Medical student killed in Nicaragua

The killing of a medical student in Nicaragua has been condemned by the World Medical Association (WMA).

Brazilian student, Rayneia Lima, was shot while driving home from her hospital shift in Managua, Nicaragua’s capital city.

WMA President, Dr Yoshitake Yokokura, said this was a tragic death and illustrated the high risks that doctors in Nicaragua are taking every day in coping with the breakdown of the country’s public health care system.

“We repeat our warning about the rapidly deteriorating situation in the country. Attacks on health workers, medical vehicles, and hospitals are unacceptable.

“The Nicaraguan Government must immediately end this state of affairs.

“The breakdown of law and order has undermined basic health care in the country and is endangering all those medical staff who are striving to deliver health care in the midst of this crisis.

“It is the duty of all of us to do what we can to bring this appalling situation to an end.”

Obesity in the USA

In an interesting and worrying trend in the USA, a major survey suggests that some people who are declaring they are exercising more may be also reporting that they are becoming more obese.

According to a Bloomberg report, about 24 per cent of US adults surveyed last year said they exercise enough each week to meet government recommendations for both muscle strengthening and aerobic exercise, according to a large annual health survey. That was up from 21 per cent in 2015.

But the same survey says 31 per cent of adults indicated they were obese last year, up slightly.

Another, more rigorous government study has also found adult obesity is inching up.

So, if more Americans are exercising, how can more also be getting fatter?

Some experts think the findings may reflect two sets of people — the haves and have-nots of physical fitness, so to speak.

Experts say it’s possible the people becoming more active are already normal weight.

The numbers come from an in-person annual national survey that for more than 60 years has been an important gauge of US health trends. Roughly 35,000 adults answer the survey every year, including questions about how often, how long, and how vigorously they exercise in their leisure time.

IMGs leaving rural practice after failing exams

ABC News has reported that international doctors are leaving practice in rural areas after failing exams set by the Medical Board of Australia (MBA).

According to the report, four out of five overseas doctors, some of whom have worked in small towns for as many as 10 years, are failing the MBA clinical exam, which is designed to prove they meet national standards.

Historically, overseas doctors were not required to sit any local exams before they were placed in ‘areas of need’ across rural Australia, where more than 3000 foreign doctors are currently practising.

MBA Chair, Dr Joanna Flynn AM, told ABC reporter Danielle Grindley that, ideally, all doctors who worked in Australia would have the full qualifications before they started work, but some years ago there was a period of workforce need, especially in rural areas.

“But today the expectation that those doctors will meet the Australian standard has become clearer,” Dr Flynn said.

“If their performance in the exam is at a very low level, it raises questions about whether they are actually safe to practise.”

In 2013, all international doctors were told they had three years to pass the clinical exam or face deregistration.

Dr Flynn said there was a period of leniency, where many doctors were given extensions, but that time had come to an end.

“The Board has a set of standards that are now being very deliberately implemented,” she said.

“For some people, that raises the bar that they have to cross to be able to either get into the workplace in the first place, or remain in the workplace.”

In a statement, a Health Department spokeswoman said the Medical Board of Australia was ‘independent of Government and neither the Minister nor the Department could intervene on individual registration matters’

What use is the high moral ground when you are being eaten alive?

BY AMA VICE PRESIDENT DR CHRIS ZAPPALA

GPs’ livelihood and ability to practise are being attacked on many fronts. Dubious role substitution creep from usurper health care practitioners must stop. Does the fight need to come to their doorstep instead of doctors always being in defence?

The Acting President of the Pharmacy Guild recently likened the AMA to a “salivating and barking dog,” following a perceived “onslaught of abuse and derision,” in a response to broader scope of practice for pharmacists. The hyperbole was rousing!

It was suggested that prescribing medications, being able to capably understand and diagnose a patient’s medical problems without appropriate training or ability to garner a full history and examine, and to provide health prevention advice is within the scope of pharmacy training? Clearly not true. The aircraft engineer doesn’t pilot the plane, serve the drinks, or unload the luggage. Being able to work a sphygmomanometer and having a basic understanding of physiology does not make you a doctor or capable of giving medical advice while standing in the middle of a retail pharmacy. The benefits of an enduring, familiar family doctor who knows you well and can provide wide-ranging advice and treatment is well evidenced and the appropriate cornerstone of our health care system. Pharmacists are not required to do any part of this job.

It was also asserted that self-defined broader scope of practice for pharmacists will also save money and time for patients. Not really if outcomes are inferior. Where is the evidence that pharmacists behaving as quasi-doctors achieves anything? Regular interactions with general practitioners is crucially important in developing an enduring bond, discussing risk factor modification, and so on. Government cannot ‘de-fund’ general practice, then attempt to remove the more simple work, and expect the system will still work given growing patient complexity and potential risk.

If you want to be a doctor – go to medical school. Australia is graduating just under 4000 doctors this year – there’s no lack of space! Please, do not abandon doing the job you are actually trained to do. Patients need direction in how to use their inhalers every few months (or their technique degrades), explain the purpose of medications (both prescribed and over the counter), clarify dosing regimens for patients, make sure warfarin interactions with diet are understood by patients, sort out pill boxes or Webster packs to reduce medication errors, and so on. This unequivocal in-scope pharmacy activity is performed far less than it should. If it was done frequently and properly, it would be far more useful to patients and contribute more robustly to the safety and quality of the system, compared to the constant attempts to do a doctor’s job in a rudimentary and inferior way.

The AMA has always decided it is morally and ethically more appropriate for doctors to not dispense medications as a system- wide policy (bearing in mind it has usefully occurred in rural areas for a long time). It would actually be very convenient to patients if doctors did dispense medications (to use one of the Guild’s main arguments for role substitution), and we could make it cheaper to the system as a whole if the costs reflected the dispensing fees only, without profit being generated, and/or any profit being retained within the practice for other patients’ services. If doctor dispensing of medications became a reality, individuals would not have to do it, if they didn’t want to. If patient convenience and cost are paramount in the system, whereas training, evidence, and professionalism do not matter as much to decision-makers, then we perhaps need to recognise this.

Offence might serve us better than defence. Is the AMA position due for a re-think?

Timing is everything

BY DR CLIVE FRASER

In my last column, I gleefully mused about what an enjoyable evening I had watching the understated spectacle of the Royal Wedding on Saturday 19th May 2018.

What I didn’t mention was the unexpected interruption to my Saturday evening at 9.55 PM precisely with an email in my Inbox from AHPRA.

My immediate reaction should have been one of relief that the good souls at AHPRA were burning the midnight oil catching up with the back-log of complaints so that they can all be dealt with in a timely fashion.

But no, the Royal Wedding was still on the ‛telly’ and I thought that history in-the-making just wouldn’t be the same if I paused and watched the Royal Wedding in catch-up mode.

My paranoia then set in. Could this email from AHPRA be about another vexatious complaint?

Had I failed to delete another favourable post on Facebook, I wondered?

I knew, though, that it must have been a very important message to disrupt myself and countless other doctors on a weekend.

Taking a closer look, though, the message had actually been sent by AHPRA on behalf of the Australian Digital Health Agency advising that, “This year, every Australian will get a My Health Record unless they tell us they don’t want one”.

I was aware that the esteemed organisation and publisher of this column, the AMA, was supportive of the MHR, but I still wasn’t sure why I was being told about all of this on a Saturday evening, and during the Royal Wedding.

Then I realised that the opportunity to opt-out of My Health Record ends on 15th October 2018. Well, the Australian Digital Health Agency better get onto telling us about it, hadn’t they?

And no worries at all that most of my patients have no knowledge at all about their digital data going online, and myself and my colleagues are still unsure about what will be shared.

After hearing that the largest online appointment booking app (HealthEngine) was sharing data with law firms, marketers, and other entities, I can understand the general public’s reservations about who has access to their health data.

Curiously, HealthEngine still has a data-sharing arrangement with the Federal Government’s My Health Record.

And, going forward, who knows who will want access with one major health fund (NIB) already stating, “We desperately need this data!”

Could all of this just be another example of how inevitable digital disruption is in our lives?

Instead of pushbikes, would Uber be delivering midwives to those home-birthing mothers?

Would Google reviews eventually replace my CPD?

But, in a digital world that operates around the clock, I’ve learnt to avoid sending emails, texts, tweets etc after close of business.

I may be awake at 3 AM and have finally found inspiration, but there is no way that I would share my thoughts after midnight lest I find myself compared with a certain US President.

So, as I delved into the fine print associated with My Health Record, I have discovered that I can be registered under a pseudonym.

I noted that DisappointedVoter and AngryTaxpayer were almost certainly taken by now.

But I was sure that DoctorCamShaft would be mine for the taking as I had the forethought to grab this moniker when Hotmail first launched in 1996.

The automotive world also targets consumers by using big data for marketing opportunities.

Setting up a bridal registry, searching on Google for a pram, or posting on social media that someone just passed their driving test all suggest life events which may trigger the purchase of a vehicle.

Trawling through this sort of data is said to be 10 times more effective than a traditional marketing campaign.

In my humble opinion, the Federal Government’s decision to make the My Health Record mandatory unless an individual advises that “they … don’t want one” should be coming with a lot more explanation.

Safe motoring,

Doctor Clive Fraser
doctorclivefraser@hotmail.com

Shared Responsibility

BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE

New amendments to the Health Insurance Act 1973, strengthening the Government’s debt recovery powers and seeking to tackle the role of corporate entities in billing under Medicare, have recently been passed by Parliament.

Practitioners may have a debt to the Commonwealth raised against them due to receipt of incorrectly, inappropriately, or fraudulently claimed Medicare benefits. However, according to the Government, a large proportion of these debts has proven difficult to collect. New powers will allow the Department of Human Services to off set a portion of future bulk billed claims against debts. If the practitioner doesn’t bulk bill, the new arrangements will allow garnisheeing of other funds owed to them.

So, more than ever, it is in practitioners’ interests to get their claiming right from the outset.

The problem, as many of you have no doubt found, is trying to get clarity when you are unsure of how to interpret an item or an applicable rule. The Department of Human Services ‘ask MBS’ email for billing enquiries was supposed to provide this. However, the answers are often very unclear or non-committal.

What you are likely to get today, at best, is the regurgitation of either the item descriptor, rules, or legislation back in response to a query. At worst, you will get a misinterpretation and advice that is contrary to the rules. The incorrect advice recently provided to a GP Registrar that GPs could not claim a consultation when providing a vaccination, where the vaccine is funded under the National Immunisation Program, is a prime example.

This is not good enough and must be addressed! The AMA Council of General Practice recently made this point to the head of compliance at the Department of Health. If the Department hopes to increase compliance through education, it needs to have on staff medical advisers who understand the legislative requirements and have experience in their application. The Department of Health should also consider bringing ‘ask MBS’ within its realm of responsibility.

The other legislative change, which will take effect on 1 July 2019, is provision for a Shared Debt Recovery Scheme. To date, all the liability for a Medicare debt has been with the individual practitioner, except in cases where another party has engaged in fraud. The new change provides that, where contractual or other arrangements exist between a practitioner and an employer or corporate entity, both may be held responsible for the repayment of the debt.

What the percentage split of the liability between the employing/ contracting organisation and the individual practitioner is, is still to be finalised. Although it is likely it will be similar to the average of current billing splits. Both sides will have the opportunity, where a shared debt determination is made, to make a case for a review of assigned liability.

The objective of this measure is for a fairer assignment of liability and to facilitate greater billing assurance from a practice level as well as from the practitioner level. This is a proposal that the AMA strongly supported as part of improving debt recovery arrangements.

We are still to see how these new compliance arrangements will play out in practice. Most GPs seek to do the right thing, and the AMA be watching the implementation of these measures with interest to ensure its fairness and appropriate application

Nicotine wars continue…

E-cigs in China

A study by the Society for Research on Nicotine and Tobacco, and published in Oxford Academic, has found that awareness of e-cigarettes is high among Chinese middle school students, but use remains very low.

The study examined data from the Global Youth Tobacco Survey, which was completed by 155,117 middle school students (51.8 per cent boys, and 48.2 per cent girls) in China.

About 45 per cent of the middle school students had heard of e-cigarettes, but only 1.2 per cent reported using e-cigarettes in the last 30 days. Among those who had never smoked, e-cigarette users were more likely to intend to use a tobacco product in the next 12 months than non-users, and more likely to say that they would enjoy smoking a cigarette.

E-cigarette use was associated with previous experimentation with cigarette smoking, having noticed tobacco advertising in the past 30 days, having close friends who smoke, and thinking tobacco helps people feel more comfortable in social situations and makes young people look more attractive.

The study concluded that e-cigarette use among youth in China remains low, but awareness is high; e-cigarette use was associated with increased intentions to use tobacco; and enhanced prevention efforts are needed to target e-cigarette use among youth.

Chinese youths use e-cigarettes as a tobacco product rather than an aid to quitting. Among never-smokers, e-cigarette users were more likely to have intentions to use a tobacco product in the next 12 months, more likely to use a tobacco product offered by their best friends, and more likely to enjoy smoking a cigarette than non-users.

Plain packs in legal win

Australia has won a landmark ruling on tobacco plain packaging laws, with a panel of judges at the World Trade Organization (WTO) rejecting arguments brought by Cuba, Indonesia, Honduras, and the Dominican Republic against the legislation.

ABC News reported last month that Honduras says it will appeal the decision, claiming that there are errors in the ruling.

The WTO panel said Australia’s plain packaging laws contributed to improving public health by reducing use of and exposure to tobacco products, and rejected claims that alternative measures would be equally effective.

The win for Australia effectively gives a green light for other countries to roll out similar laws. It could also have implications for alcohol and junk food packaging.

Australia’s law goes much further than the advertising bans and graphic health warnings seen in other countries.

Introduced in December 2012 by the Gillard Government, the law bans logos and distinctive-coloured cigarette packaging in favour of drab olive packets that look more like military or prison issue, with brand names printed in small standardised fonts.

Studies have shown that the law is an effective measure in stopping people from smoking.

E-cigs in the USA

An Open Access article published in the British Medical Journal reports that, despite an apparent overall decrease in e-cigarette use in the USA, there are indications that JUUL, a sleekly designed e-cigarette that looks like a USB drive, is increasingly being used by youth and young adults.

However, the extent of JUUL’s growth and its marketing strategy have not been systematically examined.

A variety of data sources were used to examine JUUL retail sales in the USA and its marketing and promotion. Retail store scanner data were used to capture the retail sales of JUUL and other major e-cigarette brands for the period 2011–2017.

A list of JUUL-related keywords was used to identify JUUL-related tweets on Twitter; to identify JUUL-related posts, hashtags, and accounts on Instagram, and to identify JUUL-related videos on YouTube.

In the short three-year period 2015–2017, JUUL has transformed from a little-known brand with minimum sales into the largest retail e-cigarette brand in the USA, lifting sales of the entire e-cigarette category.

Its US$150 million retail sales in the last quarter of 2017 accounted for about 40 per cent of e-cigarette retail market share.

While marketing expenditures for JUUL were moderate, the sales growth of JUUL was accompanied by a variety of innovative, engaging, and wide-reaching campaigns on Twitter, Instagram, and YouTube, conducted by JUUL and its affiliated marketers.

The discrepancies between e-cigarette sales data and the prevalence of e-cigarette use from surveys highlight the challenges in tracking and understanding the use of new and emerging tobacco products.

In a rapidly changing media environment, where successful and influential marketing campaigns can be conducted on social media at little cost, marketing expenditures alone may not fully capture the influence, reach, and engagement of tobacco marketing.

Paris bans smoking in parks

France 24 International News reports that Paris city officials have introduced a new measure to ban smoking in six public parks across the city.

The measure is part of a four-month experiment by the city to reduce smoking in public spaces.

Instead of issuing a ticket or fine, park staff will be tasked with informing tobacco users that smoking is no longer allowed on the premises.

A 2013 study of similar bans in selected parks and beaches in Canada found that, although tobacco use significantly decreased after a 12-month observation period, no venue remained 100 per cent smoke-free.

Advocating for the best possible My Health Record

I recently had a private meeting with Health Minister Greg Hunt in Melbourne to raise with him growing concerns being raised by AMA members, other doctors, security experts, politicians, patients, and the media about privacy and the My Health Record.

The AMA has a long history of supporting and promoting an efficient and secure electronic health record, but we have also emphasised that it must be the right electronic health record – one that meets clinical expectations, one that respects and protects patient privacy, and one that is acceptable and useful to doctors and patients.

Our priority has always been on ensuring that the clinical expectations of the My Health Record were achieved. However, the public and political debate around privacy and security of the My Health Record is extremely worrying, and must be resolved satisfactorily, or it could undermine the clinical objectives and benefits for doctors and patients, derailing the whole project for many years to come.

The AMA had to act, and we did.

At the National Press Club in July, I declared that I would do ‘whatever it takes’ to force the Government to act to ensure the privacy and confidentiality of the My Health Record and preserve the sanctity of the doctor-patient relationship. Only moments after the Press Club, I spoke to the Minister and arranged the now widely-reported meeting.

One of the major concerns, among others, is the provisions in the My Health Record Act 2012 that permit the My Health Record System Operator to use or disclose patient data to an enforcement body without a court/tribunal order.

So, backed by the AMA Federal Council, I took the following demands to Minister Hunt at our meeting:

Amend the My Health Record Act 2012 to ensure sensitive health data is not disclosed without a warrant or court order.
Introduce amendments so that if people choose to cancel their record, even after they opt-out, they will not end up with a permanent My Health Record.
Develop and rollout a fully resourced, public information campaign to ensure all Australians are aware of the My Health Record and have access to all the information they need to make an informed choice.
Extend the opt-out period to give people more time to consider that choice.

The Minister and the Prime Minister agreed to all these demands. Minister Hunt immediately issued a media release to that effect following our meeting.

This is a significant victory for AMA advocacy, but clearly there is still a long way to go.

The My Health Record is not new. It was formerly called the Personally Controlled Electronic Health Record and has been available and used since 2012. It is a patient’s own record – a summary of dis-aggregated information from many silos in the health system in the one place under their control.

It promises greater efficiencies in recording, storing, and sharing vital health information. It alone is not the solution, but it will be an enabler to wider platform improvement, allowing more innovation in electronic health records, communication, and information sharing. God knows, it might even spell the end of the fax machine in our health system.

As practitioners, we all know that if health care was simple and predictable, if a patient only ever needed clinical treatment from a single, regular clinician, then we would not need a My Health Record at all. The patient’s doctor would have all clinical information in their software.

But patients’ lives are more complex, dynamic, and unpredictable. Our health system is split across jurisdictions, across primary and acute settings, across private and public systems.

For me, as a GP, coordinating patient care for those with chronic and complex health conditions is one of the most frustrating aspects of the Australian health care system. Where it fails, as it often does, it is to the detriment of patient care.

Uncoordinated care is also wasteful. Tests are unnecessarily duplicated because test results are not always available to the other doctors involved in the care of the same patient. There is a real and immediate need to push for a reduction in medical harm due to things like polypharmacy and avoidable anaphylaxis.

We must solve all the problems and address all the concerns. Then we must push on to make a workable and safe electronic health record a reality, which is enthusiastically embraced. Of course, the time and effort placed on the nominated doctors, especially during the implementation, will be significant and must be recognised by the Government. This will be the focus of significant AMA advocacy going forward. Without this, the implementation will struggle significantly.

There is no doubt that more issues and concerns will arise. Some will be about the legislation and privacy. Some will be about the clinical benefits, or less than perfect interoperability. Some will be a matter for consumers as they decide whether to opt-out. Others will be for other peak bodies in the social services, security, privacy sectors, or other fields to consider.

The AMA stands ready to continue to work constructively to deliver a strong and effective electronic health record that works to improve the quality of patient care and coordination in the Australian health system.

Thank you to all of you who have provided feedback to date. I encourage you to continue to do so as we await the full and formal response from the Government on the next steps for the My Health Record.

Funding boost for Indigenous health research programs

The Federal Government has announced $23.2 million in funding for new research projects that tackle Indigenous health challenges, including kidney health and mental wellbeing.

Health Minister Greg Hunt said the National Health and Medical Research Council (NHMRC) funding was aimed at improving Aboriginal and Torres Strait Islander health outcomes.

“Investigation and investment where it is needed is critical to delivering better health outcomes for First Nations Peoples, to protect lives and save lives,” Mr Hunt said.

Monash University will receive more than $320,000 to develop a point-of-care test to diagnose and manage chronic kidney disease, which affects almost one in five Indigenous adults.

A further five projects across five different States will examine social and emotional wellbeing issues affecting Indigenous infants, children, adolescents, and young people.

The direction of future First Nations research will be informed by the NHMRC’s Road Map 3, which will include a yearly report card and a commitment to spend at least 5 per cent of annual NHMRC funding on Aboriginal and Torres Strait Islander health and medical research.

Minister for Indigenous Affairs, Ken Wyatt, said the Road Map 3 had been developed in consultation with communities, First Nation researchers, and the broader health and medical research sector.

Endometriosis plan released

Australia has its first National Action Plan for Endometriosis, the painful condition that affects one in 10 Australian women.

Health Minister Greg Hunt said that the plan is designed to improve the quality of life of patients through better treatment and faster diagnosis, with the ultimate aim of finding a cure.

The Government is investing $1.2 million to help implement the Plan’s recommendations, taking the investment in the Plan to $4.7 million.

“Endometriosis is a chronic menstrual health disorder that affects around 700,000 Australian women and girls,” Mr Hunt said.

“It often causes debilitating pain and organ damage, and can lead to mental health complications, social and economic stress, and infertility.

“Many have suffered in silence for far too long, enduring diagnostic delays of between seven and 12 years on average.

The National Endometriosis Steering Group will oversee the implementation of the National Action Plan over the next five years.

Steering Group members include Dr Susan Evans, Janet Michelmore AO, Sylvia Freedman, Nola Marino MP, Jessica Taylor, Professor Peter Rogers, Professor Jason Abbott, and immediate past AMA ACT President, Professor Stephen Robson.

More information is available at http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2018-hunt095.htm