Cataract surgical blitzes: an Australian anachronism

Surgical blitzes may achieve short-term gains, but they inhibit the development of sustainable local services

Surgical blitzes to treat eye disease are often used to redress shortfalls in service provision. In developing countries with scarce human and financial resources, such periodic visits from local or overseas health teams may be justified, as they are generally combined with building local capacity. However, Australia has no such resource constraints. Despite this, surgical blitzes occur year after year in some rural and remote locations in Australia, without concurrent development of sustainable local services. We see this as a particular problem for eye health in Indigenous people.

The first eye surgical blitzes in Australia occurred during the National Trachoma and Eye Health Program in the 1970s. At each site, an Australian Army field hospital team worked for a week, and about a hundred Aboriginal people had sight-restoring eye surgery.1 Over the years, similar army exercises were repeated across the Northern Territory, including, on one occasion, a tented field hospital being put up in a hospital car park.2

Everyone felt a very good job was being done, but nothing really changed. More recently, regular surgical blitzes, rebranded as “surgical intensives”, were started in Alice Springs and elsewhere in the NT; but these were also short-term fixes.

There is an ongoing need for more eye surgery in these areas.3 Aboriginal and Torres Strait Islander people have a sixfold greater rate of blindness than non-Indigenous Australians.4 They have 12 times higher rates of cataract blindness, but receive seven times less cataract surgery. A blind Indigenous person needing cataract surgery should be put on a surgical waiting list and operated on within 3 months.5 However, those who manage to get onto a waiting list will wait almost twice as long as non-Indigenous Australians,6 sometimes waiting several years or more before receiving surgery.

There are complex factors affecting Indigenous Australians’ willingness to attend for surgical treatment, but once a patient is ready for surgery, he or she should receive it promptly. Surgery may need to be delivered opportunistically for patients with competing community and cultural priorities. Multiple things can be done to prevent Indigenous patients from dropping out of the system: 35 such key points have been identified in the patient journey for cataract surgery.7

Blitzes seem to provide a quick and rewarding solution. Surgery gets done, patients get their vision back, and surgeons and staff feel satisfied. Blitzes usually receive government and private funding, so the investors feel good that something is being done and they obtain positive publicity. But the patients who turn up the next week do not feel so good. They do not know how long they will have to stay blind while awaiting another blitz. Those who were already on a waiting list but could not forgo family, community or cultural responsibilities for the surgery have to wait longer. The staff who worked so hard to make the blitz possible understandably need a break; until it is time to start planning the next one. The end result is that the system is never fixed and rolling blitzes become the norm in dealing with the aching unmet need.

Although there is still a long way to go, Indigenous life expectancy is improving. With an ageing population, the burden of age-related cataract is likely to double in the next 20 years,8,9 and an increasing number of older Indigenous Australians will need sight-restoring cataract surgery. We must ensure that Indigenous people do not experience unnecessarily prolonged visual impairment and blindness, to enable them to maintain quality of life and independence in these additional years of life.10 While poor vision is not the only unsolved problem in Indigenous health, it causes 11% of the health gap.11 Unlike many other conditions, most of this vision loss can be cured overnight with spectacles or cataract surgery.

What is required is adequate provision of sustainable, ongoing services.12 Surgical blitzes on their own are neither a long-term nor a sustainable solution. They may show what is possible with adequate resources over the short term, but no lasting change is implemented and the underresourced local service struggles on. Blitzes alone will not clear the growing backlog or provide sufficient volume of services to meet the increasing need for surgery; although targeted blitzes to clear a regional backlog, with concurrent development of ongoing coordinated surgical services, make sense.13 With the backlog reduced, the local service then requires appropriate resourcing to meet the ongoing need for surgery in a timely manner and to provide the direct personal interaction that is so highly valued by the Indigenous community and patients.

Unfortunately, despite the best of intentions and attempts at gaining government commitment through agreements and memoranda of understanding, the diversion of resources to arranging surgical blitzes means there are limited resources allocated to developing local services. So, paradoxically, blitzes prevent the development of the sustainable solutions needed to provide equity of care and to close the gap in Indigenous eye health.

Australia in 2015 has a sophisticated health system with the capacity to provide the services required. We cannot afford repeated short-term and unsustainable surgical blitzes. We are lucky that strong advocacy exists among vision care organisations to raise awareness of the need for long-term solutions and sustainable regional eye services.14 Australia should be leading the way in showing how to deliver eye care, rather than consistently showing how not to.

Copayments and the evidence-base paradox

To the Editor: The recent perspective by Keane on the effects of copayments on low-income populations1 overlooked the results of the 1968 decision in the Canadian province of Saskatchewan to impose a fee of $1.50 (all amounts are in Canadian dollars) for office visits and $2.00 for home, emergency department or hospital outpatient visits.

At the time the fees were introduced, the definition of low income was $1550 for single-person families to $4800 for families of five or more. The result of the fee was a statistically significant 14% decrease in the use of general practitioner services and a non-statistically significant decrease of 5% in specialist services by the poor.2 The health outcomes effect of this decrease in the use of services was not examined.

The Saskatchewan natural experiment should serve as a reminder that even small amounts of money can affect the volume of services that the poor receive.

Copayments and the evidence-base paradox

In reply: I thank Lexchin for citing the Saskatchewan natural experiment, but we do need to exercise caution when extrapolating the findings of this study to the current copayment debate.

The Saskatchewan copayments were higher ($10 to $13 in today’s money1), and broader (covering general practice, emergency department and outpatient visits). The study population was “essentially agrarian”,2 life expectancy was less than 70 years for men,3 and information-sharing technology was completely different from what we have today. The study analysed the effect of a copayment only on the poorest of families,2 defined as having incomes (in 2014 dollars1) of up to $11 500 for individuals and $32 000 for a family of five. People on such incomes might be holders of concession cards today in Australia, and would be exempt from the proposed copayment.

Furthermore, “It is, of course, not possible to infer whether the reduction in these services represents a decline in ‘abuse’ through overservicing or overutilization, or an increase in ‘unmet needs’.”2 This is a recurring theme in the copayment debate, but could not be determined in the Saskatchewan analysis.2

We also have to recognise there is an opportunity cost to any health care expenditure. Using Canada as an example, there has been a doubling in the time Canadians wait to receive specialist treatment since 1993.4 This represents reduced access to health care. Therefore it can’t be assumed that a reduction in use of general practitioner services, even among the poor, is necessarily a bad outcome if it contributes to a more effective allocation of health resources. We just don’t know.

Hospitals should be exemplars of healthy workplaces

In ancient Egypt and Greece, temples functioned as centres of medical advice and healing. Hospitals are now the temples of the health care world, performing modern-day miracles in treating illness and injury. However, the gains in life expectancy made in the past century owe as much to public health interventions as to hospital-based care,1 and in the 21st century the world faces a different set of challenges arising from chronic diseases. Tackling the root causes of chronic disease — such as poor nutrition, lack of exercise, poor housing, contaminated environments, smoking and alcohol misuse — requires more than doctors, nurses and prescription pads.

Hospitals see the consequences and bear the burden of failures to deal with the social determinants of health. Given their unique position in the health care system, it is time for hospitals to become stronger advocates for health, wellbeing and the environment. As major employers and flagship health care organisations, hospitals can influence the norms of the communities they serve by adopting model policies and practices that promote the health of patients, visitors, employees, students and trainees.

Increasingly, hospitals are required to take into consideration the health status of the communities they serve in designing and delivering their services. In the United States, this is recognised in the community health needs assessment requirements imposed on charitable hospitals by the Affordable Care Act.2 A similar push has occurred for Australian local hospital networks to ensure delivery of services based on local needs,3 and for over a decade, each New Zealand district health board has been required to create a picture of the health status of its regional population.4 We argue that these efforts will not succeed unless and until hospitals themselves are seen as showing the way in health promotion.

While quality improvement initiatives often focus on systems, processes and outcomes of care, we believe there are structural changes that seem to be low-hanging fruit. Many of these changes are relatively small and low-cost but they mean hospitals can better deliver health and wellbeing alongside health care. They include reorienting hospital policies to ensure they provide healthy, ecologically sound and sustainable environments; an increased focus on promoting health and prevention; and fostering interpersonal safety.

Hospitals as stewards of sustainability and the environment

The health of the environment affects the health of the population. Hospitals are energy- and resource-intensive, and the World Health Organization notes three benefits of making them “climate-friendly”.5 First, health benefits will accrue from reducing carbon emissions and other pollutants created by waste disposal. Second, reducing energy usage and waste will reap economic benefits. Third, there is the positive societal and environmental influence of the health sector fulfilling its obligation to “do no harm”. To achieve climate-friendly hospitals, the WHO suggests seven focus areas: energy efficiency, green building design, alternative energy production, transportation, food sustainability, waste reduction and water conservation.

With their high energy use, health services account for more than half of greenhouse gas emissions in the public sectors of large states like New South Wales.6 Estimates from the United Kingdom suggest that the travel of patients, staff and visitors to and from hospitals contributes up to 20% of the hospitals’ carbon footprint.7 Plastics account for a third of hospital waste, and a quarter of that is estimated to be polyvinyl chloride (PVC). In Australia, there is a nascent program for hospitals and dialysis units to recycle as many as possible of the 50 million intravenous fluid bags and lengths of PVC tubing used every year, rather than send them to landfill. Done well, this can be a cost-neutral waste management solution.8

A healthy hospital should measure its environmental footprint and take action to reduce it through energy and water management, waste reduction, the purchase of environmentally friendly products and the provision of transportation alternatives. Hospital administrators should think about how they could cooperate with local government and public transport services to best promote cycling, walking and public transport use.9

Sustainability strategies are possible even for established buildings, and increasing energy costs should make this an imperative. In the US state of Pennsylvania, Geisinger Health System implemented a successful energy reduction program that annually achieved more than US$6.3 million in savings, reduced greenhouse gas emissions by 80% and reduced water use by 20%.10 In an example of a countrywide approach, the UK’s National Health Service (NHS), as part of its carbon reduction strategy, has set an initial target for NHS institutions to reduce their emissions by 10% (from 2007 levels) by 2015.11

As a positive example of hospitals departing from their traditional roles, 13 of the largest American health systems have come together to create the Healthier Hospitals Initiative (http://healthierhospitals.org). Acknowledging the large amount of resources consumed by health care services and their substantial purchasing power, this program asks its members to commit to improving their energy usage, providing healthier food options and purchasing safer and less toxic products, and then measures their success. Considerable savings have already been achieved by members of this initiative and could exceed US$5.4 billion over 5 years.12 However, despite the excellent work by sentinel organisations, including the international group Health Care Without Harm (http://noharm.org), hospitals that have made this a focus remain in the minority.

Health promotion must be a core dimension of hospital services

The aim of health-promoting hospitals, a concept that has been in existence for over 20 years,13 is to reorient health services away from focusing solely on curative care towards a more holistic approach that encompasses the principles of health promotion for patients, visitors, staff and trainees.

Despite the drama and urgency usually involved, a hospital admission for illness or accident is also an opportunity for preventive interventions. Patients, families and carers are more likely to pay attention when the risk factor (eg, smoking, obesity, excessive alcohol consumption, family violence) is proximate to the lung disease, heart attack, road accident or injury that has brought them into acute care.14 Failure to tackle such risk factors and to take advantage of the “teachable moment” the presentation offers increases the likelihood that the presentation will reoccur. However, a 2010 literature review found a dearth of published, high-level research on health-promoting hospitals,15 reflecting the low priority given to research into health promotion in health care systems generally and in acute care specifically.

Even if implementing a formal health promotion framework is not possible, there are a range of areas where hospitals can lead by example. It is important for hospital patients, visitors and employees to have healthy and affordable food and beverages and an environment that encourages physical activity and connectivity.16 In addition, hospitals should facilitate breastfeeding and lactation support, access to tobacco cessation interventions including nicotine replacement therapy, and substance and alcohol misuse programs in a non-judgemental environment.

There are other prevention and health promotion recommendations that are essential, yet are too often poorly implemented. These include handwashing, influenza vaccinations, workplace violence and injury prevention, and the safe handling of dangerous chemicals and radioactive waste.

Workplace injury, violence and bullying

Recent reports highlight the importance of mental health and wellbeing in the hospital workplace. Research shows that nurses in particular are at high risk of work-related injury and stress-related illness.17,18 The latter is linked to work overload and role-based factors, such as lack of power, role ambiguity and role conflict.17 A study commissioned by the Australian Safety and Compensation Council found the most commonly reported problems were musculoskeletal injuries, stress, bullying and infection.18

Most unintentional injuries can be avoided and psychological distress can be reduced through appropriate prevention and early intervention strategies. Particular emphasis needs to be given to preventing and managing aggression and violence towards hospital staff — an increasingly common situation, especially in emergency departments19 — and bullying. These are complex problems that require multifaceted solutions, not all of which are within the purview of hospitals. But they cannot be ignored, as both workplace violence and bullying influence job performance, retention and stress,20 and these in turn influence quality and safety.

There is evidence that bullying in hospitals does not just happen between supervisors and their staff or between different professions, but is also peer-to-peer.21 Fostering a safety culture means more than drawing a line between acceptable and unacceptable interpersonal behaviour; it encompasses a culture of trust where staff are encouraged to speak up about their concerns and are comfortable about reporting mistakes and near-misses. Indeed, improving the workplace safety culture has been associated with improved outcomes for staff and patients.22 Safe work environments are also necessary for best-practice clinical learning, a key hospital function.23

Conclusion

Hospitals must become healthy workplaces in every sense. This is an integral part of the push for quality and safety in clinical care and also contributes to the triple bottom line for health care: better patient experience of care; better population health through improved social and environmental impacts; and better financial performance.24

Although hospitals have healing as their core value, they contribute to the burden of illness and injury by selling junk food, consuming enormous amounts of energy, generating waste that is simply disposed of in landfill, and through poor workplace practices. We argue that hospitals must be fully involved in the health agenda, leading the way in their communities by promoting health, providing healthy and safe workplaces and working towards environmental sustainability. They must exploit their respected status for the benefit of the communities they serve and lead the way for others to follow. The benefits will be returned quickly in terms of better health outcomes for patients and the public, workforce recruitment and retention, cleaner environments and cost savings.

Rebate freeze will leave mentally ill ‘in the cold’

Many people suffering mental illness will be left stranded without treatment unless the Federal Government drops its plan to freeze Medicare rebate indexation to mid-2018, psychiatrists have warned.

The AMA Psychiatrists Group said the prolonged indexation freeze would push up out-of-pocket costs and increase the financial pressure on patients using the private system, which treats about 70 per cent of all mental health patients.

“Given that many patients treated in the private sector find it difficult to access appropriate care in an already stretched public sector, there are concerns that this would leave many patients and their families ‘in the cold’,” the report said.

In the lead-up to the federal Budget, the AMA has intensified the pressure on the Government to dump the rebate freeze, warning it will push up patients costs, reduce access to care, cut bulk billing rates and force some GP clinics to close.

But Health Minister Sussan Ley has indicated there will not be a change of policy in the Budget, though she hinted at the possibility the freeze could end early if a review of the Medicare Benefits Schedule and other efficiency measures delivered sufficient health budget savings.

In a report to the AMA Federal Council, the AMA Psychiatrists Group also expressed alarm at what it said was an increasing push by insurers to demand patients divulge details of their medical records.

The group said patients often gave funds access to their medical records “because they are too afraid of losing their insurance cover if they refuse”.

The group said that both it and the Royal Australian and New Zealand College of Psychiatrists were concerned about the development, which was “eroding the confidential and therapeutic nature of the relationship between a patients and a psychiatrist”.

“In some cases, this can have a clinically detrimental effect on the patient,” the report said.

The RANZCP, supported by the AMA Psychiatrists Group, has launched an investigation into the issue.

In its report, the group also highlighted the valuable work being undertaken by the Private Mental Health Alliance to help inform mental health policy.

The Alliance owns and operates the Centralised Data Management Service, which collects admission and discharge information from all private hospitals operating psychiatric beds.

“The CDMS has become the cornerstone for the provision of high quality mental health care in the private hospital sector,” the group said. “The CDMS is helping the private sector and the Australian Government answer fundamental questions that can be asked of any health system – who receives what services, at what cost, and with what effect.”

The current agreement under which the AMA provides funding to the Private Mental Health Alliance expires in June, and negotiations are underway for a new three-year agreement from 1 July. The Federal Government has deferred a decision on any contribution it might make until after it has fully considered the outcomes of the National Mental Health Commission’s review of services, which was publicly released last month. No announcement is expected until after the May Budget.

Adrian Rollins

Child protection Australia 2013–14

This report contains comprehensive information on state and territory child protection and support services in 2013-14, and the characteristics of Australian children within the child protection system. This report shows that: – around 143,000 children, a rate of 27.2 per 1,000 children, received child protection services (investigation, care and protection order and/or in out-of-home care); – three-quarters (73%) of these children had previously been the subject of an investigation, care and protection order and/or out-of-home care placement; – Aboriginal and Torres Strait Islander children were 7 times as likely as non-Indigenous children to be receiving child protection services.

Priorities for professionalism: what do surgeons think?

Professionalism underpins the commitment made between a profession and society. This social contract balances the benefit to a profession of a monopoly over the use of its knowledge base, its right to considerable autonomy of practice, and the privilege of self-regulation with responsibilities and accountabilities to the community.

Medical practitioners have embraced professionalism over the millennia, from the Hippocratic Oath1 to the 19th century2 and the present day. Professionalism has recently been highlighted,3 but there have been concerns that not all its components are viewed as important4,5 or are reflected appropriately in surgical training endeavours.6

Definitions of professionalism are abundant, contested and reflect educational, sociocultural and historical contexts.7,8 Core elements include mastery of a complex body of knowledge and skills, service to others, commitment to competence, integrity, altruism and promotion of public good, autonomy, self-regulation and accountability to society.9 Given the dynamic and changing context, it is important to understand how professionalism is evolving.

Little is currently known about how surgeons involved in training and surgical trainees perceive the importance, priority or value of the different areas that they need to master to be competent and to perform well. In Australia and New Zealand, the Royal Australasian College of Surgeons (RACS) has defined the competencies required for surgical practice. The RACS surgical competence and performance guide is the basis of the curriculum that leads to the Fellowship of the College.10 It is based on the competencies developed by the Royal College of Physicians and Surgeons of Canada — the CanMEDS model.11 Local adaptation since 2001 has seen the RACS develop nine competencies to reflect the technical expertise and decision making required in surgical practice. Three attributes per competence provide further detail, although not comprehensiveness, to the overall requirements. Given the broad and changing definitions of professionalism, we evaluated the RACS competencies and associated attributes for importance.

Our study explored systematically what surgeons and surgical trainees understand as priorities for competent professional practice. It was undertaken within the broader context of developing system-wide training programs to enable surgeons to demonstrate their professionalism more fully.

Methods

Ethics approval for the study was obtained from the human research ethics committees of the University of Melbourne and the RACS. The overall research design included a detailed questionnaire comprising a number of question banks, with some free-text fields, distributed to 3054 RACS trainees and Fellows who were actively involved in the educational activities of the College. Separately and consequently, a semistructured interview was undertaken with a smaller number of the questionnaire respondents who volunteered for the interview stage. This article relates to the bank of RACS competency questions.

Participants

At the time of the distribution of the questionnaire, from 9 August to 30 September 2010, there were 1222 trainees and 4763 actively practising Fellows within the RACS. All trainees were invited to complete the questionnaire, and all Fellows recorded in the membership database as being involved in educational activities were also selected. Fellows who were not involved in surgical educational activities did not receive a questionnaire. The final number invited was 1222 trainees and 1832 Fellows from all regions of Australia and New Zealand. Although all questionnaires were identified with a unique identifier to allow for follow-up, anonymity and confidentiality were assured.

Materials and procedures

The questionnaire incorporated the nine RACS competencies and the associated three attributes per competency (Box 1), with modification for brevity and clarity. The questionnaire was content valid as it was directly based on the established RACS competency framework. Within the questionnaire, all participants were informed that the intent of the research was to progress the understanding of professionalism and the way it is supported, taught and learnt. Participants were instructed to rate the importance of each attribute for professionals on a 5-point Likert scale (1 = not at all important, 5 = very important).

The questionnaire was disseminated electronically with a follow-up email. A hard copy of the questionnaire was sent to those who had not responded and was then followed up by a telephone call.

Statistical analysis

Neither the nine competencies nor the 27 attributes have previously been confirmed statistically as independent factors. Analysis was undertaken to compare the importance of the attributes at an individual and grouped level, and to determine whether they were independent and whether the RACS groupings were confirmed by the data.

The data were coded and entered into SPSS version 17 (SPSS Inc). We also applied tests of skewness and kurtosis.12 Because of the skewed nature of the data, we conducted non-parametric statistical tests to analyse subgroups: the Mann–Whitney U test for pair comparisons and the Kruskal–Wallis test for comparison of more than two groups. The results for all attributes were assessed within their respective competencies to gain a relative understanding of the importance of that competency. Comparisons were made between Fellow and trainee, genders, age groups, specialties and regions. In this article, we present our findings for Fellows and trainees, and by gender.

We also applied tests of reliability, with internal consistency being calculated through use of Cronbach α value (theoretical values between 0 and 1). Inferential statistics were then used to identify differences between groups and to look for relationships between attributes. Groups for comparison had a sample size greater than 100. Correlation studies were structured to investigate relationships between particular characteristics of the subgroups.

We undertook multivariate analysis to establish the independence of the variables and also to determine whether the groupings of attributes proposed by the RACS within the competency framework could be validated in the context of our questionnaire. The exploratory factor analysis used an extraction method of unweighted least squares.

Results

In total, 1834 of 3054 questionnaires were returned (60%): 1204 of 1832 Fellows (66%) and 630 of 1222 trainees (52%); 1521 of 2566 (59%) male and 313 of 488 (64%) female trainees and Fellows. Seven hundred and nine (39%) responses were from general surgery Fellows and trainees and 357 (19%) were from orthopaedic surgery Fellows and trainees, the largest two of the nine surgical specialties.

The results were skewed to the more important. This was confirmed by tests for both skewness and kurtosis, both of which were evident to a high degree. Testing of reliability was undertaken, with a resultant Cronbach α value of 0.971.

The 27 attributes identified by the RACS were all graded as individual attributes (Box 2) or grouped as competencies (Appendix 1). They were all regarded as important to very important, except for responding to community and cultural needs. The top five attributes shared a sense of strong individualism, with an emphasis on being able to communicate effectively. However, there was a clear gap to the more lowly ranked attributes, particularly responding to community and cultural needs, and supporting others.

We calculated differences in the mean ranking of importance for the 27 attributes (Box 2, Appendix 2, Appendix 3). The overall mean was 4.44 (4 = important, 5 = very important). There was a small but significant difference between genders, with women regarding the overall group of attributes as more important than did men (mean, 4.51 [SD, 0.37] v 4.43 [SD 0.37]; P = 0.001) There was no statistically significant difference between Fellows and trainees for the overall group of attributes (mean, 4.44 [SD, 0.41] v 4.44 [SD, 0.40], respectively; P = 0.99).

Competencies were ranked by priority for Fellows and trainees, and for males and females (Box 3). There was consistency in the top three priorities for Fellows and trainees overall, and for male Fellows and trainees, where technical expertise, communication and professionalism were prioritised. For female Fellows and trainees, the top three priorities were communication, technical expertise and medical expertise. The lowest priorities across all groups were health advocacy, management and leadership, and scholarship and teaching.

Among individual attributes, there were statistically significant differences in perceived importance at the subgroup level (Appendix 2). In comparing Fellows and trainees, the four attributes with statistically more significant differences were caring and compassion, documenting and exchanging information, setting and maintaining standards, and responding to community and cultural needs. In particular, trainees identified as more important the three attributes for collaboration and teamwork (teamwork, documenting and exchanging information, and establishing a shared understanding).

In our analysis by gender, female trainees and Fellows ranked all attributes as more important than did male trainees and Fellows. Statistical significance was most noted for teamwork, meeting patient, carer and family needs, documenting and exchanging information, establishing a shared understanding, and communicating effectively (Appendix 3).

Although the first nine factors identified through multivariate analysis accounted for 58.8% of the total variation in the data, further analysis did not demonstrate strong grouping to the nine categories. Indeed, the covariance values of six attributes exceeded 1.0, suggesting some overlap between the groupings. Also, as the Cronbach α value was high at 0.971, some redundancy in the items was indicated statistically.

Discussion

Our study looked at the breadth of professionalism among surgeons and surgical trainees by exploring the nine competencies defined by the RACS. Our findings confirmed a clear priority ranking for these competencies and their attributes.

All competencies were regarded as important; however, there were statistically significant differences between the nine competencies and 27 attributes. Although the multivariate analysis did not confirm the independent nature of these variables, there was a clear gap between the prioritised importance of technical expertise, communication, professionalism and medical expertise compared with health advocacy, and management and leadership. Our findings suggest an emphasis on individual skills rather than on achieving a common goal. Attributes relating more to society at large were prioritised less than individualised skills. Also important was the strong similarity between the responses of the trainees and Fellows who undertake educational roles on behalf of the RACS. This may indicate the socialisation of aspirations between trainees and their mentors and educators.

Similar studies have emphasised that values held in high regard by society, such as altruism, charity and communication, are not well appreciated.6,13 Another study, which also found that none of the factors of professionalism were regarded as unimportant, argued that this added little to the broader issue of the teaching of professionalism.14 However, we contend that the prioritisation does make a difference. In a conflicted and time-pressured professional existence, a higher priority will receive attention for training and learning compared with a lower priority. The nine competencies defined by the RACS reflect what every patient needs from a competent surgeon.11 Surgeons require expertise in each of these competencies, but it is the integration of all these attributes that will make a competent surgeon. In a health environment where collaboration and teamwork is regarded increasingly as a core skill, and where the ability to influence the health system through management, leadership and advocacy is becoming more desirable, these areas will require greater prioritisation among trainees and Fellows.

Skills such as teamwork and responding to the needs of the community involve complex interactions beyond individual excellence. Medical professionalism does not take place in a vacuum. It is situated within a social context and larger systems such as the education and health sectors, the national economy and broader international influences.8 The practice of medicine needs to be rethought more broadly.

Our study had some limitations. Surveys are limited in the information they provide. The study confirmed the importance of the attributes and their relative priorities but not the statistical independence of the nine competencies. Further qualitative studies are required to obtain greater clarity between the attributes.

With the exception of responding to community and cultural needs, we found that all RACS competencies and attributes were regarded as important. The priorities showed consistency across Fellows, trainees and genders, although there were some key statistically significant differences between the attributes. This may highlight gaps that need to be addressed in selection of trainees, in current surgical training and in ongoing professional development for surgeons. Certainly these areas need to be addressed urgently.5 Attributes, behaviours, judgement and skills are displayed as our professionalism in a complex and pressured working environment that demands prioritisation of activities. These priorities are also reflected in how trainees allocate their time, through the mentors they admire and the aspirations they develop. Professionally, well-rounded and truly competent surgeons are not a static phenomenon. We live in a complex world. The implications are clear: aspiring surgeons are likely to invest more in the development of competencies that they perceive as more important.15 Competencies that are not reinforced by educators, mentors, trainers and the broader peer group are more likely to be neglected, with possible detriment to clinical practice.16

1 The nine Royal Australasian College of Surgeons competencies and their attributes10

Competency and attributes

Description

Medical expertise

Competence

Mastering and maintaining current knowledge and skills

Managing safety and risk

Ensuring patient safety by understanding and managing clinical risk

Monitoring and evaluating care

Regularly reviewing and evaluating clinical practice

Judgement and decision making

Considering options

Generating alternative possibilities and assessing them

Planning ahead

Predicting what might happen due to action or non-action

Implementing and reviewing decisions

Undertaking chosen action but reviewing its suitability

Health advocacy

Caring and compassion

A sympathetic consciousness of another’s distress

Meeting patient, carer and family needs

Engaging them in planning and decision making

Responding to community and cultural needs

Demonstrating the impact of culture and spirituality, and considering community needs

Technical expertise

Recognising conditions amenable to surgery

Understanding when intervention is or is not indicated

Maintaining dexterity and technical skills

Demonstrating sound surgical skills

Defining scope of practice

Undertaking surgery appropriate to training, expertise and surroundings

Professionalism

Insight

Self-awareness, the ability to recognise and understand one’s actions

Morality and ethics

Acting for the public good

Maintaining personal health and wellbeing

Particularly if it impacts on colleagues and team members

Communication

Discussing and communicating options

Communicating clearly with patients

Communicating effectively

With patient, family and team

Gathering and understanding information

Seeking timely and accurate information

Collaboration and teamwork

Teamwork

Ability to recognise and respect the expertise of others and work with them

Documenting and exchanging information

Ensuring a shared understanding among team members

Establishing a shared understanding

All relevant clinical information is understood by team

Management and leadership

Setting and maintaining standards

Supporting safety and quality by adhering to acceptable principles of surgery

Leading that inspires others

Appropriate mixture of both calm demeanour yet clear decision making

Supporting others

Providing cognitive and emotional help to team members

Scholarship and teaching

Improving surgical practice

Evaluating surgical practice and identifying opportunities for improvement

Showing commitment to lifelong and reflective learning

Through own learning

Teaching, supervision and assessment

Facilitating education of students, patients and colleagues

2 Overall ranking of importance of attributes defined in the Royal Australasian College of Surgeons surgical competence and performance guide*

Overall ranking of attributes from most to least important	Sample size	Mean (SD)	Median (IQR)

Competence	1818	4.77 (0.44)	5 (0)
Insight	1817	4.75 (0.46)	5 (0)
Recognising conditions amenable to surgery	1806	4.75 (0.45)	5 (0)
Discussing and communicating options	1807	4.60 (0.53)	5 (1)
Morality and ethics	1814	4.59 (0.59)	5 (1)
Communicating effectively	1806	4.58 (0.54)	5 (1)
Caring and compassion	1813	4.55 (0.58)	5 (1)
Teamwork	1813	4.54 (0.58)	5 (1)
Maintaining dexterity and technical skills	1806	4.53 (0.57)	5 (1)
Setting and maintaining standards	1806	4.51 (0.59)	5 (1)
Gathering and understanding information	1800	4.47 (0.56)	5 (1)
Considering options	1802	4.47 (0.57)	5 (1)
Managing safety and risk	1805	4.44 (0.61)	5 (1)
Improving surgical practice	1804	4.43 (0.61)	4 (1)
Defining scope of practice	1806	4.43 (0.66)	5 (1)
Planning ahead	1807	4.42 (0.62)	4 (1)
Showing commitment to lifelong and reflective learning	1808	4.39 (0.62)	4 (1)
Monitoring and evaluating care	1809	4.37 (0.62)	4 (1)
Documenting and exchanging information	1804	4.36 (0.62)	4 (1)
Leading that inspires others	1806	4.36 (0.64)	4 (1)
Teaching, supervision and assessment	1806	4.34 (0.63)	4 (1)
Establishing a shared understanding	1806	4.33 (0.62)	4 (1)
Implementing and reviewing decisions	1805	4.31 (0.62)	4 (1)
Meeting patient, carer and family needs	1805	4.31 (0.63)	4 (1)
Maintaining personal health and wellbeing	1796	4.28 (0.70)	4 (1)
Supporting others	1806	4.15 (0.71)	4 (1)
Responding to community and cultural needs	1804	3.86 (0.83)	4 (1)

IQR = interquartile range. * 5-point Likert scale: 1 = not at all important, 2 = not important, 3 = somewhat important, 4 = important, 5 = very important.

3 Importance of the Royal Australasian College of Surgeons competencies10*

	Overall			Fellow			Trainee			Male			Female
Competency	No. of responses	Mean (SD)	Median (IQR)	No. of responses	Mean (SD)	Median (IQR)	No. of responses	Mean (SD)	Median (IQR)	No. of responses	Mean (SD)	Median (IQR)	No. of responses	Mean (SD)	Median (IQR)

Medical expertise	5432	4.53 (0.59)	5 (1)	3573	4.59 (0.59)	5 (1)	1859	4.51 (0.59)	5 (1)	4506	4.51 (0.59)	5 (1)	926	4.59 (0.56)	5 (1)
Judgement and decision making	5414	4.40 (0.61)	4 (1)	3561	4.39 (0.62)	4 (1)	1853	4.42 (0.59)	4 (1)	4489	4.39 (0.61)	4 (1)	925	4.48 (0.59)	5 (1)
Health advocacy	5423	4.24 (0.75)	4 (1)	3567	4.24 (0.76)	4 (1)	1856	4.23 (0.72)	4 (1)	4499	4.22 (0.76)	4 (1)	924	4.43 (0.70)	4 (1)
Technical expertise	5418	4.57 (0.58)	5 (1)	3561	4.57 (0.59)	5 (1)	1857	4.57 (0.56)	5 (1)	4492	4.56 (0.59)	5 (1)	926	4.63 (0.54)	5 (1)
Professionalism	5427	4.54 (0.62)	5 (1)	3573	4.55 (0.62)	5 (1)	1854	4.53 (0.61)	5 (1)	4508	4.53 (0.62)	5 (1)	919	4.57 (0.61)	5 (1)
Communication	5413	4.55 (0.55)	5 (1)	3560	4.56 (0.55)	5 (1)	1853	4.54 (0.54)	5 (1)	4490	4.53 (0.55)	5 (1)	923	4.64 (0.51)	5 (1)
Collaboration and teamwork	5423	4.41 (0.61)	4 (1)	3567	4.38 (0.62)	4 (1)	1856	4.46 (0.59)	5 (1)	4498	4.38 (0.62)	4 (1)	925	4.54 (0.56)	5 (1)
Management and leadership	5418	4.34 (0.67)	4 (1)	3565	4.33 (0.68)	4 (1)	1853	4.35 (0.64)	4 (1)	4495	4.33 (0.67)	4 (1)	923	4.41 (0.63)	4 (1)
Scholarship and teaching	5418	4.39 (0.62)	4 (1)	3566	4.39 (0.62)	4 (1)	1852	4.38 (0.62)	4 (1)	4494	4.39 (0.62)	4 (1)	924	4.40 (0.62)	4 (1)
Total	48 786	4.44 (0.63)	5 (1)	32 093	4.44 (0.64)	5 (1)	16 693	4.44 (0.62)	5 (1)	40 471	4.43 (0.64)	5 (1)	8315	4.51 (0.60)	5 (1)

IQR = interquartile range. * 5-point Likert scale: 1 = not at all important, 2 = not important, 3 = somewhat important, 4 = important, 5 = very important.

AMA in the News

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

Medics to fix ‘fear’ culture, The Daily Telegraph, 4 April 2015

A change in the way doctors and nurses report abuse is needed to buck the scourge of sexual harassment and protect whistleblowers within the medical industry. AMA President A/Professor Brian Owler was committed to bringing about cultural change within the profession.

$8.40 more to see doctor, Herald Sun, 7 April 2015

Patients could be paying up to $8.40 for a visit to the doctor by 2018, more than they would have paid under the GP co-payment. AMA President A/Professor Brian Owler said the lazy policy would mean fewer patients would be offered bulk-billing.

Religious belief saw mum and baby die, The Daily Telegraph, 8 April 2015

The AMA has defended doctors at a top Sydney hospital forced to let a heavily pregnant woman and her unborn child die after the mother refused a blood transfusion because she was a Jehovah’s Witness. AMA Vice President Dr Stephen Parnis said doctors could not force a patient to accept treatment.

Not in the script – chemists selling your data, Sunday Mail Adelaide, 12 April 2015

Some chemists are selling their patients’ prescription information to a global health information company, which sells it on to drug firms, trying to boost their sales. AMA Chair of General Practice Dr Brian Morton called it an amazing invasion of privacy for purely commercial reasons.

Coalition’s ‘no jab, no pay’ policy ties benefits to immunisation, Australian Financial Review, 13 April 2015

Australian parents will lose thousands of dollars’ worth of childcare and welfare benefits if they refuse to vaccinate their children. AMA President A/Professor Brian Owler said the AMA backed the plan and said vaccination remained one of the most effective public health measures that we have.

Hospitals ‘storm’ warning, Adelaide Advertiser, 16 April 2015

The number of public hospital beds across Australia has fallen by more than 200 and no State has met emergency department targets. AMA President A/Professor Brian Owler said hospital performance benchmarks are not being met and things will only get worse as funding declines.

AMA hospital report card gives states fuel for fight, The Australian, 16 April 2015

Tony Abbott will face heightened pressure to reverse cuts of $80 billion to health and education, with a snapshot of public hospital performance handing the states fresh ammunition to press home their case. AMA President A/Professor Brian Owler will use the report to warn the Government that its extreme public hospital cuts are unjustified.

Church no longer exempt for jabs, Hobart Mercury, 20 April 2015

A religious exemption loophole, that allowed parents who opposed vaccinations to continue to receive childcare and family tax payments has been scrapped. AMA President A/Professor Brian Owler praised the move.

AMA warns against continued freeze on rebates, ABC News, 22 April 2015

AMA President A/Professor Brian Owler said at a time when the Government should be increasing its investment in general practice, the Medicare rebate freeze will eat away at the viability of individual practices.

Rape row over new anti-jab campaign, Adelaide Advertiser, 23 April 2015

A Facebook graphic on the Australian Vaccination Network site that compares vaccination to rape has been condemned by doctors, the Rape Crisis Centre, and politicians as abhorrent and insulting. AMA President A/Professor Brian Owler said the post undermines the organisation and shows lack of intelligence and common sense.

Doctors back review of Medicare rebates, West Australian, 23 April 2015

Doctors have backed a sweeping review of the Medicare Benefits Schedule, but warned the Federal Government not use it as an excuse to cut patient services. AMA President A/Professor Brian Owler agreed the MBS was outdated and said any savings from the review should be reinvested into the health system.

Aussie in sick new IS video, Sunday Herald Sun, 26 March 2015

The shocking new public face of Islamic State death cult is an Australian doctor. AMA President A/Professor Brian Owler said he was appalled that any medical professional would want to work for terrorists.

Transparency on dug company payments and trips a step closer, The Age, 28 April 2015

Patients will find out what payments and educational trips their doctors have received from drug companies. AMA Chair of General Practice Dr Brian Morton said it was insulting and naïve to suggest doctors would be unduly influenced by a free meal.

Terror doctor free to practise, Adelaide Advertiser, 28 April 2015

The Medical Board is refusing to deregister the former Adelaide doctor who left Australia to join the Islamic State terrorist group. AMA Vice President Dr Stephen Parnis said he expected the Medical Board to look closely at the case from legal and professional standards perspectives.

Scientists call for action on disease risks from climate change, Sydney Morning Herald, 30 April 2015

The Australian Academy of Science has released a report which shows a range of tropical diseases becoming more widespread in Australia due to climate change. AMA President A/Professor Brian Owler said the report should be a catalyst for the Abbott government to show leadership on reducing greenhouse gas emissions and mitigating their effects on health.

Radio

A/Professor Brian Owler, 774 ABC Melbourne, 7 April 2015

AMA President A/Professor Brian Owler talked about the decision to axe the proposed $5 Medicare co-payment in favour of an alternative Government plan to freeze the amount received by doctors in rebates.

Dr Stephen Parnis, 6PR Perth, 13 April 2015

AMA Vice President Dr Stephen Parnis discussed the use of the welfare system to boost immunisation rates. Dr Parnis said in the 1990s the Howard Government also linked immunisation to social security, which resulted in a big increase in vaccination rates.

A/Professor Brian Owler, Radio National, 16 April 2015

AMA President A/Professor Brian Owler discussed Federal funding for health. A/Professor Owler said the health system has never been adequately funded and doctors and nurses have done well to meet a rise in demand.

A/Professor Brian Owler, 2SM Radio, 16 April 2015

AMA President A/Professor Brian Owler talked about the use of paw paw for chronic back pain. A/Professor Owler said paw paw is a well-known treatment, but that people do not tend to use it as much nowadays.

A/Professor Brian Owler, 4BC Brisbane, 16 April 2015

AMA President A/Professor Brian Owler talked about the issue of health funding and the AMA Public Hospital Report Card. A/Professor Owler said the issue is capacity and resources, and that he is concerned about the future given reduced Commonwealth funding.

Dr Stephen Parnis, 2GB Sydney, 23 April 2015

AMA Vice President Dr Stephen Parnis talked about the recent Facebook post from the Australian Vaccination Skeptics Network, which compares forced vaccination to rape. Dr Parnis said the campaign shows how disgraceful and unhinged some anti-vaccination campaigners are.

A/Professor Brian Owler, 2UE Sydney, 28 April 2015

AMA President A/Professor Brian Owler talked about the Medical Board’s handling of the case of an Australian-registered doctor who has joined Islamic State. A/Professor Owler said he understands the Medical Board is working with security agencies to ensure that the public is safe, and to prevent any possibility of Dr Kamleh returning to Australia to continue practising medicine.

A/Professor Brian Owler, ABC NewsRadio, 30 April 2015

The Australian Academy of Science is warning of the impacts of global warming predicting food and water shortages, along with extreme weather events. AMA President A/Professor Brian Owler said climate change has been a political battleground and that Australia is not ready to cope with its impacts.

Television

A/Professor Brian Owler, Channel 9, 16 April 2015

AMA President A/Professor Brian Owler talked about the AMA’s Public Hospital Report Card. A/Professor Owler said many hospitals are not reaching targets in the emergency department treatment and elective surgery wait times.

Dr Stephen Parnis, Channel 9, 12 April 2015

AMA Vice President Dr Stephen Parnis talked about the Government’s announcement that childcare rebate payments will be cut for families who do not vaccinate their children. Dr Parnis said the children involved are innocent, and their futures need to be insured.

A/Professor Brian Owler, ABC News 24, 16 April 2015

AMA President A/Professor Brian Owler discussed the crisis in Australia’s public hospitals as Commonwealth funding is wound back. A/Professor Owler said the Commonwealth are not living up to their responsibilities to fund States and Territories properly to run hospitals.

A/Professor Brian Owler, Channel 9, 22 April 2015

AMA President A/Professor Brian Owler discussed welcoming the plans for a major review of the Medicare Benefits Schedule. A/Professor Owler said the review is clinician-led and is not just about finding savings.

A/Professor Brian Owler, Sky News, 29 April 2015

AMA President A/Professor Brian Owler discussed the future of the public hospital system if Federal Government cuts come into effect. A/Professor Owler said state governments lack the capacity to increase revenue to pick up the slack.

A/Professor Brian Owler, ABC News 24, 30 April 2015

AMA President A/Professor Brian Owler called on the Federal Government to show leadership on climate change or risk the health of Australians. A/Professor Owler said there was overwhelming scientific consensus that the climate is changing and there will be consequences for health.

Saving Anzacs – the heroic role of medics at Gallipoli

AMA President Associate Professor Brian Owler and New Zealand Medical Association President Dr Mark Peterson attended a special ceremony at Canakkale in Turkey on 24 April as guests of the Turkish Medical Association to pay tribute to the doctors and other health workers who risked death and serious injury to care for the injured and dying from all sides of the Gallipoli landing 100 years ago.

Below are extracts from the speech they jointly delivered.

“Each year on Anzac Day, New Zealanders and Australians mark the anniversary of the Gallipoli landings of 25 April 1915. On that day, thousands of young men, far from their homes, stormed the beaches on the Gallipoli Peninsula.

For eight long months, New Zealand and Australian troops, alongside those from Great Britain and Ireland, France, India, and Newfoundland battled harsh conditions and the Ottoman forces desperately fighting to protect their homeland.

The landings occurred in the wrong locations. Instead of gentle slopes, there were steep cliffs and the ravines that would later bear the names of Australians and New Zealanders.

Casualties were heavy right from the start. In the first four days of the campaign 3300 wounded passed through the 1^st Australian Casualty Clearing station. By the time the campaign ended, more than 130,000 men had died. Of the 14,000 New Zealanders who fought on the Gallipoli peninsula, 5212 were injured and 2779 were killed over a period of 240 days. Australian fatalities totalled 8709 and more than 19,000 were injured.

The Medical Corps faced huge difficulties and medical arrangements came in for much criticism.

A key difficulty was the lack of communication between the different elements of the medical service. Before the landings started, a draft plan to deal with casualties had been worked out. Tent subdivisions were to be set up on the beach. A medical officer was to triage the wounded, with the seriously wounded to be evacuated to vessels offshore—but only once all the troops had been landed—and the slightly wounded to ambulances. The medical officer would be notified when the ships were full and would move the wounded onto the next vessel.

The reality was very different. The final draft of the medical arrangements had not been received by the Australian and NZ divisions. Communication was poor.

Radio transmissions were not permitted. A signal telling the assistant director of medical services of the ships available to him took two days to cross one kilometre of water.

With no way of contacting the ships, requests for more vessels for the wounded were not received. No triage took place on shore…the wounded were mixed up and were brought out to troopships that were still laden with troops.

All the ships were filled with wounded by the end of the first night.

Those on shore faced bitter cold and intense sniper fire. Treatment for the wounded was basic. Morphia was given by mouth; splints were improvised with rifles and bayonets.

Stretcher bearers struggled up and down narrow tracks, most having removed their white markers to avoid being shot.

For those wounded on Gallipoli, the wait for treatment and evacuation was often long and agonising. Poor planning and the sheer scale of casualties overwhelmed the available medical resources, and poor coordination and mismanagement meant that many serious cases were left on the beach too long; once on board they found appalling conditions.

There were no beds. Some were still on the stretchers on which they had been carried down from the hills. The few Red Cross orderlies were terribly overworked. For 12 hours on end an orderly would be alone with 60 desperately wounded men in a hold dimly lit by one arc lamp. None of them had been washed and many were still in their torn and blood-stained uniforms. There were bandages that had not been touched for two or three days. Most of them were in great pain, and all were patched with thirst.

Writing from the Dardanelles, a sergeant attached to the Medical Corps sent back graphic details about the treatment of Australian wounded:

“After the first fighting a ship came alongside, and at midnight the first batch of wounded were brought on board. Some had their legs off, others lad no arms or hands, some were without fingers or toes. A lot of the poor fellows had terrible head-wounds. Some had their ears blown off, and others their eyes shot out. Nearly all had to be operated on, and this was done by lamp light.”

The role of the ambulance men and stretcher bearers was crucial during the campaign. Writing for the Colonist magazine in 1915, a correspondent described the chaos they faced and the price they paid:

“Too high an eulogium cannot be pronounced on the ambulance department. Unable to take cover, and continually working in fire-swept zones, their casualties have been abnormally high. Dressing station staff are continually being renewed.”

Although acknowledging the bravery of those who cared for the wounded, other contemporary accounts strongly criticised the lack of planning that had gone into the medical arrangements:

“The point of the matter is that there was totally inadequate medical and nursing attention on several boats. How this came about it is hard to explain because several army corps proclamations warned the men to expect heavy casualties, so the slaughter on April 25th was not unexpected.

“Of course, many of the transports went back laden with wounded, but these had in many cases just discharged troops a few hours before, and were quite unsuitable for the nature of work they were called upon to perform.”

Along with the inherent dangers of war, the threat of illness was never far off. Bodies piled up around the encampments attracted flies, and the stench was sickening.

Severe diarrhoea caused by amoebic dysentery and typhoid fever badly affected all those on shore. The conditions resulted in swarms of disease carrying flies.

This could prove as much of a challenge as the enemy. The role of the flies was recognised and a stricter public health regimen came to exist. Waste was disposed of by burning, and care was taken not to leave rations that would attract flies.

Due to these measures deaths due to communicable disease was lower for the AIF in 1915, with around 600 deaths, compared with the South African Wars for the British, where two soldiers died of communicable disease for every soldier lost in battle.

Finally, perhaps the best way to understand what it was like for those who were here at that time is to hear it in their own words. The following extracts are taken from correspondence to the Editor of the New Zealand Medical Journal from a medical officer:—

Gallipoli, 18th June, 1915.

“…For the last two months we have had a hell of a time. We have had to be within half a mile of the firing line the whole time, and for the last two months we have done all our work under continuous fire.

Our operating tent is a most amusing sight; it is more like a sieve than a tent, and yesterday I had my sterilising orderly knocked over by a bullet while at work. I lost five killed and 15 wounded of my own men. I have been very lucky myself, and though I have been hit twice—once by shrapnel and once by the fuse of a shell—I have only been bruised.

I am afraid the casualty list will be a big shock in New Zealand. We are now acting as a clearing station on the beach, where we do all necessary operations. We have done scores of trephinings and laparotomies with suturing and resections of gut. No abdominal wounds survive if not operated on. There are always multiple perforations, and very often the gut is torn completely across”.

This was the first time that both Australia and New Zealand had fought under their own flags. The ANZACs were conscious of this.

When the ANZACs set sail from Albany in Western Australia, they were expecting to go to Europe. The ANZAC troops diverted to Egypt where they continued training. They did not come to fight the Turk and had no idea that they would do so when they enlisted. Turkey had decided to align with Germany quite late and did so for self-preservation as much as anything else.

So we had ANZACs and Turks fighting not because of their antipathy between our nations but rather we had two groups of nations fighting on behalf of other nations. A mystery of human behaviour – but perhaps also another reason for empathy and respect between soldiers in the field.

For Australia and New Zealand, there was a realisation of their unique identities. They were egalitarian. The British class system was an enigma to them. They did not bow to rank but they followed orders.

Anzac Day grew out of this pride. First observed on 25 April 1916, the date of the landing has now become a crucial part of the fabric of national life – a time for remembering not only those who died at Gallipoli, but all who have served their country in times of war and peace.

We also remember the doctors and health care workers that served in war – many of whom paid the ultimate price. We remember their sacrifice and thank them for it. However, the best way that we honour their memory is to advocate for peace.

Lest we forget.”

Your AMA Federal Council at work

What AMA Federal Councillors and other AMA members have been doing to advance your interests in the past month:

Name	Position on Council	Activity/Meeting	Date
A/Prof Brian Owler	AMA President	Meeting with Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia	5/3/2015
A/Prof Brian Owler	AMA President	Meeting with Royal Australasian College of Surgeons and Australian Plastic Surgery Association Presidents	4/3/2015
Dr Brian Morton	AMA Chair of General Practice	GP Roundtable	8/4/2015
		UGPA	25/03/2015
		GP Roundtable	17/3/2015
Dr Stephen Parnis	AMA Vice President	Meeting with Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia (MBA) on improving practitioner experience with notifications	5/3/2015
Dr Andrew Miller	AMA Federal Council Representative for Dermatologists	PBS Authority medicines review reference group	13/4/2015
Dr Andrew Miller	AMA Federal Council Representative for Dermatologists	MSAC (Medical Services Advisory Committee) Review Working Group for Skin Services	20/2/2015
Dr Antonio Di Dio	AMA Member	Meeting with Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia (MBA) on improving practitioner experience with notifications	5/3/2015
Dr Roderick McRae	AMA Federal Councillor – Salaried Doctors	Meeting with Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia (MBA) on improving practitioner experience with notifications	5/3/2015
Dr Susan Neuhaus	AMA Federal Councillor – Surgeons	Meeting with Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia (MBA) on improving practitioner experience with notifications	5/3/2015
Dr Robyn Langham	AMA Federal Councillor – Victoria nominee and Chair of AMA Medical Practice Committee	Australian Health Practitioner Regulation Agency’s (AHPRA) Prescribing Working Group (PWG)	5/3/2015
Dr David Rivett	AMA Federal Councillor	IHPA Small Rural Hospitals Working Group	5/2/2015
Dr Chris Moy	AMA Federal Councillor	PCEHR Safe Use Guides consultation (KPMG/ACSQHC)	11/3/2015
Dr Chris Moy	AMA Federal Councillor	NeHTA (National E-Health Transition Authority) Clinical Usability Program (CUP) Steering Group	19/2/2015
Dr Richard Kidd	AMA Federal Councillor	PCEHR Safe Use Guides consultation (KPMG/ACSQHC)	10/3/2015
Dr Richard Kidd	AMA Federal Councillor	Gateway Advisory Group	9/2/2015