Tobacco smoking – enough of the puff

BY ROB THOMAS, PRESIDENT, AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

It is no surprise that the smoking of tobacco has decreased significantly from a generation ago, amid targeted and widespread programs to deter its use. Indeed, in Australia we seem to view our stringent tobacco legislation and divestment movements as huge wins for public health. However, what may come as a surprise is that our smoking rates are still roughly one in seven people, and it continues to cause more deaths than alcohol and illicit drugs combined.

As a young person, I’m astounded when I see friends and other young people lighting up. On the one hand, it’s probably good that myself and others have such a cultural distaste for this deadly habit, but on the other it’s tragic to see people beginning something that they will inevitably struggle with for years.

Like many medical students, I’ve spent time in respiratory medicine and seen patients dying of cancer, infection and chronic obstructive pulmonary disease, where people describe their existence as “slowly drowning”. There is simply no safe level of tobacco consumption. It shocks me that this harsh reality, not just the threat of cancer, causes more than 15,000 Australian deaths per year and yet young people continue to pretend they’re invincible.

Interestingly, in the US and UK, smoking rates are now dropping to comparable or even lower levels than in Australia, where our plain packaging and advertising laws are very strong. On a pure price disincentive, we still have some of the most expensive cigs in the world, yet perhaps we are starting to see diminishing returns on smoking rates. Clearly, more needs to be done.

Earlier in the year, AMA President Dr Michael Gannon gave out the “Dirty Ashtray Award” to the State most behind on their smoking crackdown. The Northern Territory, 11-time recipient of that award, has a rate of smoking of more than one in five, with comparatively lax laws regarding smoking in pubs, clubs and even schools. We cannot sit by while children and young people are indoctrinated into a culture where smoking is tacitly accepted.

Some advocates for smoking reduction have looked at the possibility of e-cigarettes as a tool for cessation or alternative. We must be wary of these products, none of which have yet proved to be useful as cessation tools, and may in their use and marketing make smoking more socially acceptable.

Many universities have some form of a tobacco-free policy available on their websites. However, many of these are not enforced or incomplete, meaning that smoking and particularly passive smoking continue. As medical students, we call for more stringent tobacco-free policies to reduce prevalence and change attitudes.

While universities are a great target, we need also to ensure that smoking-related disease does not become a disease of the poor. There is a significant gap in smoking rates between the highest and lowest economic quintiles (8.0 per cent and 21.4 per cent respectively). Although this gap is slowly closing, we need to pursue methods of education and intervention that promote equity and work for the people most at risk.

At the patient level, it’s important for doctors to remain vigilant, to work with smokers to quit. We acknowledge this is not easy, it is often a long and relapsing process, but ultimately it cannot just be ignored. Thankfully in medical school we are taught some of the tools of motivational interviewing, but we can’t afford complacency.

Complacency cannot be afforded at the Government level, too. The Council of Australian Governments several years ago made the target of 10 per cent daily smokers by 2018, a rate we may just fall short of. Continued efforts, including banning in public places, availability of support to quit programs and widespread public education need to continue. This is not a fight we can say we’ve won just yet.

Twitter: robmtom
Email: rob.thomas@amsa.org.au

Indigenous sexual health

BY AMA PRESIDENT DR MICHAEL GANNON

While successive governments have made significant efforts to address major chronic health problems experienced by Aboriginal and Torres Strait Islander people, sexual health issues are often left off the agenda. The rates of HIV and sexually transmitted infections (STIs) within Indigenous communities are increasing at alarming rates, and Aboriginal and Torres Strait Islander people are disproportionately affected by these conditions.

The serious consequences of untreated STIs are well documented, some of which are known have long-term effects on health. Syphilis, for example, is highly infectious and can cause heart and brain damage, while diseases such as gonorrhoea and chlamydia can lead to infertility and chronic abdominal pain. Not only do STIs affect a person’s physical wellbeing and further increase the risk of HIV infection, but the stigma attached to STIs can result in social isolation.

In 2015, the rate of syphilis among Aboriginal and Torres Strait Islander peoples was over six times higher than that of the non-Indigenous population, and in some remote areas, this rate rose up to a staggering 132 times higher. Indeed, almost 80 per cent of STIs among Indigenous Australians are found in remote communities, and a number of underlying risk factors such as poor access to health services, culturally inexperienced clinical staff, and a particularly young population contribute to such high infection rates.

In recent years we have seen significant progress in both the diagnosis and treatment of STIs and other preventable diseases. However, a syphilis outbreak across northern Australia has recently caused the number of STIs to rapidly rise and has already led to the death of at least four Indigenous Australians. This is completely unacceptable.

These statistics, while incredibly concerning, highlight a growing problem facing Indigenous Australians when it comes to their sexual health and wellbeing. It is clear that urgent action must be taken to address the high rates of STIs in Indigenous communities.

The Federal Government has shown some promise in addressing sexual health issues in Indigenous communities, by forming a Multi-jurisdictional Syphilis Outbreak Working Group to help prevent disease transmission and outbreak, and supporting the South Australian Health and Medical Research Institute to partner with the Aboriginal Nations Torres Strait Islander HIV Youth Mob to deliver awareness and education campaigns to Indigenous Australians across the country.

Yet, in March 2017, the Government confirmed the inexplicable scrapping of federal funding for both the Northern Territory AIDS and Hepatitis Council and the Queensland AIDS Council, all without conducting any community consultations or directly evaluating the programs themselves. For more than two decades, both services have delivered vital sexual health programs to remote and regional communities that experience difficulties accessing mainstream health services, and have developed close relationships with the communities that they serve. The cut in federal funding is set to bring these programs to an unfortunate and indefinite close, but it is services like these that play a key role in improving sexual health outcomes for Aboriginal and Torres Strait Islander people.

Living with a sexually transmitted disease is not just an individual health issue, but one that can impact the entire community. As HIV and STI rates for Aboriginal and Torres Strait Islander people continues to rise, we should not be cutting existing services aimed at improving sexual health practices in Indigenous communities.

The AMA understands that the Government has confirmed it will undertake an evaluation of a $24 million funding proposal to address STIs in Indigenous communities through eliminating syphilis, preventing HIV, health education, and STI screenings through outreach in vulnerable regions. However, we also understand that an outcome on this evaluation has yet to be announced.

The AMA would like to see the Government invest in areas to support ongoing efforts to address Indigenous sexual health problems, and ensure that culturally safe health care remains accessible to all Aboriginal and Torres Strait Islander people to help control the spread of STIs.

Supervisors – powerhouses of the medical workforce

By AMA VICE PRESIDENT DR TONY BARTONE

I recently had the opportunity to reflect momentarily on how our well-oiled training allows us to so confidently and expeditiously care for our patients in a vast array of situations. One of my colleagues in the clinic had to attend to a patient with chest pain in the treatment room, something most of us have had to deal with. Making sure he did not need extra assistance, I observed the calm yet confident manner with how he dealt with the critical situation.

We can do all of those things because of our medical training and education, the clinical and professional skills we learned from working with dedicated supervisors, who in many cases become our mentors and friends.

The standard of medicine practised in Australia is consistently ranked among the best in the developed world. This is because we have a highly trained medical workforce based on the established apprenticeship model, with our Colleges maintaining education and independently determined training standards.

However, this model which has served us so well in the past is now at risk. Insufficient postgraduate positions and increasing numbers of graduates and aspiring trainees are stretching the system.

Continual advocacy by the AMA has ensured that there is a growing awareness that we do not have enough prevocational and specialist training places for the increasing number of new doctors. Whether governments and health policymakers are fully awake to the urgency of these worsening shortages is a topic for another time.

Unfortunately, I think it’s forgotten sometimes that clinical supervisors are the powerhouses of our apprenticeship model of training doctors. For the AMA, it is clear that to meet the challenge of training the expanding medical workforce, more clinical supervisors need to be found, supported and properly recognised and rewarded.

Boosting supervision capacity is a pivotal issue for our doctors in training, and the AMA has developed a significant suite of policy proposals and ideas in recent years.

To assist our ongoing advocacy, the AMA, led by the Medical Workforce Committee, has prepared a position statement that brings together these policies into a stand-alone document.

Building Capacity for Clinical Supervision in the Medical Workforce 2017 affirms our view that training and supervising new doctors is just as important as delivering services in the health system.

The document emphasises that the apprenticeship model of medical training is as relevant as it was as five decades ago, and shows that building supervision capacity across the spectrum of public, private, general practice and rural settings has common and unique sets of challenges and solutions.

Any discussion on this issue should not neglect the importance of ensuring that clinical supervisors have the support they need to train the next generation of doctors, as well as fostering a culture within medicine that encourages teaching and training.

From a personal perspective, many of my colleagues and I have found supervising junior colleagues to be a demanding yet thoroughly rewarding experience, with much gained in return.

Regrettably, I hear from different sources that protected time is not always available for teaching and training and simply added onto other responsibilities. Worse still, I hear many stories of those who have ended their roles because of a lack of support time or resources. I also know of VMOs and staff specialists who are actively discouraged from setting aside time for these activities. This makes no sense at all. Surely, now is the time to be boosting, not diminishing support for our supervisors.

Building Capacity for Clinical Supervision in the Medical Workforce 2017 outlines what the AMA believes has to be done from the industrial, financial, regulatory and cultural perspectives. I encourage you to take a look.

advocacy/position-statements

[Editorial] Extreme rain, flooding, and health

The unprecedented volume of rain and floods during the past few weeks is difficult to comprehend. More than 1400 people in south Asia are dead and tens of millions more have been affected by extreme monsoon rains. The worst flooding in 100 years has left one third of Bangladesh submerged. In Nepal, almost half a million people are food insecure. More than 7000 schools have been damaged in India at the height of the exam season, with the result that many children will not complete their education.

[Series] Palliative care and management of troublesome symptoms for people with chronic obstructive pulmonary disease

People with advanced chronic obstructive pulmonary disease (COPD) have distressing physical and psychological symptoms, often have limited understanding of their disease, and infrequently discuss end-of-life issues in routine clinical care. These are strong indicators for expert multidisciplinary palliative care, which incorporates assessment and management of symptoms and concerns, patient and caregiver education, and sensitive communication to elicit preferences for care towards the end of life.

Drink and drugs, a time bomb for baby boomers

In both the UK and Australia, risky drinking is declining, except among people aged 50 years and older, new research has found.

Researchers at Flinders University and South London and Maudsley NHS Foundation Trust in England, published their findings in the BMJ, inAugust this year.

The authors believe that Western countries are sitting on a time bomb of health and social issues arising from drug and alcohol overuse among baby boomers, including a worrying trend for episodic heavy drinking in this age group.

“Alcohol is the most common substance of misuse among baby boomers which presents the most concern because of the larger number of users and wide range of negative consequences,” said Professor Ann Roche, Director of the National Centre for Education and Training on Addiction at Flinders University.

The research also found that this generational trend is not restricted to alcohol.

“Some of the pharmaceutical drugs such as opioids also have severe consequences associated with their use,” Professor Roche said.

In Australia, the largest percentage increase in drug misuse between 2013 and 2016 was among people aged 60 and over, with this age group mainly misusing prescription drugs.

However, people over 50 also have higher rates than younger age groups for both past year and lifetime illicit drug misuse (notably cannabis).

The authors are keen to highlight that this older age group’s alcohol and drug use presents specific issues that are not common in younger demographics.

“Ageing reduces the body’s capacity to metabolise, distribute and excrete alcohol and drugs, and older people are also more likely to have pre-existing physical or psychological conditions or take medicines that may negatively interact with alcohol and drugs,” Prof Roche said.

“There is also a reduction in lean body mass, resulting in higher alcohol-drug blood concentrations,” she said.

The authors of the research are calling for a coordinated international approach to manage this rapidly growing problem, including treatment programs adapted for older people with substance misuse rather than those aimed at all age groups.

“There remains an urgent need for better drug treatments for older people with substance misuse, more widespread training, and above all a stronger evidence base for both prevention and treatment,” they state in the BMJ editorial.

Dr Rao and Professor Roche said the growing influence of baby boomer substance misuse will continue to present challenges for healthcare service delivery for older people.

The study also notes that it is an additional concern the increasing proportion of women drinking in later life, particularly those whose alcohol consumption is triggered by life events such as retirement, bereavement, a change in home situation, infrequent contact with family and friends, and social isolation.

The AMA questioned the priorities of the recently released National Drug Strategy 2017-2026, noting whilst alcohol in Australia is associated with 5,000 deaths and more than 150,000 hospitalisations each year, the Strategy puts it as a lower priority than ice.

AMA President Dr Michael Gannon said he believes support and treatment services are severely under-resourced, even though the costs of untreated dependence and addictions are staggering. Alcohol-related harm alone is estimated to cost $36 billion a year.

The broader community impacts of those affected by dependence and addictions are more likely to have physical and mental health concerns, and their finances, careers, education, and personal relationships can be severely disrupted, Dr Gannon said.

The AMA’s Harmful Substance Use, Dependence, and Behavioural Addiction (Addiction) 2017 Position Statement can be read at position-statement/harmful-substance-use-dependence-and-behavioural-addiction-addiction-2017.

MEREDITH HORNE

Health Star Rating – five years on

Five years ago I authored a column in Australian Medicine advising members that after concerted advocacy on the need for easy to improve food labelling, the AMA had been recognised as a key stakeholder and invited to join the Front of Pack Labelling Stakeholder Working Group.

The Group, chaired by Jane Halton AO PSM, then Secretary of the Federal Department of Health and Ageing, was tasked with developing a new approach to front-of-pack labelling that would help consumers identify healthier packaged food options.

We recognised that the Nutrition Information Panel was too complex, and often too small to help consumers. The move also recognised that there was some level of dissatisfaction with the two most popular front-of-pack labelling approaches at the time. I welcomed the invitation to participate but am sure there was a level of scepticism about whether this diverse group of stakeholders could work together to create and implement a system that would support Australians to make healthier choices.

Five years on and the AMA has just lodged its submission to the Five Year Evaluation of the Health Star Rating system. Health Star Ratings (HSR) are now found on over 7,000 products, produced by 122 manufacturers, in major supermarkets Coles, Woolworths and Aldi. It appears that the HSR system is largely working as intended. A representative survey conducted with 1000 participants recently found that:

59 per cent were aware of the Health Star Rating system;
50 per cent were likely to use HSR on a regular basis; and
Of those using HSR, 33 per cent recalled buying a different product because it had a higher HSR.

Some food producers are reformulating their products in order to achieve a higher HSR. Regardless of the motive, removing unnecessary salt, sugar and fats from processed foods is beneficial. The AMA’s submission has recommended monitoring the number of reformulations to provide important insights into the effectiveness of the HSR system in driving change.

Consumers report that they would like to see HSR on more products. If uptake in a particular food category is low it can make comparisons difficult. The HSR system is currently voluntary, but it is essential that the food industry recognises the benefit to consumers and displays the HSR on as many products as possible. On this point, the AMA’s submission argued that any slowing of uptake should result in active consideration of the HSR becoming mandatory.

There have been some vocal critics of the HSR, but the reality is that most are not responsible for the weekly grocery shopping, the target audience for HSR. The criticisms typically focus on three issues. Firstly, that the system can’t be used to compare a can of baked beans with a tub of yogurt. This was never the intention of the HSR, rather instead it helps consumers compare similar products in order to identify the healthiest option.

Further criticism highlights that certain foods receive an inappropriately high HSR. The HSR Advisory Committee takes these concerns seriously. For example, the rules around products that display HSR based on how they are prepared (cake mixes, powdered soup, sauce mixes or drink flavourings) are currently under review.

Finally, some advocate that HSR apply to fresh foods. This was never the intention, with the HSR applying only to manufactured and processed products. A general principle that “fresh is best” is recognised by the AMA and we continue to advocate for more public education on nutrition. The HSR isn’t perfect, but it is certainly much better than nothing.

The AMA submission also advocates that HSR play a role in helping consumers to reduce consumption of ‘added sugars’ through penalisation of these additions. A recent report by the George Institute found that 70 per cent of packaged foods contain added sugars. Current labelling doesn’t provide any distinction between naturally occurring and added sugars, making it extremely difficult for consumers to identify products that contain unnecessary added sugars. Food labelling alone will not address obesity, but supporting consumers to identify healthier food products will play a part.

PROFESSOR GEOFF DOBB
AMA BOARD MEMBER

The AMA’s submission is available from: submission/ama-submission-five-year-review-health-star-rating-system

AMA letting legislators know its views on pharmacy review

Below is an edited version of the AMA’s submission to the Pharmacy Remuneration and Regulation Review Interim Report.

Overall, the AMA considers the recommendations, if implemented, will benefit consumers by improving access to affordable medicines and enhancing the quality of medicines related care provided by pharmacists.

The AMA’s submission focuses on the recommendations and options described in the interim report which impact patient care.

The recommendations and options relating to patient access to medicines and their experiences within pharmacies appear sensible and well considered.

In particular, the AMA supports:

improvements to the PBS Safety Net which would enhance patients’ understanding and access, for example, the introduction of a central electronic system that automatically tracks individual patient PBS expenditure;
audits of pharmacy compliance with medicines dispensing requirements, such as correct medicines labelling and the provision of Consumer Medicines Information leaflets, in line with State/Territory legislation and Pharmacy Board of Australia and Pharmaceutical Society of Australia guidelines; and
improvements to electronic prescription systems and medication records to enhance continuity of care and reduce medication errors. However, the AMA notes that prescribing software would require updating to enable full electronic prescribing and that a small, but still significant, proportion of medical practitioners do not use these systems, especially in rural/remote locations with poor internet connections.

The AMA supports the Review recommendation that homeopathic products should not be sold in PBS-approved pharmacies. Selling these products in pharmacies encourages consumers to believe they are efficacious when they are not.

The AMA notes the interim report proposal that if pharmacists provide a service that is also offered by alternative primary healthcare professionals, the same Government payment should be applied to that service. While a service may superficially appear the same, it is important to recognise that the delivery, quality and comprehensiveness of that service may differ between health professionals and the context within which it is provided.

For example, a patient administered a flu vaccine in a pharmacy just receives a flu vaccine. A patient receiving a flu vaccine administered by a General Practitioner also receives a preceding consultation which includes a health assessment specific to that patient, based on a sound understanding of the patient’s past history and health needs.

This might include a check whether the patient’s other recommended vaccinations are up-to-date, whether a cervical screening test is due, a blood pressure check if appropriate, a check of the patient’s adherence and tolerance of any prescription medicines, and any other appropriate and (evidence-based) opportunistic preventative health care.

Even if the General Practice employs nurse practitioners to deliver the vaccine itself, a patient has first been assessed by a General Practitioner who continues to be close at hand if needed.

If the Commonwealth Government were to consider paying pharmacists to administer flu vaccines to high risk populations, the services provided by a pharmacist and a medical practitioner in this context would not be equivalent.

Clearly there would also need to be research on whether flu vaccinations in pharmacies are cost-effective in comparison to a flu vaccination in a General Practice clinic given the value-add provided in the latter service.

Any cost-benefit analysis would also need to take into account the indirect costs of delayed or missed diagnoses leading to higher cost care, that are more likely when care is fragmented by patients relying on health care provided by a pharmacist.

The AMA agrees with the recommendations in the interim report that government-funded services should be evidence-based and cost-effective. Pharmacy-based services that do not meet these criteria, such as the Amcal’s Pathology Health Screening Service targeting “relatively young and fit customers … for general health purposes … as opposed to risk assessment or diagnosis” should not be eligible for government funding.

The AMA’s earlier submission to this review expanded in some detail regarding the push by the Pharmacy Guild, motivated by revenue generation, to expand the scope of practice of pharmacists into the provision of medical services.

The AMA has already stated its views on the barriers imposed by current pharmacy location rules in its previous submission to the Review, and in numerous earlier submissions to Government. The AMA supports changes to pharmacy regulation which would allow more pharmacies and medical practices to be co-located. The current restrictions are inflexible and are difficult to justify in terms of public benefit.

AMA understands that the Australian Government has entered into an agreement with the Pharmacy Guild of Australia to continue indefinitely the current protections the rules provide to Guild members. However, the AMA is disappointed that the Government has made this decision despite the obvious benefits that would accrue by allowing access to high quality primary health care services in a way that is convenient to patients, enhances patient access and improves collaboration between healthcare professionals.

Facilitating collaboration between medical practitioners and pharmacists will only improve patient outcomes through less medication mismanagement and better medication compliance.

The AMA agrees there are benefits in future community pharmacy agreements being limited to remuneration for the dispensing of PBS medicines and associated regulation. This would allow pharmacy programs, such as medication adherence and management services currently funded under the Agreement, to be funded in ways that are more consistent with how other primary care health services are funded.

Given these programs are about providing health services, rather than medicines dispensing per se, it makes sense for them to be assessed, monitored, evaluated and audited in a similar way to medical services under the MBS.

Approximately $1.2 billion has been provided to pharmacies under the current community pharmacy agreement without this level of transparency and accountability. No evaluations of pharmacy programs under the Sixth Community Pharmacy Agreement have been made public.

Moving pharmacist health services outside of the Agreement would also open the way for more flexible models of funding, for example, support for pharmacists working within a General Practice team and other innovative, patient-focused models of care.

The AMA would also welcome inclusion in future consultations undertaken prior to the finalisation of the next community pharmacy agreement, as proposed in the Review interim report. The AMA recognises the valuable contribution pharmacists make in improving the quality use of medicines.

Pharmacists working with doctors and patients can help ensure medication adherence, improve medication management, and provide education about medication safety. The AMA fully supports ongoing and adequate funding of evidence-based pharmacist services such as home medicine reviews and the provision of dose administration aids.

It is important that Government-funded pharmacy programs are monitored and evaluated for effectiveness and cost effectiveness to ensure the expenditure provides tax payers with value for money. The findings from these evaluations will help improve and strengthen the programs.

The AMA fully supports the recommendations made to enhance access to medicines programs for Indigenous Australians and to support Aboriginal Health Service pharmacy ownership and operations.

The full submission can be found at:

system/tdf/documents/AMA%20Submission%20-%20Interim%20report%20-%20Pharmacy%20remuneration%20and%20regulation%20review%20Jul17.pdf?file=1&type=node&id=46835

What are we training medical students for?

When young people go to medical school they are called medical students. They know that they are to learn about medicine. Everything about medical school is about learning about medicine. In fact, every waking moment is about learning about medicine.

We learn about anatomy, physiology, statistics, how to read a research paper, how to do a research project, we learn about diseases, pathology, histology, how to examine patients. We learn the right questions to ask in the right way to get the information that is needed.

We endlessly learn about rare diseases, treatment protocols and how to do various procedures and operations. Our whole lives are consumed with medical information.

But is this all that there is to medical school?

Of what value is all the medical knowledge in the world if the person holding that knowledge is miserable and unwell themselves, struggling to work and struggling to cope with people?

Students graduate at the age of 24 (at least) after the most intensive periods of their lives where literally every moment is dedicated to learning as much information as possible.

It has even been said that medical school is a prolonged period of adolescence where life skills are not learned, but one simply has to learn what other people tell you.

There is no time to notice anything else about life. Finances, relationships, property, politics, community engagement……sleep….. everything comes a distant seventh to medical school and learning. Life itself is an afterthought, something that one attends to only if one has to.

Our medical students are not taught about how to conduct or engage themselves in an empowered way in day to day life. They are taught how to recall information, pattern recognise and survive ward rounds.

But how to be in all aspects of life determines how well we are in life, not how much we know about facts.

Our statistics tell us how unwell our medical students and doctors are.

Medical students and junior doctors are not taught how to take care of their own health and well-being, and in fact the very nature of the setup of medical training encourages and fosters them to ignore their own health and well-being.

Our high rates of mental ill health, suicide and physical ill health are a painful reflection of these low standards of self-care in medicine.

Medical students are not taught how to take care of finances.
They are not taught how to be empowered and to run a business.
They are not taught the basic skills of marketing and business administration that people in engineering or even beauty school are taught, even though finally after a prolonged period of education and working they will be working in businesses in the community.
They are not taught how to have relationships with people that are equal, loving and caring that go beyond the arrangement of role of doctor and patient.
They are not taught about the importance of caring for their physical bodies, and indeed much of medical culture in fact promotes the stressing of the human body and mind, asking it to go beyond its limits without care for how it needs to be literally cared for.
They are not taught how to take care of their mental health, with instead judgement and criticism, condemnation and the drive for unattainable perfection being the daily ingrained forms of communication in medicine, none of these building self-esteem or self-worth.

The health and well-being of us doctors is poor. We are not happy; over 50% of us are burnt out. Our suicide rates are at least 2 times higher than the general public, with some studies pointing to 5.7 times higher, and these are only the suicides that we know of. We have higher rates of anxiety and high psychological distress than the general public.

The pressures on us doctors are very real and put simply, in the health care profession we are barely surviving, and most certainly not thriving.

We know medical facts, but we do not know how to take care of ourselves and keep ourselves well in life.

Doctors are disempowered as people and do not consider themselves as human beings with equal human rights, and instead in the role of ‘doctor’ in training learn to simply accept and put up with the circumstances that they find themselves in.

They agree to working arrangements that would not be accepted anywhere else in the corporate world, with many of them seeing bullying as so normal that they don’t even realise that they are being bullied, or that they are engaging in bullying.

Working relationships in hospitals are toxic between doctors and between doctors and other health care professionals. And let’s not even begin with the relationships that doctors have with administration!! This is accepted as ‘normal’ and something to ‘survive’.

Toxic relationships build bad teams and are bad for our mental health and well-being. This has a knock on effect on patient care.

We know that there are multiple determinants of health and well-being. We need to address all of these in our lives to build health and well-being

How are we in relationships? Are we loving and caring?
How are we with food? Is it for indulgence and coping with life, or nourishing the body?
How do we take care of our bodies?
How are we with our finances?
How are we with taking care of ourselves, valuing and empowering ourselves?
How are we with sleep?
How are we with our self-talk, our emotional and mental health?
Do we know how to be who we truly are in all aspects of life? Or are we boxing ourselves in, acting in different ‘roles’ in different circumstances?

As health care professionals we need to be the ones to lead the way in the health and well-being stakes to inspire our patients.

Instead at present as a whole we are more anxious, stressed and suicidal than the general public. Something is wrong here.

There are many reasons that our doctors are not thriving.

Rather than focussing on developing doctors who are simply minimally ‘resilient’ to the current stresses and strains, I propose that as part of our care and responsibility for those we train, that we prepare people to be well in life as a whole, in both medical school and in doctor training in hospitals.

If we don’t prepare our students to be well, then we are leaving them vulnerable with an incomplete education in the world. And thus far the statistics are speaking for themselves.

We need to prepare our students to be well. And we need to design our systems to support our doctors to be healthy and well and not simply ask them to put up with systems the way that they are when they are not honouring of dignity, decency or respect of general human rights.

Care for people is the foundation of health care. To move forward as an institution that leads the way in health care we need to place care for all people firmly at the foundation of our training and our work ethos, beginning with our medical students.

As part of that care, it is important for us to design programs that not only teach students about the nitty-gritties of medical knowledge and information but arm them with the tools to thrive and to live well in all areas of life; how to take care of themselves, value themselves and empower themselves in all areas of life.

Our educational processes and health care systems themselves need to empower our doctors and our students.

Only then will we have a profession that is healthy, well and able to consistently care for others in all avenues of life.

Dr Maxine Szramka (pictured above) is a Sydney-based consultant rheumatologist. She blogs regularly at Dr Maxine Speaks.

Doctorportal hosts a dedicated doctors’ health service providing support in the medical community.

What’s your view?

A Survey seeking doctors’ views on medical student professionalism issues

Being professional can mean different things to different people. In particular, the public and professionals may place different values on the importance of various behaviours. For doctors, Good medical practice: a code of conduct for doctors in Australia, provides a comprehensive general guide.

However, applying such guidance to particular issues and making judgements about the seriousness of unprofessional behaviours is often not straight forward.

In the case of medical students, the situation is even more confusing.

They are developing professionals, but how important are their professional behaviours while a student? A national survey of Australian medical students in 2016* found that medical students have widely varying opinions on appropriate professional behaviours and students also commented on the inconsistencies in how medical schools address these issues.

We’re now interested in the views of qualified Australian doctors on the same scenarios that were posed to the medical students. You are teachers and role models for these students.

Are your value judgements different? If so, what are the differences? The survey asks you to assess issues such as: “If a behaviour is unacceptable, how unacceptable is it?” and “Does it matter if a student is first year or final year?”

The overall aim of the research program is to explore the variation in attitudes to professionalism issues for medical students, study the role of context in professionalism judgements and to identify areas of professionalism teaching that may require further development.

The views of qualified Australian doctors are simply essential to create a full understanding and we very much hope you will consider participating. The anonymous, online survey should take less than 10 minutes to complete; it can be accessed using the following link https://www.surveymonkey.com/r/AMA_doctors_survey.

If you have any questions about the survey, please contact Dr Paul McGurgan, paul.mcgurgan@uwa.edu.aupaul.mcgurgan@uwa.edu.au>

Dr Paul McGurgan is Professional and Personal Development Coordinator, Faculty of Medicine and Health Sciences, UWA.

The research team includes Dr Kiran Narula (Fiona Stanley Hospital), Dr Katrina Calvert (KEMH) and Dr Christine Jorm (Hon. Assoc. Professor & Assoc. Dean [Professionalism] Medical Education, University of Sydney).