The saga of trying to put Medicare on ice

By Professor Stephen Leeder, Emeritus Professor Public Health, University of Sydney

Frozen indexation has meant effectively a cut in income for general practitioners who bulk bill their patients. Although small, it mounts up when multiplied by the number of patients they see.

If Medicare rebates on consultations lasting less than 20 minutes (the most common type of consultation) had not been frozen in 2014, instead of being $37 now they would have risen to about $40 this year if indexed to the consumer price index. That is according to a fact sheet produced by the Royal Australian College of General Practitioners.

Bulk-billing is hard to freeze

Although this may be thought to serve as a disincentive to bulk-billing, the Federal Health Minister Greg Hunt is quoted in the March 19^th issue of The Australian as “highlighting the record increase in bulk billing rates, which have risen 3.5 per cent since the Coalition won Government”. So it does not seem to have reduced bulk billing?

Mr Hunt went on to say: “In the last half-yearly figures that are just out, we’ve gone from 84.7 per cent, to 85.4 per cent, so in other words, Medicare funding is up and bulk billing rates are at their highest ever on a half-yearly basis.”

Why freeze?

Associate Professor Helen Dickinson, a public service research academic at UNSW, explained the origin of the freeze a year ago in the Conversation and reported on ABC: “Although the Coalition is largely associated with this issue, Labor first introduced the Medicare rebate freeze in 2013 as a “temporary” measure, as part of a $664 million budget savings plan … A continuation of the indexation freeze, initially for four years starting in July 2014, was further extended in the 2016 budget to 2020. It has been estimated this will save $2.6 billion from the health bill over six years.”

The intention in the proposed 2014 Federal Budget was that the freeze would work alongside a co-payment and reduced reimbursement for short consultations. The continued freeze was the only measure that cleared the Senate. Although the justification for these proposed imposts on general practice included the absolute costs of primary care, these costs included a lot of activity other than general practice. According to the Australian Institute of Health and Welfare, health expenditure in Australia in 2014-2105 was $161.6 billion.

A freeze, or frost bite?

In 2013-2014 $58.8 billion was spent on hospitals and $54.7 billion on ‘primary care’ but as just said, this includes general practitioner services (about $9 billion), other health practitioners, community health care, dental services and medications. So with a total annual health budget of $161 billion, general practitioner services amounted to $9 billion or 17 per cent. The predicted savings from the freeze, each year, represent 0.25 per cent of total health expenditure. Has such a small saving been worth it?

If seeking to save money in health care, it is probably best to look first at the big expenditure items. This is why the review of the Medicare Benefits Schedule makes good sense and why, universally, there is an interest in demanding greater efficiency from our hospitals.

But as those who have had the responsibility for running a big and complex organisation know full well, it is wise to assess the likely flow-on from any cuts. Impositions on primary care are not likely to lead to the political pushback that cuts to high-powered specialty services will elicit. But if they demoralise this workforce, heaven help you in trying to integrate care for patients with complex chronic problems. And that will cost you far more in the long term than you will save by freezing general practice rebates.

Is a freeze on Medicare fair?

My final point concerns equity. How come private health insurance premiums rise each year whereas general practice fees do not? Private insurance premiums are heavily subsidised (30 per cent or $6.5 billion in the 2016 budget) by the federal government. So the Government does not worry about indexing its contribution to private health insurance but it does for Medicare. Work that one out if you can.

Some private hospitals are safer than others – but we don’t know which

The recent jailing of British breast surgeon Ian Paterson after performing multiple unnecessary operations has highlighted the issue of hospital safety.

Paterson’s unnecessary surgeries included some performed in private hospitals, which prompted UK doctors to call for private hospitals to report similar patient safety data as public hospitals, including unexpected deaths and serious injuries.

This example shows how little we know about patient safety and quality in our private hospitals, not only in the UK, but also in Australia.

What do we know about hospital safety and quality?

In Australia, one of the best places to look for information on hospital safety and quality is the MyHospitals website, a commonwealth department site run by the Australian Institute of Health and Welfare.

The Australian Institute of Health and Welfare is provided with data about every patient treated in an Australian hospital, both public and private. Using that data, you can look up measures of safety and quality, as well as emergency department performances. You can compare public hospitals on all the performance measures, but private hospitals are excluded from the performance reports.

Further reading: Which are better, public or private hospitals?

Another good source is the New South Wales Bureau of Health Information, which allows you to compare information about the safety and quality of public hospitals in NSW. Private hospitals are not included.

Private hospitals are not all the same

Private health insurance allows you to choose your treating doctor and the hospital at which you’re treated. But how do you choose the right hospital, or the safest one? As our research shows, not all private hospitals in Australia are equal.

In 2009, the Australian Health Insurance Association (now called Private Healthcare Australia) asked me and my colleagues to look at the outcomes of care in private hospitals. We looked at death rates and the numbers of people who died during their stay in hospital, and a range of other safety and quality outcomes.

We were given access to three years of detailed data from a national sample of patients treated in 58 private hospitals. We did not know the names of the hospitals, nor patients’ names.

Our research showed some private hospitals were safer than others, but from the data we analysed we couldn’t tell which.
from www.shutterstock.com

Many kinds of hospital outcomes, such as the likelihood of dying in hospital, or contracting a serious infection, are influenced by factors such as a patient’s age, and the range of conditions that brought them to hospital. We tried to take those factors into account and published our findings on the Private Healthcare Australia website.

We found a group of hospitals that, each year, seemed to have much lower death rates than average for all the private hospitals. Those, or other hospitals, also had lower than average rates of a variety of non-fatal incidents. There was also a group of hospitals that each year had higher than average death and adverse event rates. The greater than average death rate group included hospitals where death rates were consistently up to 90% higher than average.

If you are choosing a hospital, you’d want to know which hospital was which. But that information is not publicly available. You’d also want to know if there were more recent statistics, but there is no reported follow-up study. Without better public access to such facts and figures, we’re still in the dark.

What do other countries do?

Other countries do things differently. In the US, several groups provide extensive and detailed information on a range of hospital safety and quality outcomes for almost all US hospitals, including private hospitals. The groups, which do not always agree, include commercial (Healthgrades) and not-for-profit organisations (The Leapfrog Group), and public and government bodies (such as Medicare Hospital Compare).

And in England, it is easy to look up the Care Quality Commission’s detailed reports about public and private hospitals. The reports provide an easy to read, “blow-by-blow” account of their inspections of all types of hospitals, and make a variety of judgements on what they find. They are backed up by detailed statistical reports, but only for public hospitals.

Why don’t we do this in Australia?

A representative from the Office of the Australian Information Commissioner tells me that, provided individuals are not identified, there would be no breach of privacy if private hospital safety and quality data was made public. And no-one from a state health department has yet been able to say whether such a publication would be against any law.

Private Healthcare Australia, the peak body for health insurers, says it represents:

over 12.9 million Australians who choose better quality health care services and to put their health care needs first.

Private hospitals and private health insurers are in competition with each other for the 12 million or more Australians covered by some form of health insurance. So, it is in their commercial interests to avoid bad publicity.

Surely it is the role of both state and commonwealth governments to balance these commercial interests against the public’s right to know which hospital is providing safe, high-quality care.

David Ben-Tovim, Professor, Clinical Epidemiology & Process Redesign, Flinders University

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

[Review] Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden

Type 2 diabetes in adolescence manifests as a severe progressive form of diabetes that frequently presents with complications, responds poorly to treatment, and results in rapid progression of microvascular and macrovascular complications. Although overall still a rare disease, adolescent type 2 diabetes now poses major challenges to paediatric and adult diabetes services in many countries. Therapeutic options are heavily curtailed by a dearth of knowledge about the condition, with low numbers of participants and poor trial recruitment impeding research.

[Correspondence] Attacks on health facilities and health workers: time for the Security Council to act

May 3, 2017, marked the first anniversary of a UN Security Council resolution that condemned attacks on health facilities and personnel in conflict and the “prevailing impunity” for these atrocities.1 But neither the Security Council nor governments have acted on the resolution. Now, a report by the Safeguarding Health in Conflict Coalition, Impunity Must End,2 shows that in 2016, the number and intensity of attacks on health services in 23 countries continued to be staggeringly high. In ten countries, hospitals were bombed or shelled.

New focus on Top End doctors’ health

Practising medicine in the Northern Territory can be as rewarding as anywhere else, but it has its own particular challenges. Many NT doctors work in remote and isolated regions where they have to be able to rely on themselves, without the kind of support they’d find in the capital cities.

Until recently, there were very limited health services for NT doctors and no dedicated support network. But in 2016, a group of Adelaide-based health professionals stepped into the breach and set up Doctor’s Health NT, which offers a 24-hour advisory helpline, telemedicine and a network of local GPs trained to see doctors and medical students as patients.

“The NT medical community is small, with only about 1000 doctors,” says Adelaide-based GP Dr Roger Sexton, who as director of Doctors’ Health SA was instrumental in setting up the NT satellite.

“There are interesting challenges in doing medicine out there. There’s a wide range of workplaces, from aboriginal communities to work out on the islands or in remote communities, and doctors are expected to be well-rounded and pretty self-reliant. But when it comes to their own health, one solution doesn’t always work for all doctors.”

Dr Sexton says it’s easy for NT doctors to get isolated because they personally know most of the other doctors in the Territory, which means they can’t easily get treated anonymously.

“A lot of the doctors find the convenience of self-treatment too easy. If you’re a dermatologist in Melbourne, you’ve got a very good choice of who you can see. But in the NT the options are limited. Many doctors have concerns about confidentiality, and there’s always the issue of notification sitting in the background.

“When they do seek help, they often do it selectively. They’ll see a GP for some issues but not for mental health. Often they practice a form of blended care where they do a bit of self-investigation, self-prescribing and self-referral.”

Doctors’ Health NT has a 24-hour helpline, but Dr Sexton says the penetration is pretty low, which means things have to be done a little differently.

“We’re running a trial for GP teleconsults, which gives doctors the chance to consult with a doctor who is not necessarily part of their personal network. We’ve had very strong support for that model: it’s a great way for an initial talk about an issue and some follow-up.”

He says telemedicine is an excellent way to break down isolation, particularly for doctors who pride themselves on being tough and are reluctant to admit they’re struggling.

But Doctors’ Health NT has also established a network of GPs on the ground who are trained to treat other doctors and medical students.

“We’re trying to grow that network. We have ten GPs at the moment which we hope to expand to 30.”

Dr Sexton says having a GP-centric model for doctors’ health is critical because it can address both physical and mental health issues.

“With a psychiatrist-based model you miss out on all the physical stuff, which can be very important. GPs are also a non-stigmatising way of getting a foot in the door. You can say to doctors that the approach is physical, and along the way we’ll be asking you about your life as a doctor.”

You can access the services of Doctors’ Health NT here.

For more information about health issues for doctors, access a range of online resources from Doctors’ Health Services Pty Ltd.

Disability support services: services provided under the National Disability Agreement 2015–16

In 2015–16, an estimated 332,000 people used disability support services under the National Disability Agreement (NDA), including around 3,500 who transitioned to the National Disability Insurance Scheme (NDIS) during the year. The average age of service users was 35, and around three-quarters (72%) were aged under 50. Forty-three per cent of service users had an intellectual or learning disability, 42% had a physical or diverse disability, 29% had a psychiatric disability, and 18% had a speech or sensory difficulty. Almost one-third (30%) of service users aged 15 and over were not in the labour force. Of those in the labour force, two-thirds (67%) were unemployed. Two-thirds of service users had an informal carer, most often their mother (73%). Around one in eight (12%) service users had an informal carer who was aged 65 and over.

Clinical quality registries for clinician-level reporting: strengths and limitations

Australia should learn from overseas experience of reporting clinician outcomes before considering a similar program

Clinical registries systematically collect clinically relevant data regarding specific diseases or health events using standard procedures and definitions across multiple institutions. They originated as an epidemiological construct, and were designed to measure health outcomes across whole populations, originally for epidemiological and health planning purposes. More recently, the term “clinical quality registry” (CQR) has been introduced to define registries that use specific clinical quality indicators for regular confidential and benchmarked reporting to participating sites.1 CQR reporting at a hospital level acknowledges the often inextricable links between the many factors affecting patient care, including practitioner performance, support staff, facilities, care processes, and pre- and postoperative care. CQR reporting may provide early warning of potential quality issues, and when hospitals with outlying results internally review their data and processes, it may be an effective stimulus for clinical practice change.2

Clinician-level reporting from clinical quality registries

Internationally, there is growing interest in clinician-level reporting. This is driven by diverse stakeholders:

the medical specialty colleges and health care providers, for quality improvement purposes;
regulators and jurisdictions, to identify underperforming clinicians and risks to patient safety;
health insurers, to identify costs associated with variation in practice;3
consumers, to inform clinician choice; and
CQRs themselves, to support clinician engagement.

The Australian Commission on Safety and Quality in Health Care Framework for Australian clinical quality registries1 recommends that CQRs produce routine risk-adjusted clinician reports. However, the benefits, limitations and risks associated with clinician-level reporting are not necessarily clear, and opinions vary on whether clinician-level reporting is appropriate.4 Currently in Australia, participation in CQRs is voluntary, and clinician-level reporting is based on a model of confidential feedback to individuals. Because of this, the number and composition of clinical registries that report outcomes to clinicians is unclear, although examples include the Victorian Prostate Cancer Outcomes Registry,5 and the Australian and New Zealand Society of Cardiac and Thoracic Surgeons database.6

In general, CQR data are sufficiently granular to allow reporting of clinician-level outcomes. CQRs are often based around high volume, well defined episodes of care, including procedures for which clinician-level reporting is appropriate. However, when clinical care is undertaken by generalists and non-procedural practitioners and trainees, and through multidisciplinary team-based practice, the potential implementation of broad scale clinician-level reporting is limited.

Public reporting

The first public reporting of clinician-level outcomes internationally arose following media requests for information regarding surgeon outcomes.7,8 The New York State Department of Health first published data from its cardiac surgery database for hospital-level and surgeon-level performance in 1990 and 1992, respectively. It reports data on a rolling 3-year basis (reports are available at https://www.health.ny.gov/statistics/diseases/cardiovascular), which has served as a model for other United States state benchmarking and reporting initiatives. The United Kingdom National Adult Cardiac Surgery Audit has publicly reported at a unit level since 2010–11, and about 80% of surgeons now participate in voluntary clinician-level public reporting.8 The UK National Health Service has published clinical outcome information for individual surgeons across ten specialties since 2013.9

Through its MyHospitals website and jurisdictional reports, the Australian National Health Performance Authority publicly reports and benchmarks various hospital-level indicators such as readmission rates, infection rates, waiting times and financial performance.10 Australia does not currently report clinician performance outcome data publicly. However, as CQRs continue to mature it is likely that the capability to provide clinician-level reports will eventuate.

International experience

Public reporting of clinician performance has been shown to lead to improved patient outcomes, particularly in adult and paediatric cardiac surgery.11,12 A recent systematic review of 28 peer-reviewed articles identified some evidence that public reporting can be an incentive for low-performing surgeons to improve.13 Nevertheless, international experience has highlighted a number of important considerations. These can help inform Australia’s approach to reporting clinician-level outcomes.

Low procedural numbers

Clinician activity volume may be substantially smaller than total activity volume at participating sites, leading to difficulties with statistical analysis of low volume datasets, particularly with less sensitive clinical indicators such as mortality. One UK study determined that the number of procedures necessary for the reliable detection of poor clinician performance (defined as double the national mortality rate), with a statistical power of 80%, well exceeded the typical annual numbers of procedures generally performed.14 This demonstrated that low procedural numbers may mask poor performance and lead to false complacency. Detection of poor clinician performance increased, however, when aggregated data were reported over a 3- or 5-year period.

While pooling of data over long periods reduces the timeliness of reported data and may mask deterioration in a clinician’s performance, low volume activities or low sensitivity indicators may require practical compromises. These include publishing a rolling dataset (eg, the New York State cardiac surgery database), or choosing quality indicators that occur with greater frequency than mortality rates, such as compliance with other measures that have an established association with mortality (eg, major complications or incomplete surgical resection).

Clinical indicator selection

Selection of clinical indicators appropriate to clinician-level reporting is complex, as some factors, including teamwork, communication, organisational culture and environment, may be beyond the individual clinician’s control. While benchmarked outcome measures should always be risk-adjusted to account for inherent differences in patient risk and to minimise the potential for clinician avoidance of high risk patients,15 the determination of and access to appropriate risk-adjustment factors may not always be possible. An alternative approach is to use composite measures, including a range of clinical and patient-reported outcomes that aim to provide a broader overall picture of performance. Such measures are recommended by the US Institute of Medicine,15 and may be appropriate for consideration in the Australian context, recognising however that this too is a complex field and such indicators may be difficult to construct.

Clinician performance management

Benchmarked reporting of sites and clinicians can be used for quality improvement and potentially for performance management. Registry data that highlight poorly performing clinicians may lead to hospitals reviewing or restricting clinical privileges, and clinicians retiring or resigning from the service. Following New York State’s first cardiac surgery reports, a greater proportion of surgeons with higher risk-adjusted mortality rates ceased practising cardiac surgery within 2 years.7

In the US, health service or clinician performance in relation to benchmarked quality indicators is additionally used to determine reimbursement.4 The importance of using high quality clinical indicators developed by consensus and applicable in the real world setting cannot be overstated in any potential funding and reimbursement decisions.

Recommendations

A summary of the potential advantages and limitations of clinician-level reporting is presented in the Box.

In the absence of mandatory clinician participation in CQRs, we are cautious about introducing public reporting of clinician-level data in Australia at this point in time. However, confidential clinician-level reporting may have a place if there is confidence in the accuracy of the data, and if outcomes occur with a level of frequency that would enable outliers to be detected in a timely manner.

It is therefore recommended that mature Australian CQRs adhere to the following principles, drawn from international experience, before considering clinician-level reporting:

Clinician involvement in clinical indicator and report development is essential. The degree of acceptance and use of reports is dependent on the degree to which the key constituencies are part of their development.
CQRs should identify the statistical requirements to enable detection of poor performance depending on the clinical indicator. To avoid false complacency from low volume activity, rolling datasets or reporting to the level of the team, unit or the hospital may be considered.
Careful selection of evidence-based clinical indicators and appropriate risk adjustment where benchmarking is undertaken are critical, and CQRs should monitor for unintended effects such as avoidance of high risk patients.
CQRs should ensure that systems are in place for professional support and remediation of clinicians identified as outliers. This requires vocational college or specialty society engagement, and collaboration with employing health services and jurisdictions.

Any move toward mandatory participation and public reporting of clinician-level outcomes should only be considered after a robust program of confidential clinician reporting is rigorously evaluated to assess for bias, “cherry picking” of patients, and adequacy of risk adjustment. The required support for culture and practice change will also need to have been in place for a reasonable period of time. Any consideration of performance-based incentives should proceed cautiously as Australia’s CQRs and other clinical information systems are still maturing. Given the potential benefits of public reporting, Australian CQRs should support this eventuality. However, further discussion and collaboration with government, clinicians and other key stakeholders is required to determine the most effective way forward.

Box –
Strengths and limitations of clinician-level reporting

Strengths

Limitations

Evidence of improvement in patient outcomes is enhanced with public reporting11,12

Low procedural/activity volume may lead to false complacency for low morbidity/mortality clinical indicators14

Increased clinician and hospital engagement in quality improvement activities5,13

Low procedural/activity volume may extend reporting periods required for robust statistical analysis, and reduce timeliness of feedback14

May lead to recognition and remediation of poor performers12,13

Appropriate clinical indicators are not routinely available for all medical specialties or activities, and may not provide a comprehensive picture of clinician performance16

Supports college continuing professional development programs17

Clinical indicators frequently reflect performance of team or system rather than an individual14

Data are highly valid and trustworthy when using appropriately selected, risk-adjusted clinical indicators5

Risk adjustment is complex and difficult to undertake; unintended consequences of inadequate risk adjustment may include avoidance of high risk patients, particularly if results are public7,8

Fosters discussion and learning within clinical communities2,7

Potential employment consequences for clinicians detected as outliers or poor performers7

Preparedness for practice: the perceptions of graduates of a regional clinical school

The known Universities, medical authorities and employers are interested in whether medical graduates are adequately prepared for practice. Medical graduates’ self-assessment of their capabilities on entering the workforce are relevant to this question.

The new Graduates from the Launceston Clinical School generally felt well prepared for the transition to clinical practice as a junior doctor.

The implications Reforms of undergraduate medical education should focus on moving graduates from feeling merely prepared to being well or extremely well prepared by the time they commence practice. The survey could be administered more broadly to obtain a national, longitudinal perspective of perceived preparedness.

The dual responsibility of medical schools — to train doctors in the capabilities they need for practice immediately after graduating, and to prepare them for adapting to constantly changing health employment systems — is being examined in the context of an increasing focus by governments and higher education bodies on how prepared graduates are for medical practice.1–4 Most medical graduates in Australia are employed as doctors, but it is important to determine whether all are prepared to fulfil their duty of care in the face of the challenges posed by the increasing complexity of health care practice and systems.5 Higher education leaders seek to produce graduates who are “work ready plus”; that is, possessing capabilities that are relevant for future workplace requirements, not just current needs.6

Employability skills in the medical profession are high order capabilities: knowledge and skills, the capacity to continue to learn, the ability to perform in changing contexts and to be clear in professional purpose.2,7,8 In his recent report on transforming graduate capabilities, Geoffrey Scott discussed the “work ready plus” capabilities required by university graduates for future employability, including being able to implement change, to work in partnership, and to manage the unexpected, as well as being clear about their role in driving change.6

Concern has been expressed about how prepared graduating doctors are for delivering patient-centred care, about the erosion of patient-centredness during basic medical training, and about their capacity to provide this care as health care workers.9,10 The final report of the Review of Medical Intern Training commissioned by the Australian Health Ministers’ Advisory Council noted a “lack of objective, accessible and current data … on the level of graduate preparedness”.9

As the evidence for improved health outcomes and cost-effectiveness associated with patient-centred care mounts,11,12 understanding and teaching patient-centred care is becoming pivotal for cultivating graduates with a refined professional identity; that is, with patient-centredness embedded in their sense of who they are as a doctor, in their attitude and approach to medicine, so that they are more able to champion this approach in the health care system. The synergy achieved by aligning Scott’s “work ready plus” requirements6 with patient-centred medicine will enable doctors to work in partnership with patients, to cope with uncertainty, and to develop a well formed, patient-centred professional identity for managing the complex chronic health problems affecting patients and the community.

The regional Launceston Clinical School (LCS), one of three clinical schools at the University of Tasmania, has provided about 40 students from each of the final two years of a 5-year undergraduate degree with a specific patient-centred learning program,13 alongside traditional clinical hospital rotations and case-based learning, since 2005. In the executive summary of the NSW Health Education and Training Institute Medical Portfolio Programs report, emphasis was placed on the fact that the “characteristics of future doctors and the content of the curriculum and ways of teaching and learning must reflect the need for a greater focus on professionalism and the quality and safety of patient care.”8

As a pilot study in an Australian setting, we surveyed medical graduates about their perceptions of how well their undergraduate education at the LCS prepared them for a range of practice capabilities, including those central to patient-centred care.

Methods

Study design

Graduates’ perceptions of their preparedness for practice were surveyed with a self-report instrument, administered with the cloud-based SurveyMonkey software.

Participants and sample

All contactable medical graduates who attended the LCS during 2005–2014 were invited by email to participate. Alumni records and social media, among other sources, were used to identify current email addresses. Reminder emails were twice sent to non-responders.

Survey

A survey previously developed by the Peninsula Medical School (Plymouth University, United Kingdom)3 was, with permission, modified for this study. The curricular emphasis at the Peninsula School on working with patients in activity learning contexts is comparable with the LCS patient partnership learning encounters approach.

The modified survey consisted of 44 items with the stem question, “How well did your undergraduate education at Launceston Clinical School prepare you for …”. Participants were asked to respond on a 5-point Likert scale (1, unprepared; 2, not very well prepared; 3, prepared; 4, well prepared; 5, extremely well prepared). One item in the original 39-item survey (“… functioning safely in an acute ‘take’ team”) was not applicable in the Australian context and therefore omitted. The item “… overall patient-centred practice and humane care” was not regarded as sufficiently specific for exploring patient-centred care capabilities and was replaced with seven items more explicitly related to aspects of patient-centred care preparedness (Box 1). Our 10-year experience of implementing and assessing patient-centred learning, including our development of a validated assessment instrument,13 indicated that the seven items were important components of patient-centred practice capabilities. They also reflect elements of expected practice capabilities outlined in the Australian Curriculum Framework for Junior Doctors.14

Additional data (eg, sex, number of years since graduation) were also collected. Qualitative information gathered for deeper investigation of factors affecting transition to practice is not discussed in this article.

Analysis

Responses were analysed as counts and percentages; data for all items are presented in a stacked bar chart.

In order to determine the impact of time since graduation on responses, the 44 questions were grouped into six thematic clusters identified independently by each of the four investigators, with the final themes determined by discussion (Box 1). The preparedness scores were ordinal, making an ordered logistic regression analysis appropriate. Including all six themes in a repeated measures analysis allowed each graduate to act as their own control. The relative preparedness scores for each thematic cluster were compared in repeated measures, random effects, ordered logistic regression. The “core skills” theme for those who graduated 1–4 years ago was used as the comparator for generating odds ratios for the other five themes for participants who graduated 1–4 years ago, and for all six themes for those who graduated 5–10 years ago. Data for women and men were analysed separately. In addition, a time interaction analysis compared the preparedness of 1–4 year graduates and 5–10 year graduates in each theme, separately for each sex. The mean preparedness scores (with standard deviations [SDs]) for each theme–time period–sex combination are reported for illustrative purposes only. The responses of participants of each sex in each theme were also compared to assess sex differences in perceptions of preparedness. Analyses were performed in Stata/MP2 14.1 (StataCorp).

Ethics approval

Ethics approval was obtained from the Human Research Ethics Committee of Tasmania (reference, H0015128).

Results

Survey invitations were sent to the 273 of 359 graduates (76%) for whom current email addresses could be obtained; 147 responses were received (54% of invitees, 41% of the total cohort). Twelve graduates supplied demographic data only, so that 135 graduates were included in the final sample (38% of the total cohort). Of these, 51% were men and 49% women; 71% had graduated in the past 5 years, 29% 6–10 years ago.

For 17 of the 44 surveyed items, at least 80% of graduates reported being extremely well or well prepared. For six items, at least 10% of respondents reported not being well prepared or unprepared for practice: providing nutritional care (29%), using audit to improve patient care (26%), clinical governance (23%), using informatics (11%), responding to error and patient safety (11%), and cultural competency (10%) (Box 2).

More than 80% of graduates felt extremely well or well prepared for only one of the seven patient-centred care items: understanding the concept of patient-centred practice (82%). The figures for the other six items were lower: understanding the impact of patient-centred care (78%), being comfortable with the craft of consultation (76%), shared decision-making (73%), role modelling to junior colleagues (73%), self-critique (76%), and exploration of patient needs (73%).

The 44 survey items were grouped into six broad skills clusters (Box 1). Compared with the core skills theme for 1–4 year graduates, women who had graduated 1–4 years ago perceived themselves as less prepared in all other clusters, except clinical care. Among those who had graduated 5–10 years ago, preparedness for patient-centred care was not significantly different from that for core skills among those who graduated 1–4 years ago. Men who had graduated in the previous 4 years perceived themselves as less prepared than for core skills in all clusters, except for clinical care and patient-centred capabilities. After adjusting for time interaction, the perception of preparedness among men who had graduated 5–10 years ago was statistically significantly higher for core skills and lower for the system-related capabilities group. There were no statistically significant time-related differences for women (Box 3).

For recent graduates (1–4 years ago), there were no significant sex differences in the perception of preparedness in particular thematic groups. Among respondents who had graduated more than 4 years ago, the perception of preparedness was generally higher for men, but this was statistically significant only for the patient-centred care cluster (P = 0.04; online Appendix).

Discussion

A large majority of respondents reported feeling prepared for each of the 44 capabilities covered by the survey. In 17 areas of practice, at least 80% of respondents felt well or extremely well prepared; it is encouraging that these items covered a range of professional, clinical, patient engagement and reflective capabilities, indicating that graduates had a wide-ranging sense of preparedness for their role as doctors. We found some differences in perceived preparedness among male respondents according to whether they had graduated 1–4 years ago or more than 4 years ago. It is not possible to determine whether these changes resulted from changed perception of their capabilities arising from greater professional experience, pre-registration curriculum changes, or recall bias. We postulate that the difference related to changes in their understanding of their role, as there was a significantly different perception of readiness in only two domains (and for men but not for women), and there had been no significant curriculum changes.

This study was conducted at a time of increasing national9 and international1,3,15–17 focus on the preparedness of medical graduates for practice. The General Medical Council (UK) has systematically examined the question over the past decade, and recently reported that one in ten graduates felt poorly prepared for entering medical practice.1,18 Investigations by Australian medical schools have been less systematic.6,19,20 As a consequence of the Medical Intern Training Review, national surveying of Australian interns is now being considered.9,21

Measuring insights about and reflections on practice after commencing work is a worthwhile contribution to understanding the standard of undergraduate medical education and perceived gaps in their readiness to practise as a doctor.3,17,22,23 Viewing preparedness as a continuous non-linear process1 means that it should be assessed as part of an integrated, continuous assessment model encompassing both training and practice.24 Because the performance of graduates continuously improves as they become more experienced, the question of when to retrospectively measure perceptions of preparedness needs to be considered carefully. It should ideally be undertaken at a consistent point in time after commencing practice, when results from different years can be validly compared and are not subject to biases or changes in perceptions attributable to increased experience. Further research will be needed to determine the optimal methodology for such assessment.

If the objective is to prepare a “work ready plus”6 doctor, focusing on our findings relevant to the value-added or non-technical aspects of medicine3 is useful. Preparedness for “engaging in self-directed lifelong learning” and “organisational decision-making” was rated highly, skills need for building professional development, potential leadership, and adaptive capabilities.1 The levels of perceived preparedness for “understanding the concept and impact of patient-centred practice”, “educating patients”, and “shared decision making” indicate the readiness for effective partnering with patients and families for improved health outcomes. The practice areas of “coping with uncertainty” and “reporting and dealing with error and safety incidents” are capabilities that rated less well, indicating opportunities to improve building skills for competently managing unexpected and complex scenarios that arise in health care. “Coping with uncertainty” is a central outcome for Peninsula School undergraduates; they reported a particularly high level of preparedness for this capability, a finding attributed to working with patients and colleagues in activity learning contexts.3 This suggests that when students are directly exposed to key areas of and approaches to practice, their perception of being prepared is enhanced.

That “basic nutritional care” was identified as an area needing improvement is consistent with other findings3 about the capabilities and confidence required to communicate with patients about weight and obesity problems.25 This lack of confidence is important, given increasing population levels of obesity.26

While the overall perceived level of preparedness was high for these graduates, for 61% of the surveyed items fewer than 80% of respondents rated themselves as well or extremely well prepared. There are clear implications for further improving undergraduate medical education, ensuring that graduates feel well or extremely well prepared, rather than merely prepared, by the time they commence practice.

Medical schools should provide patient-centred learning that improve graduates’ capabilities and therefore readiness for the workforce, with safe, high quality care for patients as the goal.27 The LCS curriculum follows a traditional block rotation clinical learning model with a patient partnership program spread across the year and delivered alongside case-based learning.13 As yet there are no data for a direct comparison with non-explicit teaching of patient-centred care that would allow us to determine whether such a program makes a difference to preparedness for patient-centred care. Deliberate patient-centred experiential learning recognises that graduates arrive in a hospital system where “practice in partnership”27 with patients is now expected; aligning the learning continuum expectations with those of the workplace should be driven by this recognition.

Limitations to our study include the fact that respondents’ reflections on their experiences and the expectations they faced in earlier years may have caused recall bias. It is also possible that doctors further out from graduation have different perceptions of preparedness because of their greater experience working in health care. This study is also limited by its being a single site study in a regional university with small graduate numbers, meaning that its results may not be generalisable to other medical schools. Respondents’ interpretation of what constitutes preparedness for each item may also have varied, given that there were no objective criteria for graduates to benchmark their own preparedness.1,15 The judgements of graduates cannot be assumed to be equivalent, although it is likely that each graduate applied similar judgements to each of the 44 items.

Conclusion

Overall, graduates from the LCS felt well prepared for the transition to clinical practice as a junior doctor. Repeated retrospective surveying of our graduates would offer further insights that could inform redesigning areas of the curriculum. If the survey were administered more broadly and a national, longitudinal perspective of perceived preparedness obtained, the results would enhance the integration of the teaching–learning–assessment continuum with service expectations.7,24 A key consideration for such a survey would be the optimal time point after graduation for its administration.

Box 1 –
“How well did your undergraduate education at Launceston Clinical School prepare you for …”: the 44 capabilities included in the survey, grouped into six broad skills clusters

Core skills

Taking a history

Examining patients

Skills of close observation

Selecting appropriate investigations and interpreting the results

Clinical reasoning and making a diagnosis

Prescribing safely

Advanced consultation skills

Educating patients (health promotion, public health, health literacy building)

Communicating effectively and sensitively with patients and relatives

Breaking bad news to patients and relatives

Being comfortable with the craft of consultation*

Personal and professional capabilities

Managing your health including stress

Coping with uncertainty

Understanding the purpose and practice of appraisal

Engaging in self-critique of practice and clinical encounters*

Role modelling to junior colleagues*

Coping with ethical and legal issues (eg, confidentiality/consent)

Undertaking a teaching role

Engaging in self-directed lifelong learning

Being aware of your limitations

Acting in a professional manner (with honesty and probity)

Communicating effectively with colleagues

Working effectively in a team

Patient-centred capabilities

Providing appropriate care for people of different cultures

Recognising the social and emotional factors in illness and treatment

Understanding the impact of patient-centred practice*

Understanding the concept of patient-centred practice*

Exploration of patient needs*

Shared decision-making management*

Understanding the relationship between primary/social and hospital care

Clinical care

Using evidence and guidelines for patient care

Early management of emergency patients

Taking part in advanced life support

Maintaining good quality care

Planning discharge for patients

Basic nutritional care

System-related capabilities

Clinical governance

Using audit to improve patient care

Using informatics as a tool in medical practice

Reporting and dealing with error and safety incidents

Reducing the risk of cross infection

Organisational decision making

Ensuring and promoting patient safety

Keeping an accurate and relevant medical record

Time management

* Items added to the original Peninsula Medical School survey.

Box 2 –
“How well did your undergraduate education at Launceston Clinical School prepare you for …”: responses for the 44 capability items in the survey, ranked according to the proportion who responded that they were “extremely well prepared” or “well prepared”

Number of responses for each item, 135, except: * 134 responses; † 133 responses.

Box 3 –
Comparison of responses in the different thematic groups, by sex and time since graduation

	Women					Men
	Total*	Mean response (SD)^†	Odds ratio^‡ (95% CI)	P^‡	P^§	Total*	Mean response (SD)^†	Odds ratio^‡ (95% CI)	P^‡	P^§

Graduated 1–4 years ago
Core skills	234	4.2 (0.7)	Reference			161	4.1 (0.7)	1.00
Advanced consultation	272	4.0 (0.8)	0.56 (0.38–0.84)	0.005		189	3.9 (0.9)	0.43 (0.27–0.69)	< 0.001
Personal/professional	350	3.7 (0.9)	0.27 (0.18–0.39)	< 0.001		242	3.7 (0.9)	0.30 (0.17–0.50)	< 0.001
Patient-centred	468	4.0 (0.8)	0.59 (0.43–0.80)	0.001		324	4.0 (0.9)	0.66 (0.40–1.08)	0.10
Clinical care	156	4.1 (0.8)	0.80 (0.50–1.27)	0.34		108	4.2 (0.9)	1.23 (0.75–2.01)	0.42
System-related	234	3.7 (0.9)	0.25 (0.16–0.37)	< 0.001		161	3.9 (0.9)	0.49 (0.33–0.72)	< 0.001
Graduated 5–10 years ago
Core skills	215	4.2 (0.7)	1.01 (0.41–2.49)	0.98	0.98	161	4.4 (0.7)	2.67 (1.08–6.60)	0.033	0.033
Advanced consultation	252	3.8 (0.7)	0.32 (0.12–0.84)	0.021	0.15	189	3.9 (0.7)	0.84 (0.39–1.80)	0.65	0.45
Personal/professional	323	3.7 (0.9)	0.25 (0.11–0.59)	0.002	0.80	242	3.6 (1.0)	0.40 (0.19–0.85)	0.018	0.07
Patient-centred	431	3.9 (0.8)	0.48 (0.20–1.18)	0.11	0.51	324	4.1 (0.8)	1.66 (0.77–3.59)	0.20	0.88
Clinical care	143	4.0 (0.7)	0.50 (0.19–1.34)	0.17	0.26	108	4.1 (0.7)	1.82 (0.76–4.35)	0.18	0.19
System-related	216	3.7 (0.9)	0.24 (0.11–0.55)	0.001	0.93	161	3.8 (0.9)	0.67 (0.32–1.43)	0.30	0.038

* Total number of individual responses to questions in the respective category. † Calculated for illustrative purposes only. As the Likert scale responses are inherently rank-ordered (1 to 5; not interval), a rank-ordered analysis was conducted for formal comparisons. ‡ Compared with the responses to the core skills/graduated 1–4 years ago category. § Adjusted for time of graduation (by category).

Averting avoidable deaths of nursing home residents

The safety of our older citizens can be improved by targeting known risk factors

How well are we caring for older, frail and vulnerable citizens in residential aged care facilities (RACFs)? The retrospective study of deaths in nursing homes during 2000–2013 reported in this issue of the MJA1 is an important review of the quality of care at the end of life. We could be doing better.

Ibrahim and colleagues reviewed the deaths of nursing home residents reported to coroners. The criteria for reporting deaths vary between states, but generally include any deaths from falls or other injuries, as well as other unexpected or “unnatural deaths”. This concept includes deaths resulting from injuries that:

directly caused the death, for example, a subdural haematoma sustained in a mechanical fall, or contributed to the death and without which the person would not have died … Deaths should still be regarded as unnatural even when the causative event occurred a substantial period prior to death. In those cases there is frequently some complication that actually causes the death but if it is attributable to the initial injury the death can be said to be unnatural and therefore reportable.2

Death after a fall is defined in all states as “a violent or otherwise unnatural death”2; death after surgery, such as fixation of a fractured hip, may be considered an unexpected outcome of a health-related procedure. What is natural and what is unnatural can be at the discretion of the doctor signing the death certificate, so that under-reporting of avoidable deaths is likely.

Frailty is an increasingly important concept, and can be measured using gait speed, strength, activity levels, weight loss, and comorbidities as indicators.3,4 The aged care system in Australia includes assessment services and community support mechanisms that enable older people to remain in their own homes for as long as possible. Residents of RACFs are therefore typically frail: they were no longer able to look after themselves in their own homes, and are inherently more susceptible to adverse events, particularly falls, and to suffer complications of injury, surgery, and hospitalisation. The very old (those over 85), are over-represented in the complications statistics, the result of a combination of their greater risk for falls and increased mortality from injury. Falls prevention is a complex but well researched area of health care.5 Risk assessment is only part of falls prevention; implementing guidelines for averting falls in busy and understaffed nursing homes is challenging, and must balance the freedom and mobility of residents against their risk of serious injury.

Of all deaths of nursing home residents during the study period,1 15% were attributed to external causes, most commonly falls (82% of external cause deaths). While it has long been recognised that patients with falls and hip fractures are at high risk of dying within a year of their injury, other causes of death described by Ibrahim and his co-authors are more worrying: choking (261 deaths) and suicide (146 deaths). Choking may be attributed to underlying medical conditions, including stroke and Parkinson’s disease, but the number of deaths underscores the need for expert swallowing assessment, modified diets, and sufficient staff to supervise meals or to feed patients as required. Older men are at greater risk of suicide.6 A small number of deaths resulted from resident-to-resident violence, usually involving patients with dementia. All these events are very distressing for families and staff.

Almost all incidents leading to death (96%) occurred in the nursing home where the resident lived; this is unsurprising, as this is where residents spend almost all their time. However, two-thirds of deaths occurred in hospital, not in the RACF. This may be unavoidable, as acute medical care may be needed, but it is not in keeping with the desire of most people to die in familiar surroundings. A coroner’s inquest may ensue, but Ibrahim and colleagues report that this was very uncommon (3% of external cause deaths), suggesting that examining these deaths further was not regarded as being in the public interest.

Are frail older people dying unnecessarily after a traumatic event, and in hospital rather than peacefully at home? The death of a person living in an RACF may not be regarded as “unnatural”, and may therefore not be reported to the coroner or further investigated. Families, residential care staff and doctors may regard it as the unfortunate consequence of the frailty that was the reason the older person moved to the home. The opportunity to identify and reduce risks and improve care is thereby lost. We all have the right to be safe in our homes, and the recommendation by Ibrahim and his co-authors for action in policy, practice and research should be heeded by our federal and state Departments of Health, responsible for aged care.

Work-readiness and workforce numbers: the challenges

We need clinicians prepared for work in a system of integrated, person-centred, affordable health care

Over the past 15 years or so, Australia has embarked upon what some might describe as a “courageous” solution for guaranteeing our medical workforce. Following a perceived shortage of doctors at the beginning of the 2000s, the number of accredited medical schools has grown from 10 to 20,1 with another currently undergoing accreditation; the number of medical graduates has almost tripled from 1316 in 2001 to 3547 in 2015.2 Increasingly large numbers of doctors have also been recruited from overseas to overcome shortfalls: 2820 temporary visas were granted during 2014–15 alone.3 The per capita production of local medical graduates4 and growth in the stock of foreign-trained doctors5 are among the highest in the world.

Australia is also a leader in more sensible ways: establishing rural clinical schools and regional medical schools and increasing the numbers of rural origin and Indigenous Australian medical students. Clinical training for students has spread well beyond the traditional metropolitan teaching hospital. Rural sites are at the cutting edge of reforms, including community-engaged medical education, longer, integrated clinical placements, and inter-professional learning, resulting in some solid workforce outcomes.6–8 The high levels of graduation and importation over 15 years have markedly increased doctor numbers. With 3.5 practising doctors per 1000 population (2014), Australia has more doctors per capita than Canada (2.6), the United States (2.6), New Zealand (2.8) or the United Kingdom (2.8), and exceeds the OECD average of 3.3 doctors per 1000.4

There is accordingly no overall shortage of doctors in 2017. But a regional hospital attempting to recruit an Australian-trained surgeon or psychiatrist, or a remote community looking for a broadly skilled rural generalist practitioner might beg to differ. Regional Australia remains heavily reliant on the provisional solution of importing medical labour, while growing numbers of domestic graduates jostle for internships and specialist training positions in the cities, swelling the ranks of an increasingly subspecialised metropolitan workforce. Joining them are many international recruits who move to cities after their obligatory period of service in rural areas is completed.

Factors that promote this situation include uncapped fee-for-service insurance systems, high volume corporate practice models, and the staffing and rostering proclivities of large hospitals. Threats to the system associated with the high number of city doctors include higher levels of inappropriate care servicing, fragmentation of care, yet more constraint on the scope of generalist clinical practice, and fiscal pain for taxpayers.

Increasing the number of medical graduates as a solution for workforce shortfalls has faltered because the job was only half done. Medical school, while important in itself, is the stepping-off point for further training: the first year as an intern, and then (after a period as a junior hospital doctor) years of training towards a fellowship in general practice or one of the 63 other recognised medical specialties. Australia has the second highest number of stand-alone specialty fellowships, after the US.9

As long as the funding, physical and cultural base for internship and subsequent training remains centred on big metropolitan hospitals and city practices, there be will no home-grown solution for securing our medical workforce. Even rurally inclined graduates who have trained in rural areas may feel obliged to join the race for city training positions,6 which typically means years in a metropolitan training pathway. Meanwhile, life events intervene and become barriers to returning to rural communities.

These bottlenecks in clinical training are occurring at a time when responsibility for its support is unclear, given our regionally autonomous public hospital system, funded according to clinical activity.10 With no transparent funding model for teaching and training, historical practices more or less prevail. Opportunities for interns, junior doctors and specialist trainees to train in private or non-government organisational settings remain limited.

What does all this mean for the work-readiness of an intern, or indeed of medical graduates at any point along the medical training continuum, including career-long learning?

One view of work-readiness is that provided by surveys of graduates’ own assessment of their preparedness for work as an intern in a large hospital, as described by Barr and her colleagues in this issue of the MJA.11 Their study found that the graduates surveyed generally felt well prepared with respect to 44 specific capabilities, including patient-centred care, although there was also a small number for which they did not feel well prepared, such as providing nutritional care, using informatics, and cultural competency.

These findings raises the question of the utility of the medical internship model, a problem discussed in a 2015 Council of Australian Governments review, which concluded that the model was still of value, but could be improved to better achieve its goals.12 For instance, although outcome statements for medical graduates and interns are a helpful guide for medical graduates and their supervisors, there is room for improving dialogue between universities and employers about work-readiness.

However, we believe there is a broader perspective from which to judge work-readiness: whether the training system (including internship) is producing sufficient numbers of clinicians ready for work that is aligned with community needs for integrated, person-centred, affordable health services for an ageing population that is experiencing higher levels of chronic disease.

To achieve this goal, we must ensure more equitable geographic distribution of specialist medical training, bolster clinical generalism, emphasise teamwork, and select individuals for further training on the basis of their propensity to serve community needs. We argue that these are the greater challenges for work-readiness and reform.