[Correspondence] Are doctors in training being trained?

In the Shape of Training report,1 David Greenaway called for postgraduate medical education to become broader and shorter. In response, there have been numerous appeals to redesign health-care service delivery in the UK to reduce the reliance on doctors in training and to ensure that they spend more time developing their knowledge and skills. Just how much time do doctors in training actually spend in training?

[World Report] Medical education and regulation in the spotlight in India

Experts have been debating the recommendations of an Indian parliamentary committee, which has called for a shake-up of medical education and regulatory systems. Dinesh C Sharma reports.

Education tax cap scrapped

The Federal Government has reportedly scrapped plans to axe or cap tax deductions for work-related self-education expenses just days after the AMA warned it would campaign against the idea in the lead-up to the Federal election.

The Australian Financial Review has reported the Government has dumped the idea of trading away work-related tax deductions to help fund business tax cuts in next month’s Budget, and will instead leave tax deductions alone.

The policy change came after the AMA said discussions had been held about resurrecting the Scrap the Cap alliance of more than 70 professional and educational organisations to campaign against any change to tax deductions for self-education expenses.

There had been suggestions the Government was considering imposing a standard deduction for work-related expenses, which AMA Vice President Dr Stephen Parnis said would “effectively be a cap by another name”.

In 2013, the former Labor Government announced plans for a $2000 cap on tax deductions for work-related self-education expenses, a measure that would have disadvantaged thousands of workers who have to undertake continuing education as a condition of their employment.

The proposal provoked outrage among doctors and other professionals, and the AMA was among 70 organisations that formed the Scrap the Cap Coalition to fight the change.

The Abbott Government won plaudits when it dumped the idea soon after winning the 2013 Federal election, but there were fears Prime Minister Malcolm Turnbull would reinstate the measure to help narrow the Budget deficit.

In December, the Government revealed its financial position had worsened since last year’s Budget and the deficit was on track to reach $37.4 billion in 2015-16 with no prospect of a return to surplus in the next four years.

Since then, commodity prices have tumbled lower and economic conditions have remained soft, fuelling concerns the Commonwealth’s finances have become even worse.

The Government has talked down earlier suggestions of tax cuts, and is searching hard for savings, including by trying to push more of the responsibility for health and education funding onto consumers and the states.

But Dr Parnis said earlier this week that deductions for self-education expenses should be off the savings list.

He said doctors had to continually update their skills and knowledge throughout their careers, at their own expense, and scrapping the tax break would have created a “huge disincentive”, particularly for junior doctors considering undertaking specialist training.

According to the AFR report, the Government has backed away from changes to work-related tax deductions for political and administrative reasons.

It was thought scrapping deductions, claimed mainly by middle-income earners, to pay for business tax cuts would be highly unpopular, while the impracticality of abolishing all deductions meant the Government would be left to tinker with individual measures, which would not deliver sufficient savings to be worth the political trouble they would cause.

Adrian Rollins

Govt might try cap on for size, AMA warns

The AMA has warned the Federal Government it could face a damaging campaign during the forthcoming Federal election if it revives plans for a cap on deductions for work related education expenses in its hunt for Budget savings.

As ministers come under mounting pressure to identify cuts and savings to improve the bottom line for the 3 May Budget, the AMA has called on Treasurer Scott Morrison to reaffirm the Government’s commitment to supporting the continuing education requirements of professionals, including doctors.

AMA Vice President Dr Stephen Parnis said there had been worrying reports the Government could be considering resurrecting unpopular measures, including imposing a ‘standard deduction’ for work-related expenses.

“This would effectively be a cap by another name,” Dr Parnis said.

The proposal provoked outrage among doctors and other professionals, and the AMA was among 70 organisations that formed the Scrap the Cap Coalition to fight the change.

The Abbott Government won plaudits when it dumped the idea soon after winning the 2013 Federal election, but there are now fears Prime Minister Malcolm Turnbull may reinstate the measure to help narrow the Budget deficit.

In December, the Government revealed its financial position had worsened since last year’s Budget, the deficit was on track to reach $37.4 billion in 2015-16, and warned there would be no return to surplus in the next four years.

Since then, commodity prices have tumbled lower and economic conditions have remained soft, fuelling concerns the Commonwealth’s finances have become even worse.

Dr Parnis said a parliamentary inquiry into tax deductibility added to concerns that deductions for self-education expenses could be in the Government’s sights.

“We are urging the Government to resist any moves to put in place, directly or indirectly, a cap on deductions for legitimate work-related self-education expenses in the Budget or in any new tax policies,” he said, pointing out it would have a severe impact on doctors and other professionals who must continually update their skills and knowledge throughout their careers, at their own expense.

“Doctors must learn new about new technologies, surgical techniques, treatments, and pharmaceuticals if they are to provide the best possible care to save lives and improve quality of life for their patients,” Dr Parnis said. “Doctors can spend many thousands of dollars each year undertaking mandatory courses and professional development to equip them with essential skills in caring for patients.”

The AMA Vice President said doctors in rural and remote areas would be hardest hit, because they were forced to travel to attend training courses and seminars.

He warned it would create a “huge disincentive” for junior doctors to pursue specialist education, potentially creating or adding to shortages of specialists in the future.

If the Government does include the measure in next month’s Budget, it is likely to meet with powerful opposition.

Already, discussions have been held about reconvening the Scrap the Cap alliance and mount a vigorous campaign during the forthcoming Federal election if the Government does move to impose some form of education expenses cap.

Adrian Rollins

Hospital funding deal ‘not enough’

A deal to inject up to $7 billion from the Commonwealth into the public hospital system was being mooted ahead of this Friday’s Council of Australian Governments meeting amid warnings it will not be enough to sustain services in the face of spiralling demand.

As Australian Medicine went to print, speculation was mounting that Prime Minister Malcolm Turnbull was close to arranging a deal with his State and Territory counterparts to provide a multi-billion dollar funding boost to public hospitals amid warnings that $57 billion of cuts unveiled by the Abbott Government in 2014 would plunge the system into financial crisis and cause a blow-out in waiting times.

Less than a week after meeting with AMA President Professor Brian Owler and the AMA Federal Council on 17 March, Mr Turnbull told reporters he would “have more to say in the lead-up to [the COAG meeting] relating to health and schools and so forth”.

At the AMA meeting, the Prime Minster showed keen interest in reports from Council members that public hospitals were experiencing a rapid increase in demand that vastly outstripped the pace of population growth.

Mr Turnbull wanted to know why this was occurring, and was told a big factor was increased life expectancy, which meant that patients were more likely to present with multiple chronic health conditions that were more expensive and complex to treat, placing huge demands on hospital resources.

These stresses have been reflected in the AMA’s Public Hospital Report Card released earlier this year, which showed that improvements in the performance of public hospitals had already stalled, and in some respects were starting to go backwards.

Professor Owler said this was only going to get worse as big Budget cuts began to bite next year, and warned that suggestions the Federal Government might stump up $6.7 billion over four years, to be shared among the states, would not be enough.

It is understood the Government was considering an increase in the tobacco excise and reduced tax breaks for superannuation to provide the extra funds.

But the AMA President warned that injecting an extra $6.7 billion into the system was inadequate.

“[The] figure of $6.7 billion has been talked about over the next four years to deal with both health and education, …I’m afraid that’s just not going to cut the mustard. It’s not going to mean that states can continue to provide the level of services that patients expect and deserve,” he said. “By any stretch of the imagination, cobbling together $6.7 billion over a four year period for states and territories to fund health and education is just not going to make it.”

Professor Owler said the Commonwealth needed to dump plans to index hospital funding at inflation plus population growth, which he said was completely inadequate to ensure hospitals were able to maintain their services.

Adrian Rollins

Photo: Nils Versemann / Shutterstock.com

New recommendations for Hepatitis C treatment

New recommendations have been released for the management of hepatitis C virus (HCV) infection in a consensus statement.

The statement was drawn up by Gastroenterological Society of Australia, the Australasian Society of Infectious Diseases, the Australasian Hepatology Association, the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, Hepatitis Australia and the Royal Australian College of General Practitioners.

A summary, published in the Medical Journal of Australia, says that the recommendations for Hepatitis C treatment were drawn up in the wake of the new direct-acting antiviral therapies that were added to the Pharmaceutical Benefits Scheme earlier this month.

“The introduction of DAA therapies for HCV that are highly effective and well tolerated is a major medical advance,” said Professor Alexander Thompson, director of gastroenterology at St Vincent’s Hospital in Melbourne.

“All Australians living with HCV should now be considered for antiviral therapy.”

Recommendations in the consensus statement include:

All individuals with a risk factor for HCV infection should be tested.
Annual HCV serological testing is recommended for seronegative individuals with risk factors for HCV transmission.
People with confirmed HCV infection should be tested for HCV genotype (Gt).
All concomitant medications should be reviewed before starting treatment, using the University of Liverpool’s Hepatitis Drug Interactions website.
The use of any DAA regimen during pregnancy is not recommended.
People who are not cured by a first-line interferon-free treatment regimen should be referred to a specialist centre.
All people with decompensated liver disease, extra-hepatic manifestations of HCV, HCV–HIV or HCV–HBV co-infection, renal impairment or acute HCV infection, as well as people who have had a liver transplant should be referred for management by a specialist who is experienced in the relevant areas.
All people living with HCV infection should have a liver fibrosis assessment before treatment to evaluate for the presence of cirrhosis.
People with no cirrhosis can be treated by general practitioners working in consultation with specialists.

Read the full recommendations on the Gastroenterological Society of Australia’s website.

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[Comment] Learning from role modelling: making the implicit explicit

Role models are central to the formation of physicians’ professional identity. So it is important for medical education to understand the processes by which individuals learn from role models.1–3 Although much has been written on role modelling, more data are needed to support thinking on how individuals learn from their role models. A recent study by Passi and Johnson4 casts light on the hidden process of positive role modelling in medicine.

Compliance – not just an individual responsibility

Most GPs know that, under the Health Insurance Act, if they engage in inappropriate practice they will be held to account by a Professional Services Review Committee comprised of their peers.

What seems to be less understood is that it is also an offence under the Act if a person or officer of a body corporate knowingly, recklessly or negligently causes or permits a practitioner employed by them to engage in such conduct.

Now that the responsibility for compliance policy has shifted from the Department of Human Services (DHS) to the Department of Health (DoH), it can be expected we will see an increased focus on the forces within a practice that encourage or silently condone inappropriate practice. While it has previously been difficult to assess this, the DoH is moving to make greater use of data analytics and behavioural economics to identify potential problems.

In utilising these tools, the DoH hopes that it will be able enhance the Department’s understanding of how policy impacts compliance, and better identify clusters of divergent billing behaviour. This will also inform compliance feedback, as well as the Department’s education resources and activities.

This shift in focus has in part come about following the findings of the Large Practices Project. This project was undertaken in recognition of the changing nature of general practice, with the increasing shift from small owner-operated medical practices to large corporate medical practices.

The Large Practices Project found that practice managers and staff have more responsibility for billing than expected. Most GPs learn about billing Medicare on the job or via word of mouth, and practice or business protocols affect the accuracy of Medicare billing. It was found that the culture of the practice, rather than its size, can have a significant influence on claiming behaviour.

These findings have reinforced the need for accessible education materials, and for targeted feedback on billing practices. Feedback has to be specific and directly relevant if it is to be valued and truly informative.

Medicare compliance and appropriate billing is not only an issue for each of us individually, but also as a profession. It goes to our professionalism as GPs and, when inappropriate billing practices are allowed to flourish, a knee jerk policy response is often the result, with MBS rules invariably tightened to reduce the risk of inappropriate use of MBS items. The recent restriction on claiming an item 23 with 721 is a case in point.

Thanks to AMA advocacy, practitioners who are unsure about what a MBS items covers or can be claimed for have available at their fingertips an enquiries email and a number of educational resources. Using the medicare.prov@humanservices.gov.au email for a MBS interpretation or claiming question ensures you receive the answer in writing, which is handy should a compliance issue on that matter arise. Various education resources are also available at https://www.humanservices.gov.au/health-professionals/subjects/education-services-health-professionals.

The AMA will continue to work with the DoH and the DHS to ensure compliance activities focus on supporting GPs and offering meaningful feedback and effective education.

We all know that GPs are very busy, and try to work within the system as they understand it. Punitive approaches don’t work, and compliance breaches are often simply the result of overly complex rules that are difficult to interpret or not reflective of modern clinical practice.

Rural health – the continuing challenge

Rural health is frequently inferior to city health. This old generalisation covers much contradictory detail, and exceptions abound: according to the Australian Institute of Health and Welfare, the life expectancy of non-Indigenous women in 2002-04 was much the same – 84 – whether they lived in big cities or very remote areas. For men, the difference is a matter of six months or so. And it is not a rigid generalisation: increasingly sophisticated broadband-enabled communications and ever-more efficient transport have reduced the gap between city and country.

Nevertheless, the numbers and the facts suggest that the accumulation of wealth, talent and many other features of contemporary city life confer a small advantage in life expectancy and wellbeing on city-dwellers. This disparity challenges those who hold the value that one of our social duties is to ensure, as far as possible, equality of opportunity to health and health care to all Australians. What should we do?

Two pathways to action present themselves for our consideration.

The first, and the one most easily grasped by the medical profession, concerns access to medical care in the rural setting. Massive technologically-based services can only be provided in large cities, and lesser technology-dependent services need at least strong regional bases.

We are getting better at finding ways to make these technologies available in relation to services such as radiotherapy, relieving the pressure on country women to favour radical breast surgery because they cannot afford the time and separation for chemo and radiotherapy.

But as we concentrate on providing rapid care for people with acute coronary syndrome and stroke (an increasing possibility in cities), the challenge of providing similar care in remote parts of the country may be beyond us at present.

The attitude of some to this problem – that those who live in remote parts of the country do so entirely by choice – is similar to saying that drowning people should be left, as they chose to swim or go boating.

But with telehealth, and many large city medical services increasingly interested in providing networked services to places that lack them, the problem is being partially addressed.

The search for equality of access may well require affirmative funding, and this has been recognised to some extent in fee structures and remuneration.

Equality does not mean paying the same for the care of people in different places: we need to accept that services provided beyond cities will cost more, and ensure that we finance them accordingly.

There are also concerns, raised most recently by Max Kamien, Emeritus Professor of General Practice at the University of Western Australia in Medical Observer, that the relaxation of hiring rules in many rural areas will “open the floodgates” to corporate practices.

While on the surface of it, a boost to the number of doctors working in rural areas would be welcome, this is not the case if they are being employed on short-term contracts to simply churn through large numbers of patients, and leave more challenging and time-consuming cases to existing practices. The focus needs to be on quality of care, not just quantity.

The extent to which the learned colleges have recognised the need for greater action on behalf of their rural members has been variable.

A framework for rural health developed by representatives of all Australian states, territories and the Commonwealth in 2011, recognised the need to be sensitive to the special needs of older people, babies and children, Aboriginal and Torres Strait Islander people, people with chronic disease, refugees and people from culturally and linguistically diverse backgrounds.

The second approach to rural health disparities takes us well beyond the surgery.

Even with networked services, e-health, and affirmative funding, we are faced with residual differences in health status that are attributable to the social and economic context of rural and remote life.

Medicine cannot, for example, diminish the vast distances many country people have to drive, every kilometre increasing their risk of a serious accident. At best, it can be sensitive to distance when arranging care of patients with continuing problems.

Medicine cannot do much to promote high-quality educational opportunity, although the development of regional universities and technical education capacity has been impressive in the past three decades.

Rural clinical schools have done a remarkable job in acquainting future medical practitioners and other health professionals with the challenges and opportunities of rural practice, and the long-term effects of this intervention will be seen in the next 20 years.

Medicine, though, has no influence over agricultural and extractive industry policies, all of which have great significance for employment and economic sustainability in rural communities.

These environmental factors – the social determinants of health – set the health agenda.

Some fall within the sphere of influence of public health, but many are well beyond even its wide reach.

Their importance was reviewed in a paper by Jane Dixon, from the ANU, and Nicky Welch, from Waikato University, in The Australian Journal of Rural Health in 2000. ‘What is it about rural places or the rural experience that contributes to different health outcomes?’ they ask.

The broad-spectrum advocacy of the Rural Doctors Association of Australia and the Rural Health Alliance contribute to the wider political and policy agenda that may help us to answer this question and to make serious progress.

It is vital for medicine to respond to the needs of rural communities as they are, not as they might be in a reimagined ideal world.

My sense is that we are making steady progress. The indicators that we have favour an optimistic view.

Mazda MX-5 – too much fun?

As a Baby Boomer, I’ve become accustomed to having to work hard for all of the pleasures in life, unlike those Gen XYZs, who expect the world to land at their feet.

But, there are some pleasures that I think I’ll never have.

For starters there’s a Mazda MX-5.

When it was first released in 1989, I’d just completed my specialty training.

But with a big mortgage there was no way that I could see myself splurging on a toy like the MX-5, with its sexy pop-up headlights.

When the second generation model was released in 1998, I still couldn’t see any practicality in a car that only had two seats.

Sure, I could pick up my children from school one at a time, but parental responsibility weighed heavily at that point in my life.

The MX-5 now came with a rear window made of glass, and the head-lights weren’t concealed any more.

The third generation MX-5 arrived in 2005 with a bigger two litre engine – at exactly the same time as mountains of homework and sky-rocketing school fees.

Fast forward to 2015, to an empty nest, a smaller mortgage, everyone’s education completed and the fourth generation Mazda MX-5.

With stunning styling, it was certainly looking like an attractive proposition.

But having mastered the art of delaying gratification, will I say no once more?

The current MX-5 has certainly impressed the motoring elite, having scored the 2016 Wheels Car Of The Year award, along with two previous COTY awards in 1989 and 2005.

What did they like so much about the new model?

For starters it’s much, much less expensive, with an entry-level 1.5 litre manual starting at $31,990 plus on-road costs.

It had to be cheaper than the old model to stand a chance against the Toyota 86, which is hugely popular in this demographic.

The sharper pricing is scaled back even further by offering a 1.5 litre variant motor, which is livelier and revs better than the two litre.

Buyers save $2500 with the smaller motor, but no one is short-changed.

The new MX-5 is also lower, wider, lighter, faster and more economical than the out-going model.

An MX-5 cabin is an intimate, and some might say claustrophobic, space.

In an effort to save weight, it is more about leaving things out than packing them in.

This time around there’s no cigarette lighter, just a USB socket. And the glove box has disappeared completely from the cabin.

There still is a tiny lockable compartment between the seats for loose items that would disappear with the roof down.

The interior finish is still very basic, and there is nothing plush about the upholstery in the entry-level specification.

But MX-5 drivers don’t care about any of those details.

They buy the car to drive it, and would happily sit on the floor if that could lower the centre of gravity by another centimetre.

Yes, driving the MX-5 is exhilarating, and it certainly pushed out the dopamine in my nucleus accumbens and ventral pallidum.

The motor sits way back behind the front wheels, and that perfect weight distribution means that the MX-5 moves like a ballerina.

But back at the dealership I spotted a Mazda 6 which somehow still better suited my style.

Is a Mazda MX-5 for me?

Maybe one day.

Safe motoring,

Doctor Clive Fraser

Specifications

MX-5	2015 NC	2016 ND	2016 ND
Engine	2.0 litre	1.5 litre	2.0 litre
Power	118kW @ 7000rpm	96kW @ 7000rpm	118kW @ 6000rpm
Torque	188Nm @ 5000rpm	150Nm @ 4800rpm	200Nm @ 4600rpm
Transmission	6 speed manual	6 speed manual	6 speed manual
Kerb Weight	1167	1009	1033
Power to Weight Ratio	104.4	97.5	117.4
Price + ORC	$48,380	$31,990	$34,490