Latest healthcare variations atlas released

The Third Australian Atlas of Healthcare Variation has been released and identifies high-level variation in health care use by region.

But AMA President Dr Tony Bartone said the Atlas does not satisfactorily explain the causes or offer solutions, so it should only be considered as a statistical guide.

Dr Bartone said the Atlas provides a statistical, wider-population overview of the health system that, when considered along with the many other variables at a local level, has the potential to lead to improvements in clinical decision-making and the allocation of medical services.

“The reasons for any observed variation in health service utilisation reflect regional differences in people’s health care needs, variation in the patient’s treatment preferences, or other factors that require further examination,” he said.

“Some variation in patterns of health care utilisation should be expected. Once any variation is identified, the next step is identifying good variation from bad variation, and investigating the cause.

“It is very important for policymakers to be clear what the Atlas data is and isn’t. It is good at highlighting variation in health utilisation at the regional level, but it is not good at explaining why.

“The Atlas must be considered a statistical guide only, and is definitely no substitute for clinical experience and expertise.

“For example, it is important for health care providers to be aware of the latest evidence guiding the optimal gestation period for newborns. But it is also important to remain measured when interpreting the hospital data.

“In reporting variations in caesarean sections, the Atlas claims that up to 60 per cent are being performed before full term without a medical reason.

“There is an implication that these are ‘sinful’ caesareans done before 37 weeks for no good reason.

“In fact, the most recent available data from the Australian Institute of Health and Welfare (AIHW) estimates that only about 1.6 per cent of births in Australia are truly maternal-request caesareans.

“The same data shows that less than 9 per cent of caesarean sections are performed before 37 weeks, and these are almost always because of problems such as hypertension, breech labour, or bleeding.

“About one third of caesareans performed before 37 weeks are emergency cases.

“The real-life, real-time patient experience is a better clinical indicator than statistics in many areas of medical practice.”

Dr Bartone said the AMA fully supports efforts to continually improve the level of safety and quality, and the delivery of evidence-based, high-value care.

“Clinical stewardship is a core tenet of the AMA Code of Ethics,” Dr Bartone said.

“But clinicians must always retain the autonomy to exercise professional judgement in the care and treatment of their patients.

“The analysis in the Atlas typically analyses the utilisation levels of a single health care service in isolation.

“Patients are more complex than this, and rarely have a single condition or health care need. Patients frequently present with multiple conditions with multiple causes.

“A treatment that is high value for some patients might be low value for others. Clinician-led care takes the whole patient into account before advising treatment options.

“This does not mean there is no room for improvement. Governments must acknowledge, however, that the greatest successes in boosting evidence-based care and reducing low-value care are clinician-led, based on reliable patient data.”

NPS MedicineWise CEO Steve Morris said reinforces the value of the work done by key healthcare bodies across the country to improve healthcare outcomes for Australians.

The Atlas can be viewed at: https://www.safetyandquality.gov.au/Atlas

#GoodDoctorsTeach Australian Medical Students’ National Teaching Awards

BY ALEX FARRELL, PRESIDENT, AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

Every day, great doctors around Australia go above and beyond to teach students, and role model what medicine is all about. This year the Australian Medical Students’ Association (AMSA) celebrated those teachers in medical schools and hospitals with the National Awards for Teaching Excellence.

The AMSA National Awards are the highest honour bestowed on a teacher by medical students across the country. They are based on nominations from around the country, and represent students’ appreciation and recognition of teachers who have made an especially positive impact on their studies. There are a number of award categories including excellence in teaching, in rural education, teaching by a junior doctor, and as well as teaching by a member of an allied health profession.

Although it is such an important part of the doctor’s role, the teaching culture across different hospitals varies widely. Despite the recent focus and positive steps in the last few years, bullying, harassment, and teaching by humiliation are still too common an experience. These awards are part of AMSA’s #GoodDoctorsTeach campaign, acknowledging those who tackle this by actively creating a positive teaching culture within medicine.

AMSA received close to 100 nominations for the awards. Reading those nominations was heart-warming, as student after student shared stories of the teachers who have inspired, motivated and challenged them. It was a reminder of just how significant the impact of teaching is on the lives of students, and of how many exceptional teachers there are.

On behalf of Australian medical students, I’d like to thank all the doctors and allied health professionals who make it part of their daily work to make medicine a welcoming and exciting place for students and junior doctors, and nurturing their passion. Consultant or intern; metropolitan or remote; doctor, midwife or echocardiographer: the way you treat your students is making for better future doctors, and a better medical culture in Australia.

Excellence in Teaching winner: Dr Zafar Smith (James Cook University)

Quote from students: “Dr Smith has gone above and beyond teaching us Emergency Medicine in our 3rd year. He completely re-vamped the course making it much easier to learn and more enjoyable. Every single person I know has enjoyed his lectures, tutorial and approachability. He uses interactive methods of teaching which engage the class, such as gosoapbox and kahoot quizzes to test us, and has even created a deck of cards with Emergency medicine case studies that we were all able to get our hands on and use for our exams. As this is his first year of coordinating and lecturing this course, he has outdone himself and on behalf of Med 3 at James Cook University, we would like to recognise his efforts and generosity, and the fun spirit he has brought to sometimes difficult topics.”

Excellence in rural education winner: Dr Elizabeth Kennedy (University of Melbourne, Goulburn Valley Region)

Quote from student: “Dr Kennedy has provided me with outstanding mentorship over 2018, cementing my passion for rural medicine … She is consistently motivated to include students in the extracurriculars of the medical profession, including education events in the Goulburn Valley Region, attending Youth Forums regarding young women’s health, and promoting student engagement in the community. She constantly provides me with the mentorship and support to strive for more, and to be the kind of person and doctor that is needed in a rural area. She constantly gives her medical knowledge, emotional support and more to her patients and I learn from her each and every day.”

Excellence in teaching by a junior doctor winner: Dr Kenneth Cho (University of Sydney and University of Western Sydney, Nepean Hospital)

Quote from selection panel: “Kenneth’s work developing a JMO-led bedside tutorial program and a JMO-led Friday lecture series, run by Junior Medical Officers for medical students is an example of the way anyone, despite age or experience, can lead by example to create a culture of teaching where they work.”

Excellence in teaching by a member of an allied health profession winner: Mr David Law (Echocardiographer, University of New South Wales, Coffs Harbour Hospital)

Quote from student: “David- Coffs Harbour’s most prized sonographer- is probably the only teacher I’ve had who has been able to explain ECGs in a way that makes sense. But more important than that is how he has made the hospital such an inclusive place for medical students to be, welcoming us to catheterisation lab, and always taking the time to explain things to us.”

AIHW reports confirm public hospitals strained

Australia’s public hospitals are under considerable funding pressure and are struggling to meet patient demand, according to two reports released by the Australian Institute of Health and Welfare (AIHW).

The reports, Emergency Department Care 2017-18 and Elective Surgery Waiting Times 2017-18, highlight ongoing and growing pressure on public hospitals.

AMA President Dr Tony Bartone said the AIHW reports send a clear message to the major parties that public hospital funding will be a major issue at the next year’s Federal election.

“Our world-class public hospitals – and the dedicated health professionals who work in them – are required to meet the needs of more and more Australians every year,” Dr Bartone said.

“But these reports show that the current level of public hospital capacity is falling behind patient demand. Patients are joining public hospital waiting lists for elective surgery at rates faster than public hospitals can admit them.

“And the data does not consider the hidden waiting list and the hidden waiting time – the time that it takes for a patient to be seen in the out-patient department before being placed on the list. This can be as long, or even longer, than the elective waiting list time.

“Patient presentations in emergency departments continue to increase year on year. The doctors, nurses, and other staff who work in our hospitals are some of the most skilled in the world, but they can only do so much with the funding and resources available.

“There are not enough additional beds, staff, or capacity within hospital wards to admit every patient who presents in emergency and needs urgent care. There are insufficient resources to admit elective surgery patients who wait too long in pain, at risk, or with too little mobility.”

Dr Bartone said that the AMA will increase its advocacy for public hospital funding ahead of the 2019 election.

And he said it might also be time to seriously review whether the current activity-based funding settings are adequate.

“The AMA shares the ambitions of Ministers, bureaucrats, and academics that public hospitals must lift their efficiency, improve the safety and quality of care, provide better patient discharge and care integration, embed electronic health records, and even prevent avoidable admissions,” Dr Bartone said.

“But this will take more than words to achieve. It requires funding, planning, good policy, cooperation, and commitment.”

Key findings of the reports include:

Over the most recent 12-month period, between 2016-17 to 2017-18, the growth in elective surgery admissions from public hospital elective surgery waiting lists is virtually stagnant – an increase of only 0.1 per cent.
The backlog of people waiting for elective surgery is building, not reducing. Over the last four years, 2012-14 to 2017-18, the rate that patients are joining public hospital elective surgery waiting lists outstrips the rate that patients are removed from waiting lists.
Between 2013-14 and 2017-18, the median waiting time (50 per cent of patients admitted for the awaited procedure) across all public hospitals has increased from 36 days in 2013-14 to 40 days in 2017-18.
As usual, there is variation in time waited for elective surgery between jurisdictions.
- NSW is treading water – elective surgery waiting times are relatively unchanged – but slightly worse over the last 12 months.
- Victoria, Tasmania, and NT – show improvement – especially at the 90th percentile (number of days waited to admit 90 per cent of all patients waiting for elective surgery).
- Patients in Queensland, WA, SA, and ACT are waiting longer.
The number of patients presenting in Australian public hospital emergency departments is increasing year on year. There were more than 8 million presentations in 2017-18. This equates to 22,000 patients in Emergency Department per day.
Nationally, the number of ED presentations in 2017-18 jumped by 3.4 per cent on the previous year. This is a definite spike compared to the 2.7 per cent per annum average growth in emergency presentations over the last four year (2013-14 – 2017-18).
The growth in ED presentations in most jurisdictions over the last year hovers around the national average growth rate of 3.4 per cent in most jurisdictions. Tasmania has had the highest increase in ED presentations – 3.9 per cent.
Only 72 per cent of all ED presentations in 2017-18 were completed within the recommended four hours.

“In light of these reports, the AMA repeats its call for strong public hospital funding policies for the election,” Dr Bartone said.

“We must fully fund hospitals so they can improve patient safety and build their internal capacity to deliver high value care in the medium to long term.”

One in three emergency workers have high psychological distress: survey

One in three police and emergency service workers have high or very high psychological distress, according to a landmark survey released by Beyond Blue.

More than 21,000 police, fire, ambulance and SES employees, volunteers, and retired and former personnel took part in the Answering the call survey, which set out to build a comprehensive picture of the mental health and wellbeing of police and emergency services workers in Australia.

The survey also showed that employees and volunteers report suicidal thoughts over two times more often than adults in the general population, and are three times more likely to have a suicide plan.

Employees who have worked more than ten years in police and emergency services were found to be almost twice as likely to experience psychological distress and six times more likely to have symptoms of PTSD compared to those with less than two years’ service.

In addition, over half of the employees surveyed experienced a traumatic event during the course of their work that deeply affected them.

Research to drive a targeted, national strategy

The report detailed a range of recommendations to target the mental health of police and emergency service workers.

The authors wrote that all levels of government should work together on a national policy approach. This plan should include steps to address existing mental health service gaps and develop resources to target risk factors.

The paper also recommended that the Australian Government fund and lead the development of a national centre of excellence for police and emergency services mental health – a central hub of proven and emerging best practice interventions and programs.

On the day of the survey’s release, Beyond Blue CEO Georgie Harman said that “the results will arm everyone with unprecedented national data and insights from those who serve to protect us and keep us safe.”

“It is now everyone’s responsibility – governments, agencies, police and emergency services personnel and their families, unions and peak bodies, services and other stakeholders – to come together to convert this evidence into further action and lasting change.”

“Beyond Blue will support the sector to do this; to analyse and use the research findings to continue to focus on the mental health and wellbeing of police and emergency service personnel,” Ms Harman said.

Workplace culture is a contributing factor

Patrice O’Brien, General Manager of Workplace, Partnerships and Engagement at Beyond Blue told doctorportal that poor workplace practices and culture, as well as poor health literacy, are equally debilitating as exposure to trauma.

“Many employees with high or very high distress and probable PTSD, based on psychometric testing, did not self-report that they had a mental health condition.

“This suggests poor mental health literacy among respondents. While testing suggested the presence of a mental health issue, they were unable to identify this themselves.”

Ms O’Brien said that while most personnel did not hold stigmatising attitudes towards their colleagues, “the study found very high rates of self-stigma, which can also negatively impact help-seeking behaviours.”

One of the recommendations in the report outlined the need for funding agencies to provide communication initiatives, evidence-informed professional development, education and access to resources to address mental health literacy.

It is also vital to promote an inclusive, supportive and cohesive culture free of bullying, stigma and discrimination, and implement strategies to ensure that this culture is translated into team environments.

Survey part of a three-phase research program

Ms O’Brien said the goal of the Answering the call survey was to not only generate a national picture and baseline data of the health and wellbeing of current and former emergency services personnel. The goal was also to identify factors that prevent mental illness and suicide or create risk and challenges.

“In Phase 3 of the study, the knowledge translation phase, Beyond Blue will work with individual agencies to understand how the data relates to their organisation and to identify the best ways to respond, considering the unique needs and findings of each agency.”

[Comment] Engaging men in HIV treatment and prevention

Much has been accomplished over the past two decades in global HIV treatment and prevention. Although in need of renewed emphasis, the worldwide scale-up of antiretroviral therapy (ART) has gone beyond what many imagined possible. Oral pre-exposure prophylaxis (PrEP) is available in many high-income countries and in some lower-income and middle-income countries. The US President’s Emergency Plan for AIDS Relief (PEPFAR) and other funders are expanding access to rapid or same-day ART initiation and piloting PrEP programmes in international settings.

First ever multi-drug Ebola trial for the Congo

The Ministry of Health of the Democratic Republic of the Congo (DRC) has announced that a randomised control trial has begun to evaluate the effectiveness and safety of drugs used in the treatment of Ebola patients.

The trial is the first-ever multi drug trial for an Ebola treatment. It will form part of a multi-outbreak, multi-country study that was agreed to by partners under a World Health Organisation (WHO) initiative.

Until now, more than 160 patients have been treated with investigational therapeutics under an ethical framework developed by WHO, in consultation with experts in the field and the DRC, called the Monitored Emergency Use of Unregistered and Investigational Interventions (MEURI).

The MEURI protocol was not designed to evaluate the drugs. Now that protocols for trials are in place, patients will be offered treatments under that framework in the facilities where the trial has started. In others, compassionate use will continue up to the time when they join the randomisation. Patients will not be treated noticeably differently from before, though the treatment they receive will be decided by random allocation. The data gathered will become standardised and will be useful for drawing conclusions about the safety and efficacy of the drugs.

“Our country is struck with Ebola outbreaks too often, which also means we have unique expertise in combatting it,” said Dr Olly Ilunga, Minister of Health of the DRC.

“These trials will contribute to building that knowledge, while we continue to respond on every front to bring the current outbreak to an end.”

In October, WHO convened a meeting of international organisations, United Nations partners, countries at risk of Ebola, drug manufacturers and others to agree on a framework to continue trials in the next Ebola outbreak, whenever and wherever that is. Over time, this will lead to an accumulation of evidence that will help to draw robust conclusions across outbreaks about the currently available drugs, and any new ones that may come along.

At the heart of the long-term plan and the current trial is always the goal to ensure that patients with Ebola and their communities are treated with respect and fairness. All patients should be provided with the highest level of care and have access to the most promising medications.

The current trial is coordinated by WHO, and led and sponsored by the DRC’s National Institute for Biomedical Research (INRB), in partnership with the DRC Ministry of Health, the National Institute of Allergy and Infectious Diseases (NIAID) which is part of the United States’ National Institutes of Health, The Alliance for International Medical Action (ALIMA) and other organisations.

Ambulance call-outs for pregabalin have spiked – here’s why

Pregabalin (sold under the brand name Lyrica) is prescribed as an anti-epileptic and a painkiller for nerve pain. Australian prescriptions of pregabalin have risen significantly in the past five years. It’s now in the top ten most expensive medications for the Pharmaceutical Benefits Scheme (PBS).

We’ve also seen a rise in “off-label” prescription of pregabalin. This means it’s being prescribed for conditions for which there is limited evidence of effectiveness. Pregabalin is often prescribed for chronic or persisting pain, for example, even when there is no clear nerve-related cause.

Pregabalin is thought to have effects in the brain similar to those of benzodiazepines such as diazepam (Valium) by indirectly increasing levels of the neurotransmitter GABA.

Until recently, researchers and doctors did not think pregabalin was addictive. But now studies suggest pregabalin may also have an indirect effect on the brain’s reward chemical, dopamine.

Our research, published today in the Medical Journal of Australia, shows ambulance call-outs associated with the misuse of pregabalin have increased tenfold in Victoria since 2012. This mirrors an increase in prescription rates.

Growing evidence of misuse

In 2010, the first study was published that reported on a trend of pregabalin misuse.

Since then, several international research articles have documented misuse, including using higher doses than are recommended. At higher-than-prescribed doses, pregabalin causes sedation and euphoria.

People who use opioids – painkillers like oxycodone, or illicit opioids such as heroin – have a particularly high risk of misusing pregabalin. So do those with a history of substance use problems.

People who use illicit drugs report often using pregabalin in combination with other drugs. Pregabalin has been implicated in drug-related deaths in individuals who weren’t prescribed the medication, and often in combination with other sedative medications or illicit drugs.

High rates of pregabalin use are also reported in secure environments, such as prisons, in both Australia and the United Kingdom.

What did we find?

We analysed a unique database (the Ambo Project) that documents all ambulance attendances related to alcohol and drug use and mental health in Victoria.

We found pregabalin-related ambulance attendances increased tenfold between 2012 and 2017, from 0.28 cases per 100,000 population to 3.32 cases per 100,000. Pregabalin misuse contributed significantly to 1,201 call-outs from 2012 to 2017.

Pregabalin has a sedative effect, which can be compounded when used with other drugs that cause sedation, including alcohol, or other prescribed medications such as benzodiazepines and sleeping tablets (such as Valium).

More than two-thirds of pregabalin-related ambulance call-outs were for people who also used other sedatives. Almost 90% required transport to hospital. In some situations, such sedation could be life-threatening.

Our findings of rising harms, especially from co-use with other drugs, echo findings from a New South Wales research group that used data from poisons hotline calls, hospital admissions, and coronial reports from drug-related deaths.

How to reduce the harms

Doctors need to ensure patients are provided with the opportunity for careful and considered informed consent.

Pregabalin is a high-risk medication, especially when used with other sedatives. Although some doctors are aware of the side effects and harms associated with pregabalin, many are not.

The Royal College of General Practitioners recently warned doctors to carefully assess the risks when prescribing these medications, particularly for people who are also prescribed opioids or benzodiazepines. NPS MedicineWise also recently highlighted the need for prescribers to exercise caution.

Better regulation is also needed.

Some Australian states including Victoria plan to implement real-time prescription monitoring (RTPM). This would allow authorities to monitor and regulate access to high-risk medications such as opioid painkillers (oxycodone or similar) or benzodiazepines.

But pregabalin is not on the list of medications that will be captured by real-time prescription monitoring. To reduce the high risk of harm from pregabalin misuse, we should consider adding this drug to the list.

In the United Kingdom, pregabalin will become a “scheduled” or controlled medication from April 2019. This means doctors will need to apply for a permit before prescribing it.

If this is found to be successful, Australia should consider following suit.

Shalini Arunogiri, Addiction Psychiatrist, Lecturer, Monash University; Dan Lubman, Director, Turning Point Alcohol and Drug Centre & Professor of Addiction Studies, Monash University, and Rose Crossin, Research Officer in Addiction Studies , Monash University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Reflections on a rural medicine conference

BY DR SANDRA HIROWATARI, CHAIR, AMA COUNCIL OF RURAL DOCTORS

Rural Medicine Australia is the biggest Australian conference focusing on rural medical issues. There aren’t many of you rural doctors, too few of you as a matter of fact, but still we meet every October. This meeting is getting bigger and bigger, in fact there were over 750 delegates at RMA18 in Darwin this year – that’s big.

Representatives from both State and Federal politics attend this conference. I heard that this year Federal Department of Health representative quietly went to multiple sessions to listen and absorb what us rural doctors were troubled by and advocating for. Shadow Health Minister Catherine King came to us in person to address the crowd, Rural Health Minister Bridget McKenzie relayed a taped message.

The Keynote addresses were each inspiring:

Dr Jillann Farmer, the Medical Director of the United Nations’ Medical Services Division, and a former rural Australian GP who stated she was an expert of nothing, but her generalism was her strength.
Orange Sky Laundry, networking and peer support disguised by a free laundry service.
Donna Ah Chee, the CEO or the Central Australian Aboriginal Congress of NT, an inspiring powerful Aboriginal woman.
The Rural Health Commissioner, Emeritus Professor Paul Worley, discussing something other than the National Rural Generalist Pathway, talked about the backbone behind all rural doctors – our families.
Glenn Singleman, an extreme sport enthusiast and a rural doctor, taught us that whether it’s base jumping or remote resuscitations, it is all about perception and fear

There were plenty of skill enhancing sessions, such as ENT emergencies, ophthalmological emergencies, Rural emergency workshops, and, most memorably, trauma management done outside in the stinking humidity – a real life Australian simulation.

However, many of the workshops and break-out groups were focused on the business end of life in rural Australia. For students there were lessons for preparing for exams from those who have sat them and help with career planning. There were rural women workshops focusing on the subtleties of bullying. And then there were discussion on how to survive, with stories from as far as Japan and from each State and Territory and across the medical specialties.

Rural doctors also know how to party. Every night of the conference there were events happening. Even after the conference finished I noticed there were harbour cruises, surfing in the wave pool and visits to the RFDS museum.

I have been to many conferences over the years, but this one is unique. The networking among rural doctors is so much more important for rural doctors because it becomes our safety net when we go back to the isolated areas where we live and work. We learn names and see faces – new and old – and we begin to learn who we can turn to. We also learn who we need to provide support to and foster a career in this challenging but rewarding part of medicine.

We leave the conference inspired – with good memories and a to-do list of projects for the year that follows.

RMA19 will be at the Gold Coast in October next year. Mark it on your calendar and I will see you there.

When the doctor becomes the patient

Former Federal AMA President, Dr Steve Hambleton, fell ill suddenly and unexpectedly last week in Canberra.

He flew in to Canberra early on Wednesday, November 7 for a meeting of an MBS Review Committee. He made it to the meeting, but not for long. By midday, he was in the ED at Canberra Hospital.

After tests and care and an overnight stay in Canberra Hospital, he was on a 6.00am Thursday flight home to Brisbane and straight back in to hospital in his home town.

He underwent surgery later that day, and remains in hospital recovering.

In a brief window of opportunity during his transition from robust doctor to vulnerable patient, Steve found time to write a ‘Thank You’ note to all his carers, which is also an emotive account of his patient journey.

Thank you all …

Dr Steve Hambleton

Thank you to all the people who made my stay in the Canberra Hospital a little more bearable.

Thank you to Dr Eleanor who, when I asked for help, was decisive and supported my need to seek help. Thank you to Dr Andrew for making that call to the hospital to smooth the way for me.

Thank you to the staff at the triage desk, to whom I was just another person. I was treated with care and compassion. I was not that well, and not at my best, but very grateful. I wasn’t the only one there. Around me were people from all walks of life, with a bandage here or there, and their own personal stories to tell. Some were impatient. But if it bothered them, they did not show it.

Thank you to the cleaners. Your work behind the scenes makes a huge difference. My body told me it was time to vomit, which is always a bit awkward when wearing a suit and tie. On one knee on the floor in a clean toilet rather than a soiled one made all the difference to me. I am sorry if I made your next run a little bit harder.

Thank you to the triage nurse who kept me informed while I was in the waiting area, and for showing me to my bed.

Thank you to the emergency nursing staff. You don’t know how much comfort the sight of you in your uniform brings to those of us feeling helpless.

Getting changed out of my suit (which makes me feel important) into that gown confirmed that I was truly the patient on this occasion, totally dependent on the kindness and skills of others.

Thanks to the Emergency Physician who took a history from me. You asked me to describe my pain and I could not. It was pain, bad pain. It was waxing and waning every few minutes, and I was struggling to find an adjective that would help you. You smiled and were patient as you gently probed and questioned.

I was not a very good historian. In that moment there was a lot of my history I could not remember. Certainly not dates and times, and what happened in what order, and I don’t really have any chronic diseases. It made me think about how much harder it must be for those that do.

Thank you for putting in that intravenous line, which sort of validated for me that I was not a fraud and did need to be there.

Thank you to the student nurse, who recorded my observations and administered the first of the medications. I was not well, and probably did not express my thanks all that well.

Thank you to your Senior, who was quietly guiding you as you administered the analgesia. The pain did not go away immediately, but the warm feeling on my skin was reassuring that something was being done.

I wondered how the meeting that I left was going, and what my colleagues were thinking about my sudden departure.

Thank you to the wardsmen who transported me to the radiology department on two occasions. For your light-hearted banter as we weaved our way along the corridors in my bed, which seemed to have lost its steering. We need to get that trolley fixed – it just wouldn’t go straight. Sorry about the rubbish bin. It was a welcome distraction to take my mind off the way I was feeling.

Thank you to the ultrasound operator who was gently efficient – his job was to be in that darkened room, applying his knowledge of anatomy to help answer the clinical questions.

Thank you to the CT scan nurse and the radiographer for your part of the diagnostic journey.

I spent a long time in your emergency department. I love the reference to the flight deck, which is your central point. I was there long enough to hear shift changes and the handovers.

I heard you gently managing the patient with the mental illness, whose understanding and connection with our reality was tenuous at best.

I heard you keeping the patients’ relatives informed about the next steps on their journey.

I heard you manage the man with dementia who was someone’s brother/husband/father. He was loud, and he was angry as he fought his demons. Despite that, he was treated with the same kindness as all your other patients. Do you remember telling me that by the time he left the Department that he was “the nicest old man”. I hoped that you would be around if ever I was that man in the future.

I wanted to go home but needed to stay. I needed help and you gave it to me willingly and I am so grateful. When I leaned on the call button accidentally or when I needed extra help, you were there quickly.

Did you know that if you hold your breath you can watch your oxygen “sats” go down and make the alarm go off? The machines beep to tell you when things are going well, and when they are not.

Thank you for letting me use the phone to keep my family informed. It seemed every time you came into my room, I was talking to someone else.

Thank you for letting me go home when you knew that I was still not quite right. I know you worried about whether it was the right decision. Thank you for tolerating that uncertainty.

Nothing in medicine is absolute – it’s all about trade-offs.

As I walked through the Department on the way out, I could not believe the patient load you were facing.

Thank you to the night registrar who, even at the end of his shift, had a smile for me.

Dr Steve Hambleton is a former President of the Federal AMA and AMA Queensland.

Is it possible to do Advanced Life Support training online? Dr Nick Williams might have the answer.

For most doctors requiring Advanced Life Support (ALS) credentialing, the last time they actually utilised it was when they did their last credentialing. Outside of an emergency department (ED) setting it up is an infrequent event. However, we recognise the need to maintain the skills, as many of us are required to keep it current every three years to maintain our professional CPD requirements. This was certainly my experience after having worked as a VMO in an ED in metropolitan Adelaide for 13 years and now as a visiting general practitioner to rural and remote South Australia.

One might use the phrase “in my own time” to denote the use of online learning by doctors when and where they want it. Most of us are time poor in our work environment and giving up a weekend to do the usual 2-day ALS update is not something we look forward to.

Thankfully, all that is now in the past, as the AMA has joined with the CRANAPlus to deliver an innovative online ALS module combined with practical assessment that can even be done via Skype.

The online component of the course takes approximately 3 hours to complete and can be done in multiple segments if desired. I really liked the fact that most modules allowed you to go straight to the assessment at the end of the section if you passed a pre-test demonstrating you had 100% competency in the topic.

This directly fits with adult learning principles of recognising what we already know and allowing self-direction. Module structure flows well in easy to understand steps. The layout and graphics are of excellent quality and provide in-depth knowledge of the subject.

The module includes plenty of linked resources for you to read further on any topic easily accessed via the embedded links, which have practical examples and case studies to assist in learning.

Online learning saves time in planning, transportation and cost. I was able to complete this ALS module in 3 hours, in my own time without having to leave my clinical duties or my family commitments. Online learning is the new format that doctors will have to get accustomed to for their overall CPD requirements.

The CRANAplus Advanced Life Support course can be accessed via doctorportal Learning. Once all components are completed you are directed to the CRANAplus website to arrange your practical assessment. The course is accredited with the RACGP and ACRRM, and CPD points are tracked to your CPD Tracker.

It couldn’t be simpler. Perfect for busy doctors. Significantly cheaper than a 2-day course and does the job. I recommend giving it a try.

Dr Williams is currently working with the Aboriginal Health Council of South Australia as a GP Supervisor, Aboriginal Health. This involves supporting the GP workforce in rural and remote Community Controlled Aboriginal Health Services in SA and supervising GP Registrars. He spends more than sixty per cent of his time working in rural general practice and loves it.