Issue 31 / 25 August 2014

IF you’re following the ongoing machinations of the NSW Independent Commission Against Corruption (ICAC), you may well relate to the concerns of Sydney Morning Herald columnist Elizabeth Farrelly.

She wrote last week about commercial influences being allowed to shape the built and natural environment of the state over many years, with little consideration of the ethics of such dealings.

Indeed, the recent comments of Prime Minister Tony Abbott viewed alongside those of NSW Premier Mike Baird reveal that even those on the same side of politics hold conflicting views about accepting industry funding and potential risk of undue influence.
While ICAC’s remit is to investigate corruption, it highlights the influences on decisions made by those in charge of the public good and how we can safeguard against vested interests, bias and other perverse drivers of poor decisions.

It’s a familiar dilemma for those of us working in medicine, and one that is explored in this week’s MJA InSight.

A comment article from junior doctor and research fellow Zoe Stewart takes a broad view of the factors that adversely influence the prescribing practices of young doctors, of which direct promotion from pharmaceutical companies is just one.

Likewise in her regular blog, Jane McCredie highlights non-financial factors that can influence doctors’ thinking, writing and practice.

Both commentators say being willing to examine and acknowledge these influences is the first step in limiting their impact.

Our first news story this week takes a more positive look at influence, posing the question of how to influence those at increased risk of HIV infection to undergo regular testing for the virus.

The story follows up an article published online in the MJA, in which public health experts write that increased testing will identify cases earlier, allowing treatment and early closure of the window of infectiousness. Offering enhanced access to the new rapid HIV tests is seen as a potentially valuable strategy in this setting, with some important cautions.

Commenting for our second news story about scepticism in cancer screening, Professor Ian Olver, CEO of the Cancer Council Australia, voices his frustration about the influence of the media on our attitudes.

“The difficulty is that the last study tends to trump all those that went before it in the attention it receives … Hysterical reporting puts all the emphasis on the last study published.”

It’s a plea to stick with the main game of appropriate, guideline-directed screening, and a sceptical openness to new knowledge.

Our third news story is based on a study published in JAMA Internal Medicine, whose results question the value of pharmacological venous thromboembolism (VTE) prophylaxis in all but the highest-risk hospitalised medical patients.

The topic has long been controversial in Australia, with differing estimates of the risk of VTE occurring during and after hospital admission for a medical condition, and two slightly conflicting sets of national guidelines, which have heavily influenced hospital policy and practice.

According to Dr Alasdair Millar, who spoke to MJA InSight for our story, either set of guidelines could result in about 80% of medical patients being eligible for pharmacologic prophylaxis, while he estimates that VTE currently affects 0.3% of such patients. Better ways of estimating individual risk are sorely needed to better target those who will benefit from these therapies.

The final word on influence this week goes to our rural GP commentator, Aniello Iannuzzi. He believes the division between the medical colleges and associations such as the AMA should be akin to the division between church and state, and that the colleges should work to influence quality in clinical practice rather than matters of money and politics.

The current collaboration around the Medicare copayment debate is an example of the blurring of lines that he believes will be damaging in the long run.

Understanding what influences you and how you in turn will use your influence is a great challenge in medicine. It is a painstaking process requiring intense self-scrutiny and an ongoing commitment to professionalism.

We are not perfect but, as the revelations of ICAC continue, I can’t help but wonder if our political leaders are even aware of the need to ask these questions.


Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight