Organ donation – should Australia adopt an opt-out system?

Opinion

BY DAVID TARRANT

The statistics paint a stark picture. More than 12,000 Australians suffer each year while they are on transplant waiting lists or dialysis. Six Australians will die in August alone while waiting for an organ transplant, a grim reminder of the limitations of the healthcare system in the face of overwhelming demand and scarce supply.

But is the organ donation system merely indicative of a failure by the Government to enact smart legislation that goes some way to overcoming societal apathy towards registering as an organ donor?

It has become evident that Australia’s current opt-In organ procurement legislation has failed to correct the disparity between the number of people on organ transplant waiting lists and the number of organs available for transplantation. A number of factors have been identified which potentiate this ever-widening gap. Primarily, the aforementioned societal unwillingness to registering as an organ donor, followed by potential donors’ families denying consent when donation is requested, and the reluctance of health care professionals to request that the deceased patient’s organs be donated.

Australia is ranked 20 in the world for organ donation. We are behind countries such as Croatia, Spain, Portugal and Italy. Recent international studies have demonstrated that implementation of an Opt Out system of organ procurement would increase donation rates by 50 per cent.

Spain has been most successful in implementing “soft” opt-out legislation there, sustaining the highest rate of organ donation in the world for the past two decades. Implementation of the Spanish model opt-out legislation in Australia could result in an additional 1,400 Australians receiving a transplant every year. Think about the impact of that on the healthcare system in terms of primary, hospital and allied health care, and the associated effect on patient flow.

Notwithstanding the advantages of an opt-out system for those individuals on organ transplant lists, nevertheless implementation of an opt-out system in Australia requires examination of several ethical issues. Whilst Australian law states that there is no property in a dead body, the potential for a negative impact upon individual autonomy must be considered.

Despite proponents of presumed consent suggesting that implementation of an opt-out system could improve individual autonomy, a number of authors are sceptical of this claim. However, when weighing limits of personal autonomy against the concept of benefits to society in terms of giving back to the community, under a communitarian-based approach, the number of lives that could be saved as a result of the enacting opt-out legislation could be preferable to society.

If implementation of a national “soft” opt-out organ donation legislation is proposed in Australia, enactment of this type of legislation must be prefaced by comprehensive publicity and education programs, focusing on both the general public and health care professionals. In conjunction with these amendments to legislation, Australia should adopt an individual hospital-based approach to organ donation as described under the “Spanish model”.

Australia must act now to implement these changes. People will continue to die until the disparity between organs required and those available for organ transplantation is rectified.

Views expressed in the above Opinion piece are those of the author and do not reflect official policy of the AMA.

David Tarrant is a lawyer and a registered nurse. He completed his Honours thesis on organ donation, which was published in the NSW Operating Theatre Nurses Association Journal, and has also drafted papers on related issues (in collaboration with his colleagues at Carroll & O’Dea Lawyers). Prior to embarking on his legal career, David worked in hospitals in Tamworth, Sydney and London. Following completion of his Graduate Diploma in Clinical Practice, he was awarded the Anne Carrodus Memorial Prize for excellence in clinical practice.

Public Hospital Doctors role central to AMA

BY DR ROD McRAE, CHAIR, AMA COUNCIL OF PUBLIC HOSPITAL DOCTORS

I’d like to state my thanks for all the input and interest from PHD members at our recent National Conference. It was invigorating to experience your enthusiasm for the many issues directly affecting public hospital doctors. An important issue about which I do want to remind you is actually how you “describe” yourself for AMA membership purposes. In order to keep the CPHD vibrant and relevant to key issues, we must have a solid base. Today we can choose our membership category more accurately. I hope more doctors based in public hospitals, particularly those with a Specialist qualification, will choose to identify in the public hospital doctor membership category as opposed to their medical craft group if they have one, when it comes to identifying their AMA membership as you will be invited to do soon, and thus remain engaged with the CPHD.

Vale Dr Patrick Pritzwald-Stegmann

Multiple issues are before the CPHD. None is more relevant than safety in the workplace. On July 21, a Memorial Service was held for AMA member Dr Patrick Pritzwald-Stegmann, who died after substantial time ventilated in one of our ICUs after an alleged “coward’s punch” received in the foyer of a Melbourne metropolitan public hospital resulted in a profound brain injury. This is now a Coroner’s and police matter. I am regularly horrified at the experiences of violence in our community and our workplaces, but this is all the more poignant for me as Patrick was a recent close colleague of mine with whom I had worked extensively.

There are many intersecting issues in our community, most of which lead to the public hospital system. They include mental health issues, whether acute, chronic or acute-on-chronic, illicit drug use, perhaps loading up on mental health issues, increased passive tolerance of greater violence in and by the now metropolises (as opposed to tight-knit communities), and a general lack of respect for those providing any type of community service. Emergency service providers and our colleagues and other healthcare workers in emergency departments face the brunt, but it is throughout the public hospital system. I note that our population is growing remarkably, we have generated profound productivity improvements, but there remains a yawning gap of lack of public hospital capacity investment to match the essential hospital requirements of the complex, multi-system, elderly and/or obese, chronic illness sufferers. It is readily observable how “house full” messages contribute to patient frustration, then anger and venting in our workplace. It was equally offensive to see lauding of “this is what 182 blows to the head looks like” related to a recent violent “sport” designed to inflict brain injury. It is easy to see some might link these ingredients, resulting in an unsafe workplace for us.

In perhaps a curious coincidence, I am now chairing an Australian Standards committee revising the standard Security for Health Care Facilities. It will be a template for consideration of security risks for any and all health care facilities in Australia. Its origin related to large public hospitals, but changes in technology and hospital interventions means security issues are everywhere that medicine is practised, including hospital-in-the-home and all points travelling between, patient record security, medication and medical gas security, microorganism security, IT security, food security, let alone staff safety and security. I will be pleased to receive your thoughts on this topic. Obviously not everything will be totally relevant to all, but in these days of terrorism and bioterrorism, it will be a useful tool for risk analysis. It will be a sad day if every part time medical point of care in a high rise tower through to our major teaching hospitals needs to have the same security we now take for granted on getting to the airside of an airport, surveillance cameras or requires trained and authorised security personnel with Tasers and policing powers comparable to Protective Service Officers.

Of note, none of the above may have prevented Patrick’s injury, or some of them may have caused the alleged perpetrator to pause.

Public Hospital Funding

It is clear an expansion and greater funding of public hospital’s is required to meet the increasing demand, separate to security investments. This is about to accelerate in my view as more reduce private health insurance due to increasing premiums coupled with increasing mortgage, energy and education costs pressures. An important discussion will be how best to use the now billions of tax dollars shoring up publically listed health insurance companies’ profits and employee bonus payments, whilst squeezing the marketplace and offering frequently inadequate products to bamboozled patients seeking a tax break.

Recently the Government rejected a proposal to abolish the private health insurance rebate and effectively take funds it saves from that, along with hospital funding, to provide a standard benefit for services, regardless if they happen in a public or in a private hospital. This would effectively take Commonwealth funds from public hospitals and force patients to pay more for coverage. This would reduce the amount the Commonwealth contributes to the cost of public hospitals to a paltry 35 per cent. The 42 or 43 per cent funding we’re getting from the Commonwealth now is not sustainable for future public hospital operation.

A 35 per cent share would be a disaster in the super-stretched public system and in the private system for that matter. In recent years we’ve seen the Commonwealth’s share of funding to public hospitals drop below 45 per cent with a formula that only relies on growth in CPI and population. The AMA’s Public Hospital Report Card shows that performance in the system, such as wait times in the emergency department or for elective surgery, are not improving, or indeed are going backwards. So we can be thankful that this reduction has been ruled out.

But with consideration of the way hospitals are funded, we need to focus on priorities and things that might work in the hospital system. This especially includes quality and safety initiatives as well as increasing the utility of secondary hospitals or in the community. We must put more resources into primary care prevention as a long-term strategy for reducing the rate of increase of pressure on public hospitals.

Let’s hope governments see sense and realise that proper health care is a sound investment and saves money in the long term, and that engaging with doctors is the only way to develop sound health policy. I look forward to discussing these and other issues with you in upcoming CPHD meetings and other events.

AMA’s successful stand for sensible and safe pathology testing

BY PROFESSOR ROBYN LANGHAM, CHAIR, MEDICAL PRACTICE COMMITTEE

One could be forgiven for thinking that he AMA thinks little of pharmacists, given the nature of the media reports around the recent successful AMA campaign to stop Amcal pharmacies ordering unnecessary pathology screening tests.

The truth is quite the opposite. The AMA greatly respects the valuable contribution pharmacists make in improving the quality use of medicines. Pharmacists working with doctors and patients can help ensure better medication adherence, improved medication management, and also help in providing education about medication safety.

The AMA agrees that pharmacists’ expertise and training are under-utilised in a commercial pharmacy environment where they are necessarily distracted by retail imperatives.

That is why the AMA is fully engaged in the current review of pharmacy remuneration and regulation being undertaken by an independent panel appointed by the Federal Government.

In a comprehensive submission to the panel lodged last year, the AMA was supportive of alternate models of funding being explored that would encourage and reward a focus on professional, evidence-based interactions with patients. Our submission also supported ongoing funding of effective and cost-effective pharmacist medication management programs, particularly those targeting Aboriginal and Torres Strait Islanders, and a relaxation of the restrictive pharmacy location rules.

The panel has now released an interim report revealing its likely recommendations to Government on the future of pharmacy funding and regulation.

The proposed recommendations pick up on many of the AMA’s suggestions and concerns, and, if implemented, would radically improve the transparency of pharmacy funding and refocus government investment on evidence-based and cost effective services.

Unsurprisingly, the Pharmacy Guild of Australia is highly critical of the report, slamming it as “without merit”, “ill-considered”, “threatening” and “undermining” as well as stating it has “serious concerns about the true intention of the review”.

Some of the key recommendations supported by the AMA include:

banning the sale of homeopathic products from pharmacies altogether;

physically separating other complementary medicines from “pharmacy only” (schedule 2) and ‘pharmacist only’ (schedule 3) in pharmacies to better help consumers understand that these medicines have not been assessed for effectiveness in the same way as S2, S3 and prescription medicines;

moving the funding of pharmacist services programs from the Guild-controlled Community Pharmacy Agreement to other government funding streams to improve transparency and facilitate coordination with other primary health care programs;

removing current bureaucratic barriers to medicines programs and pharmacy services that hinder access to indigenous Australians; and

changing the pharmacy location rules with potential to improve options for pharmacy co-location with general practices.

The AMA is very supportive of the interim report and lodged a favourable submission in response in July.

Unfortunately, the Guild has already brokered a deal with the Coalition Government to shelve any changes to location rules in the foreseeable future. It will be interesting to see what appetite the Government has for taking up the panel’s final recommendations, particularly given the next Federal election date is not so far away.

Relationships with industry

BY DR CHRIS MOY, CHAIR. AMA ETHICS AND MEDICO LEGAL COMMITTEE

A major priority for the AMA’s Ethics and Medico-Legal Committee (EMLC) will be the review of the Position Statement on Medical Practitioners’ Relationships with Industry 2012. The statement provides guidance for doctors on maintaining ethical relationships with “industry”, including the pharmaceutical industry, medical device and technology industry, other health care product suppliers, health care facilities, medical services such as pathology and radiology, and other health services such as pharmacy and physiotherapy.

The current Statement encompasses the following sections:

medical education;
managing real and potential conflicts of interest;
industry sponsored research involving human participants including post-marketing surveillance studies;
meetings and activities organised independent of industry;
meetings and activities organised by industry;
hospitality and entertainment;
use of professional status to promote industry interests;
remuneration for services;
product samples;
dispensing and related issues; and
relationships involving industry representatives.

Doctors’ primary duty is to look after the best interests of their patients. To do so, doctors must maintain their professional autonomy, clinical independence and integrity, and have the freedom to exercise professional judgement in the care and treatment of patients without undue influence by third parties (such as the pharmaceutical industry or governments).

But what happens when the impetus to change the relationship with industry comes from within the profession itself? For example, the AMA’s current policy on doctors and dispensing states that:

11.1 Practising doctors who also have a financial interest in dispensing and selling pharmaceuticals or who offer their patients’ health-care related or other products are in a prima facie position of conflict of interest.

11.2 Doctors should not dispense pharmaceuticals or other therapeutic products unless there is no reasonable alternative. Where dispensing does occur, it should be undertaken with care and consideration of the patient’s circumstances.

In recent years, we have heard from members who believe this position is too strict and doctors should be able to dispense pharmaceutical products, arguing that it’s more convenient for patients and leads to better compliance. For example, patients may be more likely to fill their prescriptions onsite at the doctor’s office than if they have to go offsite to a pharmacy. In addition, the doctor is there to answer any questions relevant to the prescription which will reduce pharmacy call backs and waiting times.

Historically, the AMA has strongly advocated that doctors do not make money from prescriptions. Allowing doctors to dispense pharmaceuticals or other therapeutic products (other than in exceptional circumstances) would be a fundamental shift in this position – but is that a sufficient reason not to change it?

After all, dispensing pharmaceuticals or other therapeutic products is not in itself unethical so long as it is undertaken in accordance with good medical practice. Unfortunately, however, there can still be a strong perception of a conflict of interest, particularly if doctors are making a profit rather than just recovering costs. So for many doctors – but more importantly our patients and the wider community who are our ultimate judges – this is a line which should not be crossed.

These are the types of issues the EMLC will consider in reviewing this policy and we will endeavour to seek members’ views during the process.

The EMLC will also be developing an overarching policy on managing interests, highlighting the potential for professional and personal interests to intersect, and at times compete, during the course of a doctor’s career. While a real, or perceived, conflict of interest is by no means a moral failing, it is important that doctors are able resolve any potential for conflict in the best interests of patients.

The Position Statement on Medical Practitioners’ Relationships with Industry 2012 is accessible on the AMA’s website at position-statement/medical-practitioners-relationship…. If you would like to suggest any amendments to the current Statement, please forward them to ethics@ama.com.au.

Report warns blindness set to rise

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

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

A growing ageing population is behind the rising numbers.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MEREDITH HORNE

Substance abuse needs mature policy approach

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CHRIS JOHNSON

Kristine Whorlow AM retires as CEO of National Asthma Council

The National Asthma Council Australia’s inaugural chief executive officer Kristine Whorlow AM has retired.

NAC Chair Dr Jonathon Burdon said Ms Whorlow’s decision to retire caps a remarkable career of continuous service to the asthma community, both in Australia and internationally, including the Asia Pacific region.

“Kristine is a leader in her field and her expertise has established the NAC as the leading authoritative body for asthma in Australia with a considerable global reputation,” Dr Burdon said.

“We thank Kristine for her important contribution to improving asthma management in Australia. Her achievements are many, including facilitating asthma’s recognition as a national health priority and leading the ongoing development of asthma’s national treatment guidelines.

“Kristine has generated Australian Government program funding for asthma since 2001 and recently acquired Government funding for the fifth National Asthma Strategy now in the final stages of the AHMAC process.”

Dr Burdon also announced the appointment of the NAC’s new CEO, Siobhan Brophy, effective from August 1.

Ms Brophy was the NAC’s strategy and communications manager.

The NAC’s purpose is to reduce the health, social and economic impacts of asthma throughout Australia including free education workshops for GPs and allied health professionals funded by the Australian government through our Asthma & Respiratory Education Program.

Australia’s Institute for Health and Welfare’s data shows one in nine Australians have asthma– around 2.5 million people, based on self-reported data. The data also reports one in five people aged 15 and over with asthma have a written asthma action plan.

MEREDITH HORNE

Attending the House of Delegates meeting of the American Medical Association

BY ANNE TRIMMER AMA SECRETARY GENERAL

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The organisation

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

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

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

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

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

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

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

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

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

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

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

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

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

[Comment] Informing health choices in low-resource settings

Because of the abundance of health information, available via multiple sources, it is important that individuals be able to critically appraise health claims to make well informed decisions. This is of even greater importance in low-income countries where individuals cannot afford to invest in ineffective treatments. Indeed, public health practitioners have long touted the importance of health education; for example, a variety of well tested and updated curricula to prevent adolescent pregnancy and HIV have shown positive health outcomes across low-income and high-income communities.

[Editorial] Medical education reform in China

On July 11, the State Council of China introduced bold plans to revolutionise medical education, effective immediately. Gone will be Soviet-era training in which doctors spent their career in one hospital, and over-crowded outpatient clinics that too often underutilised the expertise of staff and underserved the needs of patients. Instead, medical schools are asked to admit more, higher calibre students, and provide better quality teaching that is accredited by the Chinese Medical Doctor Association.