed, it will come as a ‘perfect storm’ that is unlikely to leave Australian healthcare, and the way it goes about its business, untouched.

 

Brett Evans and Clare Pain, Australian Doctor, 16 May 2016

Abortion on patient with multi-organ failure wrong: tribunal

A doctor faces potential sanctions for performing a late-term abortion on a woman despite tests showing she was experiencing multi-organ failure.

The patient was 23 weeks pregnant when she arrived at her appointment with Dr Mark Schulberg in August 2011 showing signs of jaundice and unable to stand unassisted.

On examination, she was found to be gravely ill and difficult to rouse, and eventually lost consciousness.

Although the Melbourne GP had ordered urgent pathology tests the previous day, he only checked the results that morning. They revealed the patient had liver and kidney failure in addition to an abnormal clotting profile.

Dr Schulberg decided to go ahead with the termination.

He told the Victorian Civil and Administration Tribunal that he thought the complications were pregnancy-related.

His decision to continue with the procedure was against the advice of the clinic’s GP anaesthetist, Dr Colin Douglas.

Because the woman was already unconscious, Dr Schulberg did not use anaesthetic.

When the ambulance arrived 10 minutes after the termination, paramedics immediately took the patient to hospital, where she was admitted to the ICU.

After a week during which her Glasgow coma score was consistently at three, the woman was discharged.

Although the tribunal accepted that Dr Schulberg thought the patient might have a septic fetus, and that he performed the actual procedure quickly and skillfully, it found that he should have urgently called an ambulance, and given the patient IV fluids and antibiotics.

Even if the abortion was urgent, addressing other potential risks of the patient’s condition was more so, the tribunal found.

It also found that Dr Schulberg should have followed up the urgent blood tests a day earlier.

Dr Schulberg argued he did not have a responsibility to follow up the tests on the day he ordered them and that he expected Melbourne Pathology to notify him urgently if the results were abnormal.

But the tribunal found that Dr Schulberg had a duty to chase the results, particularly when he had classified them as urgent because of the patient’s slight anaemia tendency to bleed, writing the note: “significant bruising +++”.

“When urgent blood test results are ordered, it is not reasonable to make assumptions — it is always necessary to check the results,” the tribunal said.

“We ultimately concluded that Dr Schulberg was taken very much by surprise by the presentation of his patient … and was somewhat out of his depth in dealing with the unusual and unexpected situation.”

Dr Schulberg was one of the few Australian doctors performing late-term abortions at the time.

It has since been revealed that James Latham Peters, an anesthetist at Dr Schulberg’s clinic, infected about 50 women with hepatitis C in 2008 and 2009.

The tribunal will hold further hearings ahead of its final determination.

Antony Scholefield, Australian Doctor, 2 June 2017

8% of nursing home deaths are a result of choking

A concerning number of premature deaths in Australian nursing homes are down to external causes including falls and choking.

A 12-year review of nearly 22,000 nursing home deaths reported to coroners has found some 15% are the result of falling, choking on food, suicide, or assault from another resident.

It also identifies a four-fold rise of such deaths over the study period—mostly from falls (81%).

Choking on food is the second leading cause of unintentional deaths from external causes, accounting for some 8%.

Only three in 100 deaths from an external cause are subject to a coroner’s inquest. In 98% of those cases, the coroner makes no recommendations about injury prevention.

“Disturbingly, there has been no reduction in the prevalence of these types of external-cause deaths over the past 12 years,” the authors write.

Study lead Professor Joseph Ibrahim says improving residents’ safety and quality of care is long overdue.

“Some people will choke because they need better disease management for Parkinson’s,” Professor Ibrahim who is a geriatric physician at Monash University tells Australian Doctor.

“Some people choke because the kitchen has sent the wrong meal and they weren’t aware, and some people will choke knowing they’ve got swallowing problems, but they don’t want a modified [diet] and they’re willing to take a risk.

“I’m hoping [this study] will change attitudes towards ageing and have people understand that injury deaths do occur, and put more value and effort in ensuring people have a better life in residential care,” he says.

Geriatrician Dr Catherine Yelland, who is based in Brisbane, says the authors’ recommendations “should be heeded” by federal and state departments of health, saying the findings on choking deaths are particularly worrying.

“Choking may be attributed to underlying medical conditions, including stroke and Parkinson’s disease, but the number of deaths underscores the need for expert swallowing assessment, modified diets, and sufficient staff to supervise meals or to feed patients as required,” she says in an accompanying MJA editorial.

Professor Ibrahim says it’s time to put more energy into aged care and follow the national approach taken in healthcare in the late 1990s to improve patient safety.

“All the things that we do better now in healthcare than we ever used to—that’s something that aged care could benefit from,” he says.

Professor Ibrahim says aged care warrants attention from the Federal Government, estimating ministers aged over 50 face using the current system in 20 years’ time.

“So if they love it—then terrific, because that’s what they’re going to be using,” he warned.

Jocelyn Wright, Australian Doctor, 29 May 2017

Troubled teens don’t outgrow suicide risk: study

Teenagers hospitalised for drug-, alcohol- or violence-related injuries continue to be at increased risk of suicide for the next decade, a study shows.

The risk is similar to that following hospitalisation for self-harm, researchers say.

Their retrospective study looks at the cause of death for nearly 5000 people, aged between 10 and 19, admitted through EDs.

It covers hospitalisations for either accident-related injury or “adversity-related injury”, which includes self-inflicted injuries from drug or alcohol use, violence and self-harm.

In the 10 years after discharge, the people with a history of adversity-related admissions were found to be 5-6 times more likely to die from suicide, drugs or alcohol compared with those who had been admitted to hospital after accidents.

The adjusted suicide rate following drug- or alcohol-related hospitalisations was similar to that following hospitalisations for self-harm.

Dr George Patton, an epidemiologist and consultant child and adolescent psychiatrist in Melbourne, said the findings showed that troubled teens did not outgrow their mental health risk

“Given that risks remain high for at least a decade, crisis presentations in adolescents should be seen as more than a passing phase,” he said in an accompanying commentary.

“The idea in the 1950s and ’60s was that marriage, mortgage and kids would sort it out. That attitude is still around. Well, I haven’t seen one study saying it’s all left behind in adolescence,” he told Australian Doctor.

According to Dr Patton, healthcare services were not providing any follow-up for teenagers who ended up in the ED after drug- or alcohol-related violence.

“There’s a level of frustration when adolescents present with something that appears self-inflicted.

“They’re an irritation; they’re wasting our time; it’s a phase,” he said.

“We don’t follow them up. We need to engage with these kids in the weeks and months after the presentation. Even brief counselling can make a difference.”

In the UK, it is standard practice to hold a specialist psychosocial assessment for adolescents who self-harm.

The study authors recommended that this approach should be considered for adolescents who present with drug- and alcohol-related injuries as well.

For support and information about suicide prevention, call Lifeline on 13 11 14.

Antony Scholefield, Australian Doctor, 31 May 2017

Retail genetics

General practitioners are increasingly encountering patients who have paid for a genetic profile. These direct-to-consumer tests are promoted through community pharmacies or other retailers, by mail order or via the internet. They usually involve the collection of cellular material from cheek swabs or saliva which is sent to a laboratory that analyses the DNA using chip array-based genotyping. These differ from the clinical genetic services that GPs can refer patients to.

Direct-to-consumer tests usually have no involvement of a medical practitioner when they are ordered and limited or no counselling is provided. Companies promoting direct-to-consumer genetic tests usually claim they are for consumer information rather than medical decision making. However, the breadth of the genetic profiles produced, particularly by predictive or pre-symptomatic genetic tests, may impact on family members, potential employment and life insurance.

Preventive care is fundamentally about risk assessment and management of a condition with a patient’s family history playing a role. This is one area where, with the appropriate training of health professionals, genetic profiles have the possibility to inform care. Despite this, direct-to-consumer genetic test reports are difficult to interpret. In 2012 only 7% of Australian genetic specialists reported they would be confident to interpret and explain the results of these tests.

Some companies specialise in pharmacogenomic tests that suggest how an individual’s genetic make-up may affect their response to certain drugs. One company pays pharmacists to collect the test and interpret the result for the consumer. The results are also sent to the patient’s GP. Pharmacogenomic tests can sometimes be a useful alternative to selecting drugs by trial and error, especially if a patient has experienced a poor response to treatment or unexpected adverse effects. However, a ‘normal’ pharmacogenomic test does not mean the patient is not at risk of drug-related adverse effects, or of not responding to a drug. Current tests only capture known variants of known genes. In addition, even if the test shows gene variants that impact on a certain drug’s metabolism, this is only one of many factors that influence how patients respond to drug therapy. Other factors include age, weight, drug interactions, allergies, renal and liver function, and psychosocial characteristics such as impaired cognition and health literacy.

Some GPs have expressed disquiet at receiving test results they have not ordered and the interpretation may be difficult. While knowledge in this area is increasing, in many specific clinical situations more work is required to ensure that test results will be meaningfully translated into clinical practice in order to achieve best outcomes for the patient.

The Australian Competition and Consumer Commission (ACCC) has been concerned that, in one case, some statements about genetic testing (in pharmacy catalogues, television infomercials, in-store brochures and other promotional materials) ‘risked conveying a false or misleading impression regarding the usefulness of the test and the consumers for whom testing may be appropriate’. Consequently, following ACCC intervention, the promotional materials containing statements of concern were withdrawn.

Some companies risk over-enthusiastic promotion. For example, testing for the AMY1 gene is claimed to reveal how well the body can metabolise starch carbohydrates. This test is said to assist with a range of weight management and other health issues. One company recommends its own preferred practitioners who offer ‘nutrigenomics’ advice, based on the test result, for a variety of health conditions.

There are also overseas companies that promote their tests in Australia via the internet. One offers genetic tests for 31 disease conditions, 53 carrier status conditions, 12 drug response genes, 6 wellness tests, 11 traits and 11 addictions. These claims appear to go well beyond the evidence base underlying the tests and do not come under the jurisdiction of Australian regulators.

Direct-to-consumer genetic profiling tests provided by Australian companies or laboratories for self-testing are classified as Class 3 in vitro diagnostic medical devices by the Therapeutic Goods Administration (TGA). Until 2010, the level of regulation in Australia was very limited. A new regulatory framework began on 1 July 2010 to ensure that all such tests undergo a level of regulatory scrutiny commensurate with their risks. Commercial medical device manufacturers must now seek a conformity assessment certificate from the TGA if they want to supply such products in Australia.

From July 2017 local laboratories who develop medical devices ‘in-house’ must maintain their accreditation by the National Association of Testing Authorities, Australia (NATA). Their tests must also meet National Pathology Accreditation Advisory Council performance standards.

It remains unclear what the potential impact of genetic profiling may be on purchasing various types of insurance, particularly life insurance. While private health insurance companies do not require consumers to undertake tests to assess the risk of disease, and premiums are not affected by the genetic test results, you are required to disclose information that may impact your insurability. Underwritten life insurance products, including cover for life, trauma, disability and income protection which may be required for business and bank loans, could be impacted by a genetic test result.

In conclusion, health professionals and consumers need to be aware that genetic tests developed in-house will not undergo regulatory scrutiny by the TGA until July 2017. In addition, promotional claims may exceed the evidence underlying the test. Furthermore, their cost is not covered by Medicare or private health insurance rebates, except for some tests, such as those that can guide cancer treatment. Health professionals should advise their patients not to purchase these tests from overseas. Patients should also discuss the usefulness of locally promoted tests with their doctor before paying for a test.

There needs to be ongoing education of all health professionals about the appropriateness and changing role of these tests as more knowledge becomes available. The education should be in keeping with useful information provided by the National Health and Medical Research Council for both consumers and medical practitioners.9 This ongoing education should be independent of the companies promoting the test.

Ken Harvey and Basia Diug, Australian Prescriber, 1 June 2017

Pharmacists urged to blow whistle on CAM tactics

Pharmacists across Australia are being urged to reveal the dodgy retail tactics used to sell unproven or ineffective complementary medicines.

The Pharmacy CAM Leaks initiative is the brainchild of pharmacist Ian Carr.

He wants grassroots pharmacists to email in the details of pharmacy marketing methods — whether pharmacies are forcing staff to hit sales targets or to flog so-called “companion” products with prescription medications.

“One of the difficulties of the issue is that there’s nothing out there in the public arena as to how the market is achieved,” says Mr Carr, who owns Saxbys Pharmacy in the rural NSW town of Taree.

“Everybody who holds this information is self-interested.”

A member of the anti-quackery group Friends of Science in Medicine, Mr Carr says he refuses to stock homeopathic products even though they are a proven revenue-maker for other pharmacies.

Asked how his own business remains profitable, Mr Carr says: “Well, maybe I’m not. But I don’t think that’s a valid argument.

“If a GP doesn’t make enough Medicare in five days, he doesn’t practise shamanism or homeopathy on the weekend.

“You should cut the business for the cloth, not the cloth for the business.

Pharmacy sales of supplements and vitamins are worth $2.5 billion, he claims, making up more than half of the $4.7 billion Australians spend on supplements.

Mr Carr says his long-term goal for Pharmacy CAM Leaks is to expose substandard practices and force pharmacy regulators to take a tougher stance.

“Pharmacists know half of what they are selling is wrong,” he says.

“I’m happy to publish stories anonymously, but really I want to approach pharmacy boards and say ‘this is going on and it is not of a sufficiently high standard’.

“It’s an elephant in the room for all the PBS contracts and quality assurance programs.

“Quality assurance comes around but nobody ever says ‘why are you selling this thing with no evidence’.”

The email address for Pharmacy CAM Leaks is: pharmacy.cam.leaks@gmail.com

Antony Scholefield, Australian Doctor, 14 June 2017

A GP reflects on a torturous stay in s critical care unit

The torturers at Guantanamo Bay could learn a thing or two from critical care units (CCU).

On my first day in CCU, post-mitral valve and tricuspid valve repair, I was subjected to the constant cries of “help me!” from the demented patient in the next cubicle.

She had received palliative orthopaedic care, and cries for help with each breath were her normal, pre-admission behaviour. No matter what strategies the staff employed nothing could calm her, and no sleep was possible for any patient in the unit.

Instead of waterboarding I was subjected to assault by slippery sheets. As I slowly slid down to the foot of the inclined bed, slippery sheets were employed to pull me up onto ice-cold regions.

Then they would decide to give me a sponge bath. If I moaned, I was interrogated: Are you nauseous? Are you in pain?

The drugs were flying: Ondansetron, Endone, Paracetamol. Mostly I just wanted some ice chips, but I was too weak to lift the spoon or to push the call button.

To cope, I developed my own strategy of removing my oxygen saturation finger probe. This always attracted their attention, so I could request some ice.

Unbeknownst to me I was on severe water restriction due to hyponatremia, and I was so thirsty after losing nearly half my blood volume during the surgery.

The cries of “help me!” were relentless night and day. Sleep deprivation from the constant ward activity, noise, and bright light completed the picture.

As my stay lengthened, every day brought new complications and associated tortures, usually at the bewitching hour of 3am.

Day two, I developed severe rapid AF followed by plummeting bradycardia. By the next night I had perfected this technique such that my nurse advised me that the entire unit had been on high adrenalin all night.

After further rapid AF I earned extra points in Critical Care with a performance of asystole for ten seconds. Three nurses appeared before me. One clutched her chest, her mouth open in shock. Another prodded me and yelled my name.

This low-tech method successfully resuscitated me from my asystole, although that night I went through the whole symphony of arrhythmias again. In the morning I heard the team leader chuckling to himself that asystole was the most stable rhythm of all.

I was still too dizzy to sit up in bed, but the consultant preferred to ‘watch’ my haemoglobin rather than transfuse me. Eventually I managed to graduate to the cardiac ward, with the prospect of a dimmable light and a door that could be closed.

I lasted half a day in coronary care before rebounding to critical care with a duodenal bleed. (I had attributed my abdominal discomfort to flatulence from having ordered baked beans for breakfast the day before.)

I had uncontrollable melena which meant that I was in nappies requiring regular changes. But at least I now qualified for three units of blood.

Two weeks after my surgery I escaped home. I had spent nine days in the intensive care unit. The usual hospital stay for valve repair is one week, including one day in CCU.

So much for being active and keeping fit. So much for beautifully clean coronary arteries.

Dr Pam Rachootin, Medical Observer, 22 June 2017

Novel midwifery program supports private patients

A pioneering midwifery-led program is supporting pregnant women’s emotional wellbeing in private sector maternity services.

Sydney’s The Mater Hospital Pre-admission Midwife Appointment Program provides women in the third trimester of their pregnancies with a free 45-minute appointment, with a specially trained midwife, to discuss pregnancy, birth and early parenting.

The initiative focuses on women’s emotional wellbeing – screening for depression, anxiety and associated risk factors as well as domestic violence screening.

It also promotes self-awareness of emotional wellbeing, along with validation and assistance for any concerns or social stresses in the women’s lives.

Statistics show perinatal depression affects up to one in 10 women during pregnancy, and almost one in seven women in the first year after birth.

While most public hospital maternity units provide psychosocial assessment and depression screening as part of routine antenatal care across Australia, implementation in the private sector has lagged behind.

The Mater is one of the few private hospitals in the nation to provide this type of self-funded service, which offers access to all women scheduled to give birth at the hospital.

The initiative enables the program’s team of 10 midwives to provide holistic multidisciplinary care to patients, providing support from the pregnancy to the birth of the baby and into the postnatal period.

The program, which began in October, has been such a success, it recently won a $10,000 national Team Excellence Award at the 11th HESTA Australian Nursing and Midwifery Awards.

Antenatal midwife coordinator Sarah Tooke, a registered nurse and midwife, says it’s imperative private patients have the same opportunity as public patients – to access a midwife.

“In the private system, patients don’t necessarily see a midwife until after they have their baby, unless they are lucky enough to have an obstetrician who has a midwife in the rooms,” she says.

“We sort of went…our patients shouldn’t be paying and missing out on a service that public patients are getting.”

The hospital partnered with The Gidget Foundation, a not-for-profit organisation that promotes emotional wellbeing for expectant and new parents. It tapped into the results of the foundation’s pilot study, which found clinically significant antenatal depressive symptoms in a sample of women accessing private obstetric care – highlighting the importance of antenatal depression screening for all women.

The hospital, a facility of St Vincent’s Health Australia (SVHA), worked with the foundation, particularly chairman and obstetrician Dr Vijay Roach, board member Catherine Knox, psychiatrist Professor Bryanne Barnett and CEO Arabella Gibson, to develop and implement the initiative.

Midwives involved in the program completed workplace training on domestic violence screening, with the program utilising SVHA’s own screening tool for family and domestic violence, while midwives also attended two training days with Professor Barnett.

In addition, a summary and referral system was developed to ensure the right support for at-risk women, with referrals to a range of pathways including obstetric social worker and midwife Deb De Wilde, the Gidget Foundation, a lactation team, discharge planning team, and the patients’ own psychological services.

“We made the program a little bit more holistic so that it has a big focus on emotional wellbeing screening – looking at those risk factors for anxiety and depression but also screening for domestic violence,” Ms Tooke says.

“Also, it just gives women the opportunity to have a chat with the midwife and ask questions, and talk about previous experiences if they had a traumatic time with feeding or a bad birth experience – just validating that.”

While the program is still in its infancy, Ms Tooke says participation has increased from an average of 35 per cent of patients to between 50 and 75 per cent of patients.

“We hope to get that up a little bit higher but the biggest focus so far has just been on successful implementation,” she says.

“What we’re really going to look at this year is doing some formal research so we can make sure we are giving the women what they want and continuing to improve what we’re offering.”

Ms Tooke says prize-money from the HESTA Award will go towards funding the qualitative research, as well as ongoing education in perinatal mental health for midwives, training for more midwives to join the team, and a postnatal follow-up appointment for patients identified with key risk factors.

The prize-money will also fund an interpreter to help meet the needs of the hospital’s high proportion of Chinese patients.

Ms Tooke, who also runs a private childbirth and parenting education business, says while feedback from women participating in the program has been overwhelmingly positive, midwives are also reaping the rewards of the service.

“I just love being able to talk to the women and actually having time to talk to them, and just developing that relationship and that trust,” she says.

“I suppose being off the ward, you just get away from that crazy, busy stuff, and you actually feel like a real midwife.

“Even though you’re not there delivering babies, you feel like you’re doing your job properly because you have the time to actually sit back and be with a woman and validate experiences and just listen.

“I think that just by getting that support in place, it can really make this time in women’s lives much more positive.”

Karen Keast, Health Times, 9 June 2017

The growing role for pharmacies in battle against post-partum depression

Stressed young mothers often turn to their community pharmacy for help and advice, especially those pharmacies which offer specialist baby clinics.

But increasingly these baby clinic services are combining with mental health services offered by the pharmacies to help mothers cope with difficult situations.

The extent of the problem is becoming clearer as more research is undertaken.

A study of current evidence on post-partum depression and parenting – reviewed in the Harvard Review of Psychiatry’s January-February edition – found post-partum depression to be a common disorder, affecting 10 to 20 per cent of mothers.

Children cared for by mothers with such depression were at risk of adverse outcomes, with increased rates of psychiatric disorders and developmental problems.

The review found this depression was clearly linked to poorer parenting behaviours, based on the results of 33 studies.

The pressures on a young mother are compounded if she is also working, and a recent La Trobe University study examined how combining work and family commitments affect parents. According to the Australian Bureau of Statistics, in 2012-13 some 48 per cent of households with children reported that both parents worked.

The lead author of the La Trobe study, Dr Elizabeth Westrupp, said the research focused on the mental health outcomes of parents when they struggled to juggle work and family responsibilities.

“We found it wasn’t a one-way street so that when mothers were juggling family/work roles they were more likely to have mental health problems.  But vice versa was also true, so when they had mental health problems they were more likely to struggle in juggling those work/family roles and responsibilities,” Dr Westrupp said.

“What we were surprised at was that these issues were just as strong as for children in primary school as they were in the first years of life.

“That was really interesting because most of the services really are focused on supporting mothers in the early post-partum period.

“We want the community and work places to really think about supporting a parent’s mental health and at the same time recognise the importance of flexible work places and flexible management within workplaces.

“We need to be able to both support parents who might already be struggling with mental health problems but also to help prevent them from occurring.“

“And also to support parents in managing their dual roles which can cause difficulties for many people.”

The pressure on these parents, particularly mothers, is clear when looking at community pharmacies, which offer both child clinics and mental health services.

Penrith High Street Chemmart Pharmacy in NSW is a local hub for young mothers seeking help, and pharmacist Janis Bardsley-Smith is the person most of them talk to.

As a mother, grandmother and specialist pharmacist she is well qualified to help young mothers.

“It’s a hard job being a young mother and we are here to help them,” she said.

“Your children teach you what you need to know in the first week but you have to teach them what you want them to know in the first month.

A lot of it is common sense but young parents get a lot of conflicting advice and this adds to the pressure on them – pressure which can be overwhelming.

“Sometimes our role is simply to clarify these things but just doing that can ease a lot of the mental health pressures on young mums.

“We know mental health issues are growing at a rapid rate and we want to help everyone in our community, not just the young mums we may see.

And there is a seamless crossover between the mental health area and parenting at times.

Mrs Bardsley-Smith said the pharmacy also had developed a program to help young mothers addicted to pain killers.

“Just being able to talk to them and help them get off the pain killers helps their mental health immeasurably,” she said.

“I think the great asset a pharmacist has is making time to talk to people. I am the front-of-shop pharmacist and it’s important when dealing with young mothers facing a stressful mental health situation that you have the right person available to talk to them.

“It’s usually not your male pharmacist because mothers want to be able to relate to someone who may have faced similar situations.

“We also are trained to recognise symptoms and we know when to refer people on for further help.  If we see a problem we always refer them when necessary to their doctor or if it is a child-rearing issue we may refer them to a nearby local specialist service.”

Ms Bardsley-Smith said the pharmacy also ran a range of programs which could directly and indirectly help the mental health of young mothers.

“We have a consulting space and offer other programs like weight loss which we find are very useful for helping young mums facing problems.

“And probably most importantly we are just available to sit down and talk. We are also open 24/7 and so we get a lot of young mums contacting us by phone or coming in in the middle of the night as we are the only accessible health professionals available at that hour.

“Customers appreciate it. They get back in contact and thank us when things settle down for them.  We have a big discount model that opened up across the road but we are finding our customers appreciate the fact that we take time for them and they are remaining loyal to us.

“I also find some young mothers don’t have family they can turn to and so they know they can ring me at any time.”

Pharmacist Meggie Baldeman of Stud Park Pharmacy at Rowville in Victoria is also seeing the stress that young mothers are increasingly facing.

Ms Baldeman said her approach when helping these women is to keep the discussion informal.

“Our customers often ask for me as I’m a young mum with a three year old and an eight month old so I am able to chat to the customers on their level,” she said.

“Breast feeding is a major issue as it causes a lot of stress and mental health pressure for young mums.

“That is an area I can talk about but I refer them to the maternal health nurse or other specialist if I see a real need for more advice and treatment.

“Lack of sleep is also an issue which causes a lot of stress and also lack of family support adds to mental health issues facing some young mothers.”

Ms Baldeman said adapting to the changes brought about after having a baby often seemed insurmountable for some young mothers.

“After you’ve had a baby it’s a big shock and a lot of young mums don’t feel confident but after we have a chat they feel more reassured and able to do the job,” she said.

“I know a lot of people come back to their pharmacy repeatedly and they ask for me because I speak from experience.

“We just have a quick chat and I find the informal approach is best as they then come back and I ask how they are going and we can keep the relationship going.

“I also address some mothers groups which a lot of mothers find really helpful.

Peter Waterman, Pharmacy News, 16 March 2016

New physiotherapy platform for knee replacement surgery

Researchers are trialling an innovative knee replacement surgery app and portal designed to assist patients with their pre-surgery preparation and rehabilitation.

The activateTKR digital platform, which features a smartphone app, wearable activity tracker and portal, aims to boost patients’ access and adherence to rehabilitation, improving their recovery and health outcomes.

The app provides patients with physiotherapy demonstration videos, pre-surgery checklists, reminders and supportive information in text, video and audio.

The wearable activity tracker encourages and monitors patient exercise, tracks sleep, and enables patients to self-monitor their progress.

Patient data links to a portal where clinicians can create tailored, individual physiotherapy programs and monitor patient progress in real-time.

CSIRO activateTKR project leader Dr Sazzad Hussain said the technology platform is designed to assist patients to prepare for their surgery and encourages patients to complete their rehabilitation program.

Dr Hussain said physiotherapists will be able to monitor patients’ functional improvement and also their compliance with the program.

“The patients start the program four weeks before surgery and they get themselves prepared, and they go off and have the surgery and then do the 12 week program,” he said.

“With the clinical portal, the physiotherapist is looking at the compliance – so are they actually doing the physiotherapy program that they’ve configured?

“And they may not be doing the physiotherapy program as expected, there could be a reason so they can look at the data, look at the steps and look at the sleep quality and the pain score.

“They can get a sense of a reason – why that may be the case, but they can also call the patient to say – it seems like you’re not complying well with your physiotherapy program, is there something that is going wrong?

“This is important because often not doing the exercises correctly or properly may lead to other complications, for example it can lead to some infection.”

Dr Hussain said the initiative is now being trialled with up to 300 patients across six hospitals in Australia, comparing the recovery of patients who receive the normal standard of care against those who receive the normal standard of care plus the digital platform.

“Then we will see, comparing with the controlled patients different measures such as the clinical measures, behavioural outcome, we are also looking at economic outcome, service delivery satisfaction, and all of those measures will tell us how the technology platform has improved patient outcome and aspects such as costs and service delivery.”

Dr Hussain said the app will be an evidence-based tool for clinicians and their patients.

“We want to say that this app has a certain level of clinical efficacy or has a certain level of patient outcome that it can achieve and it’s scientifically proven.”

The activateTKR platform is being developed in collaboration with Johnson & Johnson Medical Devices.

Karen Keast, Health Times, 14 June 2017

GP support for mandatory ‘paperless’ prescriptions

A call to phase out paper-based prescriptions has been backed by one of the RACGP’s e-Health experts.

Integrated electronic prescriptions should become mandatory for “any prescriber of a PBS-listed medicine, any pharmacist wishing to dispense a PBS-listed medicine”, according to a Federal Government review of the pharmacy industry.

In its interim report, released on Thursday, the review says the current paper-based system is outdated and inconvenient, and increases the risk of adverse medical events.

Instead, paper prescriptions should no longer be the “version of record”, and pharmacists should be able to retrieve the electronic prescription without sighting a paper version.

Dr Oliver Frank, a member of the RACGP expert committee for e-Health and Practice Systems, says many GPs are uploading electronic prescriptions to exchange software such as eRx or MediSecure already.

“If it makes the system better and saves paper, do it.”

He says the only difference in moving to a completely paperless system would be to the legal significance of the paper prescription.

At the moment, pharmacists must still scan a paper barcode to access the electronic prescription, which downloads the prescription information to the pharmacist’s dispensing software.

“I don’t need all this paper churning out of my printer all the time,” Dr Frank says.

“Why don’t we have it already?”

The review suggests a staggered rollout, beginning with a parallel system where pharmacies accept both electronic and paper prescriptions, followed by a ‘paper optional’ system and finally electronic-only.

The government should provide financial incentives for GPs, pharmacists and hospital to help transition to a paperless system, it says.

However, it adds that the government would have to develop a way to avoid ‘script channelling’ – GPs sending electronic prescriptions to favoured pharmacies to direct patients.

The review panel is accepting feedback on the interim report until 23 July before it presents its final report and recommendations to the government.

More Information:

Review of Pharmacy Remuneration and Regulation: interim report

Antony Scholefield, Australian Doctor, 23 June 2017

When it comes to exercise, is intensity or frequency more important

Professor Wendy Brown’s mother was adamant. As a keen gardener she was healthily active, taking a lot more than 10,000 steps a day, she reassured her during one of their regular phone calls.

In reality she was averaging fewer than 2500 steps, says Professor Brown, one of the chief investigators of the lauded 2002 Rockhampton, Queensland, project that helped make the goal of 10,000 steps a day world famous.

Professor Brown’s mother blamed her low step count on a broken pedometer.

“Of course the pedometer was not broken,” Professor Brown says. “The truth is that people, in general, have no idea how active they are.”

Ironically, the initial project funding pitch to Queensland Health had a target of just 7000 steps. This is because the team believed the 10,000 steps recommended by Japanese research from the 1960s was too ambitious.

The project resulted in more than 20 scientific papers. And today the WHO advises a daily target of 10,000 steps (approximately 8km).

Although app-based targets have recently attracted criticism for being too generalised, internationally recognised guidelines continue to use these benchmarks, on which population performance is inevitably measured.

In 2015, CARE Australia revealed that 93% of people were walking less than the recommended daily distance, and that the average Australian walks only 3.2km a day — the equivalent of around 4000 steps.

The 10,000 steps concept is just one of many popular methods of quantifying exercise. And often one piece of advise contradicts the next, making it difficult for GPs to compare apples with apples and present easily digestible, but scientifically palatable, advice to their patients.

A recent example of the ever-evolving paradigm was presented in a paper in the Journal of the American Medical Association that assessed the relative benefits of being a so-called weekend warrior. These are the people who meet WHO recommendations for weekly physical activity targets, but confine their exercise to just one or two days.1

WHO advises that individuals aged 18–64 should perform at least 150 minutes a week of moderate-intensity aerobic activity or at least 75 minutes a week of vigorous-intensity aerobic activity, or equivalent combinations.

The pooled analysis of population-based surveys shows that all-cause mortality risk is approximately 30% lower in active versus inactive adults, including weekend warriors and regularly active respondents who performed the recommended amount in three or more sessions a week.

Interestingly, and perhaps adding to the confusing message, the 30% reduction in mortality risk among the weekend warriors was similar to that of participants characterised as insufficiently active (31%), defined as performing less than the recommended 150 minutes a week of exercise.

Professor Brown’s recent Lancet analysis of the effects of sedentary time can also be thrown into the mosh-pit of exercise advice.2

This suggested that, among those reporting less than 5.25–7 hours a week of moderate intensity activity, more sitting time was associated with a significantly increased all-cause mortality risk, which was accelerated at very low levels of activity.

In contrast, among those reporting more than 5.25–7 hours a week of moderate-intensity physical activity, there was no increased mortality risk associated with sitting more than eight hours a hours a day — common for a sedentary occupation.

Professor Brown attempted to distinguish the wood from the trees when producing the existing guidelines for the Commonwealth Department of Health.

These state that every week Australians should accumulate 150–300 minutes of moderate intensity physical activity, or 75–150 minutes of vigorous intensity physical activity, or an equivalent combination of moderate and vigorous activity.

There was a push from sections of the scientific community to set the minimum targets at the upper levels of these recommended ranges.

These Australian guidelines differ slightly from WHO guidelines, which set minimum targets of 150 minutes of moderate exercise or 75 minutes of intense exercise, and then encourage the upper targets for “added benefit”.

There remains, however, a belief that the Australian guidelines — especially a parallel message to “do at least 30 minutes of physical activity on five days of the week” — have been under-promoted.

“I don’t think the message about 30–60 minutes has got out there yet,” says Professor Brown, the director of the Centre for Research on Exercise, Physical Activity and Health at the University of Queensland.

“A lot of people didn’t agree with going out on a limb and being different to the rest of the world.

“No-one has any problem with saying children should be doing 60 minutes per day so why should it possibly change when you get to 18?”

Middle-aged, overweight patients should be encouraged by GPs to exercise for 60 minutes a day, she says.

“The bottom line is that something is better than nothing, but try to reach the guidelines.

“If people say they don’t have time because they are working then, sure, the weekend warrior thing is fine. Have you ever seen a fat bushwalker?”

Associate Professor Andre La Gerche, head of sports cardiology at the Baker Heart and Diabetes Institute, Melbourne, turns our attention from bushwalkers to dune runners in sending a warning to potential weekend warriors.

“Consistency is a key element of health. Every bit of evidence on exercise fits a pretty simple paradigm: that all exercise is good and more is better,” he says.

“But there is the concept of the exercise paradox: exercise is clearly healthy but at the same time every bout of exercise constitutes a risk.

“If you are going to have a heart attack the most likely time is during exercise. But if you don’t do exercise the relative risk of every bout of exercise is much higher. The best way of lowering the risk is by making every bout as much a part of the routine as possible.

“You are much more likely to get an Achilles injury if you don’t run all week then do repeats up the sand dunes at the weekend.”

The JAMA results from the insufficiently active cohort reignited the debate surrounding a putative minimal exercise dosage for health benefit.

Compared with the inactive participants, there was a 17–34% reduction in risk (depending on outcome) in the insufficiently active participants, who reported one or two moderate to vigorous physical activity (MVPA) sessions per week.

There was no evidence of a dose–response pattern between total MVPA volume (in the 1–149 minutes a week range) and mortality, although there was a linear trend when analysing total physical activity of any intensity.

“This suggests that some of the health benefits observed in the insufficiently active participants may be explained by non-exercise activity, such as light intensity walking,” the authors said in a separate commentary.

Associate Professor La Gerche is no admirer of the minimal dosage concept.

“Research trying to prove you can do less and less of a good thing doesn’t pass the pub test,” he says.

“There are problems with the weekend warrior as a promotion. In reality it’s a cop-out for most people because you can find the time off if you want to.

“I would strongly argue that consistent exercise in smaller amounts is far more beneficial than having all your bite in one whack. It’s clearly second best.”

Neil Bramwell, Medical Observer, 17 May 2017

What doctors can learn from my client’s $480k defamation case

Earlier this month, the NSW Supreme Court awarded my client, orthopaedic surgeon Dr Munjed Al Muderis, $480k in damages after he was defamed by a former patient.

The headline-grabbing case started seven years ago after Dr Al Muderis performed a hip arthroscopy on Gerardo Mazzella.

Mr Mazzella brought negligence proceedings against Dr Al Muderis, claiming he had been mutilated following the procedure. Those proceedings were dismissed.

He also made a complaint to the NSW Health Care Complaints Commission, which was also dismissed.

But Mr Mazzella continued to harass the surgeon and seek vengeance on him. He started with threatening communications and phone calls at all hours of the day. He and his brother, Rodney Duncan, also decided to create a website that looked similar to Dr Al Muderis’ own website — it mimicked its style and used the same photos.

This website stated that Dr Al Muderis was “grossly negligent and he had destroyed people’s lives”. The doctor, the website declared, “deserved to be criminally charged”, and that he was “unethical” and a “disgraceful surgeon with reckless disregard for human life”.

The attack went further, with numerous posts and videos on many social media platforms including YouTube, Facebook and Pinterest, where Mr Mazzella’s complaints became more and more vitriolic.

This was accompanied by personal threats to cut off Dr Al Muderis’ penis or to kill him in revenge for the loss of sexual function Mr Mazzella claimed he had suffered.

The YouTube video was titled “Dr Al Muderis the Butcher” and the Facebook page had a ‘Wanted’ poster with images of Dr Al Muderis and captions such as “Mr Al Muderis — penis lovechild”.

The NSW Supreme Court found Dr Al Muderis was the “perfect plaintiff in a defamation proceeding”. There was no evidence to support any truth of the allegations or claims made by Mr Mazzella or his brother.

In awarding the large sum of damages, the court held it had to “console him for the personal distress and hurt caused by the publications, reparation for the harm done to the plaintiff’s personal and business reputation; and vindication of the plaintiff’s reputation”.

With the advent of social media, and in an age where people are posting comments about all types of issues without regard to the truth of the matter, it has become easy for people to defame and attack someone’s professional reputation.

Below are some of the lessons learned from this case and what to do if a former patient posts false criticisms on a website or on social media that may affect your reputation, business and career.

 

You should:

  1. Speak to your professional indemnity insurer sooner rather than later, as the patient may be considering making a claim against you in the future.
  2. Attempt to speak to your former patient and see if there is any way you can appease them.
  3. This can involve referring them to another doctor for treatment or assessment, or for a second opinion. Hire a lawyer familiar with online defamation. If trying to resolve the issue with the patient directly does not help, then direct communication with the patient should be ceased and communication only entered into through your lawyer.
  4. If a website has been created or pre-exists that names you and treats you unfairly or in a defamatory way, and without any truth or merit, then ask your lawyer to write to the owner to ask for that content to be removed.

Contact the police if the harassment is personal and threatening, or if you fear for your own safety or the safety of your staff or family. An Apprehended Violence Order can also be obtained, either by a personal application to the local court as a private citizen or through the police if they agree to get involved.

 

Your lawyer should:

  1. Perform online searches to determine who the domain registrar and registrant of the website is.
  2. Write to the domain registrar to advise them of the offending website. Often the domain registrar is unable to determine what is offensive and will want to remain impartial, so they may ask you to obtain a court order requesting them to remove the website or domain name.
  3. Write to the party posting the defamatory publications and warn them if they do not immediately remove the post they will face court proceedings.
  4. Contact social media sites such as Facebook and YouTube to advise them that the posts are contrary to their policies. And while their review process can take many weeks, they will inform you of the outcome and will possibly restrict or remove the content. However, many of these social media platforms are operated outside Australia and therefore outside the jurisdiction of Australian courts. Because of this, it may then become necessary to appoint US lawyers to relay any court orders to these companies and seek the equivalent US court orders if they do not comply with reasonable requests.

Mr Nick Birbas, Medical Observer, 19 June 2017

Most men don’t know anything about female contraception

Men want to share in decision-making about contraception but know little beyond condoms and vasectomy, an Australian study shows.

When surveyed about their favoured contraceptive methods, men had positive attitudes and high levels of knowledge for male-controlled methods but many were vague or had misperceptions about female-controlled methods, such as implants and vaginal rings.

And concerningly, responses from more than 2400 men to an online survey by Family Planning NSW found that one in three believed emergency contraception to be harmful to the health of the user.

In the survey, men most commonly reported they were currently using condoms (35%) or vasectomy (22%) for contraception, while only 1-2% were aware that their partner was using methods such as contraceptive implants, IUDs or diaphragms.

Researchers from Family Planning NSW remarked that the findings showed that men had most knowledge about the least reliable methods of contraception, including condoms, and non-reversible methods, such as vasectomy.

“Notably, the methods that men reported being most unsure about with regard to effect on the health of the user and effect on sexual interest or pleasure include the most effective, reversible, female-controlled methods,” they said.

“Almost half of [men] were unsure whether each of the long-acting reversible contraceptive (LARC) methods (intrauterine contraception, the implant and the injection) was harmful to health,” they added.

And given that 90% of men said they believed contraception decision-making should be shared between partners, the researchers said it was a particular concern that many men believed methods such as emergency contraception and oral contraceptives were harmful to health.

“Increasing men’s knowledge and attitude towards contraception, particularly the LARC methods, is an important strategy to increase uptake of these highly effective methods,” they suggested.

Michael Woodhead, Australian Doctor, 22 June 2017

Medical Directions

Fair Work Updates

Increase to minimum wages
The Fair Work Commission has announced a 3.3% increase to minimum wages. The increase applies from the first full pay period starting on or after 1 July 2017. Read more >>

Public holidays
Public holidays can be  different depending on the state or territory you work in. Employees can get different entitlements on these days. Read more >>

Contracting labour
Do you outsource your cleaning, bookkeeping or security? There are many useful fact sheets available on the Fair Work website. Read more>>

Billing new-born babies

As long as the newborn baby that is being treated, is eligible for a Medicare card GPs can treat them and bulk bill later when they have Medicare number. Read more >>

Education guide: multi-item billing

Payment for more than one service per day may be made if a patient has more than one attendance on the same day, with the same medical practitioner, as long as the subsequent attendances are not a continuation of the initial or earlier attendances. For example, if a patient sees a GP in the morning for a sore throat and then sees the same GP in the afternoon for an injury. Read more >>

PIP & PNIP updates

You can stay up-to-date with practice incentive programs through Medicare’s ‘Incentive News Update‘ – the May issue is now available. Read more >>

MBS online

The 1 May 2017 files (XML, DOC, PDF and ZIP) can now be downloaded from the May 2017 downloads page.

New resource for aged-palliative care

A new online resource – palliAGED – is available to  assist those Healthcare Professionals  who care for older Australians approaching the end of their life. Read more >>

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