more_vertThe comments by Simon Dimmitt and colleagues have already been addressed in a response to a previous letter from them.1 In particular, lowering LDL cholesterol more intensively with higher-dose statin therapy has been shown to produce larger reductions in vascular events than with smaller LDL reductions. With respect to the suggestion that adverse effects contribute to more than half of patients discontinuing statin therapy, results from randomised masked trials have shown that patients are no more likely to discontinue statin therapy than placebo; that is, Dimmitt and colleagues confuse attribution with causation (as did John Abramson and colleagues2,3).
Preference: Anaesthesia and Intensive Care
62
[Correspondence] Preventing delirium: beyond dexmedetomidine
The incidence of postoperative delirium in elderly patients is very high, particularly in patients admitted to the intensive care unit (82%) and those who have undergone major orthopaedic (51%) or cardiac (46%) surgery.1 Postoperative delirium is associated with increased morbidity, mortality, and health-care costs; however, no preventive pharmacological strategies are available.1 A Lancet study by Xian Su and colleagues (Oct 15, p 1893)2 offers new hope. Treatment with dexmedetomidine in elderly patients admitted to the intensive care unit after non-cardiac surgery reduced the incidence of delirium from 23% to 9%.
[Correspondence] Preventing delirium: beyond dexmedetomidine – Authors’ reply
We thank Sinziana Avramescu and colleagues for their comments regarding the underlying mechanism of dexmedetomidine to reduce delirium in elderly patients in the intensive care unit after surgery. We agree that the reduction of delirium incidence seen after treatment with low-dose dexmedetomidine infusion might occur because of the drug’s neuroprotective effects, which have been well documented previously.1 In our previous study,2 these neuroprotective effects were shown to be mediated through α2A adrenoceptors.
The new normal
DR JOHN ZORBAS, CHAIR, AMA COUNCIL OF DOCTORS IN TRAINING
Something strange happened to me recently that reminded me of how badly calibrated our frames of reference can be. I’m a dual trainee, and with the new training year upon us, I was migrating from the calm and collected ivory tower of the intensive care unit, back down to the chaos and madness in the pit of the emergency department. It’s clear that I like really sick people; I just can’t seem to decide on the speed of sickness that I prefer. Fast or slow? I relished the change of pace. It was frenetic. We were getting things done. I was happy.
And then we had a teaching session. One of those beautifully peaceful moments when you leave the emergency floor and you enter the tranquillity of education. We discussed stroke management. I spoke about ultrasound. So far, so good. All normal. Our director of training asked us how we were going and he made specific mention of just how busy we’d been lately. I took note and thought “OK, so we’ve had a busy few days. Nothing new here”. He kept probing and then the other trainees started talking about the pace. It then became abundantly clear to me that the last few weeks were not normal. They were chaos. The cubicle pressure, the acuity of the presentations, the backlog in the hospital… none of this was normal. Not by a long shot.
It might not sound much, but I was quite shocked by just how incorrect my frame of reference was. If you don’t have a good frame of reference, you start to misjudge things that happen. What you explained away as a quirk of the system could quite easily become a serious medical error. And so, with this new calibration I started to re-hash the events of the past few weeks. What had I missed? If this pace wasn’t normal, had I expected too much of my juniors at any point? Had I been too hasty with investigations, or documentation? What pressures had I placed on my nursing staff? Looking back with this new frame, I made my peace. Yes, things were fast. No, they hadn’t been unsafe. But I remained shocked with this error of calibration. The compass was off, and a bad compass leads you to icebergs.
I’ve been a doctor for eight years now, and in that time, I’ve had to recalibrate on several occasions. I’m no expert and I’m certainly no source of truth, but here are some common “normalities” I’ve encountered along the way:
It’s not normal to excel at every assessment along the way, and it’s normal to fail. We’ve created this system of training in which hypercompetitive medical students vie for the “best” internship (whatever that is supposed to mean) and endlessly buff their CVs to achieve immortal greatness in the specialty of their choice, to the exclusion of all others. This type of system demands that doctors perform at 100 per cent of their operating capacity, at all times, which just isn’t reasonable. I’ve spoken before about the green and red lights of assessment, and the dire lack of orange lights along the way. This isn’t normal outside of medicine and it shouldn’t be normal within it. We need systems of assessment that don’t demand shiny whitewashed walls of achievement. The odd coffee stain isn’t just acceptable, it should be encouraged. It should be a badge of honour, because stains draw attention, and they allow you to focus on how to improve yourself rather than improving at assessment. Use your frame of reference to improve, not to impress.
It’s not normal to not see your loved ones for days at a time. My partner works shift work as well, and our training has meant that while I rode the escalator down into the pit of mayhem, she’s taken the elevator to the top of the afore-mentioned tower. She relishes the opportunity to have a good laugh when I call from ED for ICU to please come and join the party. We’re less jovial about our jobs when we’re passing ships in the night, only seeing each other at the start and finish of shifts for a quick chat and a kiss goodnight. Now don’t get me wrong, we’ve chosen this life and these rosters. However, no matter how you paint it, it isn’t normal. We have had to take these runs as a sign to slow down and be sure to spend quality time with each other. If you’re going to roster work, make sure you roster life.
It’s not normal to be so close to death all the time. I’ve chosen two particularly bloody specialties, and death (often horrific death) is not uncommon. And yes, your temperament for death will be part of what guides you to your specialty. But death like this shouldn’t ever be normalised. We need to remember to debrief with those around us, especially for new staff who might not be used to the abnormality of death on invasive organ support. To extend this further, I’d like to also point out that death of our colleagues is never, ever normal. It should be treated with the utmost of seriousness and should always result in an organisational response. We should never expect doctors to just get back to business as usual when they lose a peer.
It should be normal to enjoy your job. It should be normal to be proud of your profession. It should be normal to have a healthy workplace culture. Sometimes we hit these points of normality and at other times we don’t. For my part I’m going to keep checking that compass. Pick up the deviations before we get lost, lest we run into icebergs.
Understanding the language of intensive care physicians
The surgical critical care handbook. Guidelines for care of the surgical patient in the ICU.
Jameel Ali, editor. World Scientific, 2016 (756 pp, US$175.00). ISBN 9789814663120
In the United States, surgeons (also known as surgical intensivists) often directly manage patients in the intensive care unit (ICU). Taking this into account, and despite the need to “translate” words such as “epinephrine”, “norepinephrine” and “respirologist”, I approached The surgical critical care handbook as an Australasian surgeon wishing to be conversant in the language of the intensivists to whom I entrust the care of my critically ill patients. In that respect, the book edited by Jameel Ali, Professor of Surgery and Advanced Trauma and Director of the Life Support Program at the University of Toronto, is generally fit for purpose, written in a broadly conversational style by a number of expert contributors. While not overly burdened with levels of evidence or results of randomised controlled trials, sufficient references are nonetheless provided to direct readers to the scientific background or details of operative surgery.
In a conventional conceptual framework, the book comprises two sections. “General considerations” deals largely with the various aspects of management that constitute critical care, including ethical considerations, and also involves a modicum of theoretical underpinning in respiratory physiology. “Specific surgical disorders” is a series of chapters on the pathophysiology, investigation and treatment of traumatic and non-traumatic conditions that require critical care.
The information provided in The surgical critical care handbook is as up-to-date and clinically applicable as it can be. It is reassuring to see mention of issues of increasing topical interest, such as bariatrics, transplantation and iatrogenic coagulopathies. Topics that may have needed a more in-depth discussion include chronic liver disease or liver failure in the surgical patient, major vascular injuries and other vascular pathologies, and penetrating neck trauma. Where relevant, details of surgical procedures in ICU patients are provided in sufficient detail, although the ICU-naive probably would have appreciated some specific chapters on inotropic support and monitoring modalities.
In the Australian setting, this book may be a useful resource for practitioners such as rural generalists. Surgical trainees may also find it a user-friendly aid to examination preparation and as a quick reference for problems encountered in everyday practice.
Stress and burnout in intensive care medicine: an Australian perspective
A call for a multilevel response to an evolving challenge
Intensive care medicine (ICM) is an evolving high stakes specialty. Emerging evidence raises questions about the welfare and sustainability of the ICM workforce. Clinician burnout is a phenomenon resulting in consequences for both intensive caregivers and patients.
While resident doctors, fellows and new consultants across many specialties display high levels of stress and burnout relative to the general population,1 ICM clinicians are disproportionately affected, rating higher on stress, burnout and compassion fatigue indices.2 Paediatric intensivists have markedly higher burnout rates than general paediatricians.3 An Australian ICM study described an 80% rate of psychological stress and discomfort in a practising ICM specialist population, with many reporting burnout symptoms.4
Burnout is a state of psychological distress related to chronic stress. Prevalence estimation using different tools, alternate metrics and cut-off points have made epidemiological studies of ICM clinician burnout challenging.5 The Maslach Burnout Inventory is the most commonly used burnout instrument in this area and scores three major characteristics of burnout: emotional exhaustion, depersonalisation and low levels of personal effectiveness.4 Intensive care unit (ICU) physicians and nursing staff have similar rates of burnout symptomatology, with ICU nurses reporting higher emotional exhaustion rates and ICU physicians reporting higher rates of depersonalisation and reduction in professional achievement.6 These trends suggest specific risk factors within the ICM environment.
The burnout syndrome has been described in Australian emergency medicine clinicians.7 Some protective influences appear to be ongoing professional development, dedicated non-clinical time, and a feeling of teamwork.7 Burnout does not necessarily correlate with job satisfaction, with predisposing factors in this group including younger age, workplace conflict, a lack of exercise, and excessive alcohol consumption.7 In addition to many of these stressors, intensive care clinicians are repeatedly exposed to high stakes, ethically challenging decision-making processes. The high “density” of ethical decision making in ICM contributes to moral distress and may be exacerbated by the provision of “disproportionate care”, where there is a perceived inappropriate or harmful mismatch between the level of care provision and a patient’s needs.8
Care of the health care provider and quality of patient care are interconnected. Physician burnout has been associated with lower patient satisfaction, reduced health outcomes and medical error.2 Burnout symptoms reduce potential ICM workforce capacity through increased sick leave and decreased staff retention.2 The consequences of burnt out clinicians may ripple through an entire organisation, compromising interactions between individuals and teams.
Evolving trends in Australia may further exacerbate the problem of burnout. These changes include greater intensivist coverage and shift work, an increasingly fractionalised workforce with unequal gender balance, and an evolving external and ward ICM responsibility. The move towards physically larger Australian ICUs has coincided with enhanced societal expectations of clinical outcome and an increase in interventional medicine.
We advocate for a multilevel strategy in order to address ICM workforce sustainability and welfare. The prevention and remediation of burnout requires consideration of both individual and systemic factors.9
At an individual level, a holistic approach to the ICM clinician, not just as a service provider, is required. A balance must be facilitated between work, life, clinical and non-clinical duties and career progression. Stress prevention and resilience strategies include mindfulness and cognitive techniques, coaching, mentoring and, perhaps most importantly, peer discussion.
Leadership from clinicians will be important to drive change at an institutional level. Compassionate staffing, flexible rostering, ensured leave and ongoing employee assistance programs should be broadly available. Clinicians themselves will need to foster an acceptance of their own vulnerability and cultivate an environment where open dialogue about stressors is respected.10
The College of Intensive Care Medicine and the Australian and New Zealand Intensive Care Society have roles to play in the development of performance indicators for workplace stress and burnout, with complementary advocacy for a safe, sustainable workplace. The ICM training model should encompass self-assessment and resilience skills, supported by commensurate training of trainee supervisors and senior staff.
A broader societal discussion about the antecedents of moral distress and disproportionate care is required. Shared health goal setting before crises and preparing for realistic, appropriate decisions at the end of life continue to be of great importance. Such projects may be supported at government level, with direct expert input from ICM clinicians.
While there is increasing evidence of the physical and emotional effects of the unique ICU environment on inter-professional practitioners, there remains a paucity of coordinated interventions aimed at understanding and addressing ICM clinician burnout. We advocate for a multilevel response in order to improve the welfare and sustainability of the Australian ICM workforce.
Maternal morbidity and perinatal outcomes among women in rural versus urban areas [Research]
Background:
Most studies examining geographic barriers to maternity care in industrialized countries have focused solely on fetal and neonatal outcomes. We examined the association between rural residence and severe maternal morbidity, in addition to perinatal mortality and morbidity.
Methods:
We conducted a retrospective population-based cohort study of all women who gave birth in British Columbia, Canada, between Jan. 1, 2005, and Dec. 31, 2010. We compared maternal mortality and severe morbidity (e.g., eclampsia) and adverse perinatal outcomes (e.g., perinatal death) between women residing in areas with moderate to no metropolitan influence (rural) and those living in metropolitan areas or areas with a strong metropolitan influence (urban). We used logistic regression analysis to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CIs).
Results:
We found a significant association between death or severe maternal morbidity and rural residence (adjusted OR 1.15, 95% CI 1.03–1.28). In particular, women in rural areas had significantly higher rates of eclampsia (adjusted OR 2.70, 95% CI 1.79–4.08), obstetric embolism (adjusted OR 2.16, 95% CI 1.14–4.07) and uterine rupture or dehiscence (adjusted OR 1.96, 95% CI 1.42–2.72) than women in urban areas. Perinatal mortality did not differ significantly between the study groups. Infants in rural areas were more likely than those in urban areas to have a severe neonatal morbidity (adjusted OR 1.14, 95% CI 1.02–1.29), to be born preterm (adjusted OR 1.06, 95% CI 1.01–1.11), to have an Apgar score of less than 7 at 5 minutes (adjusted OR 1.24, 95% CI 1.13–1.31) and to be large for gestational age (adjusted OR 1.14, 95% CI 1.10–1.19). They were less likely to be small for gestational age (adjusted OR 0.90, 95% CI 0.85–0.95) and to be admitted to an neonatal intensive care unit (NICU) (adjusted OR 0.36, 95% CI 0.33–0.38) compared with infants in urban areas.
Interpretation:
Compared with women in urban areas, those in rural areas had higher rates of severe maternal morbidity and severe neonatal morbidity, and a lower rate of NICU admission. Maternity care providers in rural regions need to be aware of potentially life-threatening maternal and perinatal complications requiring advanced obstetric and neonatal care.
[Correspondence] Antibiotic-impregnated catheters for prevention of bloodstream infection – Authors’ reply
Jaiben George argues that use of antibiotic-impregnated central venous catheters in paediatric intensive care contributes to the emergence of antibiotic resistance, which might diminish the effectiveness of systemic antibiotics given to children. The similar rates of antibiotic resistance in all three groups in the CATCH trial probably reflects background rates of resistance.1,2 The trial was underpowered to detect differences related to type of central venous catheters; nevertheless, there have been no published reports of increased antibiotic resistance, despite use of antibiotic-impregnated central venous catheters in adults over the past 20 years, and numerous trials involving these catheters.
Getting difficult to call Australia home
Disillusioned National Health Service doctors have been warned that they may find it difficult to get work in Australia.
Dr John Zorbas, Chair of the AMA Council of Doctors in Training, told the Financial Times that Australia’s long-standing reliance on overseas trained doctors to fill gaps in the medical workforce was waning.
Dr Zorbas said the although international medical graduates (IMGs) from around the world, including the United Kingdom, had made a “critical” contribution to the medical workforce in the last 15 years, demand was easing as an increasing number of locally trained doctors were graduating.
“IMGs looking to come to Australia need to know that job opportunities are limited, often confined to short-term roles or areas of medical workforce shortage like rural locations,” he said.
In the past 12 years the number of medical school graduates has more than doubled from 1500 to 3700 a year, creating intense pressure for advanced specialist training places.
As a result, the Government is considering removing a number of specialties from the Skilled Occupations List used to assess applications for permanent residency, including general practitioners, anaesthetists, intensive care specialists, gastroenterologists and obstetricians.
“We do not expect that this will have a big impact as there will still be other visa options available,” Dr Zorbas said. “However, it is the first sign that we are overcoming medical workforce shortages and are less reliant on international recruitment.”
He said data showed overall doctor numbers in Australia were “in balance”, even though they were not evenly distributed by location or specialty.
Adrian Rollins
Penny pinching threatens chronic care reform
The Federal Government’s landmark Health Care Homes reform is at risk of collapse because of a lack of funding, the AMA has warned.
Health Minister Sussan Ley has announced that $100 million will be provided to support the phase one trial of the reform, involving 65,000 patients and 200 medical practices in 10 regions across the country.
Under the Government’s plans, practices will receive monthly bundled payments worth an average $1795 a year to manage patients with chronic and complex health conditions. Payments will vary from $591 for chronically ill patients who can largely self-manage their condition to $1267 for those who need more intensive care and $1795 for those with the most complex health demands.
The allocations mean that patients on the lowest level of subsidy will be funded for just 16 visits to the doctor a year, rising to 48 visits a year for those deemed of highest need.
Controversially, such patients would only be eligible for five extra Medicare-subsidised visits to the doctor for health issues that lie outside their chronic illness – a major change from the current system under which patients have uncapped access to GP care.
A spokesperson for Ms Ley told Fairfax that five-visit cap was only an “indicative figure for modelling and planning purposes”, and said no patient would have their access to Medicare restricted or capped.
Ms Ley said Health Care Homes allowed for team-based, integrated care and would provide increased flexibility and coordination of services to tailor treatment to individual need.
But the details of the trial have reinforced suspicions that the Government is undertaking Health Care Homes primarily as a cost cutting exercise, and the AMA voiced concerns that if the reform was not adequately funded it could founder.
“The modelling is concerning and potentially leaves the whole program at risk of falling over because of being underfunded from the beginning,” AMA Vice President Dr Tony Bartone told News Corporation.
Dr Bartone, a GP, is the AMA’s representative on the Government’s Health Care Home Implementation Advisory Group, which last met on 30 September.
He said that, if appropriately funded, Health Care Homes could support GPs to keep patients healthier and out of hospital, but added the Government needed the goodwill of general practitioners if its trial was to succeed.
“That goodwill will evaporate significantly if there is not the appropriate funding,” he warned.
Earlier this year, AMA President Dr Michael Gannon warned that appropriate funding would be a “critical test” of the success or otherwise of the reform.
“BEACH data shows that GPs are managing more chronic disease. But they are under substantial financial pressure due to the Medicare freeze and a range of other funding cuts,” Dr Gannon said.
“GPs cannot afford to deliver enhanced care to patients with no extra support. If the funding model is not right, GPs will not engage with the trial and the model will struggle to succeed.”
Adrian Rollins