[Correspondence] A new era for medical education in Colombia

During Nov 1–3, 2017, most of the Deans of Medicine who belong to the Colombian Association of Faculties of Medicine (ASCOFAME)—a nationwide network of higher education institutions or universities with medical faculties—met in Monteria, Colombia. Their objective was to develop a consensus on medical education.1

Organ donation – it’s vital

The AMA supports organ and tissue donation, and strongly encourages individuals to consider their views on donation and discuss them with their family.

AMA President Dr Michael Gannon stressed that point when releasing, in early January this year, the AMA Position Statement on Organ and Tissue Transplantation 2017.

Increased organ donation rates could transform lives as well as save precious healthcare dollars, as organ transplants are more cost-effective than ongoing medical care, the Position Statement says.

Dr Gannon said the opportunity for organ donation was an infrequent event, and comes at an intensely emotional time for families, who will always be asked to make the final donation decision.

“The AMA thanks every organ donor for their generosity, and every donor family for making such a brave and generous decision during a very difficult time in their lives,” he said.

“Australia is a leader in organ and tissue transplantation in terms of transplant outcomes, and while donation rates are continually improving as a result of reforms introduced in 2009, there is always room for further growth.

“By increasing Australia’s rate of organ and tissue donation, more individuals and their families have the chance to benefit from life-enhancing and life-saving transplants.

“This has a positive impact on the healthcare system as transplantation of organs and tissues, such as kidneys and corneas, is cost-effective compared to the expense of providing ongoing treatment for those on waiting lists.”

The updated Position Statement, which was approved at the final meeting of the AMA Federal Council in 2017, continues to highlight issues including:

the need for a robust ethical framework for donation and transplantation;
public education and awareness;
donor families;
living donors;
education and support for healthcare workers;
quality and safety; and
cultural sensitivities.

It includes a new section on transplant waiting lists, as well as a new section on umbilical cord blood banks.

It also includes expanded sections on allocation of organs and tissues, consent to transplantation, and organ trafficking, transplant commercialism, and transplant tourism.

According to figures in the Australian Donation and Transplantation Activity Report 2016, about 1600 people are on the transplant waiting list at any given time. In 2016, 1713 people received donations from 503 deceased organ donors and 267 living organ donors.

Deceased organ donation has more than doubled since 2009 (247 donors), and the number of organ transplant recipients has increased by 81 per cent over the same period (1447 compared to 799).

The number of organs retrieved and transplanted from each donor has decreased from 3.8 in 2009 to 3.4 in 2016.

Kidneys (821) are the most commonly transplanted organ, followed by the liver (314), lungs (196), heart (124), and pancreas (52).

There were 1281 eye donors, a 1 per cent increase on 2015 (1266) and a 39 per cent increase since 2009 (922).

In 2016, there were 7468 notified tissue transplant recipients, up 17 per cent on 2015 (6421).

“Public willingness to donate requires appropriate infrastructure, communication and coordination networks, and specialist staff trained to identify potential donors and support donor families,” Dr Gannon said.

“GPs also need appropriate professional education and awareness to carry out their role of raising awareness about organ donation with patients.”

The Position Statement acknowledges the debate regarding ‘opt-in’ vs ‘opt-out’ models of organ donation, but does not support one model over the other.

It upholds the principle that either system must be based on free, informed donor choice involving the right to choose, as well as to refuse, to be an organ and tissue donor.

The AMA encourages every Australian, regardless of age, to think about becoming a donor.

Those wishing to become a donor should register their consent on the Australian Organ Donor Register at https://register.donatelife.gov.au, and tell their family about their donation wishes.

“In Australia, your family will always be asked to make the final decision,” Dr Gannon said.

“So make that very hard decision a little easier for them.”

The AMA Position Statement on Organ and Tissue Transplantation 2017 is available at position-statement/organ-and-tissue-donation-and-transplantation-2017

CHRIS JOHNSON

Encouraging more doctors to go rural

The AMA has released its Position Statement – Rural Workforce Initiatives, a comprehensive five-point plan to encourage more doctors to work in rural and remote locations, and improve patient access to care.

The plan proposes initiatives in education and training, rural generalist pathways, work environments, support for doctors and their families, and financial incentives.

It says that at least one-third of all new medical students should be from rural backgrounds.

And more medical students should be required to do at least one year of training in a rural area to encourage graduates to live and work in regional Australia.

In releasing the Position Statement, AMA President Dr Michael Gannon noted that about seven million Australians live in regional, rural, and remote areas, and they often have more difficulty accessing health services than their city cousins.

They often have to travel long distances for care, and rural hospital closures and downgrades are seriously affecting the future delivery of health care in rural areas.

For example, Dr Gannon said, more than 50 per cent of small rural maternity units have been closed in the past two decades.

“Australia does not need more medical schools or more medical school places,” he said.

“Workforce projections suggest that Australia is heading for an oversupply of doctors.

“Targeted initiatives to increase the size of the rural medical, nursing, and allied health workforce are what is required.

“There has been a considerable increase in the number of medical graduates in recent years, but more than three-quarters of locally trained graduates live in capital cities.

“International medical graduates (IMGs) make up more than 40 per cent of the rural medical workforce and while they do excellent work, we must reduce this reliance and build a more sustainable system.”

The AMA Rural Workforce Initiatives plan outlines five key areas where Governments and other stakeholders must focus their policy efforts:

Encourage students from rural areas to enrol in medical school, and provide medical students with opportunities for positive and continuing exposure to regional/rural medical training;
Provide a dedicated and quality training pathway with the right skill mix to ensure doctors are adequately trained to work in rural areas;
Provide a rewarding and sustainable work environment with adequate facilities, professional support and education, and flexible work arrangements, including locum relief;
Provide family support that includes spousal opportunities/employment, educational opportunities for children’s education, subsidies for housing/relocation and/or tax relief; and
Provide financial incentives to ensure competitive remuneration.

“Rural workforce policy must reflect the evidence. Doctors who come from a rural background, or who spend time training in a rural area, are more likely to take up long-term practice in a rural location,” Dr Gannon said.

“Selecting a greater proportion of medical students with a rural background, and giving medical students and graduates an early taste of rural practice, can have a profound effect on medical workforce distribution.

“Our proposals to lift both the targeted intake of rural medical students and the proportion of medical students required to undertake at least one year of clinical training in a rural area from 25 per cent to 33 per cent are built on this approach.

“More Indigenous people must be encouraged to train and work in health care, as there is a strong link between the health of Indigenous people in rural areas and their access to culturally appropriate health services.

“Fixing rural medical workforce shortages requires a holistic approach that takes into account not only the needs of the doctor, but also their immediate family members.

“Many doctors who work in rural areas find the medicine to be very rewarding, but their partner may not be able to find suitable employment, and educational opportunities for their children may be limited.

“The work environment for rural doctors presents unique challenges, and Governments must work collaboratively to attract a sustainable health workforce. This includes rural hospitals having modern facilities and equipment that support doctors in providing the best possible care for patients and maintaining their own skills.

“Finally, more effort must be made to improve internet services in regional and rural areas, given the difficulties of running a practice or practising telehealth with inadequate broadband.

“All Australians deserve equitable access to high-speed broadband, and rural doctors and their families should not miss out on the benefits that the growing use of the internet is bringing.”

The AMA Position Statement – Rural Workforce Initiatives is available at position-statement/rural-workforce-initiatives-2017

CHRIS JOHNSON

Background:

Most Australians live in major cities (70 per cent), while 18 per cent live in inner regional areas, 9 per cent in outer regional areas, and 2.4 per cent in both remote and very remote areas.
Life expectancy is lower for people in regional and remote Australia. Compared with major cities, the life expectancy in regional areas is one to two years lower, and in remote areas is up to seven years lower.
The age standardised rate of the burden of disease increases with increasing remoteness, with very remote areas experiencing 1.7 times the rate for major cities.
Coronary heart disease, suicide, COPD, and cancer show a clear trend of greater rates of burden in rural and remote areas.
The number of medical practitioners, particularly specialists, steadily decreases with increasing rurality. The AIHW reports that while the number of full time workload equivalent doctors per 100,000 population in major cities is 437, there were 272 in outer regional areas, and only 264 in very remote areas.
Rural medical practitioners work longer hours than those in major cities. In 2012, GPs in major cities worked 38 hours per week on average, while those in inner regional areas worked 41 hours, and those in remote/very remote areas worked 46 hours.
The average age of rural doctors in Australia is nearing 55 years, while the average age of remaining rural GP proceduralists – rural GP anaesthetists, rural GP obstetricians and rural GP surgeons – is approaching 60 years.
International medical graduates (IMGs) now make up over 40 per cent of the medical workforce in rural and remote areas.
There is a health care deficit of at least $2.1 billion in rural and remote areas, reflecting chronic underspend of Medicare and the Pharmaceutical Benefits Scheme (MBS) and publicly-provided allied health services.

Use your phone, lose your licence

The AMA has for the first time issued a Position Statement on road safety, and in doing so it has called for tougher penalties for people who use their mobile phones while driving.

Those penalties include the loss of licence for up to a year for P-plate and L-plate drivers who use the devices while driving,

Releasing the AMA Position Statement on Road Safety 2018, President Dr Michael Gannon said the AMA was committed to advocating for improvements in the way Australians drive, the cars they drive, and the roads they drive on.

“Doctors – along with paramedics, ambulance officers, and nurses – see the tragic consequences of road trauma,” Dr Gannon said.

“They see when road safety is ignored and when avoidable accidents occur – accidents that take lives and cause horrific injuries.

“The AMA is particularly concerned about the use of mobile telephones and electronic devices, including navigational devices, in cars.

“Mobile phones and other devices are driver distractions, and a major cause of accidents, trauma, and death.”

The AMA supports measures that change driver behaviour. Dr Gannon said the Position Statement aims to help change the culture and mentality about using mobile devices in cars.

“Your driver’s licence is a privilege, not a right,” he said.

“Drivers who breach the road rules are putting themselves and others at risk, and must face meaningful sanctions.

“Good habits must be ingrained in new, inexperienced drivers. There should be zero tolerance of provisional and learner drivers who use mobile phones or electronic devices, and penalties should include the loss of licence for up to a year.”

The AMA is also concerned about pedestrians and cyclists who use headphones, earpieces, or mobile devices.

“Using headphones or mobile devices while walking or cycling on or near roads is a serious safety risk, and is a factor in motor vehicle accidents,” Dr Gannon said.

“The AMA is calling for the fundamentals of road rules, including responsibility of pedestrians, to be formally instilled from a very young age through nationwide standards of road safety education.

“On average, three people die on Australian roads every day and 90 are seriously injured – two permanently.

“That represents about 33,900 adults and children every year who are killed or maimed in avoidable incidents, and thousands more who are affected by the trauma of losing a partner, relative, or friend.

“Community-led road safety initiatives, such as Black Spot programs, and identification of local traffic issues have the potential to reduce road fatalities and injuries.”

The Position Statement also calls for uniform, national criteria for assessing older drivers. The AMA endorses the joint guidelines issued by Austroads and the National Transport Commission (NTC) in their Assessing Fitness to Drive: medical standards for licensing and clinical management guidelines. A resource for health professionals in Australia (October 2016) publication.

“All States and Territories must adopt uniform criteria for assessing the functional ability of older drivers, as the discrepancies between jurisdictions are problematic,” Dr Gannon said.

“We also want doctors to be more proactive in helping older drivers to assess their ability and confidence to keep driving.

“Doctors should be providing advice on when to retire from driving. This may require medical examinations or assessments of drivers beyond a specified age.”

The AMA Position Statement on Road Safety 2018 is available at position-statement/road-safety-2018

CHRIS JOHNSON

Action needed to protect children from too much sugar

The AMA has taken a strong position on sugar, calling for a tax on sugary drinks and a ban on junk food marketing aimed at children.

Releasing its AMA Position Statement on Nutrition 2018 in early January, the AMA said the tax should be introduced as a priority.

AMA President Dr Michael Gannon said eating habits and attitudes toward food are established in early childhood and so advertising of junk food and sugary drinks to children should be banned.

“Improving the nutrition and eating habits of Australians must become a priority for all levels of government,” Dr Gannon said.

“Governments should consider the full complement of measures available to them to support improved nutrition, from increased nutrition education and food literacy programs through to mandatory food fortification, price signals to influence consumption, and restrictions on food and beverage advertising to children.

“Eating habits and attitudes start early, and if we can establish healthy habits from the start, it is much more likely that they will continue throughout adolescence and into adulthood.

“The AMA is alarmed by the continued, targeted marketing of unhealthy foods and drinks to children.

“Children are easily influenced, and this marketing – which takes place across all media platforms, from radio and television to online, social media, and apps – undermines healthy food education and makes eating junk food seem normal.”

Dr Gannon said advertising and marketing unhealthy food and drink to children should be prohibited all together, and the loophole that allows children to be exposed to junk food and alcohol advertising during coverage of sporting events must be closed.

“The food industry claims to subscribe to a voluntary code, but the reality is that this kind of advertising is increasing,” he said.

“The AMA calls on the food industry to stop this practice immediately.”

The Position Statement also calls for increased nutrition education and support to be provided to new or expecting parents, and notes that good nutrition during pregnancy is also vital.

It recognises that eating habits can be affected by practices at institutions such as child care centres, schools, hospitals, and aged care homes.

“Whether people are admitted to hospital or just visiting a friend or family member, they can be very receptive to messages from doctors and other health workers about healthy eating,” Dr Gannon said.

“Hospitals and other health facilities must provide healthy food options for residents, visitors, and employees.

“Vending machines containing sugary drinks and unhealthy food options should be removed from all health care settings, and replaced with machines offering only healthy options.

“Water should be the default beverage option, including at fast food restaurants in combination meals where soft drinks are typically provided as the beverage.”

The Position Statement says a tax on sugar-sweetened beverages should be introduced.

The recommendations were warmly welcomed by health and children’s advocates.

The AMA Position Statement on Nutrition 2018 is available at position-statement/nutrition-2018 and the key recommendations are listed here.

CHRIS JOHNSON

Key Recommendations:

Advertising and marketing of unhealthy food and beverages to children to be prohibited.
Water to be provided as the default beverage option, and a tax on sugar-sweetened beverages to be introduced.
Healthy foods to be provided in all health care settings, and vending machines containing unhealthy food and drinks to be removed.
Better food labelling to improve consumers’ ability to distinguish between naturally occurring and added sugars.
Regular review and updating of national dietary guidelines and associated clinical guidelines to reflect new and emerging evidence.
Continued uptake of the Health Star Rating system, as well as refinement to ensure it provides shoppers with the most pertinent information.

[Perspectives] Health care as a cultural borderland

As a clinician, how do you best care for patients from a wide variety of backgrounds? Cultural diversity is not merely a matter of pluralism or multiculturalism; it is often accompanied by unequal or inadequate health care. Very often, cultural diversity and health disparity go hand in hand. As a response to such inequities, various forms of cultural competence training are now viewed as an essential curriculum component in medical education programmes and a key element of effective practice. However, these educational innovations have also come under fire.

Organ donation – it’s vital

The AMA supports organ and tissue donation, and strongly encourages individuals to consider their views on donation and discuss them with their family.

AMA President Dr Michael Gannon stressed that point when releasing, in early January this year, the AMA Position Statement on Organ and Tissue Transplantation 2017.

Increased organ donation rates could transform lives as well as save precious healthcare dollars, as organ transplants are more cost-effective than ongoing medical care, the Position Statement says.

Dr Gannon said the opportunity for organ donation was an infrequent event, and comes at an intensely emotional time for families, who will always be asked to make the final donation decision.

“The AMA thanks every organ donor for their generosity, and every donor family for making such a brave and generous decision during a very difficult time in their lives,” he said.

“By increasing Australia’s rate of organ and tissue donation, more individuals and their families have the chance to benefit from life-enhancing and life-saving transplants.

The updated Position Statement, which was approved at the final meeting of the AMA Federal Council in 2017, continues to highlight issues including:

the need for a robust ethical framework for donation and transplantation;
public education and awareness;
donor families;
living donors;
education and support for healthcare workers;
quality and safety; and
cultural sensitivities.