We’re two frontline COVID doctors. Here’s what we see as case numbers rise

Peter Wark, University of Newcastle and Lucy Morgan, University of SydneyThe latest figures available show there are 1,189 people admitted with COVID-19 to hospitals in New South Wales, with 222 of them in intensive care units (ICU), 94 needing ventilation.

This week there were over 9,700 people with new COVID infections. That means about one in every 10 people with COVID are sick enough to need admission to hospital.

Recently released modelling predicts COVID admissions in NSW will rise steeply over the coming weeks and will peak in mid-October. NSW has also just announced plans for some restrictions to ease once 70% of adults in the state are fully vaccinated, a date also expected to land in October.

Here’s what this will look like for patients admitted with COVID and for hospital staff caring for them.

Here’s what happens to the lungs

Healthy lungs are like soft, fresh sponge cake, wrapped in two layers of cling wrap (the pleura), all sealed in the cake tin of the chest wall.

But with severe COVID, people develop pneumonia. This is when the spongey lung fills with fluid and becomes stiff and the muscles we use to breathe are weakened by inflammation that rages in all tissues of the body. The major consequence of this is an inability to breathe properly, a reduction in oxygen levels and inadequate oxygen supply to the body.

Severe pneumonia is usually managed in the ICU. In this pandemic, the sheer number of critically breathless patients means the intensive level of respiratory care they require is being delivered outside ICU, in wards designed for patients with other health problems.

So most of the patients admitted to hospital with COVID are actually managed by lung specialists and infectious diseases physicians with a huge input from our junior doctors in training.

COVID pneumonia is what kills patients who develop severe COVID.

About one in five develop severe breathlessness. This is when the stiffened lungs are full of fluid and every breath requires extra effort.

This severe breathlessness is hard to explain until you experience it. But it’s relentless, exhausting and frightening. Patients describe it as like “an elephant on your chest”, “a suffocation”, or there not being “enough air in the room”.

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People with COVID pneumonia need oxygen but oxygen alone isn’t enough to help with severe breathing difficulties and COVID pneumonia. Those who are most unwell may need intubation. This is when we insert a tube into the lungs connected to a machine that does the work of breathing, via mechanical ventilation. This happens in the ICU.

Expert care in an acute COVID ward is critical. Patients successfully managed will have better odds of a shorter hospital stay and not needing intubation, with its increased risk of dying.

We’re also worried about filling up the available ICU beds — a clearly finite resource.

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We’re seeing more COVID patients in ICU as case numbers rise. That affects the whole hospital

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We want to avoid intubation

As the pandemic has swept across the globe, we’ve rapidly learnt from our colleagues overseas about supporting the breathing of patients with COVID pneumonia.

Our treatments are aimed at helping patients recover more quickly and reduce the need for mechanical ventilation. Measures include:

• delivering warm and humid oxygen, which is more comfortable for patients, and protects the lining of the airways from further inflammation
• lying patients on their belly or “proning”, aims to prevent fluid from pooling at the bottom of the lungs. This improves oxygen levels and makes breathing more comfortable. It also reduces the need for mechanical ventilation. This is safe and cheap, and is comfortable for most people even those who are very overweight, and pregnant women
• continuous positive airway pressure or CPAP can also be used to help reduce the work of breathing for people with severe breathlessness. These machines are used to deliver oxygen via a mask and help by opening up fluid-filled, stiff lungs.

These treatments are labour intensive and have long been available in the ICU where nursing to patient ratios are higher.

However, in NSW, hospitals with the highest current numbers of patients with severe COVID (such as Liverpool, Nepean and Westmead) have had to rapidly adapt their wards to deliver this treatment outside the ICU.

The published modelling predicts such treatments will spill further into the COVID wards of every hospital in NSW.

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We need the staff to manage this

Treatments like proning and CPAP are time-consuming and require experienced doctors, nurses and support staff.

Ideally, every patient with severe COVID pneumonia should have at least one nurse each for every hour of the day — a 1:1 nursing ratio.

Staff need to know when to start these treatments. They also need to know how to read the signs of deterioration that signal the patient, who despite everyone’s best efforts, will need intubation.

Fitting the CPAP mask and adjusting the oxygen requires experience and training. Staff help patients to eat and drink, go to the toilet. They administer complex medications, comfort the grieving, frightened and confused.

They do this while dressed in a hot gown, wearing goggles and gloves and a tight, fitted N95 mask. Every single clinical interaction is stressful and intense.

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Plans are under way

Plans are under way to manage the expected surge in cases.

Staff are being trained and we are preparing to get enough equipment where it’s needed. The problem is this will go on for many more weeks, staff will get tired, physically and emotionally, and we don’t want this to be any worse than it must be.

If you want to help, get vaccinated and stay at home. Please put up with the restrictions and lockdowns for a little longer.

Now is the time for everyone to come together so we come out of this in one piece and can continue to offer the best of medical care.

Peter Wark, Conjoint Professor, School of Medicine and Public Health, University of Newcastle and Lucy Morgan, Clinical Associate Professor, Concord and Nepean clinical schools, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Media and politicians often defer to the AMA on COVID policies. But what role should the doctors’ group have in the pandemic?

Lesley Russell, University of SydneyAlmost every day in recent months, Australian Medical Association (AMA) president Dr Omar Khorshid has appeared in the media, commenting on various issues related to the coronavirus pandemic.

These include changing recommendations about the use of the AstraZeneca vaccine, urging the New South Wales government to institute tighter lockdown measures, and welcoming National Cabinet’s roadmap out of the pandemic.

The raft of AMA media releases, doorstops, and television and radio slots goes beyond the pandemic to expressing concerns about climate change and doctors in Myanmar. Khorshid even outlined the AMA’s Vision for Australia’s Health at the National Press Club address in June.

Why is the AMA so regularly deferred to by politicians and media alike? And what is its role in the pandemic?

Historically, it has protected doctors’ professional and financial interests

The AMA (and its predecessor, the British Medical Association) built its reputation as a powerful, aggressive lobby group – essentially a medical union. It’s focused on protecting doctors’ professional interests and financial autonomy, and preserving the status quo in health care.

The self-published volume to commemorate the AMA’s 50th anniversary – ironically titled “More than Just a Union” – boasts of efforts to forestall government attempts to make health care universal and affordable.

The most egregious of these was the relentless opposition to the introduction of the Pharmaceutical Benefits Scheme, Medibank and then Medicare.

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Underpinning this opposition was a fear of controls and interference by both governments and health insurers, and efforts to expand the scope of practice for health-care providers other than doctors.

How the AMA has shaped past health policies

Those past fears are echoed today in the AMA’s continuing opposition to a range of proposals that are seen as impinging on doctors’ autonomy.

These include resistance to payment mechanisms that would move from fee-for-service (an itemised fee charged for every visit) to capitated fees for ongoing care of a chronic condition.

Concerns about the adequacy of doctors’ Medicare rebates are ongoing and, in some cases, justified. These concerns have led to the AMA issuing its own fee guidance to doctors.

The AMA has a particular aversion to “US-style managed care” which it describes as “a recipe for cost-cutting and less choice”. The AMA fears Medicare and private health insurers will try to push doctors, hospitals and patients into coercive contracts with capped funding payments, and require defined standards for performance, quality and outcomes.

Meanwhile, the AMA has consistently pushed back on increasing the roles for midwives and nurse practitioners in the health-care system, and is vehemently opposed to pharmacists having an increased prescribing role.

The AMA has opposed nurses doing work traditionally done by doctors.
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Yet the AMA has also played a significant leadership role in highlighting important issues as varied as Indigenous health, tobacco and vaping regulation, boxing injuries, treatment of refugees, and climate change.

Inside the AMA machine

The AMA’s federal secretariat has excellent resources to assist with this work – experts in policy development, economic analysis and communications. This is highlighted in the report cards it regularly issues, which have the capacity and status to influence public opinions and government policy.

The AMA is diligent about making sure its voice is heard with budget commentary and submissions to a range of enquiries and reports. According to the AMA website, in 2020 it made 45 submissions – a mammoth task of preparation and approval.

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This latter task is never easy for the AMA. It is an inherently conservative body, more comfortable with the conservative side of politics, although this has varied with the public face of the president.

Internal infighting was conspicuously highlighted when Dr Michael Gannon, in his successful 2016 run for AMA presidency, chided then-president Dr Brian Owler for opposing funding cuts in health in the 2014-15 Budget and the medical treatment of asylum seekers.

Gannon said:

The criticism that is made of the current leadership [of the AMA] is that it’s strong on progressive policies but not listened to by the conservative government.

Ultimately, these in-house conflicts undermine the effectiveness of the organisation’s loud public voice. It can agree with or oppose government proposals, but is rarely able to generate enough internal consensus to offer alternatives.

All this serves to cast the AMA today as something of a chameleon organisation trying to be all things to all people. On the one hand, it’s always at war with government (regardless of political party) over members’ interests. On the other hand, it elevates issues of social responsibility and publicly positions itself as seeking to advance community health.

We see this dichotomy playing out in the pandemic. Along with supportive words to the public and comments on governments’ actions, the AMA is raising the usual concerns and is “working tirelessly” to shore up its influence in the corridors of power.

How the AMA is using its influence in the pandemic

It is likely the AMA’s influence on the federal government led to the initial decision to roll out the vaccination of the general public primarily through GPs.

The AMA highlighted that rolling out the campaign through general practice was the best way to encourage the community to get vaccinated and noted “significant reservations” about the role of pharmacists in the vaccine rollout.

This follows years of opposition to pharmacists playing a role in the flu vaccinations rollout, as you can see in this media release from 2014:

AMA media release screenshot

But many busy GP practices were unable to gear up for COVID-19 vaccinations and initially they were unable to manage the storage requirements for the Pfizer vaccine. These were later modified and since June practices can apply to also administer the Pfizer vaccine.

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Responding to questions The Conversation’s political correspondent Michelle Grattan raised last week about how the AMA shaped the vaccine rollout, Dr Khorshid said the program was slowed by “supply constraints and hesitancy due to changing advice”:

In recent weeks, we have seen how both GPs and pharmacists are needed to ramp up
vaccine delivery, especially in coronavirus hotspots.

On other issues, the AMA has been very supportive of the expanded telehealth services that were put in place early in the pandemic to allow patients to have a consultation with their doctor by video or phone.

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Initially these consultations were required to be bulk billed, but the AMA has now persuaded the government to remove this requirement. This means patients whose doctors do not bulk bill will now have out-of-pocket costs for telehealth consultations.

Meanwhile, AMA media releases also credit the organisation for proposing the government’s yet-to-be-implemented vaccine indemnity scheme.

Striving for relevance and public trust

The AMA is driven by the need to demonstrate relevance to today’s cohort of doctors and the public in the face of increasing competition for members and attention.

When the federal AMA was formed in 1962, 95% of doctors were members. As of 2018 it was less than 30%.

The specialist colleges have captured many doctors and most GPs belong to the Royal Australian College of General Practitioners (RACGP) and/or the Australian College of Rural and Remote Medicine.

So it’s no surprise the RACGP is also an active player on behalf of its members – the advocacy pages of its website show it claims some of the same policy victories as the AMA. Its president is also a frequent media presence on the pandemic and other issues.

Many of Australia’s problems with vaccine rollout and compliance with lockdowns are due to confusing communication strategies from governments and the poor quality of public education campaigns. There is certainly room for effective communicators, speaking in language that everyone understands, to step into this space.

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Just the facts, or more detail? To battle vaccine hesitancy, the messaging has to be just right

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The public sees doctors as trusted voices and doctors working at the coalface are uniquely placed to comment on the health-care consequences of the pandemic.

The AMA (and other medical organisations) have spent decades building access to media and politicians. This means that often their voice is heard above those who have more expertise and their concerns are more obvious than those of affected communities. This is a privileged situation that should be used for public good, ahead of any organisational self-interest, during the pandemic and in the years ahead.

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Editor’s note: The Conversation contacted the AMA for a response and in a statement, Dr Omar Khorshid said, “the issues the AMA advocates on are in the interests of doctors, the wider health professions, and patients”. He said these issues “go to the heart of our healthcare system and all health professionals, including nurses”.

Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Doctors must now prescribe drugs using their chemical name, not brand names. That’s good news for patients

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Matthew Grant, Monash University

From today (February 1), when you receive a prescription in Australia, it will list the name of the medication’s active ingredient rather than the brand name. So, for example, instead of receiving a prescription for Ventolin, your script will say “salbutamol”.

This national legislation change, called active ingredient prescribing, is long overdue for Australian health care.

Using the name of the drug — instead of the brand name, of which there are often many — will simplify how we talk about and use medications.

This could have a range of benefits, including fewer medication errors by both doctors and patients.

What is an active ingredient?

The active ingredient describes the main chemical compound in the medicine that affects your body. It’s the ingredient that helps control your asthma or headache, for example.

Drugs are tested to ensure they contain exactly the same active ingredients regardless of which brand you buy.

There’s only one active ingredient name for each type of medical compound, although they may come in different strengths. Some types of medications may contain multiple active ingredients, such as Panadeine Forte, which contains both paracetamol and codeine.

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Prescribing generic drugs will reduce patient confusion and medication errors

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There can be several brand names

Until now, doctors and other prescribers have used a mixture of brand and active ingredient names when prescribing medicines. An Australian study found doctors used brand names for 80.5% of prescriptions.

Different brands are available for most medications — up to 12 for some. Combined with active ingredient names, this equates to thousands of different names — too many for any patient, doctor, nurse or pharmacist to remember.

Older people are at higher risk of making medication errors, as they tend to take more medications.
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Here’s an example of the problem.

I ask John, a patient whom I’ve just met, whether he takes cholesterol medications, commonly called statins. The active ingredient names for this group of medications all end in “statin” (for example, pravastatin, simvastatin).

“Ummm, I’m not sure, is it a blue pill?” John asks.

“It could come in many colours. It might be called atorvastatin, or Lipitor,” I reply. “Perhaps rosuvastatin, or Crestor, or Zocor?”

“Ah yes, Crestor, I am taking that,” John exclaims, after deliberating for some time.

This is a common and important conversation, but could be simpler for both of us if John was familiar with the active ingredient name.

And while we did eventually come to the answer, this medication could have easily been overlooked, by both John and myself. This may have significant implications and interact with other medicines I might prescribe.

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Cause for confusion

The main problem with using brand names for medications is the potential for confusion, as we see with John.

A prescription written using a brand name doesn’t mean you can’t buy other brands. And your pharmacist may offer to substitute the brand specified for an equivalent generic drug. So, people often leave the pharmacy with a medication name or package that bears no resemblance to the prescription.

When the terms we use to describe medicines in conversation, on prescriptions and what’s written on the medication packet can all be different, patients might not understand which medications they’re taking, or why.

This often leads to doubling up (taking two brands of the same medication), or forgetting to take a certain medication because the name on the package doesn’t match what’s written on your medication list or prescription.

Confusion resulting from using brand names has been associated with serious medication errors, including overdoses. Elderly people are the most susceptible, as they’re most likely to take multiple medications.

Even when the confusion doesn’t cause harm, it can be problematic in other ways. If patients don’t understand their medicines, they may be less likely to be proactive in making decisions with their doctor or pharmacist about their health care.

Health professionals can also get confused, potentially leading to prescribing errors.

What are the benefits of active ingredient prescribing?

The main benefit of the switch is to simplify the language around medications.

Once we become accustomed to using one standardised name for each medicine, it will be easier to talk about medicines, whether with a family member, pharmacist or doctor.

The better we understand the medications we’re using, the fewer errors we make, and the more control we can take over our medication use and decisions.

A pharmacist can let you know which brands of your medication are are available.
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This change will also serve to promote choice.

When you’re prescribed a medicine with a certain name, you’re more likely to buy that brand. In some cases there may be generic medicines that are cheaper and just as effective. Or there may be other forms of the medication that better suit your needs, such as a capsule only available in another brand.

Not too much will change

This new rule is not expected to lead to extra work for doctors, pharmacists or other health professionals who prescribe medicines, as most clinical software will make the transition automatically.

Doctors can elect to still include the brand name on the prescription, if they feel it’s important for the patient. But aside from some limited exceptions, the active ingredient name will need to be listed, and will be listed first.

Some active ingredient names may be a bit longer and more complex than certain brand names, so there might be a period of adjustment for consumers.

But in the long term, this change will streamline terminology around medicines and make things easier, and hopefully safer, for everyone.

Next time you receive your prescription, have a look at the name of the active ingredient. Remember it, and use that name when you talk to your family, doctor and pharmacist.

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Matthew Grant, Palliative Medicine Physician, Research Fellow, Monash University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

It’s perfectly legal for doctors to charge huge amounts for surgery, but should it be allowed?

Desperate families are increasingly turning to crowdfunding campaigns to raise tens of thousands of dollars for surgery and other medical expenses.
From shutterstock.com

Louisa Gordon, QIMR Berghofer Medical Research Institute

Australia’s Chief Medical Officer Brendan Murphy will investigate how to better protect patients from doctors charging “really unjustifiable, excessive fees” of up to A$10,000 or more for medical procedures.

Murphy said it was potentially unethical for doctors to charge such high out-of-pocket fees that left families in severe financial pain, and that contrary to some patients’ hopes, paying more didn’t equate to better outcomes.

The call comes as desperate families increasingly turn to crowdfunding, remortgaging their homes and eating into their superannuation to raise tens of thousands of dollars for surgeries and other medical expenses.

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It is perfectly legal for a doctor working in private practice to charge what they believe is fair and reasonable. It’s a private market, so buyers beware.

But that doesn’t mean it’s right, or that it should be allowed to continue.

Not everything is available in the public system

Some patients’ out-of-pocket costs are from the gap between what their private health insurance and/or Medicare will pay for a procedure or treatment.

But some treatments aren’t funded by Medicare or offered in public hospitals because their safety, efficacy and value for money have not yet been demonstrated.

Medical technologies, devices and surgical techniques need to be rigorously tested in clinical trials to demonstrate safety and clinical effectiveness. They will only be widely adopted when they have a strong evidence base.

Out-of-pocket costs can be particularly high for patients with cancer.
From shutterstock.com

When the government pays for a health service, value for money is also considered. For really expensive services and medicines that have the potential to greatly benefit patients, the government will try to negotiate prices down, to reduce the impact on the health budget.

While a lack of evidence of a benefit does not necessarily mean the procedure does not benefit patients, the outcomes need to be reviewed and demonstrated to justify its ongoing use.

Sometimes new technologies are adopted prematurely based on weak evidence and strong marketing which can lead to poor investment decisions. This was the case with robotic surgery for prostate cancer, offered early in private practice in Australia, only to find later it was no better than traditional surgery.

If a patient chooses to spend money on a high-risk surgery, is it really anyone’s business?

Sometimes patients will choose to undergo high-risk surgery, not covered under the public system, and are willing to pay out of their own pocket, or raise the funds through crowdsourcing or remortgaging their home.

Some will argue the value is whatever the patient is willing to pay for it and it’s up to the patient’s own risk-benefit preferences.

There are some major problems with this. Patients often make health decisions while distressed, ill and emotional. They may not be able to determine the best course of action or have all the information at hand. They must trust the doctor and his or her superior knowledge and experience.

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Health economists call this “asymmetric information”. The doctor has extensive years of training, expertise and qualifications. The patient has Dr Google.

A key reason governments intervene in health care systems is to avoid market failure arising from unequal information and the profiteering of providers.

Our ‘fee-for-service’ system is failing

In the private system, doctors are paid a fee for each service they provide. This creates an incentive for doctors to provide more services: the more services they provide, the more they get paid.

But the high volumes of testing, consultations and fragmented services we’re currently seeing aren’t translating to a better quality of care. As such, economists are calling for major reforms of our fee-for-service private health system and the way that doctors are paid.

This could involve paying doctors for caring for a patient’s medical condition over a set period, rather than each time they see the patient, or charging private patients a “bundled fee” for all the scans, appointments and other costs associated with something like a hip replacement.

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Out-of-pocket costs are very high for some Australians with cancer. A quarter of Queenslanders diagnosed with cancer will pay provider fees of more than A$20,000 in the first two years after diagnosis.

While what constitutes “value” will be in the eye of the beholder, a well-functioning and sustainable health system is one that puts patients’ interests above all others and holds health providers accountable.

Australia’s universal health care system is one of the best in the world and we need to work hard to preserve it. Surgeries costing tens of thousands of dollars will continue unless the government regulates private medical practice or reforms the way doctors are remunerated.

It’s time to cap what physicians can charge for services and provide incentives for specialists to bulk-bill their patients.

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Louisa Gordon, Associate Professor – Health Economics, QIMR Berghofer Medical Research Institute

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Doctors may be prescribing antibiotics for longer than needed

Most recommended courses last between three and seven days.
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Allen Cheng, Monash University

For most infections, the long-standing advice is to take a full course of antibiotics.

The rationale for not simply stopping antibiotics as soon as you start to feel better is that antibiotics don’t kill the bacteria instantly. If stopped too early, the remaining bacteria, which are exposed to low concentrations of antibiotics, tend to be more resistant. These can then re-grow, causing recurrent infection, or spread to other people.

The recommended length of the course depends on the type of infection, the likely cause, and how effective the antibiotics are at killing the bacterium and penetrating to the site of infection.

For infections commonly seen in general practice, most recommended courses last between three and seven days. For more serious infections requiring hospitalisation, the recommendations are generally a little longer.

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A recent study from the United Kingdom found a substantial proportion of antibiotic prescriptions in general practice were for longer than these recommendations. While for each prescription this may have only been a few days longer, for the UK as a whole this amounted to about 1.3 million days of antibiotics more that would have been necessary.

Researchers are currently investigating how much of a problem this is in Australia.

There’s little evidence to suggest longer courses of antibiotics benefit patients. In fact, even the recommended lengths could be too long for many infections.

Why are courses longer than recommended?

The most important determinant of duration in primary care is probably the size of the pack the antibiotics come in.

But the number of tablets in a pack is rarely the same as the length of a course. One Australian study looked at 32 common prescribing scenarios and found that the pack size only matched the recommended duration of antibiotics in four cases.

Other reasons antibiotics may be prescribed for longer than recommended is when patients are given “repeats” and taking a second course of antibiotics. Often, the doctor isn’t actively prescribing a second course, but their medical prescribing software is printing a “repeat” on their prescription by default.

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In hospitals, clinical uncertainty plays a large role. It is sometimes suggested that antibiotics are used for the benefit of the patient, but at other times to allay the treating doctor’s anxiety.

While the motivation to make sure infections are properly treated is understandable and well-intentioned, particularly in patients who might still be critically unwell for other reasons, continuing antibiotics for too long increases the risk of side effects and antibiotic resistance.

Do we even need a full course?

We may be able to stop antibiotics before we reach the end of our course. The body has the capacity of “mop up” small numbers of bacteria, so at least for milder infections, it may not be necessary to kill them all.

This is important because using antibiotics for too long can be a problem in causing antibiotic resistance. This can occur within individual patients by exposing bacteria elsewhere in the body to antibiotics, but also because antibiotics are eliminated from the body and can contaminate the environment.

We didn’t always standardise the duration of antibiotics. Harry Dowling, one of the pioneers of early antibiotic use, once said

The duration of treatment just evolved. There was no rationale for any single length of time. We saw how long it took for the temperature to come down and gave antibiotics until it did, and then some.

The durations recommended in guidelines often come from arbitrary decisions made in early studies, which have translated into some odd “rules” about antibiotics:

• prime numbers for durations of up to a week (three, five or seven days)
• even numbers for more serious infections that take weeks to eradicate (two, four or six weeks)
• multiples of three for really tenacious infections such as bone infections (three months) or TB (six months).

In writing guidelines for doctors, we often wrestle with whether to set a fixed duration (such as seven days), a range (five to ten days), a minimum (at least five days), a maximum (up to ten days) or wordy qualifications (usually five days, or ten days for severe illness or where there is a slow response).

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What about serious infections?

For deep or severe infections, we want to be sure the infection won’t return. Recent research has focused on defining the shortest effective duration of treatments.

A recent trial compared whether seven days or 14 days of antibiotics were required for some types of bloodstream infection, and found outcomes to be similar.

Researchers have also been testing the use of oral antibiotics for two of the most difficult infections to treat – endocarditis (infection of the heart valves) and ostemyelitis (infection of bone) – which have needed intravenous antibiotics for six weeks or longer. These trials have shown a shorter course of intravenous antibiotics with an early switch to oral antibiotics may be adequate.

Shortening the duration of antibiotics is one important way to reduce antibiotic use, the key driver of antibiotic resistance.

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Allen Cheng, Professor in Infectious Diseases Epidemiology, Monash University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

How can Australia have too many doctors, but still not meet patient needs?

If you live in a rural area, you would never think Australia had too many doctors.
from shutterstock.com

Richard Murray, James Cook University and Andrew Wilson, University of Sydney

The statement “we have plenty of doctors in Australia” would probably not pass the pub test. Especially if the pub was in a regional city, a remote town or a less-than-leafy suburb. But it is true all the same – statistically at least.

With 3.5 practising doctors for every 1,000 people in 2014 (4.4 per 1,000 in major cities) we’ve never had so many. In 2003, there were 2.6 doctors for every 1,000 people in Australia, which is closer to the proportion in similar countries now, such as New Zealand (2.8), the UK (2.8), Canada (2.6) and the USA (2.6).

Yet at 2.6 per 1,000 was when we decided we were “short” and went on to double the number of medical schools and almost triple the number of medical graduates in a little over a decade.

And then there’s this question: if we are now so flush with medicos, why do we still need to import so many from overseas? To fill job vacancies, the Australian government granted 2,820 temporary work visas to overseas-trained doctors in 2014-15. In the same year, Australian medical schools graduated another 3,547.

This heroic level of doctor production and importation is right up there internationally. Among wealthy nations, Australia is vying for the top spot, with only Denmark and Ireland in the same league of doctor-production for population.

So why do we have too many doctors, but think we have too few?

Our approach to medical training

In a Medical Journal of Australia editorial published today, we examine the question of “work readiness” in our new medical graduates from arguably the most important perspective: what the community needs from future doctors.

To what extent is our medical training system producing doctors who will be providing the high quality, person centred, affordable health services we need, given we are an ageing population living with higher levels of chronic and complex health conditions?

There have been arguably three problems with the Australian approach to the medical workforce to date. First, we didn’t finish the job of production; second, we’ve allowed too much medical specialisation in major cities; and third, our models of health care and the ways we pay for it are out of step with where community needs are heading.

1. Production

Back in the early 2000s, the biggest issue relating to the training of Australia’s medical workforce was a shortage of doctors in regional and remote areas. So, in addition to boosting medical student numbers overall, we set up rural clinical schools and regional medical schools, and increased admission of students who were already residents of rural areas.

While results of these policies have been positive in terms of graduate rural career intentions and rural destinations, the job was really only half done. What we didn’t do is reform the training that goes on after medical school.

That involves internships and training for one of 64 specialty fellowships, including general practice. Because of that, too many of our medical graduates are now piling up in capital city teaching hospitals, locked in a fierce competition for ever-more sub-specialised training jobs.

Meanwhile regional Australia remains hooked on a temporary fix of importing doctors from overseas. Hence the recently announced funding for 26 new regional training hubs. The aim is to “flip” the medical training model, so the main training is offered regionally with a city rotation as required.

2. Excessive specialisation

There’s no question we need a reasonable number of doctors who are experts in a narrow field. However, there’s now an imbalance between an inadequate number of medical generalists and excessive numbers of specialists in every major medical field.

Regional Australia in particular needs more generalists; that is rural generalist GPs, general surgeons, general physicians and the like.

3. Financing and models of care

Health expenditure is driven by three main factors: growth in population, providing more care for each patient and the increase in the proportion of older people with increased complex care needs.

Improvements in health-care technology means we can diagnose illness more accurately, less invasively and earlier, and we have more effective treatments.

However, in a system that pays on the basis of every service provided (regardless of need) there is also a risk of provider-induced demand. This can lead to inappropriate medical care, with examples in unwarranted eye, knee and back surgery, imaging, colonoscopy, and medication for depression and other conditions.

An undersupply of doctors is associated with lower rates of health-care use, whereas oversupply or mis-distribution can lead to higher rates of inappropriate care. Balancing the distribution of doctors according to need has important consequences for health-care costs.

Time for action

Make no mistake, Australia’s current health system is good by world standards. But the headwinds are building. The population is ageing, we’ve got more people with chronic and complex health-care needs, and the costs of new medicines and technologies continue to escalate.

Having injected a massive boost of doctors into a fee-paying healthcare system without regard to population need, workforce mix, geographic location, health-care models or financing reform, we have put the future at risk.

Let’s not let this bold experiment fail for want of follow-through. We need more urgency in providing the incentives and training opportunities to get our growing junior medical workforce into the specialties and areas that are underserved.

We have to stop allowing medical specialty training to be driven by the work rostering requirements of metropolitan hospitals. We must increase the number of specialist training positions based in regional centres.

And we especially need to expand the number of broadly-skilled rural generalists and get serious about efficient, team based, health-care models. This requires cooperation by all governments, medical schools, specialist colleges and the profession – and the time to act is now.

Richard Murray, Dean of Medicine & Dentistry, James Cook University and Andrew Wilson, Co-Director, Menzies Centre for Health Policy, University of Sydney

This article was originally published on The Conversation. Read the original article.

Latest Persecution News – 12 March 2012

Doctors Try to Save Remaining Eye of Ugandan Pastor

The following article reports on the recovery of a Ugandan pastor from an acid attack by Islamic extremists.

http://www.compassdirect.org/english/country/uganda/article_1422178.html

 

India Briefs: Recent Incidents of Persecution

The following article provides a ’round up’ of persecution incidents in recent times in India.

http://www.compassdirect.org/english/country/india/article_1424992.html

 

Christian Woman in Pakistan Freed after ‘Blasphemy’ Accusation

The following article reports on the release of a Christian woman falsely accused of desecrating the Quran in Pakistan.

http://www.compassdirect.org/english/country/pakistan/article_1427582.html

 

The articles linked to above are by Compass Direct News and  relate to persecution of Christians around the world. Please keep in mind that the definition of ‘Christian’ used by Compass Direct News is inclusive of some that would not be included in a definition of Christian that I would use or would be used by other Reformed Christians. The articles do however present an indication of persecution being faced by Christians around the world.

Pakistani Christian Sentenced for ‘Blasphemy’ Dies in Prison

Murder suspected in case of Christian imprisoned for life.

LAHORE, Pakistan, March 15 (CDN) — A Christian serving a life sentence in Karachi Central Jail on accusations that he had sent text messages blaspheming the prophet of Islam died today amid suspicions that he was murdered.

Qamar David’s life had been threatened since he and a Muslim, Munawar Ahmad, were accused of sending derogatory text messages about Muhammad in June 2006, said David’s former lawyer, Pervaiz Chaudhry (See “Pakistan’s ‘Blasphemy’ Laws Claim Three More Christians,” March 10, 2010).

David was convicted under Section 295-C under Pakistan’s widely condemned blasphemy laws for derogatory remarks against Muhammad in a case registered at Karachi’s Azizabad Police Station, with another case registered at Saddar Police Station pending. Maximum punishment for Section 295-C is death, though life imprisonment is also possible. On Feb. 25, 2010 he received a sentence of life in prison, which in Pakistan is 25 years, and was fined 100,000 rupees (US$1,170).

Chaudhry, who said he was David’s counsel until Islamic threats against his life forced him to stop in July 2010, told Compass that the Christian had expressed fears for his life several times during the trial.

“David did not die of a heart attack as the jail officials are claiming,” Chaudhry said. “He was being threatened ever since the trial began, and he had also submitted a written application with the jail authorities for provision of security, but no step was taken in this regard.”

Conflicting versions of his death by jail officials also raised doubts.

A jail warden said David was reported crying for help from his cell today in the early hours of the morning. He said that David, who was breathing at the time, was transported to the Civil Hospital Karachi (CHK), but that doctors there pronounced him dead on arrival.

He also said, however, that he had heard from colleagues that David was found dead inside his cell and that his body had been sent to the hospital for post-mortem, not for treatment. Investigations are underway, he added.

Karachi Central Prison Deputy Superintendent Raja Mumtaz said David was shifted to CHK for treatment after jail staff members found him crying for help with “one hand on the left side of his chest.” He said the prisoner was first taken to a local healthcare center, but that doctors there suggested that he should be taken to a hospital for proper treatment.

Mumtaz said that David was shifted to the hospital at around 10:45 a.m. today and was alive when he reached the hospital.

Sindh Inspector General of Prisons Ghulam Qadir Thebo insisted to BBC that David died of natural causes, saying he was housed in a Christian-only wing in which no Muslim prisoners had access to him.

“Our investigations have not yielded any evidence of foul play,” Thebo told BBC. “There is no evidence to suggest he was murdered.”

David’s family reached Karachi today to take custody of the body. An impartial probe and autopsy report is awaited, as no jail officials were ready to say on record whether they had seen any visible injury on David’s body.

David’s son, Aqeel David, told Compass that the family had been informed only that his father had suffered a heart attack and died while he was being taken to the hospital.

“We don’t know anything besides this little piece of information that was given to us on the telephone,” he said. “We are unsure about the circumstances surrounding my father’s death because of the serious nature of the cases against him.”

David’s former attorney said that the trial in which David was convicted and sentenced was a sham.

“The judge acquitted Ahmad in this case, even though all 11 witnesses clearly pointed out his direct involvement in the incident,” Chaudhry said.

In regard to the other blasphemy case registered at the Saddar Police Station, Chaudhry said he had cross-examined witnesses who had again accused Ahmad of mischief and absolved David of any wrongdoing.

“Ahmad’s lawyer had filed an application for re-examining the witnesses when I withdrew from the case,” Chaudhry added. “I stopped pursuing his cases last year because of serious threats to my life by Islamist groups who used to gather outside the courtroom.”

Chaudhry said threats were made “both inside and outside the courtroom.”

During the cross-examining of witnesses, he said, Senior Superintendent of Police Muhammad Afzal had also admitted that Ahmad was the real culprit and that David was arrested on the information of “some sources.” Chaudhry said there was no relation whatsoever between Ahmad and his client before the trial started.

“They were complete strangers,” Chaudhry said. “David was definitely framed in these cases.”

Report from Compass Direct News
http://www.compassdirect.org

Pakistani Muslims Beat Elderly Christian Couple Unconscious

80-year-old’s bones broken after he refused prostitute that four men offered.

SARGODHA, Pakistan, October 21 (CDN) — An 80-year-old Christian in southern Punjab Province said Muslims beat him and his 75-year-old wife, breaking his arms and legs and her skull, because he refused a prostitute they had offered him.

From his hospital bed in Vehari, Emmanuel Masih told Compass by telephone that two powerful Muslim land owners in the area, brothers Muhammad Malik Jutt and Muhammad Khaliq Jutt, accompanied by two other unidentified men, brought a prostitute to his house on Oct. 8. Targeting him as a Christian on the premise that he would not have the social status to fight back legally, the men ordered him to have sex with the woman at his residence in village 489-EB, he said.

“I turned down the order of the Muslim land owners, which provoked the ire of those four Muslim men,” Masih said in a frail voice. District Headquarters Hospital (DHQ) Vehari officials confirmed that he suffered broken hip, arm and leg bones in the subsequent attack.

His wife, Inayatan Bibi, said she was cleaning the courtyard of her home when she heard the four furious men brutally striking Masih in her house.

“I tried to intervene to stop them and pleaded for mercy, and they also thrashed me with clubs and small pieces of iron rods,” she said by telephone.

The couple was initially rushed to Tehsil Headquarters Hospital Burewala in critical condition, but doctors there turned them away at the behest of the Jutt brothers, according to the couple’s attorney, Rani Berkat. Burewala hospital officials confirmed the denial of medical care.

Taken to the hospital in Vehari, Inayatan Bibi was treated for a fractured skull. The beatings had left both her and her husband unconscious.

Berkat said the Muslim assailants initially intimidated Fateh Shah police into refraining from filing charges against them. After intervention by Berkat and Albert Patras, director of human rights group Social Environment Protection, police reluctantly registered a case against the Jutt brothers and two unidentified accomplices for attempted murder and “assisting to devise a crime.” The First Information Report (FIR) number is 281/10.

Station House Officer Mirza Muhammad Jamil of the Fateh Shah police station declined to speak with Compass about the case. Berkat said Jamil told her that the suspects would be apprehended and that justice would be served.

Berkat added, however, that police appeared to be taking little action on the case, and that therefore she had filed an application in the Vehari District and Sessions Court for a judge to direct Fateh Shah police to add charges of ransacking to the FIR.

Doctors at DHQ Vehari said the couple’s lives were no longer in danger, but that they would be kept under observation.

Report from Compass Direct News

Muslims Force Expat Christian Teacher to Flee Maldives

Mistaking compass she drew for a cross, parents of students threatened to expel her.

NEW DELHI, October 5 (CDN) — Authorities in the Maldives last week had to transport a Christian teacher from India off one of the Islamic nation’s islands after Muslim parents of her students threatened to expel her for “preaching Christianity.”

On Wednesday night (Sept. 29) a group of angry Muslim parents stormed the government school on the island of Foakaindhoo, in Shaviyani Atoll, accusing Geethamma George of drawing a cross in her class, a source at Foakaindhoo School told Compass.

“There were only 10 teachers to defend Geethamma George when a huge crowd gathered outside the school,” the source said by telephone. “Numerous local residents of the island also joined the parents’ protest.”

The school administration promptly sought the help of officials from the education ministry.

“Fearing that the teacher would be physically attacked, the officials took her out of the island right away,” the source said. “She will never be able to come back to the island, and nor is she willing to do so. She will be given a job in another island.”

A few days earlier, George, a social studies teacher, had drawn a compass to teach directions to Class VI students. But the students, who knew little English, mistook the drawing to be a cross and thought she was trying to preach Christianity, the source said. The students complained to their parents, who in turn issued a warning to the school.

Administrators at the school set up a committee to investigate the allegation and called for a meeting with parents on Thursday (Sept. 30) to present their findings. The committee found that George had drawn a compass as part of a geography lesson.

“However, the parents arrived the previous night to settle the matter outside the school,” said the source.

According to local newspaper Haveeru, authorities transferred George to the nearby island of Funadhoo “after the parents threatened to tie and drag her off of the island.”

The teacher, who worked at the school for three years, is originally from the south Indian coastal state of Kerala. Many Christians from Kerala and neighboring Tamil Nadu state in India are working as teachers and doctors in the Maldives.

Preaching or practicing a non-Muslim faith is forbidden under Maldivian law, which does not recognize any faith other than Islam. The more than 300,000 citizens of the Maldives are all Sunni Muslims.

A string of 1,190 islands in the Indian Ocean off Sri Lanka in South Asia, the Maldives is the only country after Saudi Arabia that claims to have a 100 percent Muslim population. As per its constitution, only a Muslim can be a citizen of the country. Importing any literature that contradicts Islam is against the law.

Many of the more than 70,000 expatriate workers in the Maldives are Christian, but they are allowed to practice their faith only inside their respective homes. They cannot even get together for prayer or worship in each other’s houses – doing so has resulted in the arrest and deportation of expatriates in the past.

The Maldives was ruled by an authoritarian, conservative Muslim president, Maumoon Abdul Gayoom, for 30 years. The nation became a multi-party democracy in 2008 with Mohamed Nasheed – from the largely liberal Maldivian Democratic Party (MDP) – as the new president.

Gayoom’s right-wing party, the Dhivehi Rayyithunge Party (DRP), however, managed to win a simple majority in the People’s Majlis – as the parliament is known in the Maldives – in the 2009 parliamentary election. The Maldives follows the presidential system.

The DRP-led opposition often criticizes Nasheed’s government, accusing it of being liberal in cultural and religious matters, which DRP leaders claim will have a bearing on the country’s sovereignty and identity.

A key ally of the MDP, the Adhaalath Party, also holds conservative views on religion and culture.

Many in Maldivian society, along with religious and political leaders, believe religious freedom is not healthy for the nation’s survival, although the Maldives does not perceive any threat from nearby countries.

Report from Compass Direct News