The hidden waitlist in medicine

The recent release of specialist outpatient waiting times by the new South Australian government caused outrage when it was revealed some patients had been waiting more than 16 years for an appointment.

This is not a new problem. A 2000 Senate Committee Report cited consumer concerns about long outpatient waiting times, as did the 2005 Forster report into Queensland’s health system.

Access to timely care is the cornerstone of an efficient and effective health-care system. Delays decrease patient satisfaction, prolong periods of pain and discomfort, and create uncertainty for patients. Worse, a patient’s health might deteriorate while waiting with an undiagnosed condition.

Room for improvement

Historically, much of the conversation on waiting times at public hospitals has been about elective surgery. While efforts to report and reduce waiting times for elective surgery have been established nationwide, these figures only account for the time from a specialist appointment to the date of surgery.

This obscures the sober reality of even longer waits from GP referral leading up to the initial specialist appointment. This unreported wait is known as the “hidden” waitlist.

Currently, the quantity and quality of publicly available data on outpatient specialist clinics vary significantly between states, making it difficult to do national comparisons. Victoria has the most comprehensive data, reporting waits for the average patient, as well as how long the 10% of patients with the longest waits spent on the list for each specialty and urgency category.

While Queensland and Tasmania have also published data on all referral categories, they use different measures. South Australia has only published average wait times for non-urgent referrals.

States also use different urgency categories to triage outpatient referrals. In Victoria, referrals are stratified into two categories based on queuing theory, which suggests the most efficient form of prioritisation is one with the fewest possible categories. Meanwhile, other states (WA, Tasmania and Queensland) function with three priority categories.

These different approaches to reporting make it impossible to compare states. Some 10% of patients wait more than three months in many Queensland clinics, and more than two months in Victoria.

Five comparable specialties in Queensland & Victoria with the longest waits.
Queensland Health Quarterly information for Specialist Outpatient 2018, Victorian Health Services Performance Statewide Performance Data. Note: The clinically recommended wait time for Urgent (Category 1) patients is <30 days. The 90th centile wait time is the within which 90% of patients attended their first appointment., Author provided

Why do such long wait times exist?

The number of specialists available and the hours they choose to work in public hospitals affect the number of clinic appointments available. In aggregate, 48% of specialists work across both public and private sectors, 33% work only in public and 19% work only in private practice.

A study revealed that on average, orthopaedic surgeons and rheumatologists spend more than 70% of their time in private practice. Private practice generally offers higher incomes to doctors.

With such long wait times, patients who can afford it may turn toward private specialist services to skip the queue, leaving patients who cannot afford the high out-of-pocket costs charged by specialists to wait.

The burden of out-of-pocket costs also falls disproportionately on those with multiple diseases, the least disposable income and older households, excluding them from accessing more timely care in the private sector.

What can be done?

Some health services have implemented strategies to reduce outpatient waiting times. This can include using more allied health services where appropriate. For example, using physiotherapists to see patients in orthopaedic clinics can help patients get non-surgical treatment for their condition earlier.

Other good solutions include a non-contact first specialist appointment, where a specialist looks at a patient’s clinical notes and sends their recommendation to the referring GP.

States need to address long outpatient waits. And they need to be accountable for doing so.

We need better data on outpatient specialist clinics accessible in all states. Ideally, the data reported would be based on a national standard, as we currently do for elective surgery and emergency services.

Tessa Tan, Grattan Institute Intern and Bachelor of Medicine student contributed to this article.

Stephen Duckett, Director, Health Program, Grattan Institute

This article was originally published on The Conversation. Read the original article.

The bush GP: what it’s really like working in a remote location

Being a GP in a remote outback location is rewarding work – but it’s not necessarily for the fainthearted. You’re likely to be the only doctor there, and if things go wrong, help may be some time coming.

“You’re by yourself, you’re thrown in the deep end and you’ve got to manage that,” says Dr Chris Clohesy (pictured), who has spent the last five years working as a GP in remote communities in Northern Territory, after a 20-year career in the city. “There’s the constant threat that something will come up that takes you to the limit and there’s no one holding your hand. You’re asking yourself: am I up to it?”

Dr Clohesy recounts a time when he had to manage a child who had drunk petrol and was fitting.

“I was in a remote community and there was only me and a couple of nurses. We didn’t have much equipment and we were talking to Darwin by phone, with a plane a good couple of hours away. This one had a good outcome, but you remember these things. They’re frightening and challenging situations.”

And then there are the more quirky episodes that a doctor is never going to experience in a suburban Sydney clinic – such as the occasional veterinary intervention, for example.

“Late one day a chap brought in his dog, which had been run over and had a massive abdominal wound, extending from the groin to the belly. Can you do anything, the owner asked. So we sewed the dog up and gave it some antibiotics and incredibly, the dog survived. I couldn’t believe it! So you do have to think out of the square and handle some weird cases.”

The key to working remote, Dr Clohesy says, is to keep your skills and knowledge up to scratch.

“It’s a difficult process finding the educational resources to be able to upskill. I spend a lot of time hunting down courses and clinical attachments to keep me up to date. And it’s a lot of time and money. Rural and remote doctors have the same educational requirements as everyone else, but it’s a lot harder to get them. And for junior registrars studying for exams it’s really hard, particularly if you have a dodgy internet connection!”

Online learning definitely has a big role to play for rural and remote doctors, Dr Clohesy says.

“But it’s got to be good. You can’t just put something up on the internet and say, there you go. There’s still got to be some sort of human contact with that online course where you can actually talk to someone, and an expert you can contact really enhances the course.”

Dr Clohesy recently flew to Melbourne to do an Advanced Life Support course. He says he paid his own airfare, plus the $700 for the course, with the whole trip taking three days.

“That’s so I’m up to speed on the cardiac stuff I need to deal with out here. It’s not about sitting about under a palm tree on the beach; it’s a serious challenge.”

And it’s also important to keep your outside interests and lifestyle ticking over, Dr Clohesy says, whether it’s sport, exercise, fishing or reading.

“At the moment I’m getting my bikes and gym equipment shipped to me by barge from Darwin. Luckily, where I am has a swimming pool, so I can do my laps which is important to me.”

Keeping in the medical loop and maintaining your networks is also important when you’re working in remote locations.

“I belong to the AMA, I join as many committees as possible, and all that improves my interactions with other doctors.”

The job definitely has its own rewards, Dr Clohesy says.

“Most doctors are out here because they want to help, and they want to look after these impoverished people, and that gives them a huge amount of satisfaction.”

Junior doctors may think if they go rural they’ll miss out on positions in metropolitan hospitals, but that’s not at all the case, Dr Clohesy says.

“These days, as a junior doctor, it’s really positive to have a CV with some rural work on it. It shows you can work independently.”

And there are various incentives, such as the General Practice Rural Incentives Program, which pays doctors an annual amount for working in rural and remote areas, with the amount rising with each extra year of service.

“We have a public health role. I think it would be great if all doctors did a six-month stint in a rural or remote community. We’d overcome a lot of deficiencies if that happened.”

Are you working in a remote or rural community? Doctorportal Learning has a number of online learning modules that may suit your certification needs.
Our Cranaplus Advanced Life Support Certification can be completed entirely remotely, with an online theory component and a clinical assessment using Skype. This module is the only accredited ALS in Australia that enables you to undertake the clinical assessment via a virtual platform.

Should we teach death in schools?

A proposal from the Queensland branch of the AMA might have schools slotting death lessons into the timetable in between Maths and English.

AMA Queensland Chair of General Practice Dr Richard Kidd says in a rapidly ageing society, educators should be demystifying the processes of ageing and dying.

“Young people need to be educated about medical, legal and other issues that surround ageing and dying so they are capable of making informed choices when the time comes,” Dr Kidd says.

“More than any other generation, they will need to understand advance care plans where their loved ones decide how they want care to be delivered at the end of their lives. Young people also need to know how to make a will.”

Dr Kidd says he has seen cases of young adults getting terrible injuries playing sport, and that it would have been a huge help to families and doctors if they’d known how the loved one had wanted to be cared for in their final days.

“I’ve seen people as young as 21 being thrust into the role of power of attorney,” he says, adding that their lack of knowledge makes for a steep learning curve in how to act in the best interests of their loved ones while remaining within the law.

He says that “death lessons” could incorporate the legal aspects of what mental and physical capacity means, how to draw up a will and an advance care plan, and the biological processes of dying and death.

Knowledge around death and advance care plans could facilitate people dying at home rather than in a hospital, Dr Kidd says. Although the vast majority of people say that they would prefer to die at home, only 15% do, he notes.

“Many more people could die at home if there had only been a bit of preparation,” he adds.

He says that in many families, death is a taboo subject that only gets discussed once it’s too late.

The proposal has been put to the Queensland government and has got backing from Palliative Care Queensland, whose CEO Shyla Mills says learning about death at school would make young people more resilient about loss, ageing, dying and grief.

“While there is pressure on educators to add more material into the school curriculum, death is our only 100% guarantee in life and the effects of our ageing population will be felt most by those at school today,” she comments.

Do patients care what you look like?

Do you have a visible piercing or tattoo? If you do, you probably remove or cover it up before turning up to work, either because of the hospital or practice dress code, or because you fear your patients might disapprove. But perhaps you don’t need to cover up after all. According to a new study from the US, patients don’t really care if you have visible body art, and don’t consider you any less competent if you’re inked or pierced.

The innovative, nine-month study involved nearly 1000 patients who were interviewed after presenting at an emergency department. The seven participating doctors alternated from day to day between wearing fake piercings and tattoos with their scrubs, or wearing no body art. After treatment, patients were asked to rate the doctors from 1 to 5 on their competence, professionalism, approachability, trustworthiness and reliability. Patients were simply told the survey was aimed at improving care at the hospital, and weren’t specifically asked about tattoos and piercings.

Whether or not doctors had piercings or tattoos did not seem to have any bearing on how patients scored them for any category. Doctors were scored highly around 75% of the time, regardless of the presence or absence of body art.

The finding runs contrary to a slew of studies which have suggested that, yes, patients are concerned about your appearance and that it may affect the way they judge your competence. For example, another recent US study, the largest of its kind, involved over 4000 patients who were given photos of doctors dressed in a variety of ways. Doctors wearing a traditional white coat were rated more highly in terms of knowledgeability, trustworthiness, approachability and several other metrics compared with those dressed in different attire.

“Nuanced policies addressing physician dress code to improve patient satisfaction appear important,” the authors of that study concluded.

But the authors of the tattoo/piercing research say the white coat study and others similar to it are flawed, for several reasons. To begin with, the study was based on showing pictures of doctors to patients, rather than interacting with actual doctors in a genuine clinical situation. And secondly, it was not blinded to the participants. In other words, patients involved in the white coat study knew what they were being asked to evaluate, while in the tattoo/piercing study, participants were unaware that their attitudes to body art was what was being assessed.

That’s not to say patients don’t show prejudice based on a doctor’s appearance or on their non-medical qualities. There is plenty of research to show that patients can be less accommodating with doctors whose race or ethnicity is not their own, or with female doctors.

In a recent survey of 1,200 doctors, female physicians were far more likely to say they had experienced bias due to their gender (41%), compared with male physicians (6%). Female doctors were also more likely to hear comments about their age (36% vs 23% of men) and weight (15% vs 9% of men).

Around 70% of black and Asian doctors in this US-based survey had heard biased remarks about their race or ethnicity from their patients.

Close to a third of patients surveyed said they would be inclined to avoid a healthcare professional based on personal characteristics, such as gender, sexual orientation, ethnicity, religion or political views.

You can access the studies cited in this article here, here and here.

GPs and specialists: a dialogue of the deaf?

Ask almost any specialist about their dealings with GPs, and they’re likely to admit that coordination with primary care could be better. And ask any GP about their dealings with specialists, and you may well be on the receiving end of a gripe or two. Melbourne oncologist and Guardian columnist Dr Ranjana Srivastava has recently written that “shared decision-making that involves a specialist and a GP is rare”. She says that for all the talk of teamwork, there’s a lack of communication that has real downsides for the patient. Increasing numbers of patients with chronic comorbidities end up with fragmented care, Dr Srivastava says, with GPs being kept out of the loop due to delayed discharge summaries, and specialists finding it hard to track down busy GPs.

Who’s to blame? According to two large studies, it’s the specialists – if you’re a GP, that is. And of course it’s the GPs, if you’re a specialist. The first study, from the Netherlands, surveyed around 500 doctors – around half of whom were GPs and the rest specialists – about their mutual communications. The vast majority of GPs (85%) thought they were easily accessible by phone. The specialists did not agree: only 32% thought you could easily get a GP on the phone. The specialists were also sniffy about GP referral letters: just 29% of them thought referral letters were generally adequate. Nearly 90% of specialists thought they correctly addressed the issues in the referral letter. Unsurprisingly, the GPs disagreed: only half of them thought specialists adequately addressed the questions.

And did the specialists report back to the GPs in a timely manner? Yes, said 62% of specialists. No, said 78% of GPs. But when they did finally get that specialist report, the GPs overwhelmingly (92%) considered that they followed the specialist’s recommendations. Not so, said the specialists, fewer than half of whom thought the GPs did what was asked of them.

A US study finds similar disagreement between GPs and specialists. This was a considerably larger study involving nearly 50,000 doctors, who were asked about referral and consultations between primary care and specialist physicians. Around 70% of GPs reported that they always or most of the time sent notification of a patient’s history and reason for a referral to a specialist. But there may have been some fibbers among that cohort, as only 35% of specialists said they always or most of the time received such notification. But the imbalance worked both ways: while over 80% of specialists said they always or most of the time sent consultation results to the referring GP, only 62% of GPs agreed that this was the case. Doctors who did not receive timely communications were more likely to report that their ability to provide high-quality care was threatened.

The authors say their study shows the need for “systematic structures, tools and processes for information creation, transfer, receipt, and recognition by the sending and receiving physicians”.

Miscommunication between doctors is widely recognised as one of the main drivers of medical error. The Australian Medical Association has recently published guidelines to improve communications between GPs and other treating doctors. The AMA says specialist outpatient services need to have transparent systems that inform patients and referring doctors of expected wait times for services, and track the priority of referrals.

According to the new guidelines, discharge planning should include telephone, video or face-to-face case conferencing prior to discharge that includes GPs or referring doctors, and a documented plan of care.

“We are delivering very good outcomes for patients in the Australian health system, but we can and should do better. We are confident that the AMA guide will contribute to improved communication and, in turn, better overall care,” AMA President Dr Tony Bartone says.

Is breaking bad news to patients an art you can learn?

Being the bearer of bad news is often the unhappy duty of doctors, and can be incredibly challenging. Getting it right is not only hugely important for patients and their families, it’s also critical to the well-being of the doctors themselves.

Some doctors are better at it than others, but the good news is that even for those who don’t feel they manage it well, this is certainly a skill that can be honed.

“One of the lessons of the workshop is that communication skills can be learned and developed,” says Dr Ruvishani Samarasekera, a paediatric registrar at Sydney Children’s Hospital. “There are doctors who are not naturally empathetic or lack an emotional IQ, but they were still able to improve their communications skills to manage these situations better.”

Dr Samarasekera attended the Complex Communication in Health Care workshop under the guidance of Professor Stewart Dunn, a medical psychologist specialised in the psychological care of cancer patients and their families. The workshop uses actors playing patients in realistic scenarios where workshop attendees have to break bad news, often in difficult, complicated scenarios.

“There is not a lot of formal training in breaking bad news in medical school,” Dr Samarasekera says. “Then, when you are a junior doctor the task is usually done by the most senior doctor. As you progress throughout your career, there is an expectation that you will then learn from what you have witnessed. But that’s not always the case.”

She recalls a very difficult case with a 21 year old patient in ICU who had complications related to morbid obesity early in her career.

“I witnessed the consultant telling the patient’s parents that he had passed away as a result of these complications. I remember how the consultant tactfully brought them into a private room and the non-verbal cues in the consult. I remember thinking how I wanted to communicate with such empathy and learn to use my own style as well.”

She says that learning and trialling diverse techniques in a workshop with actors is a very different experience to interacting and debriefing with colleagues. It is an immersive and safe experience that covers everything from the way doctors should be positioned in the consult to the words they should use, directly approaching the bad news or leading the patient towards it.

“Some scenarios we did were around breaking bad news with oncology patients, others were interactions with family members and telling them the news. And then there were other scenarios around daily communication skills with your colleagues.”

The course gave her more confidence that she could perform these difficult tasks, she says.

“I had a 10-year-old patient who’d been in and out of the ED over the course of two months with vomiting and clinically she had some concerning signs of unsteady gait. This was a red flag and so there was a looming question of whether this could be a brain tumour. Due to my earlier experiences observing my seniors in oncology combined with the practical skills gained in the workshop, I felt better equipped dealing with this emotionally challenging situation. From guiding the parents, preparing them for the likelihood of what the imaging would show and then discussing the results after.”

She says the situation was complicated by the fact that the parents had been in some denial about the symptoms and their child’s unsteadiness and had also at times received reassurance about them.

“You have to deal with this level of complexity; you have to be empathetic but honest, so that they are on your side as they go through the journey of diagnosis and treatment.”

Breaking bad news is one of the most difficult communications challenges in medicine, but not the only one. Dealing with colleagues, particularly at opposite ends of the hierarchy, can be challenging.

“One of the workshop scenarios that really struck a chord with me was one about being a junior doctor and dealing with the consultants,” she says.

The particular scenario involved a registrar being asked to be on call, despite a long-planned commitment towards a birthday party for her own child.

“The consultant very subtly manipulated her and made her feel like she couldn’t say no without losing something in her career. That kind of pressure is a huge part of medicine. The actors played out this scenario and the attendees had to decide whether they would intervene in the scenario they had witnessed. Talk to the consultant, perhaps, or try to empower the junior doctor. Some even thought the situation was not concerning, or that the junior doctor just needed to be more resilient. It was interesting to see how people responded.”

Professor Dunn will be moderating two workshops in Sydney on complex communication in health care this year. The workshops will cover breaking bad news, open disclosure, end-of-life conversations and dealing with conflict in the workplace. Read more about the workshops and sign up here.

The doctors who received Queen’s Birthday honours

Former AMA President Professor Brian Owler is one of over 40 Australian doctors recognised for their service in the Queen’s Birthday honours list announced on Monday.

A neurosurgeon, Professor Owler was appointed a Member in the General Division of the Order of Australia (AM), for his “significant service to medicine through the leadership and administration of professional medical organisations, and to education”.

Professor Owler first came to mainstream prominence in a media campaign to highlight the horrors of high-speed car accidents.

“It sometimes just takes one split-second decision to end in a world of tragedy and I have seen everyday people, good people, who made those split-second decisions that ended up costing either them or tragically their family and their children’s lives and of course the lives of others as well,” he says.

Among other doctors to be honoured is Professor Mark Brown, appointed Member of the Order of Australia, who is recognised for his work in nephrology and in medical research, particularly in hypertension in pregnancy. The professor of renal medicine at UNSW was instrumental in setting up the renal supportive care program at St George Hospital in 2009, and has also been involved in an award-winning outreach program for homeless men with Mission Australia.

Dr Andrew Skeels, formerly the medical director of Clare Holland House in Canberra, has been recognised with an AM for his work in palliative care. In an interview with Fairfax Media, Dr Skeels said the greatest lesson he has learned from palliative care is to be able to understand the situation from the patient’s perspective.

“Learn to walk in their shoes and see the world in their eyes and that’s very different to a lot of other areas of medicine and it took a long, long time for me to learn that,” he said.

Professor David Cooper, who sadly died in March aged 69, was posthumously appointed a Companion of the Order of Australia for his “eminent service to medicine, particularly in the area of HIV/AIDS research, as a clinician, scientist and administrator, to the development of treatment therapies”. Professor Cooper diagnosed some of the first HIV cases in Australia in the early 1980s. He was the inaugural director of the Kirby Institute in 1986 and dedicated his professional life to research that ultimately transformed an HIV diagnosis from a death sentence to a manageable chronic disease.

Below is a list of AMA members and former members who have been recognised in this year’s Queen’s Birthday Honours list:

OFFICER (AO) IN THE GENERAL DIVISION

Professor Rinaldo BELLOMO

Ivanhoe Vic 3079

For distinguished service to intensive care medicine as a biomedical scientist and researcher, through infrastructure and systems development to manage the critically ill, and as an author.

Professor Christopher Kincaid FAIRLEY

Hawthorn Vic 3122

For distinguished service to community health, particularly in the area of infectious and sexually transmitted diseases, as a clinician, researcher and administrator, and to medical education.

Emeritus Professor Vernon Charles MARSHALL

Ivanhoe Vic 3079

For distinguished service to medicine, particularly to renal transplant surgery and organ preservation, to accreditation and professional standards, as an academic, author and clinician.

Dr David Charles PESCOD

Beveridge Vic 3753

For distinguished service to medicine, and to Australia-Mongolia relations, particularly through the provision of surgical and anaesthetic care, and to health education and standards.

Professor Michael Francis QUINLAN

Nedlands WA 6009

For distinguished service to medicine, particularly through strategic leadership in the development of tertiary medical and social education in Western Australia as an academic and clinician.

MEMBER (AM) IN THE GENERAL DIVISION

Professor Rodney John BABER

Surry Hills NSW 2010

For significant service to medicine in the field of obstetrics and gynaecology as a clinician and researcher.

Professor Anthony Frank BROWN

New Farm Qld 4005

For significant service to emergency medicine as a clinician, author and educator, and to professional organisations.

Associate Professor Geoffrey David CHAMPION

Mosman NSW 2088

For significant service to medicine in the field of paediatric rheumatology, and to medical research and treatment of musculoskeletal pain.

Dr Michael Gerard COOPER

Castlecrag NSW 2068

For significant service to medicine in the field of anaesthesia as a clinician, teacher, mentor and historian.

Dr Paul Vincent DESMOND

Albert Park Vic 3206

For significant service to medicine in the field of gastroenterology as a senior clinician and researcher, and to professional associations.

Dr Charles Roger GOUCKE

For significant service to medicine in the field of pain management as a clinician, academic and mentor, and to professional societies.

Dr Timothy Roger HENDERSON

Alice Springs NT 0870

For significant service to medicine in the field of ophthalmology, and to Indigenous eye health in the Northern Territory.

Dr David Russell HILLMAN

Nedlands WA 6009

For significant service to medicine as an anaesthesiologist and physician, to medical research into sleep disorders, and to professional organisations.

Professor Lawrence William HIRST

Chelmer Qld 4068

For significant service to medicine in the field of ophthalmology through the development of clinical care techniques and eye disease management.

Dr Ian John KRONBORG

Footscray Vic 3011

For significant service to medicine, particularly gastroenterology, and through innovative substance abuse treatment programs.

Professor Christine Faye McDONALD

East Malvern Vic 3145

For significant service to respiratory and sleep medicine as a clinician-researcher, administrator, and mentor, and to professional medical organisations.

Dr Terence William O’CONNOR

Greenwich NSW 2065

For significant service to medicine, particularly as a colorectal surgeon, and as an educator, clinician and administrator of medical organisations.

Professor Brian Kenneth OWLER

Wahroonga NSW 2076

For significant service to medicine through the leadership and administration of professional medical organisations, and to education.

Adjunct Associate Professor Leslie Lewis RETI

Toorak Vic 3142

For significant service to medicine in the field of gynaecology and women’s health as a clinician and educator, and to the community.

Adjunct Associate Professor Andrew Harris SINGER

Downer ACT 2602

For significant service to emergency medicine as a clinician, educator and administrator, and to professional medical organisations.

Dr Andrew Scott SKEELS

Bruce ACT 2617

For significant service to medicine, particularly in the field of palliative care, as a clinician and educator.

Professor Bernard Mark SMITHERS

Toowong Qld 4066

For significant service to medicine in the fields of gastrointestinal and melanoma surgery, to medical education, and to professional organisations.

Emeritus Professor David Harry SONNABEND

Rose Bay NSW 2029

For significant service to medicine in the field of orthopaedics, as a clinician and administrator, and to medical education.

Dr Domenico (Dominic) SPAGNOLO

Mount Lawley WA 6050

For significant service to medicine, particularly in the field of pathology, as a clinician, and to medical education as a researcher and author.

Dr John Douglas TAYLOR

City Beach WA 6015

For significant service to medicine as a urologist and urogynaecologist, to medical education, and to the community.

Dr Philip Geoffrey THOMPSON

Kenthurst NSW 2156

For significant service to medicine as a plastic and reconstructive surgeon, to health initiatives in South East Asia, and to professional organisations.

Professor David Allan WATTERS

Newtown Vic 3220

For significant service to medicine and medical education in endocrine and colorectal surgery, and through leadership roles with professional organisations.

Professor John William WILSON

Prahran Vic 3181

For significant service to medicine, and to medical research, in the field of respiratory disease, and to professional organisations.

MEDAL (OAM) IN THE GENERAL DIVISION

Dr Terence Francis AHERN

Brunswick Vic 3056

For service to medicine, particularly in the field of general practice.

Dr Peter Chester ARNOLD

Edgecliff NSW 2027

For service to medicine through a range of roles with professional organisations, and as a general practitioner.

The late Dr Keith Francis BECK

Late of Wauchope NSW 2446

For service to medicine through a range of roles.

Associate Professor Terry Dorcen BOLIN

Bellevue Hill NSW 2023

For service to medicine in the field of gastroenterology.

Dr Alan Edward BRAY

Woodville NSW 2321

For service to medicine, particularly to vascular surgery.

Mr Ian Alexander CAMPBELL

Horsham Vic 3400

For service to medicine as a surgeon.

Dr Kevin John CHAMBERS

Mildura Vic 3500

For service to medicine, and to the community of Mildura.

Clinical Associate Professor Michael James COOPER

Sydney NSW 2000

For service to medicine in the field of gynaecology.

Dr Jane Helen GREACEN

Bairnsdale Vic 3875

For service to medicine, and to community health.

Dr Jacqueline Kim MEIN

Cairns Qld 4870

For service to medicine, and to community health.

Mr Hugh Simpson MILLAR

Hawthorn Vic 3122

For service to medicine, particularly to otolaryngology.

Dr Michael MIROS

Loganholme Qld 4129

For service to medicine, particularly to gastroenterology.

Mr Donald Ivan MOSS

Ballarat Vic 3350

For service to medicine, particularly to urology.

Dr Roderic John PHILLIPS

Vic

For service to rogaining, and to paediatric dermatology.

Adjunct Clinical Professor John Graham ROSENTHAL

South Perth WA 6951

For service to medicine, and to the community of Western Australia.

Dr Richard Frank WILSON

Summertown SA 5141

For service to the community through a range of roles, and to medicine.

When the doctor becomes the patient

Doctors, like everyone else, get sick, and they are sometimes diagnosed with life-threatening illnesses that put them on the other side of the consulting desk and plunge them into the hospital system. In the process, do they gain special insights into medical practice, and if so, which ones?

It was in the whirlwind following her diagnosis of breast cancer that cardiologist Maria Rosa Costanzo first experienced the horrible feeling that her illness was “robbing me of who I was. I wondered if I could ever be the same”.

“As I patted myself on the back for saving others’ lives, did I ever truly reflect on how those therapies might affect patients’ humanity and sense of self?”

In an article about her experience, Dr Costanzo writes about how, as a practising physician, she’d never considered how “routine” tests could make a patient feel scared and humiliated.

“I became acutely aware of the latter while lying face-down on the MRI table, my breasts hanging indecently through strategically placed holes. No amount of professional success…could save me from indignities so many patients have endured through the years.”

She recalls how she’d always encouraged patients to enroll in trials. Hoping to practice what she preached, she decided to sign on to a trial, only to be horrified by the potential side effects mentioned on the consent form: nausea, vomiting, alopecia, diarrhoea, leukopenia, loss of fingernails.

Chemo left her feeling broken and helpless, sapping her desire for all her usual pleasures: reading, travelling, fashion.

It took a life-threatening illness to grasp the “critical importance” of quality of life in treatment, she says.

“Undeniably, breast cancer is a life-changing event; however, I’d never have predicted how it would change how I saw medicine,” she writes.

It’s a common theme among doctors who have found themselves on the other side of the equation. British oncologist Victoria Lavin recalls telling her patients, “You’re so brave; you can fight this”. And yet when she herself was diagnosed with breast cancer, it felt anything but a fight.

“I won’t be asking my patients to go into battle in future,” she writes.

After prescribing countless of chemotherapy, there were still things to learn when you actually had it yourself, she found.

“Intravenous dexamethasone makes your bottom tingle when administered. Subcutaneous filgrastim stings it you give straight from the fridge.”

Hair loss was another thing that in her practice Dr Lavin had tended to gloss over. Now she realised it did really matter: “It changes a person’s whole identity”.

Many of the things treating doctors tend to discount as trivial they suddenly realise are important when they’re on the receiving end. Unreturned phone calls, long waits and lack of communication can be frightening when you’re seriously ill. Psycho-oncologist and cancer survivor Dr Mindy Greenstein found it impossible to nail her radiologist down on what he’d actually seen on her breast ultrasound: “Suspicious” is all that he would say. When a biopsy is done and the surgeon says the results won’t come for several days, she finds herself tearful and upset.

Doctors often learn a certain distance when faced with seriously ill patients. But when they become a patient themselves, they can find that approach cold and dispiriting. An emotional patient is often patronised and quickly referred on to a psychologist, says Dr Greenstein.

“Oncologists have learned many things,” she writes of her own experience, “but apparently, comforting a cancer patient isn’t one of them.”

For most doctors it’s a jolt being on the other side of the equation. The role reversal of becoming a patient can hit at the self-esteem of a group not known for a lack of it. Some doctors may even feel an entitlement to treatment, purely on the strength of being a doctor.

When Adelaide-based rheumatologist Mark Awerbuch was diagnosed with acute T-cell lymphoblastic leukaemia, his only hope after chemo had failed was a bone marrow transplant. But when his haematologist denied him the treatment on account of its low chance of success, he felt cheated.

“I thought it was treacherous and and cowardly that a profession to which I had contributed for years, doing a lot of pro bono work, lecturing, mentoring, tutoring, and they turned their back on me and said no, we can’t help you.”

Dr Awerbuch eventually forked out hundreds of thousands of dollars for treatment in Israel, which proved to be successful.

Almost all doctors who have endured life-threatening illness say it’s changed their approach to medicine for the better. But it’s a conundrum: if being ill makes you a better doctor, what about all the doctors who have not had that experience? Are they worse for it?

Dr Kevin Campbell, writing on the experience of the doctor as patient, says he believes that time spent as a patient should be a part of medical education.

“Even though most physicians do their very best to show compassion, provide support and empathy, it is often not enough. Sometimes we must look through the eyes of those for which we care in order to better serve their needs.”

You can access the articles referenced in this story here, here, here, here and here.

The ‘disease prestige ranking’ and why it matters

The name of an illness can affect the level of care a person receives. Cancer sufferers experiencing fear and uncertainty may have access to cancer care centres. Donations and bequests enable these centres to offer everything from accessible parking, to wig and beauty services, to comprehensive clinical care.

A person with arthritis, on the other hand, may have little access to public services. For instance, there is only one rheumatology nurse for every 45,000 people living with rheumatoid arthritis.

While suffering can be severe across all diseases, access to care is uneven. The hierarchy that determines how little or how much support is available for an illness is known as “disease prestige”.

The idea was introduced in the 1940s and since then a number of researchers have tried to classify diseases on a hierarchy of prestige. The higher a disease is on this hierarchy, the more resources and community support available for its sufferers. The lower a disease, the less resources.

Generally, high-prestige diseases are treated with technically sophisticated procedures, occur in the upper part of the body and often affect young people. Heart disease and childhood cancer are examples.

Low-prestige diseases tend to be vague and difficult to diagnose and treat. Many carry shame and stigma, or are thought to be the “fault” of the sufferer. Examples include urinary incontinence, schizophrenia and liver disease.

Urinary incontinence

Urinary incontinence describes any accidental or involuntary loss of urine from the bladder. It ranges in severity from “just a small leak” to complete loss of bladder control and can seriously affect a person’s well-being. Urinary incontinence affects 13% of men and 37% of women. It particularly affects people after surgery (such as hysterectomy or prostate cancer surgery) and women after childbirth.

Incontinence can be treated and managed. In many cases it can also be cured, but only a third of people who experience incontinence will discuss their condition with a health professional. Like many people with embarrassing conditions, people who have urinary incontinence may keep it secret due to shame.

Despite the fact this condition is common and can be disabling, there is little investment in care. In 2010, the health system invested around A$270 million in urinary incontinence. The remainder of the A$67 billion impact of this disease fell on patients and carers.

Disease champions have targeted such discrepancy in different ways. The Incontinence Foundation, for instance, has used comedians to promote its cause in the “Laugh without Leaking” campaign.

Schizophrenia

As we move down the hierarchy, we’re more likely to strike diseases with stigma, such as mental illness. Schizophrenia is an illness that disrupts the functioning of the human mind. It causes intense episodes of psychosis, involving delusions and hallucinations, and longer periods of reduced motivation and functioning.

The causes are not clear, but are probably due to a combination of genetic, psychological and social factors. Schizophrenia affects 1% of the population and often begins in adolescence. Despite the fact schizophrenia is common in the community, it is poorly understood and often feared.

Patients with mental illnesses often avoid disclosing their illness because of active discrimination in the workplace, at home or in institutions, such as insurance companies. Unfortunately, people with schizophrenia can also experience significant stigma from health professionals and can have poor health outcomes with early death from physical illness.

American academic and schizophrenia sufferer Elyn Saks and other high-profile people living with schizophrenia are addressing the stigma, but progress is slow.

Elyn Saks shares her experiences with schizophrenia in this TED talk. Source: YouTube.

We can understand the impact of disease prestige for diseases like schizophrenia by looking at fundraising. The Pink Ribbon campaign for breast cancer has raised an average A$6 million per year. In contrast, schizophrenia, which causes about half the burden of disease of breast cancer, raised A$100,000 last year through SANE Australia.

Liver disease

Stigmatised diseases include those that could be influenced by a person’s behaviour, such as cirrhosis of the liver. Cirrhosis is a type of liver scarring which can be caused by excessive alcohol consumption, hepatitis B and C (which can be the result of sexual transmission or drug use), and fatty liver, common in obesity and diabetes. Stigma stops the majority of people living with viral hepatitis enjoying the quality of life they deserve.

However, liver disease can also occur in children. Liver transplant is the only treatment available for children with severe acute liver failure or chronic end-stage liver disease, certain metabolic diseases and some liver cancers. In 2012, there were more than 6 million Australians living with liver disease and more than 7,000 deaths due to liver disease in Australia. However, Commonwealth research funding is low.

Research funding

Research funding from Commonwealth sources, such as the National Health and Medical Research Council (NHMRC), follows the disease prestige hierarchy. Burden of disease can be measured in DALYs (Disease Adjusted Life Years), a way of quantifying the healthy years lost to disease.

If we compare the research investment across the national health priorities, we see each year of healthy life lost attracts different levels of investment, depending on the disease involved. The Medical Research Future Fund may extend this discrepancy, with almost half of its initial investments being earmarked for cancer research.

The following graph shows the National Health Priority diseases, as reported by the NHMRC, and maps the research investment per DALY. We have calculated the investment for the low-prestige diseases by searching for grants allocated from 2010-2016 that mention liver disease, schizophrenia or urinary incontinence.

As a community, we should aim to reduce suffering across the hierarchy of disease prestige. We need to consider issues of justice and equity, not only across populations, but also between diseases. When we raise money for health care, we need to consider who funding supports and who it does not. We also need to create clinical, educational and research priorities that recognise the complexities of funding the breadth of illness that occurs in the community.

Louise Stone, Clinical Associate Professor, ANU Medical School, Australian National University

This article was originally published on The Conversation. Read the original article.

Has it got any easier for women in medicine?

In 2015, vascular surgeon Dr Gabrielle McMullin unleashed a storm of controversy when she said in an ABC interview that female trainees approached for sex by senior colleagues should “comply with the request” if they wanted a career. When a female surgical trainee complains about sexual harassment, she said, “you can be sure they will never be appointed to a major hospital”.

The outcry over her comments sparked a mini “MeToo” moment in Australian medicine and led to the commissioning of a damning report into sexual harassment from Royal Australasian College of Surgeons (RACS). The report contained multiple reports of female doctors expected to provide sexual favours in return for tutorship, along with outrageous stories of discrimination, including one female surgeon who was told she would only be considered for a job if she “got her tubes tied”.

The report recommended a mandatory training module for surgeons, Operating With Respect. But according to the RACS’s own figures, by late last year only 60% of surgeons had completed the course, with the figure dropping to only about half of surgeons in NSW.

Three years on, has anything changed? Perhaps not, at least not in surgery, according to a new study presented this month at the RACS Congress in Sydney. The study is authored by Sarah McLain, a final year medical student, who says there remains a “hidden curriculum” holding women back in surgery. Although women now make up well over 50% of medical graduates, only 12% of surgeons are female, with just 4% of orthopaedic surgeons are women.

Unlike the male students, female med students interested in pursuing a career in surgery are routinely asked how old they are, whether they are married and whether they are planning to have children.

“Being a woman means you might have children and you are therefore perceived as being less committed. You’re told surgery is hard or competitive, with the insinuation that you’re not competitive enough,” she told Fairfax Media.

Her study found a lack of women in leadership roles in medical schools, with only 20% of deans and 5% of heads of surgery at medical schools.

“You can’t underestimate the importance of positive female faculty surgical role models,” Ms McLain said.

Of course, gender discrimination and disparities are by no means limited to surgery. Female doctors are considerably less likely to become specialists than men, and even when they do, they earn substantially less than their male peers. The pay gap between full-time male and female medical specialists stands at 33.6%, with a 24.7% gap between male and female GPs.

Around 63% of graduates from Australian medical schools were women in 2015, and at the beginning of their career their earnings don’t differ from their male colleagues. But as their career progress, a gap appears and then continues to widen. A report from Level Medicine says the reasons for this are complex and include more women in lower paid specialities, less success in negotiating remuneration, and more women taking time off to raise a family.

But these factors do not explain away all of the disparity in earnings, the report says. Around a quarter to half of the pay gap cannot be attributed to hours worked, career interruptions or to employment type, it notes. The rest of it is more to do with systemic discrimination, which includes lack of leadership on pay equity from the colleges, discrimination against women in the more highly paid specialties such as surgery, a lack of female leadership roles and a lack of flexible training and working.

But sexual harassment and pay disparity are not the only issues facing women in medicine. There is good evidence that female doctors are more likely to be affected by burnout than their male colleagues. One theory is that this is due to societal expectations for women to show more empathy than men. In a highly stressful, life-or-death environment like medicine, this can quickly translate into compassion fatigue and put an intolerable stress on female doctors’ mental health. A disturbing study found that while the suicide rate of male doctors was about 40% higher than that of men in the general population, the rate for female doctors was 130% higher than in other women.

Clearly, there is much more to be done before the medical profession can be truly said to be female-friendly.