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Preference: Administration and Health Services

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Regional variations in ambulatory care and incidence of cardiovascular events [Research]

BACKGROUND:

Variations in the prevalence of traditional cardiac risk factors only partially account for geographic variations in the incidence of cardiovascular disease. We examined the extent to which preventive ambulatory health care services contribute to geographic variations in cardiovascular event rates.

METHODS:

We conducted a cohort study involving 5.5 million patients aged 40 to 79 years in Ontario, Canada, with no hospital stays for cardiovascular disease as of January 2008, through linkage of multiple population-based health databases. The primary outcome was the occurrence of a major cardiovascular event (myocardial infarction, stroke or cardiovascular-related death) over the following 5 years. We compared patient demographics, cardiac risk factors and ambulatory health care services across the province’s 14 health service regions, known as Local Health Integration Networks (LHINs), and evaluated the contribution of these variables to regional variations in cardiovascular event rates.

RESULTS:

Cardiovascular event rates across LHINs varied from 3.2 to 5.7 events per 1000 person-years. Compared with residents of high-rate LHINs, those of low-rate health regions received physician services more often (e.g., 4.2 v. 3.5 mean annual family physician visits, p value for LHIN-level trend = 0.01) and were screened for risk factors more often. Low-rate LHINs were also more likely to achieve treatment targets for hypercholes-terolemia (51.8% v. 49.6% of patients, p = 0.03) and controlled hypertension (67.4% v. 53.3%, p = 0.04). Differences in patient and health system factors accounted for 74.5% of the variation in events between LHINs, of which 15.5% was attributable to health system factors alone.

INTERPRETATION:

Preventive ambulatory health care services were provided more frequently in health regions with lower cardiovascular event rates. Health system interventions to improve equitable access to preventive care might improve cardiovascular outcomes.

Post-Traumatic Stress – the Tony Dell story

Tony Dell is the only living Australian to have played Test cricket and served in active combat. Selected by Sir Donald Bradman as Australia’s 255th Test cricketer, Dell, a tall left-arm fast bowler, played two Tests under legendary captain Ian Chappell.  His debut was against England in the seventh Test at Sydney (1970-71), where he took five wickets; opening the bowling with Dennis Lillee. Dell claimed six Test wickets at 26.66, and took 41 first-class wickets at 26.70 (best 6/17) before retiring at just 27 years old.  

Back in 1965, long before his Test and Queensland Sheffield Shield career began, a young Tony Dell was called up for National Service, and served in 2RAR (2nd Battalion, Royal Australian Regiment) in Vietnam from 1967-68.

About 10 years ago, Tony walked into the office of Mental Health Australia (where I was Director of Communications) and told me he had post-traumatic stress. He wanted to do something to help veterans and others who experience this condition. PTS (many feel the word ‘disorder’ stigmatises those with the condition), as Tony Dell’s website explains, is “contracted when the human brain is subjected to some sort of adverse experience, tragic event or fear that it wasn’t built to withstand. Many humans can be subjected to events that can cause this condition. In fact, nearly all of us can experience some sort of event which will challenge our senses. This can have just a short-term effect or it can be long lasting, depending on the person and the event.”

For those with PTS, the memory of traumatic events can be suppressed into the subconscious. If the event isn’t dealt with, it can foment and affect the person’s life in debilitating ways. Symptoms can appear gradually without the person really noticing or being aware of the cause.

Tragically, for many war veterans and others who have untreated PTS, suicide is too often the outcome. It is reported that in the past decade Australia has lost more veterans to suicide than killed on the battlefield.  Tony’s story – from Test cricketer to divorce, and family problems – is commonplace for many veterans, but also for police, SES volunteers, firefighters and those who experience trauma through violence, accidents or natural disasters. 

What Tony Dell did to change this should be an episode of Australian Story. From absolutely nothing, he created StandTall4PTS [http://standtall4pts.org/], a unique campaign that has brought together the Australian Defence Force, police, sporting celebrities and others to raise awareness of PTS. StandTall4PTS has Sir Angus Houston, retired CDF, as patron. His campaign has been endorsed and supported by Prime Ministers, Test cricketers and leading sportspeople.

Dell’s aim is to ensure that medical practitioners and community health services understand what PTS is, how it impacts on the families and friends of those who experience it, and to ensure there are properly funded and appropriate resources in place for people with PTS.

The problem with PTS is that it is often couched within mental health, although many experts believe this isn’t how we should understand and respond to PTS. Although there is no definitive data available, some estimates are that about 1.5 million Australians have PTS to some extent.

In an interview with CricInfo, Dell said this about living with PTS: “It can be bad dreams, flashbacks, night sweats, teeth grinding, fear of being in crowds. For 20 or 30 years if I went into a room or a restaurant or something, I’d sit with my back to a wall facing out. You can become a workaholic. I know in my case I’d get up at the crack of dawn, go to work and wouldn’t come home until late at night because you’re subconsciously keeping yourself busy and shutting out times when you can sit and think. A lot of guys can’t handle it and start hitting the booze or drugs, substance abuse, and then it gets too much for a lot of people.”

When I met Tony Dell, he had only recently been diagnosed with PTS. It was only through his local Vietnam Veterans Drop-In Centre that he discovered what had affected him for decades. Anecdotally, there are many similar stories of people with undiagnosed PTS who churn in and out of various health services because of a lack of awareness and understanding of this condition. 

Today, Tony Dell runs a nationwide campaign to improve research to increase our understanding of PTS and ensure better pathways for help and treatment for those affected and their families.

SIMON TATZ, AMA, DIRECTOR, PUBLIC HEALTH 

 

 

AMA contributes to new guidelines

Two members of the AMA policy team have been thanked for their contributions to the first edition of the Guidelines for on-screen presentation of discharge summaries, developed by the Australian Commission on Safety and Quality Health Care.

Chair of the AMA Council of General Practice, Dr Richard Kidd, and Chair of the AMA Ethics and Medico Legal Committee Dr Chris Moy both took part in developing the guidelines.

Chief Executive Officer of the Commission, Adjunct Professor Debora Picone, expressed her gratitude to the doctors in a recent letter to AMA President Dr Michael Gannon.

“Development of the guidelines was supported by a clinical expert group that included and informed through an extensive national consultation,” Professor Picone wrote.

“I would like to take this opportunity to thank Dr Richard Kidd and Dr Chris Moy from the Australian Medical Association who contributed to this important work.”

The Guidelines for on-screen presentation of discharge summaries are available on the Commission’s website at: https://www.safetyandquality.gov.au/publications/national-guidelines-for…

According to the site, the guidelines specify the sequence, layout and format of the core elements of hospital discharge summaries, as displayed in clinical information systems.

They were developed through extensive research, consultation and iterative testing with more than 70 clinicians.

The guidelines are intended to be adopted by vendors of medical software, and health services that procure and implement systems which generate and present discharge summaries.

“The clinical handover of a patient on discharge from hospital generally occurs using an electronic discharge summary (eDS),” the guidelines say.

“A discharge summary is a collection of information about events during care of a patient by a provider or organisation, in a document produced during a patient’s stay in hospital, as either an admitted or non-admitted patient, and issued when or after the patient leaves the care of the hospital.

“Clinical handover is a known area of potential risk for patient harm, particularly in the transition from acute care to the community setting. Discharge summaries are critical for providing well-coordinated and effective clinical handover because they are the primary communication mechanism between hospitals and primary health care providers.”

In July 2012, the Commission was appointed to develop and manage a clinical safety program for the My Health Record system, which is a secure online summary of health information, personally controlled by individuals.

Patients’ discharge summaries can be added to their My Health Record. As part of the Commission’s clinical safety program, eight clinical safety reviews of the My Health Record system were completed.

The fourth clinical safety review, conducted in 2014, included an end-to-end investigation of the accuracy and data quality of eDS.

The guidelines were endorsed by the National Health Chief Information Officer Forum in August 2016 and presented at the Commission’s Inter-Jurisdictional Committee in October the same year, and are now freely available on the Commission’s website.

Other safety in e-health findings can also be found on the Commission’s website at: https://www.safetyandquality.gov.au/our-work/safety-in-e-health/

Chris Johnson

 

Do homework before choosing private health insurance

AMA President Dr Michael Gannon has urged health insurance consumers to shop around.

Before buying private health insurance (PHI) or changing insurers, he said, consumers need to be assured they will get value for money.

“Too many Australians aren’t getting value for money,” he said following the release of the AMA Private Health Insurance Report Card 2017.

“A lot are. Private patients admitted to private hospitals around Australia have normally got a very positive story to tell about the care they’ve received.

“But for too many people, when they get sick, when one of their loved ones gets sick, they either find they’re not entitled to treatment in a private hospital, they’re shipped off to the public hospital, or they’re told that there’s going to be a significant delay in treatment or significant out of pocket expenses.

“What the Report Card tries to do is give people an idea about which policies might suit them and their family best.”

Dr Gannon said people should thoroughly research and compare the various and varied policies on offer to ensure they are getting value for money.

More importantly, he said, they should know exactly what they are covered for in the event of accident, illness, or injury.

“Australian families now contribute a substantial proportion of their household income towards private health insurance, so it is important they know exactly what they are getting from their investment,” Dr Gannon said.

“Family budgets are under pressure with cost of living increases, which have been added to with the recent annual increase in PHI premiums.

“The AMA Private Health Insurance Report Card 2017 provides consumers with clear, simple information about how health insurance really works.

“It shows that there are a lot of policies on offer, which provide significantly varying levels of cover, gaps, and management expenses. There are a lot of policies on the market that do not provide the cover patients expect when they need it.

“If people have one of these ‘junk policies’, the AMA encourages them to check their policy matches their current and anticipated health care needs. And, if not, dump it for better cover.

“Our Report Card will help people to understand their product, and allow them to make changes to get better cover and better value for money.

“We show what insurance policies may or may not cover, what the Medicare Benefits Schedule (MBS) covers, and what an out-of-pocket fee may be under different scenarios. 

“The Report Card also highlights that private health insurer benefits vary significantly between policies and insurance companies.

“Benefits vary State by State, so this year we’ve highlighted the percentage of hospital charges covered by funds in each State to help consumers better understand what they are buying.

“The percentage of services with no-gap are detailed State by State, and we reveal what each of the PHI funds has reported they spend on management and administration compared to what they pay out as benefits to patients.

“There is data on the level of complaints each fund receives, and we’ve also warned people about the dangers of doctor rating sites.”

Although it is understandable that people are looking to save money, the AMA advises they should not be deceived into downgrading to a junk policy.

From the AMA’s perspective, junk policies should not exist at all.

Dr Gannon said PHI needed to be simplified, more transparent, able to cover the real costs of treatment – including theatre fees, equipment, consumables, hospital costs, and staff time.

“The funds must put the interests of their policyholders first and foremost, and stop pointing the finger at doctors or pushing increased out of pocket costs onto patients when their products do not deliver what patients expect,” he said.

“Benefits for doctors represent less than 10 per cent of the money paid out by Australia’s biggest health insurer.

“We need to ensure that patients retain the right to choose the doctor that is right for them, and to have their treatment at a facility that suits them.

“Equally, we need to ensure that doctors can refer patients to the right specialist – not just the one that an insurer deems appropriate. Insurers do not know the difference between specialist and sub-specialist treatment.

“We must not end up with US-style managed care where a clerk in an office on the other side of the country, not the patient and their doctor, decides what care is affordable.

“Sometimes, preserving that choice might mean treatment in a public hospital. Products must preserve flexibility. Some of our best, most highly-trained doctors work in public hospitals.

“And for those in rural areas, it is often only the public hospital that is available. They should be able to use their insurance product as they need to.

“These decisions – these patient rights – are far too important to be taken away by insurers in an effort to further bolster their profits.

“The AMA wants this Report Card to be a catalyst for greater transparency and clarity from the private health insurers about their products, and a signal to consumers to thoroughly know their PHI product before signing up.”

Since the release of the inaugural AMA Private Health Insurance Report Card in March 2016, the Government has established the Private Health Ministerial Advisory Committee to examine all aspects of private health insurance.

The AMA Private Health Insurance Report Card 2017 is at ama-private-health-insurance-report-card-2017

Chris Johnson

 

Bupa keeps the best the PM has to give

The country’s largest private health insurer, Bupa, has secured the services of one of Prime Minister Malcolm Turnbull’s top bureaucrats.

Rebecca Cross, head of domestic policy in the Department of Prime Minister and Cabinet, has been seconded to the multi-billion-dollar insurer through a direct arrangement between Bupa and the department.

She was originally seconded under a partnership program between the Australian Public Service Commission and the Business Council of Australia.

Her contract has now been extended directly with Bupa.

Chris Johnson

 

Latest submission to Senate on private health insurance

The following is an edited and condensed extract of the AMA’s submission to the ACCC report to the Senate on private health insurance.

In Australia, the public and private systems work together as a part of a health system that provides patients with universal access to affordable health care. The balance between the private and public system cannot be overlooked.

The private health sector is a large contributor to the system.  In 2014-15, 42 per cent of all hospital separations were funded by private health insurance; where 50 per cent were public patients and the remainder were self-funded. Not only is it a large contribution, but it is a cost effective one.  In 2014-15, there were 4.1 million privately insured hospital separations for approximately $12 billion in outlays, or around $3000 per separation, compared to 5.9 million separations in the public sector for a combined government outlay of $48.1 billion (or $8,100 per separation). While the service mix and complexity may differ between the sectors, the private sector very efficiently complements the public sector. If consumers withdraw from the private sector, these services will need to be provided by the public sector. Under current capacity, the public sector will either not meet the additional demand, or will only do so at a higher cost to governments.

We need to ensure that as private health insurers interact with patients and hospitals, the underpinning regulation promotes the efficient supply of health services. Private Health Insurance (PHI) has specific features that make the design of efficient regulation especially complex. This is further compounded by the specific historical development and place of PHI in the Australian context – as a form of supplementary insurance to Medicare, with the primary purpose of providing private hospital cover. Current regulation, as well as defining the scope of the cover PHI provides, includes restrictions on premiums through Community Rating and Lifetime Cover, means-tested subsidies for PHI take-up (the PHI rebate which is among the top 20 most expensive Federal Government programs), along with means tested tax penalties (the Medicare Levy Surcharge) for the failure to take out cover, and price controls over increases in PHI premiums.

Managed care

 Australians can choose to obtain their health care solely from Medicare or use a combination of Medicare and PHI to meet their medical needs.

PHI offers several advantages over the public system: a patient has the option of being treated by their own doctor, they have more control over when and where they receive medical care, and the waiting times for elective surgery tend to be considerably shorter.  In short, PHI provides choice for the patient and, without that choice, its value is diminished.

Yet there is a subtle, and defined, shift from a system of patient control to managed care occurring in Australia. Australians do not want US-style managed care imposed on a system that currently produces superior health outcomes at lower cost (USD$4420 here compared with $9451 in the United States). Managed care, in terms of health care, means a person agrees to only visit certain doctors and specialists within their health care plan – limiting their choice of practitioner.  Australia and Australians have not had a public conversation about whether they agree to relinquish control over their health and their health system to the private health insurers. (This change has occurred through the change to the contracting with hospitals with no-pay clauses; publication of practitioner details; establishing closed shop referral databases; and demanding pre-approvals prior to surgery.)

Competition in the sector

The level of competition along the supply side of private health services impacts upon the competition between private health insurers.  Both insurers and providers (hospitals and practitioners) have indicated that competition is not as effective as it might be. 

Some of the inputs to the provision of health can be influenced or controlled by the private health insurer. These are generally limited to hospital contracts, but do stretch to the pre-approving of surgery. As a result, contracting between the insurers and hospitals (large groups through to day surgeries) has become more vexed and publicly acrimonious at times.

Contracting is a voluntary, deliberate, and legally binding agreement between two or more competent parties.  However, it can be argued that firms are not operating in a competitive market and the factors at play are such that agreements are not voluntary. Hospitals need to have a contract with the major private health insurance funds (suppliers). Some insurers have such a strong market position that they would be considered price makers, where others are considered to be smaller, and thus price takers. Smaller insurers are beginning to contract as a collective to improve market power, and the Australian Health Service Alliance now represents 28 of the 36 registered health funds, creating what they claim is the third largest buying group. 

Furthermore, a small day surgery that may be practitioner-led may not have an equal power relationship when entering a contracting arrangement, nor the ability to undertake the detailed financial modelling that insurers can use to gain a more attractive contracting outcome – this can effectively provide the ability for insurers to determine what small day practices remain viable. This is problematic as small day surgeries can remove cases from the higher cost environment of overnight hospitals, as well as be areas where innovation can flourish.

As a result of this imbalance, the AMA is beginning to see variations in contracts that shift the nexus of control from the provider/patient to the private health insurance fund – managed care. 

Publication of a practitioner’s details

Private health insurers offer gap cover schemes to provide their members with certainty about out-of-pocket expenses for their privately insured medical care. Medical practitioners electing to participate in a gap cover scheme must agree to the terms and conditions that are set by the insurer.  One of the common terms and conditions is that the medical practitioner agrees to information about them being published including their name, practice address, contact details, gap agreement usage and participation rate, and average gap charges. 

Bupa has a ‘Find a Healthcare Provider’ section of its website. It provides information on the gap payment that may apply with providers it is contracted with, as well as information on the percentage of services, roughly, under which providers participate in its gap scheme.

Nib, Bupa and HBF are major shareholders of a system called Whitecoat, which owns a database that provides information on practitioner charging patterns using data gleamed from the HICAPS system.  Under the Whitecoat system, a provider’s agreement with the payment processing system (HICAPS) will lead to publication in the directory.  The directory is segmented by insurer, and only a customer of Nib can find Nib data about a practitioner’s billing practices or percentage of services provided under a no-gap or known gap scheme. 

Not unlike Trip Advisor, the Whitecoat site also allows consumers to search, find and book a clinical provider as well as review and share their experience.  Whitecoat has stated that the customer reviews are vetted to ensure they do not contain clinical details, however, members have raised concerns that the vetting process is not foolproof.

Already it hosts over 40,000 providers (thus far, mainly allied providers such as dentists) and shares 250,000 patient reviews. Around six million private health insurance members will have access to this information.

However, these types of websites have the potential for significant unintended consequences. Far from helping health consumers, posting outcomes of treatment online could lead to reduced access to care, particularly for patients with chronic and complex health problems.

Referrals databases for consumers and general practitioners 

Medibank has announced it is providing information to the referrals database Healthshare that will allow general practitioners to identify specialists who charge gap fees.

This initiative will provide information to approximately 85 per cent of general practitioners as to which doctors are part of Medibank’s ‘no-gap’ or ‘known gap’ schemes. The converse of this is that general practitioners will therefore know which doctors are not part of Medibank’s ‘no-gap’ or ‘known gap’ schemes as they will not be on the Medibank list. 

Effectively this action by Medibank (which will undoubtedly be followed by the other large funds) could have a detrimental impact upon the referrals received by practitioners who are not part of Medibank’s ‘no-gap’ or ‘known gap’ schemes, as patients are increasingly weighing gap charges into their decision on which specialist they choose. It is a closed shop, and it means that who is the most appropriate clinician for the referral, based on medical advice, may not be the consumer’s driving motivation.

Again, this is a private health insurer influencing the provision of services and determining who may provide a service and, since they set the ‘no-gap’ or ‘known gap’ amounts, at what price.

Setting of premiums

The regulation of PHI premiums sits on top of this complex regulatory environment. It has a dual goal of protecting consumers from excessive pricing and the Commonwealth from fiscal risk. However, it has been argued by the PHI sector that this regulation provides an inefficient outcome.

Many stakeholders are of the view that the compliance costs of the premium setting process are out of proportion to the benefits that are obtained. These concerns tended to focus on the process being too long, the amount of information required, and claims that outcomes would be the same even if the requests for increases in insurance were not reviewed.

A relevant consideration to the process and its ongoing appropriateness is whether market failures exist in the PHI market that justify the current suite of regulations. There are 36 PHI entities competing in the market. However, the Australian industry is highly concentrated. The two largest insurers, Medibank and Bupa, have 55.4 per cent of the market.  The Private Health Insurance Administrative Council in 2013 indicated that there does not appear to be ‘unbridled competition’.

Premiums are a key driver in the choice of insurance for consumers. The increase in exclusionary products has not been at the expense of growth in excesses and co-payments that are also used to mitigate premium costs.This indicates that consumers are purchasing products with excesses, co-payments and exclusions to minimise their premiums. Therefore any methodology to set premiums must ensure that this product remains viable and attractive to consumers. 

PHI used to be run mainly by not-for-profit funds. However, around 70 per cent of the insured population are now covered by ‘for-profit’ funds. The shift to a for-profit industry has created a greater need to ensure that there are sufficient profits to allow a respectable return to shareholders. It would appear that the private health insurers are not averse to increasing premiums in order to ensure a sufficient return for their shareholders. APRA data show an industry surplus (before tax) of $1.56 billion for the 2015-16 financial year (up from $1.45 billion for the previous year).  Nib’s 2017 half-year results showed a sizable return on equity of 31.7 per cent.  

The Federal Government has a decided stake in ensuring participation in PHI. The Government’s regulatory environment of incentives and penalties all but guarantees customers to private health insurers and has ensured that the PHI industry is one of the Australian economy’s more protected industries. However, it also has the effect of undermining consumer confidence in the product.  Allowing an industry with limited competition to set its own premiums may contribute to a further decline in confidence.

The full submission can be found at:  submission/ama-submission-accc-report-senate-private-health-insurance

 Jodette Kotz 

AMA Senior Policy Advisor

 

The “surprise question” for predicting death in seriously ill patients: a systematic review and meta-analysis [Research]

BACKGROUND:

The surprise question — “Would I be surprised if this patient died in the next 12 months?” — has been used to identify patients at high risk of death who might benefit from palliative care services. Our objective was to systematically review the performance characteristics of the surprise question in predicting death.

METHODS:

We searched multiple electronic databases from inception to 2016 to identify studies that prospectively screened patients with the surprise question and reported on death at 6 to 18 months. We constructed models of hierarchical summary receiver operating characteristics (sROCs) to determine prognostic performance.

RESULTS:

Sixteen studies (17 cohorts, 11 621 patients) met the selection criteria. For the outcome of death at 6 to 18 months, the pooled prognostic characteristics were sensitivity 67.0% (95% confidence interval [CI] 55.7%–76.7%), specificity 80.2% (73.3%–85.6%), positive likelihood ratio 3.4 (95% CI 2.8–4.1), negative likelihood ratio 0.41 (95% CI 0.32–0.54), positive predictive value 37.1% (95% CI 30.2%–44.6%) and negative predictive value 93.1% (95% CI 91.0%–94.8%). The surprise question had worse discrimination in patients with noncancer illness (area under sROC curve 0.77 [95% CI 0.73–0.81]) than in patients with cancer (area under sROC curve 0.83 [95% CI 0.79–0.87; p = 0.02 for difference]). Most studies had a moderate to high risk of bias, often because they had a low or unknown participation rate or had missing data.

INTERPRETATION:

The surprise question performs poorly to modestly as a predictive tool for death, with worse performance in noncancer illness. Further studies are needed to develop accurate tools to identify patients with palliative care needs and to assess the surprise question for this purpose.

Why don’t we speak openly about doctor suicides?

Why don’t we speak openly about doctor suicides?

 

Just over a week ago, I read an obituary in a medical publication about a young talented and clearly lovely junior doctor. Her life and achievements were celebrated, but no mention was made of the cause of her untimely death. Some colleagues and I surmised it was suicide, but then we wondered why it was it was not mentioned in the obituary.  Subsequently, suicide was confirmed, but at the time it felt as though there was an embargo on talking about doctor suicide. There is a shame about discussing it in public, and if this is the case, how can we possibly learn about the things that lead to suicide in our colleagues? We discuss medical cases openly so that we might learn, but why not of our colleagues who reach a point of no return?

It is well known that doctors do have a higher rate of suicide than the general public. These results have been reported as being up to 5.7 times higher than the general public. Female doctors are at the greatest risk with rates 2.27 – 5.7 times higher.

These results are staggering, but the fact that we have suicide at all in the profession is indicative of a deep dis-ease in our profession.

How is it that we can have people who are caring by nature, who choose to do medicine to care for people, but ending up so despairing that they take their own life?

And worse, that their colleagues and medical friends do not notice their decline to that point and are often completely surprised to hear of the death of a colleague in such a fashion?

These suicide statistics have been known for some time, yet until now, no true action has been undertaken.

In response to recent matters, last month the NSW Health Minister Brad Hazzard, instructed his staff that they have one month to come up with a plan for the doctor suicide crisis. It is great to see urgency brought to this matter, but is one month really enough and will it really get to the root of the cause?

What we are looking at here are ingrained issues, where for so long suicide has been accepted as a “sad yet inevitable”, or an “occupational hazard”. I was taught the statistics as though it was an inevitability that could not be altered. But is this really the case, and is this the way we would or ought to approach other health issues?

As doctors, we care about the health of people in medicine, yet we do not appear to be taking the same care and attention to the health of people in our own medical community.

Doctor suicide occurs within the context of the health care system and culture

Increasingly the culture of medicine is being revealed as replete with bullying and harassment. Far from caring for health care professionals, the culture of medicine is that of judgement, critique, condemnation, blaming and shaming. There is no true care and attention brought to the health and well-being of doctors and we are not trained in any suitable way how to deal with the emotional demands of the job, nor are we taught how to look after our own health and well-being.

Medicine is not a culture of peer support, but rather of peer competition and judgement. Any sign of human vulnerability and feelings is seen as a sign of failure. Medicine teaches you to be a “doctor” and not who you are as a human being. You are taught to “toughen up”. You learn that only the tough survive. There is stigma for those with mental health issues. People become isolated, hiding what they are going through. There are definitely some cultural factors that need addressing.

I have heard it said more than once that medicine is more stressful than being in the army or in a war zone, and that there is more compassion for your well-being when you are a soldier. In such a harsh environment, does it really surprise us that people do not survive?

As health care experts, why are doctors ‘surviving’ and not thriving?

Doctor suicide is the end of a long line of health issues for doctors, who are well known to have worse mental health than the general population on a number of counts. For every doctor who actually dies by suicide there are many who make an attempt but survive. Statistics show that  40-55% of the profession are burnt out with all of the personal health issues that entails such as higher rates of cardiovascular disease, anxiety, depression, diabetes, musculoskeletal disorders and suicidal thoughts. 25% of the profession have thought about killing themselves.

Doctor suicide exists in a longstanding culture that is well established to be uncaring and, at times, frankly abusive towards its own professionals. Suicide is an absolute tragedy but the day-to-day ill health of the medical profession is also a serious issue that needs to be recognised.

If we are serious about dealing with doctor suicide, we need to address the entire medical culture and system including the educational, medico-legal and regulatory aspects as well as personal factors at play. We need to be willing to make the needed changes. But we cannot do that until we are completely open about it and willing to examine the issue in absolute fullness.

Given the long association of suicide with the medical profession, there is clearly something amiss and thus something that can potentially be rectified. Let’s not look for short term solutions. Let’s aim to truly address the situation in full and get to the roots of the matter. Lives depend on it.

Dr Maxine Szramka is a Sydney-based rheumatologist and Clinical Senior Lecturer at the University of Wollongong. She blogs regularly at Dr Maxine Speaks.

Doctorportal hosts a dedicated doctors’ health service providing support and information about suicide prevention in the medical community.

For support and information about suicide prevention, call Lifeline on 13 11 14

[Comment] A better world towards convergence of longevity?

Forecasting life expectancy by age and sex is broadly used for research and planning of health sevices, social services, pensions, and economics, and has been developed at the national and multicountry levels.1–3 The basic idea for predicting life expectancy is closely related to the concept of epidemiological transition.4 However, the idea is neither entirely based on evidence nor well-defined methodologically.2 Improvement in life expectancy is achieved through reductions in infant and younger age mortality and the progressive delay of mortality among older people.