Medical briefs

No sugar tax in sight

The Federal Government has signalled it is unlikely to implement a sugar tax or other financial incentives to influence eating habits.

Convening the first meeting of its Healthy Food Partnership, Rural Health Minister Fiona Nash – who also has oversight of food policy – indicated that although the Federal Government wanted to encourage consumers to make healthier food choices, it would not seek to “force feed” them.

“Government can’t force feed healthy food to its citizens,” Senator Nash said. “It is up to individuals to take responsibility for what they eat. Government’s role is to educate and provide tools to help people make healthy choices.”

The Partnership includes representatives from food manufacturers and producers, industry groups, the Public Health Association and the Heart Foundation.

Senator Nash said it had been formed to come up with strategies to increase the consumption of fresh fruit and vegetables, as well as to reformulate food to make it healthier, and to “deal with” issues of portion and serve sizes.

Organ donations on the rise

There was a 10 per cent increase in the number of deceased organ donors in the first nine months of the year.

Australian and New Zealand Organ Donation Registry figure show there were 320 deceased donors between January and September, and there were 907 transplant recipients – including 48 who received multiple organs.

AMA President Professor Brian Owler said the increase was encouraging but, with about 1600 people waiting for a transplant at any one time, many more donors were needed.

Professor Owler encouraged people to think about becoming a donor, and urged families to respect the wishes of those who chose to become a donor.

Rural health talks

Rural Health Minister Fiona Nash has convened a meeting of 17 organisations representing rural health professionals, students and instructors as part of an effort to boost health services in the bush.

Senator Nash said a key focus of discussions was ways to increase the number of doctors and other health professionals working in rural and regional areas.

The Minister said that it was not just more doctors who were needed in rural areas, but the whole gamut of other health professionals, including nurses, physiotherapists and dentists.

Fmr NSW Health Minster joins Medical Deans

Former New South Wales Deputy Premier and Health Minister, Carmel Tebbutt, has become head of the peak body representing the nation’s Medical Deans.

Ms Tebbutt, who entered NSW Parliament in 1998 and served in a variety of ministerial portfolios while in government, did not contest the 2015 State election.

She is married to Federal Labor frontbencher Anthony Albanese.

Online credential check for overseas doctors

Overseas medical graduates looking to work in Australia will now have their qualifications verified through a web-based system that will also allow them to keep electronic records of education, training and licensing credential following an agreement struck by the Australian Medical Council and the US-based Educational Commission for Foreign Medical Graduates.

Under the deal the AMC, which provides a centralised service for specialist medical colleges and other organisations to check the credentials of international applicants, requires overseas medical graduates (OMGs) to have their qualifications and experience verified by the Commission from primary sources through its Electronic Portfolio of International Credential (EPIC) program.

The AMC said the EPIC program provided it with a secure, web-based platform for authenticating the credentials of applicants, and enabled paperless processing and record-keeping.

The Commission said OMGs could use EPIC to build a “digital portfolio” of verified credentials accessible anywhere, and could be used to satisfy the requirements of regulators, potential employers and other organisations.

Put cancer drugs on fast track

The Federal Government should speed up approval processes for new cancer drugs and look at developing a national medicines register, a Senate inquiry has recommended.

An investigation into the availability of specialist cancer drugs said that the current trend toward a larger range of treatments that are targeted at small populations of patients is likely to continue, putting increasing pressure on the medicines approval process.

Senator Catryna Bilyk, who was a member of the inquiry, told Parliament that there was increasingly a personalised medicine approach in which the genetics of tumours are established and high-throughput screening of existing medications is undertaken to determine which drugs that show activity against the tumour. This is used by oncologists to inform their treatment.

“More targeted medicines and therapies have the ability to increase the range of treatment options for cancer patients, resulting in improved quality of life and survival for many patients,” Senator Bilyk said.

But such treatments can be very expensive, and often patients face a lengthy wait before they can get subsidised access while regulators, medical experts and ministers assess them for efficacy and cost effectiveness.

The inquiry recommended a comprehensive review of the system, including looking at fast-track processes used overseas, and suggested the Government consider setting up a national register of cancer medicines.

National registration for paramedics

The Federal Government has opposed a move to establish a single national registration scheme for paramedics.

A majority of the nation’s health ministers agreed to include paramedics in the National Registration Accreditation Scheme at a meeting in Adelaide last month, overriding the objections of Federal Health Minister Sussan Ley.

The move is seen as consistent with a push to establish nationally-recognised qualifications across a range of occupations.

But New South Wales has reserved its right to opt out of the process, and, according to a communique from the meeting, Ms Ley argued it was “not consistent with the principles of the NRAS as a national regulatory reform”.

Adrian Rollins

[Editorial] The Global Burden of Diseases: living with disability

The UN observes the International Day of Persons with Disabilities on Dec 3, 2015. This year, three themes are highlighted in the agenda: making cities inclusive for all, improving disability data and statistics, and including those with invisible disabilities in society and development. These themes echo the specific mention of persons with disabilities in five of the Sustainable Development Goals (SDGs): education; economic growth and employment; creation of inclusive, safe, resilient, and sustainable cities; reduction of inequalities; and data collection related to monitoring the SDGs.

Unprofessional behaviour on social media by medical students

Social media are defined as a group of internet-based applications that allow the creation and exchange of user-generated content within a virtual community or network.1 Their rapid growth over the past decade has caused a paradigm shift in the way people communicate. The social media service Facebook reported 1.19 billion active users in 2013, and as early as 2008 the site was used by 64% of medical students,2 increasing to 93% of Australian first-year health professional students in 2013,3 suggesting that Facebook and other social media services form a growing part of students’ lives.

Earlier research has examined the use of social media by medical students and doctors for personal purposes and discussed the implications for medical professionalism.4 One study5 explored American medical schools’ experience of medical students posting improper content online, including profanity, discriminatory language, depictions of alcohol intoxication, and sexually suggestive material. Such cases have led to disciplinary action and even expulsion.6 In response to the growing use of social media and concerns about its effect on professionalism, the Australian Medical Association published a guideline on online professionalism for medical students and practitioners in 2010.7

Some behaviours are clearly unprofessional, such as the posting of patient information or any content that involves illegal activity. Depending on the context, depicting alcohol use may also be unprofessional.

We hypothesised that social media usage would be high among medical students, and that unprofessional material would be commonly posted and publicly available online. Additionally, we anticipated that medical students would know the relevant guidelines,7,8 and that they would moderate their online behaviour accordingly.

The aim of our study was to assess social media use patterns among medical students, and to identify factors independently associated with reporting evidence of unprofessional behaviour on social media. We specifically investigated whether being exposed to guidelines on social media professionalism was associated with reduced prevalence of such behaviours.

Methods

An online survey comprising 35 questions with a skip-logic design was developed using the SurveyGizmo platform. Not every question was put to every respondent, as not all were applicable. The survey was conducted between 29 March and 12 August 2013.

Any student who was currently enrolled in a medical degree (undergraduate or postgraduate) at an Australian university was eligible to respond; 16 993 students were potentially eligible, including international students.9 Students were recruited by contacting student organisations and Australian Medical Students Association (AMSA) representatives from each medical school and asking them to disseminate the recruitment information. The assistance of medical school deans was sought for internal promotion of the survey on online learning management systems (eg, Blackboard and Moodle). The study was also promoted by these groups through Facebook and Twitter.

A standard consent page that detailed the purpose of the study was displayed before the survey was delivered. All responses were recorded, although only complete responses were included in the final analysis. As an incentive to complete the survey, students were offered the chance to win a prepaid debit card to the value of $500, to be allocated randomly to one respondent; contact details were collected for this purpose in a separate form to ensure that identifying details could not be linked to the survey data. Vendor-provided duplicate protection technologies were used to prevent multiple responses by an individual. Funding was not received from any external body, with all costs borne by the authors of this article.

“Unprofessional content” was defined as an online depiction of illegal activity, overt intoxication or illicit drug use, or the posting of patient information. If students had removed unprofessional content posted by themselves or others on their account, it was not assessed as evidence of unprofessional behaviour.

Data were exported from the platform and analysed with SAS 9.4 (SAS Institute). Univariate comparisons were performed using χ², Student t– and Wilcoxon rank-sum tests as appropriate, according to the type and distribution of the data. Parametric data are reported as means and standard deviations, non-parametric data as medians with interquartile ranges (IQR), and categorical variables as numbers and percentages. Multivariable logistic regression of “unprofessional behaviour” was performed using backwards elimination techniques, with univariate P < 0.25 as the cut-off for inclusion; results are reported as odds ratios (OR) with 95% confidence intervals. Multicollinearity was assessed by evaluating coefficient changes between univariable and multivariable models and using variance inflation factors. P < 0.05 (two-sided) was defined as statistically significant.

The study was approved as a low-risk project by the Monash Health Research Ethics Committee (MUHREC LR 2012001495).

Results

It was not known how many of the 16 993 students enrolled at Australian medical schools received notification about the survey, but 1027 from 20 medical schools (21 at the time of study enrolment) initially responded. Of these, 880 students fully completed the survey (85.6%) and thus comprised the study cohort.

Of the 880 students who submitted complete responses, 534 (60.6%) were undergraduates, 391 (44.4%) were from Victorian medical schools, and 875 (99.4%) used Facebook. The next most commonly used social networks were YouTube (853 students, 96.9%) and blogging platforms (399 students, 45.3%). Every student used at least one social network, with a mean of 5.5 networks per student (95% CI, 5.31–5.67). Online professionalism teaching had been received by 305 students (34.9%). Other demographic data are included in Box 1.

Unprofessional content was reported by 306 students as (34.7%) being present on their accounts. Evidence of intoxication was reported by 301 students (34.2%), evidence of illegal drug use by 14 (1.6%), depiction of an illegal act by 10 (1.1%), and the posting of patient information by 14 (1.6%). The proportion of students who reported seeing unprofessional content on other medical students’ accounts was much higher than that of those who reported it being present on their own account (Box 2).

Most students were aware of social media guidelines, with 475 (53.9%) aware of a professional body guideline, 363 (41.2%) of a university or clinical school guideline, and 584 (66%; 95% CI, 63%–69%) of at least one of the two. There was no association between knowledge of social media guidelines and unprofessional behaviour on social media (OR, 0.77; 95% CI, 0.54–1.11; P = 0.16). Most respondents (796, 90.5%) agreed or strongly agreed with the statement that they were held to a higher standard of professionalism than the general community; 27 (3.1%) disagreed and four (0.5%) strongly disagreed (Box 3 and Box 4).

Of the 875 students who used Facebook, 848 (96.9%) had changed the default security settings and 744 (85.0%) had a private profile; 618 students (70.6%) had increased their privacy and security settings by restricting content to groups or specific individuals.

After adjusting for covariates, unprofessional content was associated with students reporting that they had posted to their accounts evidence of alcohol use (OR, 6.50; 95% CI, 4.42–9.56; P < 0.001) or racist content (OR, 2.45; 95% CI, 1.15–5.20; P = 0.02), that they had used MySpace (OR, 1.51; 95% CI, 1.09–2.1; P = 0.01), and planned to change their profile name after graduation (OR, 1.61; 95% CI, 1.12–2.31; P = 0.01). Behaviours less likely to be associated with reporting of unprofessional content included believing that videos depicting medical events with heavy alcohol use are inappropriate (OR, 0.73; 95% CI, 0.63–0.85; P < 0.001), and being happy with their social media portrayal (OR, 0.57; 95% CI, 0.45–0.74; P < 0.001) (Box 4). Exposure to guidelines had no effect on students reporting unprofessional behaviours. The act of completing the survey itself caused 493 students (56.0%) to check their privacy settings, and 307 (34.9%) to change them.

Discussion

Our study found that social media use by the study population of medical students was nearly universal; further, 34.7% of respondents reported evidence of unprofessional content on their accounts. More students reported viewing unprofessional content on other students’ accounts than on their own. Unprofessional content was reported despite exposure to guidelines and education about online professionalism.

Medical students are held to higher standards of professionalism than general university students, and we found that most students are aware of this. This is relevant, as unprofessional conduct (online or offline) by a student may lead to disciplinary action, and has also been found to be associated with lapses during later professional practice.6,10

Factors associated with unprofessional content

Several factors were associated with the presence of unprofessional content, including evidence of alcohol use or racist content, and planning to change one’s profile name after graduation. Conversely, being happy with their social media portrayal appears to reduce the posting of unprofessional content by students. The implications of the association of unprofessional content with MySpace use are uncertain, and may now be weaker, given the decline in use of this platform.

The association between posting unprofessional content and the intention to change social media profile names on graduation suggests that students were aware that they had unprofessional content on their accounts but were not intending to remove it. This is despite knowing about the relevant guidelines and believing they are subject to a higher expectation of professionalism than the general public. As changing one’s profile name may not effectively conceal an individual’s identity, such strategies provide a false sense of security and, paradoxically, encourage unprofessional behaviour.11

Professionalism guidelines

Medical associations and professional organisations have published guidelines and other literature7,8 in response to earlier research and reports in the media. Our results suggest that, despite the widespread dissemination and awareness of professional body guidelines in Australia, there appears to have been only a minimal impact on medical students’ behaviour.

There is a distinction between disseminating guidelines and formally integrating social media instruction into medical curricula. Senior clinicians and teachers who have not used social media may teach professionalism “largely in the context of the physician–patient relationship”,12 and be ill-equipped for teaching their juniors about professionalism in a social media context.13 Our findings show that reducing the unprofessional use of social media will require more than providing guidelines.

Privacy settings

The finding that 71% of students who used Facebook had set their account to “private” was higher than the 37.5% among US medical students reported in a 2008 study.2 Private profiles allow a medical student to partition “personal” information from their public persona. However, they do not provide a completely safe sanctuary for unprofessional behaviour. Data leaks, changes to terms and conditions, and public dissemination of previously private information mean that private content posted to social media may still become more widely available.

Reading and interpreting online content is highly subjective, and the level of professionalism expected in both public and private spaces varies between individuals. Completing the survey led 35% of students to adjust their privacy settings, suggesting that being prompted to do so, combined with their reflecting on a desirable public image, may be an effective intervention. The higher proportions of participants who reported having seen rather than posted unprofessional behaviour also highlight an intrinsic attribute of social networks: that a single example of unprofessional content may be seen by a large number of medical students. While use of a private profile may not reduce the incidence of unprofessional content, it does reduce the size of the potential audience for that content.

Strengths and limitations

There are some limitations to our study. Participation was voluntary, and many participants were recruited through social media; each factor introduces selection bias. Our survey included only a small proportion of the 16 993 Australian medical students in 2013; we were unable to estimate the number of students who were actually aware of the study. A large proportion of participants were from a small number of Victorian universities, the state in which the authors of this article reside, and this may limit extrapolation of the results to other medical student populations. The survey was conducted in 2013, and the time that has elapsed between collecting and publishing our data is also acknowledged.

Our study relied on the self-reporting of specific content on social media, and did not record the prevalence of unprofessional behaviour itself. This has the potential for introducing both information and recall bias, as students may report their own behaviour differently to their perception of others’. In addition, the accuracy of participants’ responses could not be verified. The findings of this study cannot be extrapolated to qualified medical practitioners or to other allied medical staff.

Nevertheless, our study is the largest to examine medical student professionalism on social media, and has identified factors that may predict and protect against future unprofessional behaviour. It also showed that the act of completing the study was sufficient to change some behaviours, so that introspection itself may be a beneficial tool for educators seeking to address this problem.

Conclusion

The use of social media by the surveyed students was almost universal, and unprofessional behaviours on social media were exhibited by a significant proportion of medical students, despite widespread awareness of guidelines about professionalism. Content posted online is effectively in the public domain, and management of their online identity is therefore now part of a student’s professional responsibility. Medical educators should consider approaches beyond simply providing guidelines or policies, and students should be regularly prompted to reflect on their activities, to evaluate their online behaviours, and to temper them if appropriate.

Box 1 –
Demographic characteristics of students reporting or not reporting evidence of unprofessional behaviour^∗

	All students	Students reporting no evidence of unprofessional behaviour	Students reporting evidence of unprofessional behaviour	P

Number	880	574	306
Median age (IQR), years	22 (20–24) [range, 16–40]	22 (20–24)	22 (21–24)	0.95
Enrolment type
Undergraduate	534 (60.6%)	359 (67.4%)	174 (32.6%)	0.11
Previous health care degree^†	98 (28%)	66 (67%)	32 (33%)	0.65
Domestic^‡	826 (94.1%)	527 (63.8%)	299 (36.2%)	0.001
Year of study
1st	184 (20.9%)	122 (13.9%)	62 (7.0%)	0.79
2nd	173 (19.7%)	117 (13.3%)	56 (6.4%)	0.48
3rd	189 (21.5%)	124 (14.1%)	65 (7.4%)	0.93
4th	169 (19.2%)	103 (11.7%)	66 (7.5%)	0.21
5th	93 (10.6%)	55 (6.3%)	38 (4.3%)	0.21
6th	71 (8.1%)	53 (6.0%)	18 (2.1%)	0.09
University attended
Monash (Victoria)	278 (31.6%)	190 (21.6%)	88 (10.0%)	0.19
Western Australia	116 (13.2%)	73 (8.3%)	43 (4.9%)	0.60
Melbourne (Victoria)	113 (12.8%)	79 (8.9%)	34 (3.9%)	0.29
Deakin (Victoria)	78 (8.9%)	49 (5.6%)	29 (3.3%)	0.71
Queensland	48 (5.5%)	30 (3.4%)	18 (2.0%)	0.75
New England (NSW)	48 (5.5%)	25 (2.8%)	23 (2.6%)	0.06
Western Sydney (NSW)	39 (4.4%)	29 (3.3%)	10 (1.1%)	0.30
Others	160 (18.1%)	99 (61.9%)	61 (38.1%)	0.36
Received instruction about online professionalism
Yes	305 (34.9%)	199 (22.8%)	106 (12.1%)	0.45
No	421 (48.2%)	268 (30.7%)	153 (17.5%)
Not sure	147 (16.8%)	102 (11.7%)	45 (5.2%)

∗ All values reported as number (and column percentage) unless otherwise stated. † Percentage refers to medical postgraduates only. ‡ Australian and New Zealand citizens, and Australian permanent residents.

Box 2 –
Unprofessional behaviours on medical students’ social media accounts, self-reported (own account) v observed (others’ accounts)

* Posted by self v posted by others: P < 0.001.

Box 3 –
Characteristics of students reporting or not reporting evidence of unprofessional behaviour^∗ (univariate analysis)

Students reporting no evidence of unprofessional behaviour

Students reporting evidence of unprofessional behaviour

Do you use:

Facebook

566/567 (99.8%)

304/305 (99.6%)

1.0

Twitter

208/574 (36.2%)

145/306 (47.4%)

0.002

107/574 (18.6%)

93/306 (30.4%)

0.01

Do you think it is appropriate to be Facebook “friends” with:

Allied health staff

333/570 (58.4%)

213/302 (70.5%)

< 0.001

Junior doctors

443/571 (77.6%)

263/304 (86.5%)

0.0016

Nurses

322/568 (56.7%)

209/303 (70.0%)

< 0.001

Patients’ families

17/570 (3.0%)

7/303 (2.3%)

0.67

Patients

12/570 (1.38%)

3/303 (0.34%)

0.33

Have you ever posted content which could be interpreted as:

Racist

16/566 (2.8%)

25/302 (8.3%)

< 0.001

Sexist

225/568 (39.6%)

166/301 (55.2%)

< 0.001

Containing frequent swearing

58/569 (10.2%)

91/301 (30.2%)

< 0.001

Discussing a clinical site in a negative light

88/568 (15.5%)

93/302 (30.8%)

< 0.001

What guides your professionalism on social media?

Concerns about appearing unprofessional to friends, family, or peers

407/574 (70.9%)

192/306 (62.8%)

0.01

Belief that as a medical student I am held to a higher standard of professionalism

522/570 (91.6%)

274/304 (90.1%)

0.53

University social media guidelines or policy guides my behaviour

148/574 (25.8%)

58/306 (19.0%)

0.02

Concern about appearing unprofessional to general public

414/574 (72.1%)

198/306 (64.7%)

0.03

Do you believe professionalism extends to social media presence?

516/568 (90.8%)

246/306 (80.4%)

0.0001

Do you feel you have control over social media portrayal?

454/567 (80.1%)

218/303 (71.9%)

0.008

Are you happy with your social media portrayal?

504/569 (88.6%)

228/305 (74.7%)

0.0001

Do you use a pseudonym for your profile name?

46/566 (8.1%)

40/306 (13.1%)

0.02

Do you plan to change your Facebook profile name after graduation?

138/574 (24.0%)

110/306 (36.0%)

0.0001

Are you a domestic student?

527/572 (92.1%)

299/306 (97.7%)

0.0008

Have you read or been instructed about a social media guideline?

412/574 (71.8%)

219/306 (71.7%)

0.95

∗ All values reported as number and percentage of responders.

Box 4 –
Reported factors independently associated with unprofessional behaviours (multivariate analysis)

OR (95% CI)

Evidence of any alcohol use (not intoxication)

6.50 (4.42–9.56)

< 0.0001

Evidence of posting racist content

2.45 (1.15–5.20)

0.02

MySpace use

1.61 (1.09–2.10)

0.01

Planning to change profile name upon graduation

1.61 (1.12–2.31)

0.01

Believing that recording videos of medical events depicting heavy alcohol use are inappropriate

0.73 (0.63–0.85)

< 0.0001

Happy with social media portrayal

0.57 (0.45–0.74)

< 0.0001

Read or been educated on social media guidelines

0.77 (0.54–1.11)

0.16

OR = odds ratio. Hosmer–Lemeshow H statistic for goodness of fit, 5.31; P = 0.72; area under receiver–operator characteristic curve, 0.80.

[Comment] Offline: Gender equality—the neglected SDG for health

“Wives should have the same rights and should receive the protection of law in the same manner as all other persons…the defenders of established injustice do not avail themselves of the plea of liberty but stand forth openly as the champions of power.” John Stuart Mill’s 1859 essay, On Liberty, may not be the cri de coeur those working for gender equality today would hope for in a post-2015 world. But Mill’s link between liberty, the rights of women, and universal education was one of the first and most striking modern statements advocating greater gender empowerment (at least by a man).

#InternCrisis worsens

In the early 2000s the Federal Government began funding new medical schools in response to reports of an increasing shortage of doctors in Australia.

This was the obvious policy response and, at the time, every new medical school (including several established while Tony Abbott was Health Minister) was lauded as a success. As a result, the number of medical graduates has nearly doubled in the past ten years.

Soon enough, the attention shifted from medical student numbers to the availability of internships and training positions at some undefined point in the future. There seemed to be little interest from decision makers in the problem, since a) it was poorly understood, b) it seemed some years away and c) it’s a difficult problem to solve – universities educate medical students with federal funding, but hospitals, colleges and state governments train the graduates. The Council of Australian Governments did, however, guarantee internship positions for all domestic medical graduates.

In late 2012, the problem seemed to come to a head, and pressure from AMSA, the AMA and other groups led to increases in training positions from State governments, as well as a $10 million commitment from the-then Labor Government, to find more positions.

The incoming Coalition government committed to a Commonwealth Medical Internship Initiative in 2013, to fund up to 100 extra internships each year for four years in non-traditional settings such as private hospitals and rural areas.

Despite the best efforts, the bureaucracy of the current system has been an issue.

While applications were submitted, in most instances, in May, and offers began to be released in July, there are still hundreds of students waiting for positions, with a significant number of positions still remaining.

The states have done their best to eliminate the confusion caused by students accepting offers in two places, and by the practice of taking students who have accepted offers in one State and placing them somewhere else. But, until there is a nationally co-ordinated system for internship allocation, we will continue to lose graduates overseas while they wait for the states to sort out their processes.

A new development occurred in South Australia this year. A ministry official from SA Health met with some student representatives to politely inform them that up to 10 per cent of the domestic graduates who had trained in South Australia would have to look to other states for internships. A subsequent bunch of questions from journalists to the South Australian Health Minister had Jack Snelling promising that there would be internships for South Australian graduates. But it isn’t clear how long that guarantee will last for, or if those jobs will be in South Australia.

The universities must share some of the blame. The only students to miss out on internships so far have been international students. These students had a medical degree promoted to them, and came out to this country with high hopes of starting a career. Their fees help fund medical education for universities as a whole. However, most of them were not aware that internships might not be available upon their graduation.

While the situation for those seeking internships is somewhat perilous, spare a thought for those prevocational doctors who are applying for specialist positions – not only are positions limited, but there is very little data to show what the state of affairs actually is.

Ultimately, something will have to give – either universities will need to be more tightly regulated regarding their student numbers; State governments, colleges and hospitals will have to make more training room, or students and young doctors will give up and work elsewhere.

We need leadership. The Council of Australian Governments needs to come together and work on a plan for medical training in Australia, and finish what was started more than a decade ago.

‘Extreme’ GST on health makes no sense

The sickest and most vulnerable in society would be hit hardest if the Federal Government moved to impose a consumption tax on health care, AMA President Professor Brian Owler has warned.

The Turnbull Government has initiated a wide-ranging discussion on tax reform that has included suggestions the Goods and Services Tax be raised to 15 per cent or be expanded to include health care, education and fresh food.

Treasurer Scott Morrison has sought to distance the Government from what he has described as more “extreme” proposals, and it has been reported that health and education will remain exempt because of complexities in applying the indirect tax to these services.

But Professor Owler said it was nonetheless important to discuss why health should remain GST-exempt.

He said imposing a consumption tax on health would have a “very significant impact” on the cost of health care, particularly for the most unwell and chronically ill.

Consumption taxes, because they apply across the board, are seen as inherently regressive, and Professor Owler said that was particularly the case when they were applied to health.

“It doesn’t get much more regressive [than] when it comes to health care, because this is going to be a tax on the sickest, most unwell people in our society; those who can least afford to pay a significant increase in health care costs,” he said.

Professor Owler said Australian patients already paid among the highest out-of-pocket costs in the world for their health care, and adding a GST would exacerbate the situation, to the particular detriment of the poorest and sickest.

It has been suggested that the impact of a GST on health could be offset by compensation payments, but Professor Owler questioned the practicality of the idea, particularly in directing it to those who most need it.

He said if fresh food was to be kept GST-exempt, so should health care: “We are talking about excluding fresh food, presumably because we want to preserve people’s health. So it makes no sense, then, to apply the GST to health care when people are actually sick and when they can least afford it”.

Adrian Rollins

Never-ending intern and training crisis looms again

Hundreds of medical graduates and junior doctors face missing out on vital training places in the next two years without urgent investment by Federal, State and Territory governments, the AMA has warned.

As aspiring doctors and specialists scramble to secure internships, prevocational and vocational positions, the Association has urged governments to honour existing training funding commitments and lift their investment in specialist education if the country is to avoid a looming shortage of doctors.

Medical graduates in South Australia are facing uncertainty following indications the State Government is preparing to renege on its commitment to fund internships for all SA medical graduates.

The AMA has warned that, on current projections, 22 SA medical graduates will miss out on an internship in the State in 2017, rising to 39 in the following year.

Further along the training pipeline, the AMA has told a Health Department review of the Specialist Training Program (STP) that the number of places provided under the scheme will increasingly fall short of what the nation needs.

AMA President Professor Brian Owler said modelling by the former Health Workforce Australia indicated the nation was facing a shortfall of 569 first-year advanced specialist training places by 2018, increasing to 689 places in 2024 and 1011 places in 2030.

He warned this would have knock-on effects throughout the medical training pipeline, and there are concerns it could leave the nation short of the specialists it needs to meet future demand.

HWA predicted general practitioners, psychiatrists and anaesthetists, in particular, could be in short supply by 2030, and the problem will be especially acute in rural and regional areas.

Professor Owler said the Government should boost the size of its well-regarded STP program from 900 to 1400 places by 2018, and to 1900 places by 2030.

“We should now be trying to improve the distribution of the medical workforce and encouraging future medical graduates to train in the specialties where they will be needed to meet future community need for healthcare services,” he said.

Until now, much of the growth in training opportunities has been at the undergraduate level. In the past decade there has been a 150 per cent jump rapid expansion in the number of medical school places, and currently there are 3736 students enrolled nationwide.

But the AMA and the Australian Medical Students’ Association have warned that much of this investment will be wasted without a commensurate increase in intern, pre-vocational and specialist training places.

Modelling undertaken for the Australia’s Future Health Workforce identified an emerging mismatch between trainees and the number of vocational training places, with a shortfall of around 1000 places by 2030.

Professor Owler said this was particularly concerning because the pressure on intern places nationwide meant there was no guarantee that SA graduates unable to secure a place locally would be offered an internship interstate.

In its submission to the STP review, the AMA urged that the program be used to help address current and developing workforce shortages in particular specialties and regions.

It said the program could make an important contribution to relieving shortages in the specialist workforce in rural areas by increasing the priority given to providing training positions in rural and regional areas.

Already, 41 per cent of STP training positions are in rural Australia, but the AMA has argued this should be increased, in part by shifting away from the current emphasis on one-year placements to a structure that instead supports clear and co-ordinated pathways for trainees interested in pursuing rural careers.

It said STP funding could support the establishment of regional training networks – vertically integrated networks of health services and regional prevocational and specialist training hubs – which the AMA has proposed as a way of remedying chronic rural workforce issues by enhancing generalist and specialist training opportunities and supporting prevocational and vocational trainees to live and work in regional and rural areas.

“Medical training does not stop at the gates of the medical school,” Professor Owler said. “We have seen a massive investment in extra medical school places, which must not be allowed to go to waste.

“It is important that all governments look beyond the intern year. With medical workforce planning data showing shortfalls in specialist training places, we need investment across the medical training pipeline,” he said.

Adrian Rollins

Exploring the value of interprofessional student-led clinics for chronic disease patients

Interprofessional student-led clinics have recently been established to extend educational capacity beyond traditional single-discipline placements in the acute sector and to facilitate the development of a collaborative approach to health care.1 Although student satisfaction with interprofessional education (IPE) is common,2 it is unclear whether IPE improves chronic disease management, a global priority of health care practice.3 This study explored the impact of interprofessional student-led clinics on chronic disease management in the primary care setting.

Patients (n = 44) with chronic disease at a primary care practice in Melbourne were invited to attend a student-led interprofessional clinic made up of senior university student volunteers from medicine, nursing, occupational therapy, pharmacy and physiotherapy. In a one-hour consultation between May and September 2014, mixed-discipline student teams interviewed patients to explore their perceived health issues, review medications and make recommendations to the treating general practitioner. Postconsultation, health issues identified by students were analysed to determine if any new health concerns had been identified. At 6-week follow-up, patient files were audited and GPs consulted to determine whether the students’ recommendations had been implemented.

New health issues were identified in five patients. Medication modifications were suggested for 17 patients, of which action was undertaken for 12 patients at follow-up. Referrals for additional services or support were recommended for 29 patients, of which action was undertaken for nine patients at follow-up. Referral recommendations included physiotherapy, podiatry and diabetes education, and new preventive health approaches were commonly adopted.

The ability of student teams to identify previously unknown health issues and propose useful health management changes highlights the potential of IPE to improve the management of patients with chronic disease. Findings from this study resonate with previous literature which suggests IPE can lead to improved patient health management.4 Over time, GPs acquire a breadth of knowledge about their patients’ health, but student teams in this study only had a single consultation with each patient. Longitudinal exposure to interprofessional consultations may facilitate students to evaluate and further refine their health management recommendations.

This study builds upon the literature examining chronic disease management by interprofessional student teams in primary care. The use of outcome measures such as health issues, medication and referral recommendations facilitated an objective assessment of health management changes. Limitations of this study are that all participants were volunteers and a comparison group was not employed. There is also the potential for experimenter bias, as one of the authors (M D) was a treating GP for some of the patients in the study. Employing a random sample of patients in future studies is recommended.

Positive early findings suggest further investigation of the potential of interprofessional student-led clinics to improve health care management for patients with chronic disease is warranted.

[Comment] Religion and Ebola: learning from experience

The largest Ebola epidemic in history, in 2014–15, profoundly disrupted three west African countries that bore its brunt: Guinea, Liberia, and Sierra Leone.1 Effects include more than 10 000 deaths, more than 26 000 people infected,2 and high social and economic costs. Religious beliefs and practices shape (positively and negatively) ways of caring for the sick, patterns of stigma, and gender roles. Throughout the crisis, religious institutions have provided services including health, education, and social support.

Worrying signs of breakdown in national training commitment

The country will remain heavily reliant on overseas-trained doctors to plug significant health service gaps unless the Federal Government revives a national focus on issues around medical workforce planning, the AMA has warned.

AMA President Professor Brian Owler has written to Federal Health Minister Sussan Ley urging her to put medical training and workforce on the agenda of the 6 November meeting of Federal, State and Territory health ministers amid worrying signs of a breakdown in national cooperation and coordination on the issue.

Professor Owler told Ms Ley that it appeared “increasingly likely” that the South Australian Government would renege on its guarantee, made as part of a national agreement struck in 2006, to fund sufficient intern training places to continue the education of medical graduates, the numbers of which are growing because of increased Commonwealth investment in medical school places.

He said that, on current projections, 22 South Australian medical graduates would miss out on a local internship in 2017, and up to 39 in 2018, forcing them to look interstate if they were to continue their training.

The situation is seen as part of a broader loss of focus on medical training and workforce planning, deepened by the Federal Government’s decision to abolish Health Workforce Australia and absorb its functions within the Health Department, and exacerbated by the slow pace of work in establishing the National Medical Training Advisory Network.

Professor Owler warned of potentially serious consequences if the period of policy drift was allowed to persist.

“The Federal Government must show leadership on this issue.”

“With a growing lack of leadership, it appears that jurisdictions are increasingly making parochial decisions on medical workforce planning without regard for broader community need,” the AMA President said.

“In this regard…the South Australian Government appears to consider itself no longer bound by the commitments it has given at COAG [Council of Australian Governments], and holds the view that other states [and] territories can take up the slack in any event.

“If one jurisdiction is allowed to walk away from this fundamental COAG commitment, others may follow this lead.”

Australia is heavily reliant on overseas medical graduates to plug holes in the medical workforce, particularly in rural and regional areas, and Professor Owler said this would persist as long as governments failed to focus on training and planning issues.

He said it would be a waste of taxpayers’ increased investment in medical school places if governments failed to fund sufficient intern, prevocational and specialist places to complete their training.

“It is simply not acceptable for governments to ignore the growing supply of local graduates and the need to support them in progressing through the medical training pipeline to full specialist qualification,” Professor Owler said.

Adrian Rollins.