The saga of trying to put Medicare on ice

By Professor Stephen Leeder, Emeritus Professor Public Health, University of Sydney

Frozen indexation has meant effectively a cut in income for general practitioners who bulk bill their patients. Although small, it mounts up when multiplied by the number of patients they see.

If Medicare rebates on consultations lasting less than 20 minutes (the most common type of consultation) had not been frozen in 2014, instead of being $37 now they would have risen to about $40 this year if indexed to the consumer price index. That is according to a fact sheet produced by the Royal Australian College of General Practitioners.

Bulk-billing is hard to freeze

Although this may be thought to serve as a disincentive to bulk-billing, the Federal Health Minister Greg Hunt is quoted in the March 19^th issue of The Australian as “highlighting the record increase in bulk billing rates, which have risen 3.5 per cent since the Coalition won Government”. So it does not seem to have reduced bulk billing?

Mr Hunt went on to say: “In the last half-yearly figures that are just out, we’ve gone from 84.7 per cent, to 85.4 per cent, so in other words, Medicare funding is up and bulk billing rates are at their highest ever on a half-yearly basis.”

Why freeze?

Associate Professor Helen Dickinson, a public service research academic at UNSW, explained the origin of the freeze a year ago in the Conversation and reported on ABC: “Although the Coalition is largely associated with this issue, Labor first introduced the Medicare rebate freeze in 2013 as a “temporary” measure, as part of a $664 million budget savings plan … A continuation of the indexation freeze, initially for four years starting in July 2014, was further extended in the 2016 budget to 2020. It has been estimated this will save $2.6 billion from the health bill over six years.”

The intention in the proposed 2014 Federal Budget was that the freeze would work alongside a co-payment and reduced reimbursement for short consultations. The continued freeze was the only measure that cleared the Senate. Although the justification for these proposed imposts on general practice included the absolute costs of primary care, these costs included a lot of activity other than general practice. According to the Australian Institute of Health and Welfare, health expenditure in Australia in 2014-2105 was $161.6 billion.

A freeze, or frost bite?

In 2013-2014 $58.8 billion was spent on hospitals and $54.7 billion on ‘primary care’ but as just said, this includes general practitioner services (about $9 billion), other health practitioners, community health care, dental services and medications. So with a total annual health budget of $161 billion, general practitioner services amounted to $9 billion or 17 per cent. The predicted savings from the freeze, each year, represent 0.25 per cent of total health expenditure. Has such a small saving been worth it?

If seeking to save money in health care, it is probably best to look first at the big expenditure items. This is why the review of the Medicare Benefits Schedule makes good sense and why, universally, there is an interest in demanding greater efficiency from our hospitals.

But as those who have had the responsibility for running a big and complex organisation know full well, it is wise to assess the likely flow-on from any cuts. Impositions on primary care are not likely to lead to the political pushback that cuts to high-powered specialty services will elicit. But if they demoralise this workforce, heaven help you in trying to integrate care for patients with complex chronic problems. And that will cost you far more in the long term than you will save by freezing general practice rebates.

Is a freeze on Medicare fair?

My final point concerns equity. How come private health insurance premiums rise each year whereas general practice fees do not? Private insurance premiums are heavily subsidised (30 per cent or $6.5 billion in the 2016 budget) by the federal government. So the Government does not worry about indexing its contribution to private health insurance but it does for Medicare. Work that one out if you can.

[Department of Error] Department of Error

Ahern AL, Wheeler GM, Aveyard P, et al. Extended and standard duration weight-loss programme referrals for adults in primary care (WRAP): a randomised controlled trial. Lancet 2017; 389: 2214–25—In table 5 of this Article, the percentage of participants in the brief intervention group who reported attending nine or more meetings should have been 7%. This change has been made to the online version as of May 17, 2017, and the printed Article is correct.

President highlights AMA influence

AMA President Dr Michael Gannon opened the 2017 National Conference lauding the political influence of the organisation he leads.

He told delegates that the past 12 months had been eventful and had resulted in numerous achievements in health policy.

“The AMA is a key player in Federal politics in Canberra. The range of issues we deal with every day is extensive,” Dr Gannon said.

“Our engagement with the Government, the bureaucracy, and with other health groups is constant and at the highest levels.

“Our policy work is across the health spectrum, and is highly regarded.

“The AMA’s political influence is significant.”

Describing the political environment over the past year as volatile – which included a federal election and two Health Ministers to deal with – Dr Gannon said the AMA had spent the year negotiating openly and positively with all sides of politics.

“Our standing is evidenced by the attendance at this conference of Prime Minister Malcolm Turnbull, Opposition Leader Bill Shorten, Greens Leader Senator Richard Di Natale, Health Minister Greg Hunt, Minister for Aged Care and Minister for Indigenous Health Ken Wyatt AM, and Shadow Health Minister Catherine King,” he said.

“Health policy has been a priority for all of them, as it has been for the AMA.”

While the Medicare rebate freeze was the issue to have dominated medical politics, there are still more policy areas to deal with in the coming year.

The freeze was bad policy that hurt doctors and patients.

“I was pleased just weeks ago on Budget night to welcome the Government’s decision to end the freeze,” Dr Gannon told the conference.

“The freeze will be wound back over three years. We would have preferred an immediate across the board lifting of the freeze, but at least now practices can plan ahead with confidence.

“Lifting the freeze has effectively allowed the Government to rid itself of the legacy of the disastrous 2014 Health Budget.

“We can now move on with our other priorities… We will maintain our role of speaking out on any matter that needs to be addressed in health.”

Dr Gannon said while the Medicare freeze hit general practice hard, it was not the only factor making things tough for hardworking GPs.

General practice is under constant pressure, he said, yet it continues to deliver great outcomes for patients.

GPs are delivering high quality care and are the most cost effective part of the health system.

“One of the most divisive issues that the AMA has had to resolve in the past 12 months is the Government’s ill-considered election deal with Pathology Australia to try and cap rents paid for co-located pathology collection centres,” Dr Gannon said.

“We all know that our pathologist members play a critical role in helping us to make the right decisions about our patients’ care. They are essential to what we do every day.

“It was disappointing to see the Government’s deal pit pathologists against GPs.

“The pathology sector is right to demand that allegations of inappropriate rents are tackled, and the GPs are equally entitled to charge rents that place a proper value on the space being let.

“The recent Budget saw the rents deal dumped in favour of a more robust compliance framework, based on existing laws. This is a more balanced approach.

“The AMA will work with Government and other stakeholders to ensure that allegations of inappropriate rents are tackled effectively.

“We want to ensure that patients continue to access pathology services solely on the basis of quality.”

The AMA is a critical adviser to the Government on its roll-out of the Health Care Home trial.

It shares the Government’s vision for the trial, but will continue to provide robust policy input to ensure it has every chance of success.

The AMA has secured a short delay in the roll-out of the trial.

Other issues the President highlighted as areas the AMA is having significant influenced included: the Practice Incentive Program; My Health Record; Indigenous Health; After-Hours GP Services; the MBS Review; public hospitals; private insurance; and the medical workforce.

Chris Johnson

What links anxiety, depression and insomnia

Good sleep is essential for our mental well-being. Just one night of disturbed sleep can leave us feeling cranky, flat, worried, or sad the next day. So it’s no surprise sleeping problems, like difficulty falling asleep, not getting enough sleep, or regularly disrupted sleep patterns, are associated with anxiety and depression.

Anxiety and depression, which can range from persistent worry and sadness to a diagnosed mental illness, are common and harmful.

Understanding the many interacting factors likely to cause and maintain these experiences is important, especially for developing effective prevention and treatment interventions. And there is growing recognition sleep problems may be a key factor.

Which problem comes first?

The majority of evidence suggests the relationship between sleep problems and anxiety and depression is strong and goes both ways.

This means sleep problems can lead to anxiety and depression, and vice versa. For example, worrying and feeling tense during bedtime can make it difficult to fall asleep, but having trouble falling asleep, and in turn not getting enough sleep, can also result in more anxiety.

Sleep disturbance, particularly insomnia, has been shown to follow anxiety and precede depression in some people, but it is also a common symptom of both disorders.

Trying to tease apart which problem comes first, in whom, and under what circumstances, is difficult. It may depend on when in life the problems occur. Emerging evidence shows sleep problems in adolescence might predict depression (and not the other way around). However, this pattern is not as strong in adults.

The specific type of sleep problem occurring may be of importance. For example, anxiety but not depression has been shown to predict excessive daytime sleepiness. Depression and anxiety also commonly occur together, which complicates the relationship.

Although the exact mechanisms that govern the sleep, anxiety and depression link are unclear, there is overlap in some of the underlying processes that are more generally related to sleep and emotions.

Some aspects of sleep, like the variability of a person’s sleep patterns and their impact on functioning and health, are still relatively unexplored. More research could help further our understanding of these mechanisms.

Sleep interventions

Disentangling which problems come first, and under what circumstances, is difficult.
masha krasnova shabaeva/Flickr, CC BY

The good news is we have effective interventions for many sleep problems, like cognitive behaviour therapy for insomnia (CBT-I).

So there is the possibility that targeting sleep problems in people who are at risk of experiencing them – like teenagers, new mothers and people at risk for anxiety – will not only improve sleep but also lower their risk of developing anxiety and depression.

Online interventions have the potential to increase cost-effectiveness and accessibility of sleep programs. A recent study found a six-week online CBT-I program significantly improved both insomnia and depression symptoms. The program included sleep education and improving sleep thoughts and behaviours, and participants kept sleep diaries so they could receive feedback specific to their sleep patterns.

We’re conducting some research to improve and even prevent physical and mental health problems early in life by targeting sleep problems. Using smart phone and activity tracker technology will also help tailor mental health interventions in the future.

General improvements to sleep might be beneficial for a person with anxiety, depression, or both. Targeting one or more features common to two or more mental disorders, like sleep disturbance, is known as a “transdiagnostic” approach.

Interventions that target transdiagnostic risk factors for anxiety and depression, like excessive rumination, have already shown some success.

A good foundation

For many people, treating sleep problems before treating symptoms of anxiety and depression is less stigmatising and might encourage people to seek further help. Addressing sleep first can develop a good foundation for further treatment.

For example, people with a depressive disorder are less likely to respond to treatment and more likely to relapse if they have a sleep problem like insomnia.

Many of the skills learned in a sleep intervention, such as techniques for relaxation and reducing worry, can also be used to help with daytime symptoms of both anxiety and depression. And this is not to mention the physical benefits of getting a good night’s sleep!

If you’re concerned about your sleep or mental health, speak to a health care professional such as your GP. There are already a number of effective treatments for sleeping problems, depression and anxiety, and when one is treated, the other is likely to improve.

And with research in this area expanding, it’s only a matter of time before we find more ways to use sleep improvement interventions as a key tool to enhance our mental health.

Professor Emeritus John Trinder contributed to this article.

Joanna Waloszek, Postdoctoral Research Fellow in Psychology, University of Melbourne and Monika Raniti, Master of Psychology (Clinical)/PhD Candidate, University of Melbourne

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

The one thing that helps in chronic disease

Exercise, exercise and more exercise should be recommended to people with non-communicable chronic diseases, say Finnish researchers.

And it doesn’t necessarily matter what kind of exercise, or even what kind of chronic disease the patient has, according to a new umbrella review of 85 meta-analyses.

Aerobic exercise, resistance training, or a combination of both all improved functional capacity in roughly equal measure across 22 common chronic diseases, in randomised trials comparing exercise therapy with no treatment or usual care.

Chronic diseases in the review included osteoarthritis, rheumatoid arthritis, coronary artery disease, heart failure, type 2 diabetes, various cancers and Alzheimer’s disease.

The review encompassed 146 physical and functional capacity indicators, such as the six-minute walking test, maximal lower body muscle strength, balance tests and self-assessed ability to carry out everyday functions. Around 85% of these indicators were improved with exercise, with 20% showing large improvement.

These improvements were similar in both objective performance measurements and patients’ own assessment of their function.

At the same time, reported adverse events were no greater in exercise versus control groups.

The study authors from the University of Jvaskyla say research into exercise in chronic conditions has generally been more focused on risk factors, prevention and risk of death, and has often overlooked the importance of physical functioning.

Better function improves coping with daily living and may lessen pain and even disease progression, the researchers say. On a societal level, there are also economic benefits in reducing care needs of people with chronic conditions and improving their ability to live at home.

The authors suggest exercise therapy should be recommended to all patients with non-communicable chronic diseases, although training programs should be progressive and include follow-ups to monitor adherence, effectiveness or any adverse effects.

You can read the study here.

[Comment] Computer-assisted diagnosis for skin cancer: have we been outsmarted?

Skin cancer is the most common malignancy in fair-skinned populations, with melanoma incidence the highest in New Zealand and Australia (50 and 48 per 100 000 population, respectively) and projected to increase in the UK (from 17 to 36 per 100 000 population) and in the USA (from 29 to 32 per 100 000 population) between 2007–11 and 2022–26.1 Non-melanoma skin cancer is up to 20 times more common than melanoma worldwide.2 For every melanoma diagnosed, there are from three to 40 benign lesions biopsied; the proportion of biopsied lesions that are benign is generally greater in primary care than in specialist settings.

Failing to plan is planning to fail: advance care directives and the Aboriginal people of the Top End

Advance care directives can enable Aboriginal people to fulfil their end-of-life wishes to die in their community

The United Kingdom’s great wartime Prime Minister, Sir Winston Churchill, once said “he who fails to plan is planning to fail”. These prescient words resonate for advanced care planning and end-of-life decision making.

Advance care directives (ACDs) are used in all Australian states and territories, but take different forms and names. In the Northern Territory, they are known as advance personal plans (APPs).1 An APP allows not only for advanced consent decisions in relation to life support and palliative care, but also the appointment of a substitute decision maker. The powers of the substitute decision maker under the Advance Personal Planning Act 2013 can include health and financial matters.1

ACDs have a valuable role for Aboriginal and Torres Strait Islander (respectfully referred to hereafter as Aboriginal) Australians for two important reasons. First, Aboriginal people suffer from higher rates of life-limiting conditions and burden of disability approaching end of life.2 Second, because of their strong connections to land and community, Aboriginal people from rural and remote regions have a strong preference to “die at home connected to land and family”.3 McGrath outlined a fear of dying away from home for Aboriginal patients from remote communities and outstations, who were relocated to tertiary facilities often hundreds of kilometres away.3 Early discussion of end-of-life preferences, with the use of an ACD, could play an important part in preventing unnecessary displacement of patients by allowing those who wish to die in their community to do so.

Nevertheless, the sparse research in this area suggests that advanced care planning is not common place for most Aboriginal people.2,4 Some of the reasons for this include the taboo of death talk, communication barriers, presence of multiple clinicians (with no single professional taking on the responsibility for initiation of discussion), uncertainty in prognosis, availability of family (often limited by distance), scarcity of Aboriginal health practitioners, and the formal, structured approach of an ACD. Regardless, Sinclair and colleagues demonstrated acceptance for ACDs in their qualitative study of Aboriginal people in the Great Southern region of Western Australia.2 Their patients outlined the potential for the ACD to ameliorate family disputes. The authors called for an increased role for the family, use of Aboriginal health practitioners, and a whole-of-community approach in implementing ACDs.2

The NT APP is a formal, structured document, which necessitates English language proficiency and health literacy. Previous authors have suggested that these characteristics make ACDs an ineffective document for many Aboriginal patients.2 Despite the nature of the population of the NT and the Royal Darwin Hospital (RDH), its Aboriginal health practitioners are not required to undertake training in the use of the APP as part of their curriculum. It is these same individuals who have been delegated the task of helping Aboriginal patients to complete their ACDs.2 In a Canadian context, Kelly and Minty have called for less formal documentation of aboriginal patients’ wishes.5 A culturally appropriate, less formal document that allows for immediate and future planning may also be most pertinent in an Australian context. However, this carries with it the peril of operating outside the legal protections afforded by the APP. Perhaps, an option for the NT is the creation of an educational document to help inform Aboriginal people about APPs. Similar documents exist in other states, such as Advance care yarning in South Australia.6 The cultural diversity among the Aboriginal peoples of Australia behoves the development of such a document in the NT.

To further examine ACDs for the Aboriginal people of the Top End, especially in the context of life-limiting illness, Territory Palliative Care, Program of Experience in the Palliative Approach (PEPA) and the Aboriginal Medical Services Alliance Northern Territory plan to conduct focus groups with key stakeholders in the NT. Focus group sessions will be run in conjunction with PEPA workshops over the next 12 months. Focus groups will be scheduled in Darwin, Alice Springs, Katherine, Tiwi Island, Gove, Wadeye, Maningrida and Groote Eylandt. Key issues to be examined include the applicability of the current APP for Aboriginal people, education of Aboriginal health practitioners, the utility of a Top End-specific educational document, and the suitability of a less formal document such as a personal portfolio. Funding is being sought for the focus groups and creation of a culturally appropriate education document. In the interim, a steering committee has been created by the RDH to consider the key issues.

Immunisations in pharmacies

BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR PUBLIC HEALTH, UNIVERSITY OF SYDNEY

Controversy swirls around this topic. I sounded out several colleagues, including pharmacists.

An infectious disease physician: “(I see) no fundamental reason why not … under certain conditions: they keep recipients on site for 15 mins to make sure they do not suffer anaphylaxis; they [are] trained to resuscitate; they record the vaccination and report to the Immunisation Register and to the recipient’s GP and provide the recipient with an appropriate record. It might suit … families lacking access to bulk-billing GPs or who can’t organise appointments.”

An interested physician recognised this contentious issue, mainly because it disrupts GP-patient relationships.

“I’ve never been convinced (by the AMA), especially (regarding) flu vaccine – where adults >65 and parents of school-age children (need) GP appointments at convenient times. Pharmacists are well-equipped for following procedures, including cold-chain logging and record-keeping.”

Pharmacists recognised the risk of commercial pressures. Some saw pressure from the corporate chains which dominate retail pharmacy. They spoke of decreasing professional satisfaction, rather as can be heard said in general practice about corporatisation.

Westmead Hospital’s chief pharmacist, David Ng, helped set up the first pharmacy program in South Australia. He wrote: “There has been a pharmacy influenza immunisation program in several (American) states since the 1990s. South Australia and Queensland … introduce[d] enabling legislation and training programs several years ago, followed by NSW in 2015. Queensland has extended (these) programs to measles and pertussis.

“This service is underutilised because [there is no] MBS (rebate) and … the need for two pharmacists to be present for one to administer vaccine.

“Large chains … circumvent this by introducing contract GPs or nurse immunisers.

“… the system does not appear ready for a major influenza pandemic!”

An academic perspective

Professor Iqbal Ramzan, Dean of Pharmacy at the University of Sydney, commented: “Falling vaccination rates … pose a public health threat …all health professionals [must) maximise vaccine coverage.

“Most jurisdictions allow pharmacists (with) approved training to provide influenza vaccination. While there may be some disquiet within the medical fraternity, pharmacists have the requisite theoretical knowledge and, with training, the skills required to administer vaccines. Pharmacies offer easy access … this also provides GPs with valuable time to discuss complex issues with their patients.”

To their credit, pharmacists have established sophisticated training and operating procedures. Accreditation is recognised for best practice.

The facts of the matter

A recent paper, Evaluation of the first pharmacist-administered vaccinations in Western Australia: a mixed-methods study,by H Laetitia Hattingh and colleaguesreported on 15,621 influenza vaccinations administered by pharmacists at 76 community pharmacies in 2015.

They found “no major adverse events; less than 1 per cent of consumers experienced minor events, which were appropriately managed. Between 12 per cent and 17 per cent eligible [for] free influenza vaccinations chose to have it at a pharmacy.

“A high percentage was delivered in rural and regional areas [where] pharmacist vaccination facilitated access. Immuniser pharmacists reported feeling confident … and [felt] that services should be expanded to other vaccinations.”

The authors concluded: “Vaccine delivery was safe. Convenience and accessibility were important. There is scope to expand to other vaccines and younger children; however, government funding needs to be considered.”

This is a work in progress. While risk is often part of treatment, its acceptability there is because we can see readily that the risk of doing nothing is greater. This is not as clear in relation to prevention where the risk of developing the condition is vague and located somewhere in the future. But discussions of this sort are an essential part of our national immunisation program’s public acceptability. Whoever does the immunising must be prepared to have it with those being immunised.

Health Financing – building a framework for the long term challenge

BY ASSOCIATE PROFESSOR SUSAN NEUHAUS, CHAIR, HEALTH FINANCING AND ECONOMICS

Health financing is Health Financing and Economics Committee’s (HFE) principal responsibility and central to HFE’s terms of reference. As HFE members will attest, health financing is the largest, most complicated, and all pervasive topic that the committee has the privilege of dealing with.

At its meeting on 1 April 2017, HFE considered the critical elements of current health financing arrangements and the developments and trends likely to impact on those arrangements.

HFE discussed how to build a framework for long term health financing arrangements that are fair, robust and sustainable, and deliver certain and sufficient funding for health care, now and into the future.

This is a challenging task. Health financing is a very complicated policy area. There have been a number of reviews into the system over the years which have discussed (with varying rigour and results) issues surrounding managing costs within components of the health system, with a view to sustainability over the longer term. The overall success of these reviews in terms of lasting, positive improvements has, however, been limited and there have been both overlaps and gaps in their terms of reference.

Public understanding of health financing issues, and the public’s preparedness to consider changes to arrangements for health care, are also limited. Many commentators took this as a key lesson of the 2016 Federal Election. They considered that governments will find it difficult to develop, legislate and implement significant reforms in health without public suspicion of potential impacts on basic Medicare arrangements. Framing a new approach to health financing is clearly not a task for the short-term.

HFE agreed the long-term health financing conversation should be framed in terms of the future health system in 2035. The conversation will need to include all significant stakeholders – organisations and people with a direct interest in the financing of health care, with a view to arriving at a broad consensus on a fair, affordable and sustainable system, and one that takes into account predicted changes in health care needs, advances in medical technology and new information and health management platforms. Consumers should be involved in the conversation.

As a starting point, HFE decided that the AMA could facilitate a discussion around the health system, which could include signalling a number of possible pathways but would not singularly propose a solution.

HFE members noted there is a need to create a space for this discussion that is free of the usual criticisms and stakeholder-positioning that have plagued other reviews and policy processes.

This conversation needs to focus on cost management and obtaining value. It could canvas issues such as whether the health system needs to provide all possible health care to all people at vast and accelerating expense, or should it manage costs by some method.

There needs to be an understanding of the cost drivers going forward, particularly technology and the ageing population, and a national conversation about the level of service we want our health system to deliver in the future.

The conversation should also encompass specific issues identified by HFE members.

These include the need to not only consider efficiency in clinical settings such as hospitals, but also consider efficiency within administration departments, given the growth in these departments within the hospital sector.

Primary health care needs an increased investment, with an understanding of where future pressures and the value of future primary care interventions could be.

The contribution of private health insurance to the overall health system and health financing arrangements also needs to be considered as part of this discussion, particularly given the increasing amount of Government and private spending propping up the industry.

Supporting this work, it would be useful to have a review of the programs run by Government to ascertain which ones are producing good outcomes.

HFE recognised that large-scale change is not likely in the near future. The vision for the future health system must be beyond the three year election cycle. Support from all political parties will be necessary to prevent undermining of solutions.

An important overall outcome of this work should be a ‘vision’ for health financing arrangements that should allow the AMA to be able to hold any Government into the future to account.

The vision also needs to speak to AMA members (and other health care providers) that may be disillusioned or feel abandoned by current arrangements, whether working in general practice, public or private hospitals.

If you have views on how health financing arrangements should change, please contact me. HFE will welcome your input.

Changing our professional culture – what can we do as individuals?

BY DR KATHERINE KEARNEY

Culture is defined as the “total of human behaviour patterns and technology communicated from generation to generation” (New Webster’s Dictionary). How do you define yourself within the broad umbrella of medicine? Are you a doctor, and connect broadly with other doctors as colleagues, or do you feel a stronger association with your fellow nephrologists, cardiothoracic surgeons or general practitioners? Who do you consider your peers and your fellow professional representatives to the broader community? How does that influence your interaction with other doctors, other healthcare professionals and healthcare delivery systems?

Healthcare delivery is a team sport. Broadly speaking, our teams can be as large as our entire hospital operational staff, to “geriatrics team C” with a few consultants, a registrar and an intern. To make it easier for ourselves, we often choose to identify with those closest to us in personality and in daily interactions. I believe it is important to think about the broader profession and our professional culture. What is our professional culture, and what impact is it having on the health and wellbeing of doctors, broadly speaking?

Undoubtedly, medicine is a culture of high achievement and has always been so. High stakes selection processes are becoming universal given the enormous numbers of doctors in training entering the prevocational system as interns, approximately 3,300 in 2015 (MTRP report). It is becoming the norm that trainees have committed early, and committed fully to pursuing a wide range of extracurricular activities such as research, audits, extra qualifications like graduate diplomas or masters, sit on committees relevant to their future goals and have lofty achievements outside of medicine in their hobbies; climbing mountains, volunteer work, high level sporting achievements.

The pressure is immense, amongst a group that is naturally incredibly high achieving. I’ve certainly heard statements from tremendously successful senior colleagues that they would never have gotten onto their training pathway in the current era. Relentless accumulation of accomplishments does not necessarily make for a happy, fulfilled person nor a superior clinician – we see this in disconnects between CVs full of achievements and a lack of correlation with clinical success. I’m as guilty as anyone else at relieving my anxiety about the future of my career by punishing schedules of extracurricular activities. What are truly important achievements to us individually, and how can we bring clarity by appropriately setting personal and professional goals?

Throughout most training pathways, there are high stakes barrier assessments – some of which, such as physicians college exams, are only held on an annual basis. A failed assessment reverberates around hospital and medical community and has a huge impact on the trainee. With this increasingly competitively environment for training positions, as well as failing being challenging personally for those who’ve failed at little in their lives, it can feel like the this stumble means heading to the back of the pack. Differentiating clinical competence from assessment success is very important.

What can we do as individuals to change this perception? Firstly, challenge our own preconceptions about what the journey to success looks like. There are always dead ends and wrong turns, in choosing training pathways or places of employment.

There are many doctors with happy, fulfilled lives and careers who took the opportunity to change tack from surgical training or physician training to pursue general practice or radiology. These stories aren’t talked about enough. We can help each other raise our sights, see the forest for the trees, and change paths to something that is more fulfilling.

We can advocate for complete training programs in rural and regional areas. We can advocate for linking training pathways to workforce requirements, as well as better production and availability of data on what the actual workforce looks like – so we might be able to see our place within it.

Being a doctor is a lot more than just practicing medicine. We are part of a profession, and it’s up to all of us to contribute to making our profession a more supportive place to learn and grow.