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Preference: Administration and Health Services

2

Publically funded contraception set for challenge by the Trump administration

With the politics in the United States still playing out on the Affordable Care Act, the White House has reportedly moved forward with a plan to cut a provision that was introduced to protect women’s reproductive rights.

The Affordable Care Act expanded contraception coverage to about 55 million women with private insurance coverage.

The Trump administration is expected to amend the Federal regulation that requires employers to provide health-insurance plans that offer preventive care and counselling – which the US Department of Health and Human Services has interpreted to include contraception – at no cost.

The expected Presidential executive order will allow any business or organisation to request an exemption on religious or moral grounds.

The Obama administration issued regulations allowing religious employers to opt out of offering contraceptive coverage. However affected employees were then covered directly by their insurers.

Gretchen Borchelt, Vice President for Reproductive Rights and Health at the National Women’s Law Center, has said that hundreds of thousands of women could lose access to their birth control “if this broad-based, appalling, and discriminatory rule is made final”.

Many family planning advocates are concerned that this policy shift will see a result to an increase in abortion rates across the US. Recent research by the Guttmacher Institute suggests that improved contraceptive use, resulting in fewer unintended pregnancies, likely played a larger role than new state abortion restrictions in the decline between 2011 and 2014.

The American Congress of Obstetricians and Gynaecologists has issued a statement that denounces any plan to roll back contraception coverage, saying that any move to decrease access to these services would have a damaging effect on public health.

“Contraception is an integral part of preventive care and a medical necessity for women during approximately 30 years of their lives.

“Since the Affordable Care Act increased access to contraceptives, our Nation has achieved a 30 year low in its unintended pregnancy rate, including among teens.

“Unintended pregnancies can have serious health consequences for women and lead to poor neonatal outcomes,” the statement reads.

MEREDITH HORNE 

Report warns blindness set to rise

A new study published in Lancet Global Health warns the number of blind people across the world is set to triple within the next four decades.

The research predicts cases will rise from 36 million to 115 million by 2050, if treatment is not improved by better funding.

A growing ageing population is behind the rising numbers.

Some of the highest rates of blindness and vision impairment are in South Asia and sub-Saharan Africa.

Although the percentage of the world’s population with visual impairments is actually falling, according to the study, the global population is growing and so the number of people with sight problems will soar in the coming decades.

Analysis of data from 188 countries suggests there are more than 200 million people with moderate to severe vision impairment.

That figure is expected to rise to more than 550 million by 2050.

“Even mild visual impairment can significantly impact a person’s life,” said lead author Professor Rupert Bourne, from Anglia Ruskin University in Cambridge.

“For example, reducing their independence…as it often means people are barred from driving.”

He said it also limited people’s educational and economic opportunities.

The worst affected areas for visual impairment are in South and East Asia. Parts of sub-Saharan Africa also have particularly high rates.

The study calls for better investment in treatments, such as cataract surgery, and ensuring people have access to appropriate vision-correcting glasses.

Professor Rupert Bourne said that interventions provide some of the largest returns on investment in eye health.

“They are some of the most easily implemented interventions in developing regions because they are cheap, require little infrastructure and countries recover their costs as people enter back into the workforce,” he said.

In Australia, the CEO of the Fred Hollows Foundation, Brian Doolan, spoke to the research, saying that more needs to be done for social development, targeted public health agreements and accessible eye health facilities.

“The strategies being used around the world have been shown to work, all we need is to get them to the right scale to address the growing global need,” Mr Doolan said.

According to Mr Doolan, the leading cause of blindness worldwide is poverty, followed by gender.

The report also indicates Aboriginal and Torres Strait Islander people are still three times more likely to be blind than other Australians. Most blindness in Australia is due to readily preventable or treatable causes of vision loss, including cataract, diabetes, refractive error and trachoma.

The AMA continues to call on the Federal Government to correct the under-funding of Aboriginal and Torres Strait Islander health services, including programs to limit preventable blindness.

MEREDITH HORNE

Substance abuse needs mature policy approach

The AMA has called on the Federal Government to treat substance abuse and other behavioural addiction problems within the community as a high-level priority to address.

Substance dependence and behavioural addictions are chronic brain diseases and people affected by them should be treated like any other patient with a serious illness.

AMA President Dr Michael Gannon said while the Government responded quickly to concerns about crystal methamphetamine use, with the National Ice Action Strategy, broader drug policy appears to be a lower priority.

“I don’t think we need to underestimate the cancer in our society that methamphetamine causes. It’s destroying lives, it’s destroying communities, it’s destroying families,” Dr Gannon said.

“But we can acknowledge that and at the same time reflect on the carnage that legal drugs still cause.

“Twelve per cent of Australians are still smoking. It’s the only habit that kills over half of its regular users and certainly impairs the health of the remainder.

“And alcohol; it’s a difficult conversation. So many of us enjoy a drink. Not many of us would think that we are problem drinkers. But if you look at how deeply inculcated in our society drinking alcohol is, you start to get an idea about the potential harm it causes.”

Given the consequences of substance dependence and behavioural addictions, the AMA believes it is time for a mature and open discussion about policies and responses that reduce consumption, and that also prevent and reduce the harms associated with drug use and control.

“Services for people with substance dependence and behavioural addiction are severely under-resourced. Being able to access treatment at the right time is vital, yet the demand for services outweighs availability in most instances,” Dr Gannon said.

“Waiting for extended periods of time to access treatment can reduce an individual’s motivation to engage in treatment.”

Substance abuse is widespread in Australia. Almost one in seven Australians over the age of 14 have used an illicit substance in the past 12 months, and about the same number report drinking 11 or more standard alcoholic drinks in a single session.

Substance use does not inevitably lead to dependence or addiction. A patient’s progression can be influenced by many things, such as genetic and biological factors, the age at which the use first started, psychological history, family and peer dynamics, stress, and access to support.

The AMA recently released its Harmful Substance Use, Dependence, and Behavioural Addiction (Addiction) 2017 Position Statement, pointing outthat dependence and addiction often led to death or disability in patients, yet support and treatment services were severely under-resourced.

The costs of untreated dependence and addictions are staggering. Alcohol-related harm alone is estimated to cost $36 billion a year.

Those affected by dependence and addictions are more likely to have physical and mental health concerns, and their finances, careers, education, and personal relationships can be severely disrupted.

Left unaddressed, the broader community impacts include reduced employment and productivity, increased health care costs, reliance on social welfare, increased criminal activity, and higher rates of incarceration.

About one in 10 people in Australian jails is there because of a drug-related crime.

Dr Gannon said the Government’s updated National Drug Strategy was disappointing because no additional funding had been allocated to it, meaning that measures requiring funding support were unlikely to occur in the short to medium term.

“The recently-released National Drug Strategy 2017-2026 again lists methamphetamine as the highest priority substance for Australia, despite the Strategy noting that only 1.4 per cent of Australians over the age of 14 had ever tried the drug,” he said.

“The Strategy also notes that alcohol is associated with 5,000 deaths and more than 150,000 hospitalisations each year, yet the Strategy puts it as a lower priority than ice.”

Dr Gannon called on the Government to focus on the dependencies and addictions that cause the greatest harm, including alcohol, regardless of whether some substances are more socially acceptable than others.

“General practitioners are a highly trusted source of advice, and they play an important role in the prevention, detection, and management of substance dependence and behavioural addictions,” he said.

“Unfortunately, limited access to suitable treatment can undermine GPs’ efforts in these areas.”

Behavioural addictions also include pathological gambling, compulsive buying, and being addicted to exercise or the internet.

Like substance dependence, they are recognised as chronic diseases of the brain’s reward, motivation, memory, and related circuitry.

Go to:  position-statement/harmful-substance-use-dependence-and-behavioural-addiction-addiction-2017 to read the full Position Statement.

CHRIS JOHNSON

 

 

Breast or otherwise, new mothers need support

Non-breastfeeding mothers need greater support to help them feed their babies without being made to feel guilty, the AMA insists.

Releasing the AMA’s Infant Feeding and Parental Health 2017 Position Statement recently, AMA President Dr Michael Gannon said new parents who did not breastfeed their infants should be supported in their efforts to ensure their children receive optimal nutrition.

Breastfeeding may not be the best choice for all families, and there must be a balance between promoting breastfeeding and supporting mothers who cannot or choose not to breastfeed.

“Mothers may feel a sense of guilt or failure, and it is important that their GPs and other medical practitioners reassure them about the efficacy and safety of formula feeding, and work to remove any stigma,” Dr Gannon said.

“Although it is different in composition, infant formula is an adequate source of nutrients. Parents seeking to bottle feed their infants need support and guidance about how much and how often to feed their infant, how to recognise when to feed their infant, and how to sterilise and prepare formula.”

Hospital-based milk banks provide a valuable source of nutrients for infants with a clinical need for donor human milk, such as those who are premature or underweight.

Informal breastmilk sharing arrangements that occur without medical oversight pose significant risks to infant health, including the transmission of harmful bacteria or communicable diseases.

Parents should be educated about the potential harms of sourcing unpasteurised and untested milk for their infants, to ensure they are able to make informed decisions.

Dr Gannon noted that breastfeeding was the optimal infant feeding method, with current Australian guidelines recommending exclusive breastfeeding until six months.

But mothers and other caregivers who cannot or choose not to breastfeed must have access to appropriate care and assistance to formula-feed their children.

“There’s no doubt that breast is best, and in Australia, 96 per cent of new mothers start out breastfeeding their baby,” Dr Gannon said.

“Babies who are breastfed are at less risk of infection, sudden infant death syndrome, and atopic diseases like asthma, eczema, and hay fever.

“The maternal antibodies in breastmilk help to protect infants before they are old enough for their first childhood vaccinations.

“Babies who are breastfed are less likely to become obese or develop type 2 diabetes as children and teenagers, and are less at risk of high blood pressure.

“Breastfeeding helps mothers bond with their babies, recover from childbirth, and regain their pre-pregnancy body weight, and it is also associated with reduced risk of some cancers.

“Yet we know that many mothers do not persist with breastfeeding. Only 39 per cent of infants are exclusively breastfed to four months, and just 15 per cent to six months.”

This highlights the need for more support to allow mothers to extend the duration of their breastfeeding if they wish to, Dr Gannon said.

Women can be discharged from hospital as early as six hours after giving birth, long before their milk has come in.

The AMA President said they should only be discharged when they are physically and emotionally ready to return home.

The Position Statement calls for doctors, medical students, and other health professionals to be appropriately trained and educated about the benefits of breastfeeding, including how to support mothers who experience difficulties with breastfeeding.

It also notes that parents should be aware that anatomical difficulties, such as colic, tongue tie, or feeding and swallowing disorders, occur in both breast- and formula-fed infants. Parents should consult their general practitioner for support and referral to appropriate medical care.

The Position Statement says that postnatal depression is estimated to affect one in seven new mothers in Australia, and women who are unable to breastfeed in line with their intentions may be at increased risk.

However, there is limited access to specialised mother and baby units, and women who are waiting to access these services need to be monitored and supported in the interim.

The full Position Statement position-statement/infant-feeding-and-parental-health-2017  can be viewed on the AMA’s website. 

CHRIS JOHNSON

AMA delivers submission to Government review into aged care facilities

The AMA has submitted its views on the Federal Government’s regulatory activities applying to quality of care in aged care residential facilities.

The Oakden report shed light on a wide range of issues facing aged care. AMA members have reported that the occurrences at the Oakden Older Mental Health Service were not isolated incidents – indicating a problem with the current aged care system.

The proportion of Australians 65 years of age and over is predicted to increase to 18 per cent by 2026. It is also predicted that 900,000 Australians will have dementia by 2050, almost triple the 342,800 recorded in 2015.

It is evident that the health care needs of residents in residential aged care facilities (RACFs) are increasing in complexity.

The majority of Aged Care Funding Instrument (ACFI) assessments indicate a “high” need of care across all three assessment categories (activities of daily living, behaviour, and complex health care). The Government must ensure the sector has the capacity to provide quality care for this growing, more complex, ageing population.

The issues at Oakden were brought to the attention of the Northern Adelaide Local Health Network when a client was admitted to an Emergency Department with significant bruising to his hip. A person’s health status is a significant identifier for the quality of an aged care facility or home service. When serious health issues arise, aged care issues are commonly noticed.

Medical practitioners – whether at the Emergency Department, or consulting patients at an aged care facility – may have a unique opportunity to identify issues with the quality of an aged care home or signs of elder abuse.

Medical practitioners are also the second highest profession Australians trust and should be considered part of the aged care workforce to increase quality of care.

Many points made in the submission have been previously made by the AMA, and they are not newly arising issues in the aged care sector. The AMA has been advocating for some time to ensure medical and nursing care for older Australians, including lodging submissions to the multiple aged care reviews that have occurred recently.

In this submission, the AMA argues that:

  • Medical practitioners should be included as part of the aged care workforce to ensure residents of aged care facilities are receiving quality care;
  • Aged care needs funding for the recruitment and retention of registered nursing staff and carers, specifically trained in dealing with the issues that older people face;
  • The aged care sector needs a contemporary system that embraces information technology infrastructure for patient management;
  • A contemporary IT system for medication management will reduce the risk of polypharmacy, and in turn reduce the likelihood of cognitive impairment, delirium, frailty, falls, and mortality in RACFs;
  • There needs to be clear, specific, and confidential complaints referral pathways in each RACF so information on complaints processes are easily accessible to both residents and staff;
  • There needs to be increased awareness of mental health issues to include funding for appropriate mental health services in the ACFI assessment process; and
  • The aged care system needs an overarching, independent, Aged Care Commissioner who provides a clear, well-communicated, governance hierarchy that brings leadership and accountability to the aged care system.

Many of these issues need to be reflected in specific accreditation standards that have a strong focus on health. In particular, an “access to medical care” standard should be introduced. To receive funding from the Federal Government, an aged care facility must pass accreditation standards that are assessed by the Australian Aged Care Quality Agency.

The AMA recognises that these standards will vary with the introduction of the single set of aged care quality standards, however, there are several required improvements that should be included in the new standards.

For some standards a flexible approach is adequate, as different services have different capabilities and capacities. However, this may lead to inconsistencies between each assessor, or the assessment process not picking up on vital signs of incompetence.

Standards that relate to medical care should not be subject to interpretation to ensure quality care is received. RACFs must be aware of their specific responsibilities.

Residents should have access to, and their medical needs met by, qualified medical practitioners. Rather than vague standards that say RACFs should ensure compliance with all relevant legislation, a medical care standard should reflect aspects of the National Safety and Quality Health Service Standard.

People living in aged care facilities should have access to the same quality health services as other Australians. The AMA has been advised that currently, RACFs (with the exception of facilities that provide acute services) do not have to comply with these standards.

The current policy settings do not support GPs working after hours, neither does it acknowledge the benefits of continuity of care. AMA members report that continuity of care goes generally unacknowledged in many RACFs and a resident’s management plan is not well known. This creates an environment where the default step for RACF staff may be to refer the patient to an ED.

One concept worth considering is an MBS item for phone consultations with a nurse or carer from an RACF to incentivise doctors to be on call after hours. This could in turn increase the number of doctors who make themselves available out of normal business hours and reduce costs in comparison to reimbursing a GP physically-attended consultation. In addition, the care of patients’ regular GP would avoid unnecessary referrals to the ED and the associated triage issues.

AMA members have reported cases where registered nurses are being replaced by junior personal care attendants, and some RACFs do not have any nurses staffed after hours. This presents significant communication difficulties.

A recent survey identified low staffing levels in residential aged care as the main cause of missed care. The Government must ensure that aged care facilities are not restricted due to a workforce shortage. The decline in the proportion of nurses and enrolled nurses needs to be reversed to ensure residents are provided with timely and appropriate clinical care. This is critical to the success of the aged care system.

While the Government’s complaints process is seeing improvements, there also needs to be a focus on the RACF’s internal complaints process. The culture in many RACFs discourages making complaints, and this was especially seen at Oakden – where staff complaints were answered with bullying and harassment from management. The Government needs to ensure that the privacy and confidentiality of both aged care staff and consumers are protected when making a complaint.

Aged care staff should be properly trained on the ethical, medical and legal issues that can arise from using a restraint, and also educated on ways to improve the aged care environment through ensuring a friendly physical space, and through social and staffing structures.

In order for the aged care system to evolve, we must also consider that, like the broader health system, aged care impacts upon State, Territory, and Federal Governments. However, there is a lack of coordination between the levels of jurisdiction. Aged care is the purview of the Commonwealth but when a health complication arises, residents are often transferred to a hospital which is the responsibility of the State or Territory Government. This means that the States often bear a financial cost resulting from issues that arise in a Commonwealth-run aged care environment.

The Australian aged care system is heavily regulated and, with reform underway, regulation may increase over time. Without adequate financial support, guidance, and accountability from the Government, RACFs and other aged care services will continue to struggle to meet these complex regulations.

CHRIS JOHNSON

The full submission can be viewed at: submission/ama-submission-review-commonwealth-government%E2%80%99s-regulatory-activities-applying-quality

 

National Social Housing Survey: detailed results 2016

This report provides an overview of national-level, state and territory findings, as well as comparisons across public housing, state owned and managed Indigenous housing and community housing tenants. The report shows that the majority of tenants are satisfied with the services provided by their housing organisation, with community housing tenants the most satisfied. Tenants report a range of benefits from living in social housing and the majority live in dwellings of an acceptable standard.

[Comment] Family-delivered rehabilitation services at home: is the glass empty?

In low-income and middle-income countries, meeting inpatient and outpatient rehabilitation needs of stroke survivors with insufficient staff and facility resources is especially challenging. Family-delivered rehabilitation services might be an innovative way to augment intensity of practice.1 The ATTEND Collaborative Group’s ATTEND trial,2 published in The Lancet, is to our knowledge the first appropriately powered trial to investigate the effect of family-delivered, home-based rehabilitation intervention for patients with stroke in a low-middle-income country.

Attending the House of Delegates meeting of the American Medical Association

BY ANNE TRIMMER AMA SECRETARY GENERAL

The annual meeting of the House of Delegates (HOD) of the American Medical Association (AmMA) is the only event in which all of “organised medicine” in the United States physically comes together at the same time and place.

The program for the annual HOD meeting is immense. There is a mix of open sessions and committee sessions in the lead in the HOD meeting itself. Eight committees meet over the course of two days to work their way through a comprehensive agenda of reports and resolutions that amend existing policy or introduce new policy. The result of the committees’ work is then caucused by the participating representative societies and associations in preparation for debate on the floor of the HOD.

The HOD opens with a formal speech by the President (who completes a one-year term at the close of the HOD meeting) and another by the CEO. The meeting then opens to debate on the reports and resolutions that have come forward from the committees. This takes two days and can continue into a third day of the business isn’t completed.

As an international guest at this year’s meeting in June, I was invited to observe all proceedings and I made the most of the invitation by attending an open forum of the Council on Ethics and Judicial Affairs, two committee meetings, and the HOD meeting.

The conduct of the debate is democracy in action. The Speaker and Deputy Speaker control the debate with great deftness and humour. Speakers line up, as they do at the AMA National Conference, waiting to be recognised to speak.

There were several recurring issues that resonated. The first, and most pressing, was that of access to health care, even more so with legislation introduced by the Trump administration to wind back the Affordable Care Act (ObamaCare) which would have the result that 23 million Americans would lose cover. The legislation (the American Health Care Act or AHCA) is causing deep concern within the AmMA about the likely outcome.

Delegates debated the acceptability of per capita caps under federal Medicaid funding, which are a key element of the AHCA and are being considered for incorporation into the Senate version of the legislation that is still being drafted. The delegates rejected any proposal for caps on the basis that they would weaken States’ ability to respond to enrolment changes, greater care needs or breakthrough treatments.

The tactics of health insurers to deny cover for patients, or to create delays for physicians in trying to secure approval, were raised on many occasions. One of the more interesting debates focused on a resolution for AmMA to advocate for a public option to provide health cover where no insurance cover exists. This aspect of the original ObamaCare legislation was removed as a compromise to get the majority of the legislation through the Congress. AmMA voted to support the inclusion of a public option. The Australian health system was cited in debate as an exemplar of a system where there is public cover but also a right to choose private cover.

The networks established by the insurers are shrinking, often with the result that patients lose the physician they have had all of their lives. The provision of out of network care carries significant cost for patients who are not covered if they need care at a hospital that is not within their insurer’s network. This has an impact on emergency doctors who won’t turn patients away if they present at an out of network emergency department. At times the patient may not even be aware that they are out of network.

The resulting “surprise bills” come about either because the patient has presented out of network or because the cover they have is inadequate for the procedure that is undertaken. Delegates were critical of “outlier” medical colleagues who levied significant bills in these circumstances, attracting the ire of patients and media.

This has led to consideration in several States of a “fair minimum benefit”. However as States have been ratcheting down the benefits paid under Medicare, doctors are concerned that any benefit that is tied to Medicare will be inadequate for the service that is provided. Delegates discussed the potential for an independent database to be used as a reference point for charging (which sounds not dissimilar to the AMA Fees List).

Another example of egregious insurer behavior occurs in emergency departments where the insurer withdraws cover on the basis that the reason for presentation is not an emergency. To overcome this the patient is forced to seek pre-approval.

The issue of physician health was raised on several occasions. The concern is with burnout, exacerbated by the frustrations of dealing with the health insurers in seeking pre-approval for patients, and the electronic health record. Speakers referred to the extensive delays created by the system. Reference was also made to depression and suicide among doctors.

The open session of the Council on Ethics and Judicial Affairs provided a forum for the AmMA to obtain member feedback in the development of a new policy on euthanasia and physician assisted suicide. Among the speakers from the floor were physicians from the five States where it is already legal for doctors to prescribe end of life pharmaceuticals. In California, for example, physicians can choose to opt into the process with 18 per cent currently doing so. The legislation provides multiple safeguards.

Colorado is the most recent State to introduce euthanasia. The State medical society undertook a two year consultation before changing its policy to accommodate the change. In that State a patient must be able to self-administer the medication. However the cost of effective medication can be a barrier to a patient carrying out the euthanasia.

In the State of Oregon where euthanasia has been legal for 20 years, the State medical society has maintained a neutral position.

Notwithstanding that euthanasia is legal in some States, the debate emphasised the need for a better understanding of the role of palliative care and the place of hospice care. Patients at the end of life were often ignorant of the benefits of palliative care.

The address by the outgoing President of the AmMA, Dr Andrew Gurman, highlighted the big issues faced by the AmMA over the previous 12 months. These included the requirements of the health insurers for pre-authorisation of drugs and medical devices before they could be prescribed or utilised in surgery; gun control as a public health issue; the defeat of proposed health fund mergers which would have further reduced access to health care; and physician burnout.

Dr Gurman highlighted what he described as “advocacy at its most basic, human level” when he met with medical trainees who had grown up in the US but now feared deportation under proposed changes announced by the Trump administration.

The Executive Vice President and CEO, Dr James Madara, highlighted that the AmMA recently celebrated its 170th birthday, having been established in 1847. He identified three strategic areas for current focus in the work of the AmMA: 

  • Practice satisfaction and professional practice;
  • Medical education; and
  • Patients with pre-diabetes.

This last point relates to the fact that a staggering 83 per cent of health services in the US are for chronic conditions.

Unsurprisingly an opinion poll released while I was in the US has health as the number one issue for the electorate.

The AmMA’s work on medical education centres on online learning to provide tools and resources to physicians, including the recent release of an online education program on best use of electronic health records. This is part of a project entitled health 2047 (for the 200th birthday of the establishment of the AmMA) which aims to return to the physician one hour per day of the working week. Many speakers identified that navigating the current EHR system currently consumes up to two days each working week.

The AmMA is also working to protect patients at risk of losing their health cover by expanding meaningful coverage and including safety nets.

Resident mental health is now mandated as part of every residency program.

The contributions from the medical students were among the most compelling. The medical student section put forward a motion calling on the AmMA to be a leader in advocacy on the social determinants of health. The National Academy of Medicine established a framework in 2016 to better understand the social determinants. As several delegates pointed out, without understanding the social context of a patient there may be impacts on the care that is given. Examples provided were a patient living in accommodation with no running water, or with no access to transport to attend a pharmacy to have a prescription filled.

Another significant public health issue that attracted debate is the opioid epidemic in the US which has arisen as a result of the over-prescribing of pain medication.

 The organisation

The AmMA’s revenue in 2016 was $323.7 million with a profit of $13.6 million.

The House of Delegates is the supreme policy making body and elects the office-holders, including the President-elect who then becomes President the following year. It also elects the members of the Board of Trustees.

The Board of Trustees is the principal governing body and takes actions based on the policy and directives of the HOD. It exercises broad oversight and guidance with respect to management systems and risk through the oversight of the Executive Vice President (the CEO).  It has 21 members who have fiduciary responsibility for the organization and select and evaluate the CEO. The members include a student, a resident, a young physician, and a public member.

The eight Councils are standing, domain based, expert bodies. They are: 

  • Council on Constitution and Bylaws
  • Council on Ethical and Judicial Affairs
  • Council on Legislation
  • Council on Long Range Planning and Development
  • Council on Medical Education
  • Council on Medical Service
  • Council on Science and Public Health
  • American Medical Political Action Committee.

The Sections and Special Groups represent the constituent groups and provide a channel for outreach and member insights. They are as diverse as the Advisory Committee on LGBT Issues, the International Medical Graduates Section, the Medical Student Section, and the Organised Medical Staff Section.

The HOD draws representation from the State and territorial medical associations (260 delegates) and national medical specialty societies (205 delegates). It has 528 delegates and the same number of alternate delegates. With Past Presidents and observers there are approximately 1200 attendees at the HOD annual meeting.

The rules for participation of a national medical specialty society are complex and are based on the number of its members who are members of the AmMA at the rate of one delegate per 1,000 AmMA members with every eligible national medical specialty entitled to at least one delegate. Similarly every State/territory is entitled to at least one delegate.

In addition delegates represent Federal Services (Air Force, Army, Navy, Department of Veterans Affairs, and the US Public Health Service); AMA Sections; other national societies; and professional interest medical associations.

AmMA represents approximately 25 per cent of American physicians. However as the umbrella body representing the entire profession it is the voice in Washington DC that speaks for all physicians.

Each policy that is put before the HOD has a fiscal note on the likely cost of the proposal if adopted. This is a good discipline in either reducing or refining some resolutions.

Every policy is recorded in PolicyFinder which is an electronic database available online and updated after each meeting of the HOD.

As a final note, every resolution or policy that is put forward is framed as ‘our AMA’ undertaking the specified action. This engenders a sense of ownership and pride in the organisation’s advocacy.

 

Ten tips for medical expert witnesses

 

Doctors can play an important role as medical expert witnesses in the decision process in Australian courts and tribunals. There’s a limited supply of them, however, which means they are much in demand.

Medical expert witnesses are used in three main types of legal encounter. Firstly, in civil cases where the expert is required to give evidence as to whether another doctor acted in accordance with the accepted standard of care; secondly, in cases where another doctor faces disciplinary action; and lastly in coronial inquests where a medical expert witness is asked to help determine the cause of death and any role a person or institution may have played in it.

It’s important to understand the onus of proof in courts, which can vary considerably from what would be considered scientific proof in the medical world. In civil cases, legal proof is based on the balance of probabilities, while in criminal courts proof must be beyond reasonable doubt.

Expert medical witnesses have important duties in the legal system and it is not up to them to decide whether a doctor or other defendant is “guilty”.

Most states and territories have codes of conduct for expert medical witnesses which is important to read before you write your initial report.

Here are a few tips for doctors who have been offered or are thinking about a role as a medical expert witness:

  • The role can be time-consuming and it may not be feasible to be doing it in your “spare time”;
  • Be fully prepared and have your opinion formed before you are called upon to testify;
  • Develop a clear reasoning for your opinion, but do not hypothesise about what may or may not have happened in any case;
  • If you have any concerns about your opinion, go through them with the lawyer who engaged you before writing your report;
  • If something is unclear, you may decide you need to give two different opinions based on two different possible scenarios;
  • Don’t contradict in court what you have already written in your report;
  • Be aware of outcome and hindsight biases. These involve judging a decision on the basis of outcomes rather than what led up to the decision in the one case; and in the other, it involves predicting the probability of an adverse event retrospectively;
  • Be clear on levels of evidence and recognise the differences between a directive, a policy, a standard, a guideline and a position statement;
  • Don’t fall into the trap of being an advocate for the lawyer who hired you;
  • Be aware that expert medical witnesses can face disciplinary action for evidence given in court which is seriously flawed.

Source: Avant

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