A stitch in time: the fine art of suturing

Suturing is one of the oldest of medical arts. Its practice goes back at least 5,000 years, with evidence from mummies showing that Ancient Egyptians used plant fibres, hairs and tendons to sew up wounds. Today, basic suturing is something that all doctors are expected to master, and practically all GPs will have to perform at some stage.

The scariest part of learning how to suture, says Perth-based GP Dr Alison Soerensen, is when you’re presented with your very first patient.

“Up until then, you’ve practised on pig skin or pig trotters, but that’s not a perfect substitute for the real thing. ‘You’re my first one’ doesn’t necessarily go down well with the patient!” she laughs.

But Dr Soerensen says she was relatively lucky with her first experience, which involved a very elderly patient without too many concerns about cosmetic outcomes, and who had a very good relationship with the GP who was supervising the intervention.

“The GP said something like: ‘It’s her first time, but don’t worry, I won’t let her sew your foot to your elbow or anything’, and the patient was OK with it.”

Dr Soerensen says an easier first-time experience for med students might arise if they’re doing a surgical rotation, with the patient under general anaesthetic. The surgeon might do most of the suture and then let the student finish it.

“The advantage in that scenario is the patient is asleep and you’re not having the added pressure of them watching what you’re doing. And if you make a mistake it’s very easy for the surgeon to correct it.”

Dr Soerensen says that in many medical disciplines, “you’d struggle without some suturing skills”. A common issue is getting the skin edges to come together, which can be particularly difficult with elderly patients whose skin is fragile and tears easily. Scarring is not an issue with the actual intervention, but it’s a risk you should discuss with patients.

Another issue, says Dr Soerensen, is non-compliant patients. It could be an elderly patient with dementia who has cut her head in a fall and doesn’t understand the need to keep still during the intervention.

“Or, on the other end of the age scale, you’ve got the two-year-old with laceration. You might normally think about glueing, but then you’d worry the child might pick at it and you’d have an open wound again. So it’s a question of do you suture, and do you look at sedation to try and get a good result.”

Often the decision whether to suture or not can be a bit of a grey area, with different doctors having different opinions.

“You have to discuss it with the patient. For example, a lot of biopsies will heal fine by themselves, but you’ll get a little circular scar. Suturing might minimise the scar, but then you’ve got another needle going in. You have to talk to the patient to see what they want.”

Dr Soerensen says there’s a lot of variation among GPs as to how much suturing they do, although most would at least have one case per month.

“The more you do, the more confident you are, and that’s why you have GPs that essentially end up subspecialising in skin work, because it’s what they’re good at and they enjoy it. The more you do, the quicker you get, and the better results you get. Like everything else, there’s a learning curve.”

Want to sharpen your suturing skills? Sign up to doctorportal’s online Basic Suturing module to learn about wound assessment and cleaning, suturing technique and post-suturing wound care.

This one-hour course is designed for beginners and is accredited with ACEM, ACRRM, CICM and ANZCA.

Six keys to apologising for medical error

If you practise medicine for any length of time, you’ll inevitably end up being involved in a situation where a patient has been harmed due to medical error. Open disclosure to the patient is not only expected, it’s often mandated by the healthcare provider. And a key element of open disclosure is an apology to the patient or their family, using the words “I’m sorry” or “we are sorry”.

It’s by no means easy to do. Saying sorry in a medical context is so much more difficult than in other situations, according to a new interview-based study on apology in medicine, because the stakes are so high.

“As a doctor, the problem is much more serious than anything you encounter in everyday life,” one of the doctors interviewed for the study said. “When it concerns more important problems, it costs me more to make the effort to go and apologise, I say to myself, I have to through with this.”

Another barrier to apologising for medical error, the study suggests, is the fear of being blamed and fear of a demand of compensation by the patient affected. But actually, research shows that in medicine, as in other fields, apologies help resolve conflicts and litigation and are associated with fewer malpractice suits.

All Australian jurisdictions have so-called “apology laws” that protect doctors who apologise for adverse events from liability before the law. The aim of such legislation is to create an environment where doctors can express regret without it being used against them in any future litigation.

An effective apology is critical to allowing the doctor-patient relationship to continue despite what has happened, and minimises the chances of a complaint against the healthcare provider. Getting the wording right is also crucial, and should include the word “sorry”, using formulations such as “I’m sorry this has happened”, or “I’m sorry this hasn’t turned out as expected”.

Here are some tips on how to say sorry after medical error.

Acknowledge that the error has occurred;
Apologise and/or express regret for what happened;
Be careful about wording. Make sure you use the word ‘sorry’, but avoid saying you personally are liable or speculating on what staff members were at fault;
Go through the facts as you know them, and what you expect will happen next;
Listen to what your patient has to say on the matter;
Let your patient know what is being done to ensure a similar event won’t happen again.

For more information on open disclosure, click here.

Source: Avant

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

Do doctors die better than other people?

A few years ago, a compelling essay written by a retired US doctor went viral. In the essay, Dr Ken Murray explored how doctors navigate the business of their own death. He wrote about a colleague who had discovered discovered a lump in his stomach, the diagnosis of which turned out to be pancreatic cancer. Surgery could increase his poor odds of survival, from 5% to 15%, but the colleague wasn’t interested – he knew only too well how brutal the treatment was and what poor quality of life it led to. Despite the fact that he would in all probability recommend such treatment to a patient, he declined it himself.

Doctors, the author posited, die differently from their patients. When push comes to shove, they want fewer treatments, rather than more. They value quality of life over a few extra weeks or months, or even a longshot chance of a cure. They treat their patients one way, and yet they do it themselves in a different way.

But is it true? What’s certainly right is that almost all doctors have an experience of being involved in giving futile care to a patient. And that, in turn, impacts how they think they want to be treated themselves at the end of their life. Performing CPR – which has a very low chance of success, can result in broken ribs, and all in all seems a pretty unpleasant way to end one’s days – seems to have a particular effect on the way doctors envisage their own end of life. One recent study of over 1,000 doctors showed that almost 90% would not wish to be resuscitated if terminally ill. Another study surveyed both doctors and their patients as to what kind of end-of-life care they would prefer. Doctors opted for less treatment than their patients in almost all cases. They were also more likely than the general public to have drawn up an advance directive that lays out care plans in the event that the patient is unable to make decisions.

But do doctors’ previously stated wishes correlate with what actually happens to them at the end of their life? Two studies give slightly different responses, but the answer seems to be mostly ‘no’. A 2016 retrospective study published in JAMA, which looked at where nearly 500,000 people died, found that physicians were only slightly less likely to die in a medical facility than the general population, despite the surveys showing that the vast majority of people – doctors included – would prefer to die at home. Another study found similar hospitalisation rates among doctors and the general population at the end of life, although doctors were a little more likely to opt for hospice care.

The final question to ask seems to be why doctors get roughly the same treatment at the end of life as everyone else, despite their stated preferences. Dr Daniel Matlock, co-author of the study on doctor hospitalisation rates, says the problem is that the odds may be stacked against patients getting the end-of-life care they want, even if the patient is a doctor. Once you find yourself locked into the medical system, it can be almost impossible to extricate yourself from it, particularly when you are already frail and ill.

“These things that encourage low-value care at the end of life are big systems issues,” says Dr Matlock. “And a strong, informed patient who knows the risks and benefits – maybe even they have a hard time stopping the train.”

A caveat is that all the aforementioned studies were carried out in the US, where end-of-life treatment tends to be more aggressive than in Australia and futile treatment more common. Unfortunately, no studies of this kind have been carried out in Australian populations.

Is there a wrong and right way to break bad news?

Being the bearer of bad news is one of medicine’s more emotionally challenging responsibilities. Getting it right is crucial not only for patients and their families, but also for the well-being of doctors themselves.

“If you’re giving someone bad news, it’s going to be pretty brutal for both the person receiving the news and the one giving it,” says Professor Stewart Dunn, a medical psychologist specialised in the psychological care of cancer patients and their families.

To look at what happened to doctors when they gave bad news, Professor Dunn and his team monitored the heartbeats of consultants and registrars as they interacted with a professional actor playing a woman finding out that she’d lost her husband.

“From even before the woman comes through the door, the doctors’ heartbeats went up by an average of 35 beats above baseline, which underlines how stressful the situation is. And there was no difference between consultants and registrars, which suggests this doesn’t get any less stressful with experience.”

Professor Dunn said his team identified three main approaches doctors used to giving bad news. There was the “blunting style”, where the doctor quickly gets to the point and gives the news using non-euphemistic terms such as “has died” or “has passed away”.

The record, Professor Dunn said, was a mere eight seconds from when the woman walked in the door to the doctor telling her that her husband had died.

While the “blunting style” was relatively common, more common still was the “forecasting style”, where the doctor fires warning shots to let the person know there’s bad news coming.

“For example, the doctor may start out by reminding the woman that when her husband had his first heart attack, she’d been told there would be damage to the heart and that he was still in a danger period. The doctor is telegraphing that something bad has happened, but takes one to two minutes to come out and actually say it,” Professor Dunn said.

Then finally there was a small group of doctors who were “stallers”, who took a long time to get to the point and concretely convey the news.

“These doctors obviously get very distressed themselves, and it’s like they’re waiting for the woman to say, ‘Oh, he’s dead’, so that they don’t have to say it themselves.”

Professor Dunn said that while the first two styles could be effective, depending on how the doctor handled the period after they’ve broken the bad news, the “stalling” method was to be avoided.

“When the doctor stalls, the person knows something bad’s happened but is getting more and more confused and hanging onto the hope that it’s not the worst possible news. And when they find out that it is, they feel betrayed.”

It normally takes around three minutes for the news to properly sink in and for the person to appreciate what it means, Professor Dunn said. During that period the person might question it, for example asking the doctor whether they’re sure they’ve got the right name.

“It’s a stage of disbelief. If you tell someone something terrible that will change their lives forever, it takes a while to come to terms with it.”

Following that, there may be a period of sitting with the patient, riding out the storm with her. This period of support is crucial, particularly for the doctors who tend towards a “blunting style”. Then, within reason, doctors should allow the patient to decide when the encounter comes to an end, usually after about 10 minutes or so. This is the point when the person says they need to act – call a relative, or see the body.

Professor Dunn said patients want doctors to express some emotion; they want reassurance that the doctor expects and understands that the patient is devastated.

“But a no-no is to say ‘I know how you feel’. You can never know how a person feels in such circumstances. It’s better to say something along the lines of ‘I understand that this is devastating for you.’”

After an encounter, it’s important that doctors debrief, which is not something they always do.

“All the literature on burnout shows that it comes from unresolved situations where stress accumulates. Doctors often say they reduce their stress by things like exercise, playing music or playing sport. Those things do reduce stress but they don’t necessarily impact on burnout in the way that debriefing and talking to colleagues do.”

Professor Dunn will be moderating three 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.

How I managed my late-career switch from general practice to obstetrics

Was it the thought of slippery little beings being delivered into my welcoming hands? Was it a feeling of bored complacency? Or – perish the thought – a midlife crisis? The prospect of change enticed me when I applied for entry into the Advanced Diploma of Obstetrics traineeship. Naysayers and sceptics abounded, with sagas of sleep deprivation, eight-litre postpartum haemorrhages and lightning ambulance trips with arms, elbows and shoulders up vaginas supporting uterine inversions. “You’ll come crawling back to general practice begging for your job back” they sniggered.

My initial few weeks were a terrifying blur of inexplicable acronyms, abbreviations and staccato instructions yelled in rapid transit. “CTG” no longer meant “close the gap”, “stretch and sweep” didn’t connote house work, and third stage had little to do with opera. I learnt to wear only meconium coloured clothes, to roll up my sleeves before rupturing membranes, and that amniotic fluid rots the Velcro on shoes.

The seriousness and difficulty of my new challenge was quickly apparent. Simple procedures like cannulation, long forgotten, had to be perfected. My first few vaginal examinations during labour left me perplexed. Didn’t these women have cervixes? I wish someone had taken the trouble to describe them as a stretched balloon with a hole, instead of the nose like structure to which I was accustomed in general practice. I now use this handy analogy as a teaching tool.

Twelve hour days, plus nights on call, with missed meals were followed by intense studying for the written and clinical exams. Challenging for the young, but nearly impossible in one’s sixties. My energetic, obsessive personality prevented me from leaving until every “i” was dotted and ”t” crossed, so my hours escalated in a malignant fashion, inversely proportional to my sleep time. I hated living away from home and my long-suffering husband. My first rental accommodation was cockroach ridden, dark and depressing – a far cry from the beautiful rural farm that is my home. I missed my children and grandchildren, my friends, my life. Family events came and went in my absence. I suffered severe insomnia as well as horrific nocturnal leg cramps. I’d awake up to six times a night, screaming in agony, with my gastrocnemius muscles caved in. Initially I blamed my marathon walking on hard surfaces, until the correlation with the most stressful days became evident. How my neighbours must have loved me!

Learning skills from people the age of my children was humbling, and often humiliating. Negotiating different, and often aberrant, personalities amongst consultants was challenging. It was evident that one particular “boss” thought I should be at home knitting, while others patiently tolerated my slow but steady acquisition of skills. Another was openly disdainful. Initially, I simply tried too hard. To my horror, a patient complained that I hadn’t finished an examination when she’d asked me to do so. My boss had told me it was IMPERATIVE to complete this examination to avoid a dire clinical outcome and I’d gone at it like a bull at a gate. Naturally, I apologised, but my first ever patient complaint distressed me and crushed my already waning confidence.

The competitive atmosphere of the hospital took me by surprise. Gone was the collegiate atmosphere of General Practice. It was dog eat dog now! Fights for the caesarean lists, scrambling for labour ward shifts, crafty manipulation to avoid certain consultants. And I was as guilty as anyone! Those – like me- who were less aggressively competitive, missed out.

Surgery almost proved my nemesis. It had been nearly forty years since I’d graced an operating theatre or studied anatomy. Scrubbing, gloving and turning to tie up sterile gowns were nearly my undoing. Gnarled theatre sisters rubbed their withered hands with glee when I contaminated myself yet again, or forgot the name of some ubiquitous, obscure instrument! I mean, why the eponymous title for forceps? (Greene Armytage? Moynihans? Wrigleys?). Pointing or referring to them as “that one” didn’t really inspire confidence!

Surgical knot tying practice left my home resembling a sadomasochism den. Although I can certainly tie a hook on my fishing line better now! Other trainees learnt surgery so much more easily than I did! Yet, learn I painstakingly did. It seemed to take forever, but I can now perform straightforward caesareans, challenged occasionally by the odd impacted or high floating head. Instrumental births were difficult, but I am gaining my confidence. I passed my theoretical and clinical examinations with flying colours, and my “case syntheses” were marked as “excellent”.

After 18 interminable months, my traineeship is effectively over. Other trainees are progressing well but I still have a couple of skills to sign off. This, of course, presents a new challenge! I have begun ad hoc locums as an obstetrics registrar, but I am now the bottom of the pecking order as far as skills acquisition goes. Where to from here?

I look back at these 18 months with a mixture of horror and deep satisfaction. The knowledge that I was accumulating was massive and interesting, the studying strangely enjoyable, the care of mothers in labour and birth exhilarating. I’m often asked: ”Why? What are you planning to do with these skills?” My original plan was GP Obstetrics in remote and third world regions. Now I am assailed with self-doubt. Am I capable? Do I have the stamina? Can I cope with the stress and the inevitable occasional adverse outcome?

At this stage I can’t answer these questions. But the other day, as I delivered a beautiful baby boy with forceps, following a long and exhausting labour, I felt that slippery little bundle in my welcoming hands and witnessed the joy and relief on his parents’ faces, and all those negative memories flew out the window as I immersed myself in the miracle of new life, and felt so grateful to be a small part of this exquisite epiphany.

What to tell your patients about complementary medicines

Over 60% of Australians take some form of vitamin or mineral supplement, and the complementary medicine industry in this country alone was worth around $3.5 billion in 2016. Many doctors will roll their eyes at such expenditure and possibly blame pharmacists for providing these products with a sheen of medical plausibility. But it’s worth asking what exactly the evidence is for supplements, whether there are patients who should be taking them, and what doctors should be telling their patients about them.

A new viewpoint published in JAMA lays out the evidence for vitamin and mineral supplements. It notes that the vast majority of randomised clinical trials of supplements have not shown benefits for the prevention of chronic diseases not related to nutritional deficiency. Indeed, some trials have shown harms with high doses of micronutrient supplements, including increased risk of stroke, cancer and death.

The upshot is that doctors “should counsel their patients that supplementation … provides little if any benefit,” the Boston-based authors say.

But although supplements aren’t recommended for the general population, there are high-risk groups for whom they may be a good idea, they note. These are:

Pregnant women, for whom 0.4-0.8mg/d folic acid is recommended for preventing neural tube defects. Supplemental iron might also be needed in pregnant women with low levels of haemoglobin or ferritin. Calcium and vitamin D supplementation may provide benefits, but confirmatory trials are needed.
Children who are exclusively or partially breastfed could benefit from supplemental vitamin D (400IU/d) from soon after birth, along with supplemental iron (1mg/kg/d) from 4 months. But healthy children on a balanced diet have no need for supplements.
Adults over 50 may benefit from vitamin B12, vitamin D or calcium supplementation, but only if their levels of these are lower than recommended.

Clinicians should always ask about use of micronutrient supplements if patients are taking other drugs, to ensure there are no unwanted interactions. For example, vitamin K supplements could lessen the effects of warfarin, while vitamin B7 can interfere with the accuracy of troponin testing.

At the same time, it’s best to not be too judgemental of a patient’s use of vitamin and mineral supplements, given their prevalence in the general population.

You can access the Viewpoint here.

How common are doctor impostors?

On Monday this week a Brisbane court fined a man $3,000 for pretending to be a surgeon at the city’s Lady Cilento Children’s Hospital. Nicholas Delaney, 25, stole security credentials to enter the hospital but never interacted with patients, his solicitor told the court. His solicitor said the reason for his pretence was “to make friends”, in particular with a man who worked at the hospital whom he’d met through a dating app. But when Delaney asked for his credentials to be renewed, inquiries were made and his deception unravelled.

A more serious case came to light last year, in which a fake doctor worked in the NSW public health system from 2003 to 2014, treating patients in Wyong, Gosford, Hornsby, Royal North Shore, Manly and Mona Vale hospitals. Shyam Acharya had had some medical training and stole another doctor’s identity in order to practise. He treated hundreds of patients, with his performance reviews describing him as “above average” and a former colleague saying he was “certainly not the worst” he’d worked with. Acharya fled the country when his fraud was discovered and his whereabouts are currently unknown.

You might think these are one-off cases, but doctor impostors may be more common than supposed. Dan Sefton, a British emergency doctor and screenwriter of the BBC fake doctor drama Trust Me, is of the opinion that “there are loads of people who aren’t real doctors”.

“It’s not that hard to fake it if you have some qualifications. Part of this thing is that people don’t ask too many questions,” he told the BBC.

Dr Sefton said there had been a case of a bogus doctor working at his own hospital.

“He only got found out through some administrative thing, because he was actually pretty competent,” he said.

“Often these doctors are very professional and get along very well with their colleagues. The only flaw is that they aren’t real doctors.”

A 1996 study reported on 30 cases of fake doctors working in the National Health Service in the UK and there have been plenty of cases since then. One of the most notorious was Levon Mkhitarian, who treated 3,363 patients in his time working for the NHS. Originally from Georgia, Mkhitarian obtained provisional registration to work under supervision but failed to complete the year’s training required. After fraudulently securing a job, he was struck off, but then forged a host of documents and stole the identity of another doctor to continue working. He was eventually caught out in 2015 and sentenced to six years in jail.

And then there was the case of Stewart Edwards, who practised as a GP for 34 years in the north of England before being exposed. Or the German fake doctor, Christian Eberhard, who forged a degree certificate from Oxford University, trained in surgical techniques and spent two years as an assistant surgeon. During that time he took part in spinal, liver and lung surgery and even amputations.

But perhaps the most chilling imposter of all was Jean-Claude Romand, ostensibly a renowned doctor working at the World Health Organisation in Geneva, living in bourgeois comfort just over the border in the French Alps with his wife and kids. Then one day in 1993 something truly terrible happened. Romand killed his parents and his wife and children, swallowed a handful of barbiturates and set fire to his home. But he didn’t die – he was rescued by the emergency services and arrested by the police.

What came out then was astounding. Romand had no medical qualifications at all. Instead of working at the WHO Geneva headquarters, he’d spend his days sitting alone in its car park. Occasionally, he’d say he had to travel abroad to a conference; on those days, he’d stay at a cheap hotel near the airport, boning up on whatever destination he’d claimed he was going to, in order to have stories to tell his family. He kept up this pretence for 18 years.

Romand had been a medical student, but had inexplicably skipped his second year medical exams. He covered up, and told his parents he’d passed, and continued to pretend to attend medical school. That original lie came to be the cornerstone of a whole edifice of deception, which he bankrolled by embezzling the savings of family and later friends. The murder spree came just as that edifice was about to come tumbling down, as relatives began asking for the money back that Romand had claimed he had invested in Switzerland for them.

Romand was sentenced to life imprisonment in 1996 and his case is the subject of at least one book and several movies.

Codeine upscheduling: what doctors need to know

Today’s the day when codeine-containing products can no longer be bought over the counter at pharmacies and legally require a prescription as schedule 4 drugs. Here’s what you need to know about the change:

What is being changed and why?

In 2016 the Therapeutic Goods Administration proposed rescheduling all codeine-containing analgesics to Schedule 4 (prescription only). It received submissions from pain specialists reporting rising levels of codeine dependence and from members of the public whose families had been destroyed by codeine addiction. Although some bodies, notably the Pharmacy Guild of Australia, argued against upscheduling, the TGA eventually decided that codeine-containing products would become Schedule 4 from February 1, 2018.

It cited the likely public health benefits of such a move, based on the evidence of harm due to dependence on easily accessible, over-the-counter products. In 2013 well over half of codeine-containing analgesics in Australia were sold over the counter. From 2014 to 2016, the proportion of people seeking help for opioid addiction rose from 2.7% to 4.6%, and around 150 people a year die from overdose due to opioid overdose per year.

This may not be the TGA’s last move concerning codeine. It is reportedly looking into banning GPs from prescribing strong opioids as a means of addressing misuse and overdose. Other restrictions on the horizon may concern pack sizes, along with a review of indications and label warnings.

Are GPs likely to see an influx of patients seeking codeine products?

This may happen, but it may also take a while for people struggling with codeine addiction issues to come out of the woodwork.

There is some anecdotal evidence of patients stockpiling codeine products in anticipation of restrictions. Self-denial and the stigma attached to addiction may also hinder people from coming forward, and it may be some time before the extent of the problem can be quantified.

What should doctors tell their patients about codeine products?

The TGA says it’s important for GPs to develop practice policies for prescribing analgesics and know when to refer to pain specialists or allied health professionals for alternative therapies.

If you have a patient presenting with pain who has previously self-medicated with over-the-counter codeine products, here are some approaches:

Ask open-ended questions about your patient’s pain and don’t presume they’re just after painkillers;
Manage expectations: let your patient know that sometimes pain management is a long-term process that requires more than drugs;
Tell them that there’s evidence low-dose codeine is no more effective than OTC products without codeine, and that higher-dose codeine is indicated for acute rather than chronic pain;
Ensure your practice has a drugs of dependence therapy agreement policy to inform people about the risks of codeine dependency;
If you suspect a patient of substance abuse, use this opportunity to organise proper care and consider referral to local drug and alcohol services.

Read more tips and talking points on managing patients who were previously on OTC codeine medication here.

What you need to know about sharing clinical images via smartphone

Imagine this scenario: you’re a recently graduated doctor working at a medical clinic in rural Australia. A person presents with a bite of what seems to be a poisonous spider – but you’re not sure. You take a photo of the skin lesion on your phone, and post it in a social media group to source swift advice from more experienced experts.

Digital image capturing devices like smartphones have enormous potential to facilitate communication for time critical medical interventions. And, as a society, we all seem to be part of a contract where we tacitly consent to immediate, mass distribution of images depicting us.

But there’s a catch: image capture and storage may fail to comply with current legislative frameworks for privacy, with significant ethical, legal and security implications.

As a society, it’s time for us to review how digital imaging is changing healthcare, security and other specialities.

Legal use of information

Australian legislation refers to the 1988 Privacy Act framework for guidelines about the legal and ethical use of information, including images.

This legislation was developed during a time of centralised practice of medical photography – when images were physically stored at a hospital, and could not be reproduced, or accessed, without due authorisation.

But all this changed with the advent of smartphone-enabled cameras that can capture, process and mass distribute an image instantly.

Legislative changes to the Australian Privacy Act took effect in March 2014 following the introduction of the Privacy Amendment Act 2012 and the Privacy Regulation 2013.

Under these changes, people or medical professionals with unsecured patient images on their smart devices could face fines up to A$340,000, and institutions up to A$1,700,000 for breaches of patient privacy.

At a national level, mandatory data breach notification obligations will come into force in early 2018.

But it’s not clear how this federal legislation interacts with state regulation of digital images. Individual state governments apply a range of acts to meet specific requirements in some sectors.

For example, those that apply in the medical sector in Victoria include the Freedom of Information Act, Guardianship and Administration Act, Medical Treatment Act, Health Records Act, Charter of Human Rights and Responsibilities Act and the Mental Health Act.

Different states and territories have different acts, and this is problematic. Digital images can be sent instantly across state or national borders and easily redistributed through social media. So which laws should apply?

How photos aid medical practice

Medical photographs can be an essential part of patient treatment. They allow medical staff to document the treatment of illness, to communicate among medical professionals and to teach.

A phone capture of your health image may be shared without your consent.
www.shutterstock.com

Surveys of image usage in Australian hospitals suggest that medical professionals frequently capture and store patient data on smartphones, sharing them between colleagues.

Although legislation requires signed informed consent for the storage and use of images, this appears often not to be collected, especially if a patient is not in a state to be able to grant consent. This means there is a large disconnect between image usage, and legislative requirements.

Medical professionals including doctors and nurses have probably been the most progressive in enabling surveys of current professional practices. This serves as a high value source of information for considering how changes in technology and work practice may need to be reflected in consistent legislation, independent of state borders.

Also a problem in policing

Collection and application of digital imagery in policing similarly presents new legal and ethical challenges.

In Australia, various states are either trialling or using body cameras, and police may be permitted to use personal capture devices.

But guidelines for when images of a potential crime should be captured are different between Australian states. Concerns over when evidence should be collected, and who has access to such evidence have only started to be considered in Australia.

Towards solutions

We recently discussed issues relating to legal and ethical use of digital images at the 2016 Australian Ethics Network conference.

The field of ethics management aims to ensure that data is collected, stored and distributed in a way that is consistent with moral principles, and legislative framework within a given jurisdiction. The use of digital images that can be instantly transferred across state and national borders presents many challenges.

We need sector and region specific information to answer these questions. What are the benefits to a medical professional of having instant image access, how should this be balanced with personal consent if a life is in danger? How should use of images for policing be balanced with privacy if image distribution may result in the prevention of crime?

Possible technology solutions could include developing apps that securely store and manage data by restricting access to authorised persons. Such a process will require coordination between policymakers and professional sectors, and a conversation with the public on how we can best use digital images in an ethical way, not only for medicine but across research disciplines.

Adrian Dyer, Associate Professor, RMIT University; Jair Garcia, Research Officer, RMIT University, and Ted Rohr, Director, Research Ethics & Compliance Support, UNSW

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

Write for us!

Doctors have always been writers. Literary history is replete with them: Anton Chekhov, Somerset Maugham and Arthur Conan-Doyle are just some of the many who hung up their stethoscopes to devote themselves to the written word. More recently there have been the doctor memoirists: maybe you have read books by the likes of Henry Marsh, Siddhartha Mukherjee or Paul Kalanithi. And there are superb journalists like Melbourne oncologist Ranjana Srivastava, who has a regular column in the Guardian.

Of course, you might be just too busy to write the magnum opus you know you have inside you, and yet you still have the urge to put pen to paper. If so, the doctorportal blog might be the right bite-sized platform for you. We’re looking for blogs 600 to 1000 words long, on any kind of medical subject, as long as it’s interesting. It could be something topical about Medicare rebates, it could be about new treatments in your specialty area, or it could be about the restless quest for meaning in the face of death: it’s up to you! Recent doctorportal blogs include Dr Pamela Wible’s impassioned plea for better understanding of doctor suicides; a Melbourne gastroenterologist on why gluten-free is bad for you if you don’t have coeliac disease; or another on what lifestyle changes you should make to avoid dementia. Our blogs are widely read and are included on a newsletter sent out to over 30,000 of your colleagues.

Whether you’re a GP, specialist or trainee, you’ve almost certainly got something interesting to say about your life in medicine. It’s not hard: here are some tips on blog writing for doctors from the British Medical Association to help you along the way.

If you’re interested, please feel free to pitch your idea to our online editor Hugo Wilcken at hwilcken@mja.com.au .