AS the Editor-in-Chief of the MJA, I am in the very privileged position of being among the first to critically evaluate early and emerging data. I’m also able to talk to experts around the world through my medical, research and academic links.

Early on in what is now a pandemic, I remember seeing the first outbreak data from China and proposed R0 values, and initial models of exponential spread. Evidence from past outbreaks provides many lessons including the importance of the public health measures going very hard and very early, well before all the facts are in. I therefore watched with increasing alarm as despite the early warnings from the World Health Organization (WHO) there were limited initial steps taken by many governments. I remember when I first saw the alarming Imperial College modelling for the UK and US, and the impact of mitigation versus suppression strategies in terms of hospital deaths from COVID.

  • This article was first published as a preprint at the MJA’s website. Read the original here

Last week the MJA published a new model of ICU bed availability, mortality and COVID admissions, validated against Italian data by Meares and Jones. The model is grim; it proposes that a hypothetical hospital in Sydney may face a steady state of 20 new positive COVID-19 admissions each and every day, one requires ICU admission for 10 days, and a 20% increase each day. By day 15 when ICU beds run out, the mortality more than doubles and stays that high, as has happened in Italy. Those who do outbreak modelling know how complex the models can be and how many unknown assumptions need to be inputed especially early in a new infectious outbreak; some use super computers to do their calculations and can take months or years to build. However, the predictive validity of complex models in an outbreak may also fail to hold up elsewhere because human behaviour is complex and changes. For this reason, sometimes simple models are more robust, at least early on when it matters.

Many have spoken out about the public health measures needed to suppress COVID and recently bold action has been taken in Australia and elsewhere; those medical leaders who have stepped up and the political leaders who have heeded the advice early enough are the initial heroes of this pandemic.

The next wave of heroes will soon emerge, namely the frontline clinicians in each hospital who will look after the COVID surge. As I write this piece the medical profession largely continues to undertake business as usual although major preparations are underway to increase ICU bed and ventilator capacity, and personal protective equipment (PPE) is being donned to protect staff. Based on the ICU bed modelling today it won’t be enough.

Those who will face the COVID frontline and manage the sickest patients will need our greatest support, every single one of them. We will need to ensure we don’t waste current stocks of PPE and more is obtained, a clear Government priority we must support by cancelling routine surgery and procedures. I hope there will be directives to order manufacturers to make what we need and fast; we would retool factories in wartime and not rely alone on private companies to step up as many have, and while some dislike the wartime analogies they resonate with me.

We will need to work together to support our medical teams. For two-doctor or health professional families with dependents, both must not be placed at high risk of exposure and severe disease, not a straightforward rostering task, particularly outside of major hospitals and in rural Australia.

We need a statewide and preferably a country-wide plan; the states closing borders is counterproductive to our response, in my view. Training of all staff needs to ramp up and this must be more than simple videos on-line. Mental health support needs to be put in place as post-traumatic stress disorder will be a serious risk, and now. We need to also protect staff financially and professionally. It is as yet unclear what the indemnity implications are for doctors called up to work outside their scope of their usual practice and this must be resolved immediately. I am a gastroenterologist; I am fully prepared to step up to either work on COVID wards or fill the gaps in the non-COVID wards, if required. But what happens if I make a mistake? And if I die will insurance cover my family?

The Australian health Practitioners Regulation Agency is working to determine the role of medical students in this hour of need. Only those near graduation could play a direct clinical role under close supervision if they volunteered but we had better start upskilling them now if this is going to prove of any use; it takes time to transition from a medical student to a fully functioning safe and competent intern. Calling doctors out of retirement is happening in the UK and this may be needed but I hope not, as this strategy places the most vulnerable in the wrong place. We will also need our health system leadership to understand at a time like this the structure should, in my view, be a military-like command-and-control one, led by senior frontline clinicians; bureaucrats must step out of the way.

The MJA has stepped up to do its part in this crisis including ultra-rapid review of COVID papers and pre-print publication so the newest data and viewpoints are released as soon as possible. In addition, all COVID articles are fully free access for anyone to read. Our medical and structural editors are working from home and the MJA will continue to publish as usual in these extraordinary times. The new rapid publication risks errors, but being too slow with information sharing is a much bigger risk. We will work to refine the preprints prior to publishing online early and in print, and correct and update along the way.

Models matter even if they are imperfect representations of the real world. The same could be said for climate change models and health, but that is a topic for another day.  While the results reported by Meares and Jones may represent a worst-case scenario and may not come to pass, we must better prepare, now. Over the coming months it’s going to take courage, brains and a concerted unified effort by the medical profession to manage COVID. Let’s not leave anyone behind.

Distinguised Laureate Professor Nick Talley AC is Editor-in-Chief of the Medical Journal of Australia. He is a neurogastroenterologist, past president of the Royal Australasian College of Physicians. He is currently Pro Vice-Chancellor, Global Research, at the University of Newcastle.



The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.


I am prepared to work outside my usual scope of practice if called on to back up my colleagues on the COVID-19 frontline
  • Strongly agree (44%, 178 Votes)
  • Agree (32%, 130 Votes)
  • Neutral (7%, 30 Votes)
  • Disagree (7%, 29 Votes)
  • Strongly disagree (7%, 27 Votes)
  • I already am (2%, 7 Votes)

Total Voters: 401

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9 thoughts on “COVID-19: Bureaucrats must get out of the way

  1. Andy says:

    Prof Talley is one of the most respected physicians alive in the world today. I suspect that modesty would prevent his agreeing with me.

  2. Ian Hargreaves says:

    Many issues are indeed tricky. It is correct to disparage the closing of state borders (possibly in breach of Section 92 of the Constitution, but that would take some years for the High Court to resolve), however we are a federal democracy, not a dictatorship. States have sovereign rights, including control of hospitals. It made sense in 1901, it’s stupid now (with or without a crisis) to have states, but we are stuck with that.

    Dr Talley, you are a sniper who wants to push the generals out of the way, and take command in “a military-like command-and-control one, led by senior frontline clinicians; bureaucrats must step out of the way.” Whose doors will you order welded shut? – the Wuhan evidence shows it works. Do you have the stomach to order victims dragged off in vans by spacesuited soldiers? – watch it on 4 Corners. Would you nicely ask people to self-quarantine, then watch as they poured onto the last trains like at Milan station, or off the Ruby Princess, or would you order a shoot-to-kill lockdown?

    Sadly, those of us who are Hippocratic clinicians are even more squeamish than the elected pollies when it comes to making decisions which harm the patient/colleague/voter in front of us. You hear the Italian doctors making pleas for people to do the right thing, you don’t hear President Xie having qualms about post traumatic stress disorder and needing “to also protect staff financially and professionally.” Doctors are cannon fodder in the Communist Revolution, maybe Dr Li Wenliang will be rehabilitated postmortem, maybe just demonised as a super spreader.

    “I am a helicopter pilot; I am fully prepared to step up to either work on Qantas A380s or fill the gaps in the 747s, if required.” A skilled bureaucrat like Alan Joyce would laugh at such a ludicrous suggestion. This attitude of professional pluripotence is why we need bureaucrats to restrain the enthusiastic amateur from having a go at something they’ve never actually done before, or last done in the previous millennium, under suboptimal emergency conditions. As a hand surgeon I’ve seen too many people stuffed up by doctors who were willing to have a go at something out of their specialty area.

    That’s why it’s illegal to work in an area for which you lack indemnity cover, e.g. doing a spot of anaesthetising if you’re not an anaesthetist. “But what happens if I make a mistake?” Ask Dr Bawa-Garba. The law says being overworked is no excuse for a mistake. It’s not a law I’d personally agree with, but that’s the point of having laws rather than personal choice. The federal and state governments could legislate to give protection to all doctors working on COVID patients, as they do to judges, or soldiers in wartime. But if you think it’s wrong for an SAS soldier in Afghanistan to shoot an unarmed enemy, you might have qualms about being the one personally responsible for refusing to treat someone’s granny. You might even want a bureaucrat to make the call that no-one over 60 gets intubated, so you aren’t agonising over each patient you condemn.

    While the suggestion of allowing medical students to be sacrificed is worthy of President Xie, it is misplaced. They are students, not doctors, and selected for interview bravado and enthusiasm. They need to be protected, e.g. by placing all students/interns in corona-free hospitals, or in sections like gastroenterology or hand surgery, where risks are lower.

    Let those who have skills and training do their job (my son is a final-year anaesthetic registrar, trained for years in airway management), keep the rest of us treating our own patients (particularly the emergencies in our own fields), and let the bureaucrats earn their generous salaries by doing what they do best, which at this time is making hard decisions indeed.

  3. Anonymous says:

    Agree with Tim. This is unbalanced and ill-informed coming from the Editor of the MJA. I hope it is not quoted in the media.

    There is no mention of the fact that this is an economic as well as a health emergency. Recessions and economic depressions also have severe health consequences, including family breakdown and suicide.

    Why not discuss the Swedish model of strict isolation of the elderly and otherwise vulnerable, while allowing fit younger people to get it, become immune and then return to work – including caring for sick elderly people?

    I don’t oppose the Government’s current restrictions. But they can’t go on forever. When they are lifted, the second wave will be much less dangerous if there is some immunity amongst younger people

  4. Frances Connor says:

    Thank you, Nick, for being the voice of reason. Many of us share your views and have shared your article. Front line staff are very much aware of the issues you raise, but hampered by systemic inertia. The shortfall in PPE is particularly alarming. Thank you for his excellent piece. Hopefully it will help build the momentum we need.

  5. Anonymous says:

    Spoke with my son in NY (Mt Sinai Group) this morning. Two week occupancy limit at the moment for all ICU ventilator beds then extubation to sink or swim. No live discharges recorded from these wards!
    Age level and underlying disease status triaging (for death) already operating by necessity.
    Average time to death from the onset of significant breathing difficulties in the at risk group – 4 hours.
    Staff being decimated by lock down and even death of their front line colleagues

  6. Andrew Jamieson says:

    Not a helpful headline. Many medical administrators are working insightfully and very hard on this, advising political decision making. It’s not always followed but it often is. The AMA thrust of “ let the doctors on the ground sort this out” is flawed, as many clinicians do not have the skills to manage large scale organizational challenges. Of course clinicians on the ground need to be closely involved. – but supported by competent clinical “bureaucrats”.

  7. Kate Schilling says:

    Unless the Medical Boards and Indemnifiers give us the green light I will not work outside my scope. I am afraid that it could add insult to injury if push comes to shove, don’t trust the medical Boards. Your licence depends on it.

  8. Dr David De Leacy says:

    Spoke with my son in NY this morning (NY Mt Sinai group). At this point virtually nobody is exiting ICU alive after the fixed allotted two weeks on ventilators and the age and underlying disease triaging ( for death) is well established.

  9. Tim says:

    This guy is entitled to his opinions but IMHO his scholarship is limited to IBS (he calls this neurogastroenterology in his bio) and his own advancement. Most of the argument in this opinion piece relates to him noting his credentials, which are scant in this field.

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