Coordinated approach needed to improve Indigenous ear health

Ear health is the focus of the 2017 AMA Indigenous Health Report Card, with doctors calling on all Governments to works towards ending chronic otitis media.

Releasing the Report Card in Canberra on November 29, AMA President Dr Michael Gannon challenged the Federal Government and those of the States and Territories to work with health experts and Indigenous communities to put an end to the scourge of poor ear health affecting Aboriginal and Torres Strait Islanders.

The Report’s focus on ear health was part of the AMA’s step by step strategy to create awareness in the community and among political leaders of the unique health problems that have been eradicated in many parts of the world, but which still afflict Indigenous Australians.

“It is a tragedy that in 21^st century Australia, poor ear health, especially chronic otitis media, is still condemning Indigenous people to a life sentence of hearing problems – even deafness,” Dr Gannon said.

“Chronic otitis media is a disease of poverty, linked to poorer social determinants of health including unhygienic, overcrowded conditions, and an absence of health services.

“It should not be occurring here in Australia, one of the world’s richest nations. It is preventable.

“Otitis media is caused when fluid builds up in the middle ear cavity and becomes infected.

“While the condition lasts, mild or moderate hearing loss is experienced. If left untreated, it can lead to permanent hearing loss.”

Dr Gannon said that for most non-Indigenous Australian children, otitis media is readily treated, but for many Aboriginal and Torres Strait Islander children, it is not.

Estimates show that an average Indigenous child will endure middle ear infections and associated hearing loss for at least 32 months, from age two to 20 years, compared with just three months for a non-Indigenous child.

The Report Card, A National Strategic Approach to Ending Chronic Otitis Media and its Life Long Impacts in Indigenous Communities, was launched in Parliament House by Indigenous Health Minister Ken Wyatt

Mr Wyatt commended the AMA on its 2017 Report Card.

Over the past 15 years, he said, the AMA’s annual Report Card on Indigenous Health has highlighted health priorities in Australia’s Aboriginal peoples and communities.

“Reports can be daunting and they can be challenging,” the Minister said.

“But above all, they can be inspiring.”

Mr Wyatt said it was a tragedy that the most common of ear infections and afflictions were almost entirely preventable.

Yet left untreated in Indigenous children, they had lifelong effects on education, employment and well-being.

“It’s not somebody else’s responsibility. It’s the responsibility of all of us,” he said.

“Hearing is fundamental.”

Shadow Indigenous Health Minister Warren Snowdon also commended the AMA on its report.

He said the Government and the Opposition worked collaboratively on Indigenous health issues.

“We’re not interested in making this a point of political difference, we’re interested in making it a national priority,” he said.

Green’s Indigenous Health spokeswoman Senator Rachel Siewert welcomed the Report and stressed the importance of addressing Indigenous health issues.

Australia’s first Indigenous surgeon, ear, nose and throat specialist Dr Kelvin Kong, who is also the Chair of the Australian Society of Otolaryngology Head and Neck Surgery’s Aboriginal Health Subcommittee, received the report with enthusiasm.

He said cross-party support on this issue had been “phenomenal”.

Dr Gannon said the AMA wants a national, systematic approach to closing the gap in the rates of chronic otitis media between Indigenous and non-Indigenous infants and children in Australia.

The Report calls on Governments to act on three core recommendations: namely, that a coordinated national strategic response to chronic otitis media be developed by a National Indigenous Hearing Health Taskforce under Indigenous leadership for the Council of Australian Governments (COAG); that the wider impacts of otitis media-related developmental impacts and hearing loss, including on a range of areas of Indigenous disadvantage such as through the funding of research as required are addressed; and that attention of governments be re-directed to the recommendations of the AMA’s 2015 Indigenous Health Report Card, which called for an integrated approach to reducing Indigenous imprisonment rates by addressing underlying causal health issues.

“We urgently need a coordinated national response to the lasting, disabling effects and social impacts of chronic otitis media in the Indigenous adult population,” Dr Gannon said.

The AMA Indigenous Health Report Card 2017 A National Strategic Approach to Ending Chronic Otitis Media and its Life Long Impacts in Indigenous Communities can be found at article/2017-ama-report-card-indigenous-health-national-strategic-approach-ending-chronic-otitis

CHRIS JOHNSON

Royal Commissions must spark changes for treatment of young people

Two recent Royal Commissions have inquired into systemic and institutional failure to protect vulnerable young people. The formula is roughly consistent. Both inquiries, Royal Commission into the Protection and Detention of Children in the Northern Territory and Royal Commission into Institutional Responses to Child Sexual Abuse, began with an initial exposé which generated enough public outrage to force a Government response.

In both cases, the subsequent investigations uncovered layers of abuse and neglect far more pervasive than anybody could have ever imagined. What remains to be seen, is the extent to which these Royal Commissions generate enough momentum to result in meaningful and positive change.

The findings of the Royal Commission into the Protection and Detention of Children in the Northern Territory are abhorrent. Children as young as ten serving custodial sentences in conditions that could not be deemed appropriate for any child, let alone some of our most vulnerable.

The final report of the Royal Commission delivered 43 recommendations, all with a subset of more detailed recommendations. In essence, the Report demands a drastic overhaul of the entire juvenile justice system.

A major finding from the Royal Commission is the relationship between Fetal Alcohol Spectrum Disorder (FASD) and juvenile incarceration. FASD occurs as a result of fetal alcohol exposure, and results in lifelong neurodevelopmental impairments. At present, we do not know the extent of its prevalence in Australia but it is thought to be endemic in some custodial settings.

Overseas studies have found that young people with FASD are almost 20 times more likely to enter the criminal justice system than their peers. Unsurprisingly, this carries a significant financial burden for both adult and youth justice systems. The relationship between FASD and the criminal justice system is dual in that FASD increases the likelihood a person will come into contact with the system, and then subsequently impedes their ability to navigate it. A particularly troublesome aspect of FASD is that many of its manifestations can simply appear as disobedience or behavioural problems to the untrained eye.

Young people are not routinely screened for FASD upon entering the juvenile justice system, and the Commission was told there are currently no plans to implement such an initiative. The Department of Health maintains that rates of FASD within the Northern Territory custodial settings are likely to be relatively low due to the high proportion of alcohol-free communities in the NT. However, the Commission received expert advice to the contrary, suggesting that as many as a third of all of the young people in youth detention could have FASD.

While there is no cure for FASD, behavioural and education interventions can improve outcomes for people with a diagnosis of FASD. Routine and psychosocial support are both beneficial to people with FASD, yet if the findings of the Royal Commission are anything to go by, these were not on offer to any of the young people in the care of the Northern Territory detention and protection systems.

In 2016, the AMA released a position statement Fetal Alcohol Spectrum Disorders (FASD) – 2016. The statement calls for strategies to identify and support people with FASD who come into the education, criminal justice and child protection systems consistent, broadly similar with the findings of the Royal Commission.

So far, these calls remain unmet.

It is vital that the findings of the recent Royal Commission are not simply a catalyst for collective shame, but for meaningful and positive change. Remorse and reflection can do very little for the young people in the youth justice system, and those that are yet to enter it, but they stand to benefit a lot from systemic changes to the youth criminal justice system.

BY GEORGIA BATH
AMA POLICY ADVISER

OPINION – Can safer surgery be legislated?

BY DR PETER SUBRAMANIAM

In June, a Royal Australasian College of Surgeons Queensland Audit of Surgical Mortality report sparked Queensland government action that may trigger new federal and state laws for public reporting of patient safety data across public and private hospitals. By August, Queensland had released a discussion paper and its push for such standards nationally was supported by federal and state health ministers at COAG Health Council. The Council tasked the Australian Commission on Safety and Quality in Health Care to work with ‘interested jurisdictions’ on such standards and to incorporate the work into national performance and reporting frameworks.

Compliance with audits of surgical mortality like the Queensland report is a mandated professional practice requirement for all surgeons while all public hospitals and almost all private hospitals already participate in the audits. So, the question doesn’t appear to be hospitals’ compliance with public reporting of performance data on patients admitted to hospital under a surgeon. The relevant questions seem to be what constitutes metrics of patient safety-oriented surgical performance and whether legislation can protect patients’ safety.

What are the metrics of patient safety-oriented surgical performance?

Patients admitted under a surgeon in a hospital are treated by a surgical team regulated by the hospital’s organisational framework that is part of a public or private hospital network. So, correctly, the metrics of patient safety-oriented surgical performance are metrics of the effectiveness of both surgical team performance and organisational performance of the hospital and its parent organisation. Only if both sets of metrics are reported will the public be fully informed about whether the hospital, public or private, is effective at protecting their safety.

This concept of patient safety-oriented surgical performance is backed by evidence. Patient safety depends on effective surgical team communication and adverse events by individual surgical team members are typically rooted in faulty systems and inadequate organisational structures. This evidence is reflected in local experience of more than 33,000 cases over eight years reported in the Australian and New Zealand Audit of Surgical Mortality National Report 2016. Its key points include that surgical team communication is a key element of good patient care and delayed inter-hospital transfers of patients with limited reserves can significantly affect surgical outcomes.

So, metrics of patient safety-oriented surgical performance must show effective surgical team communication as being timely decisions and actions to prevent, diagnose and treat surgical complications and deteriorating patients e.g. prompt resuscitation and surgery for postoperative bleeding. Likewise, such metrics must also show effective hospital and parent organisational systems enabling surgical teams’ decisions in a way that protects patient safety e.g. prompt inter-hospital transfers, timely ICU bed and OR access, safe working hours and staff levels.

Can legislation protect surgical patient safety?

The results of the Australian and New Zealand Audit of Surgical Mortality suggest surgical patient mortality represents a segment of Australia’s aging population who are at the extreme of life with co-morbidities that are a stronger predictor of death than the type of surgery. When an acute surgical condition supervenes, they have a rapidly shrinking window of opportunity with almost a quarter being irretrievable. They are prone to surgical complications which often leads to cardiac or respiratory failure with rapid deterioration and death. Nonetheless, surgical mortality in Queensland and nationally has been improving over the last eight years so it is difficult to envisage how new legislation will add much to improving surgical patient safety.

Is legislation necessary?

In 2016, a number of NSW private hospitals did not participate in the audit of surgical mortality despite compliance by all public and private hospitals in all other jurisdictions through the system funded by all State and Territory Governments. If legislation is to bring private hospitals in line with this public reporting system, it should be directed specifically for this reason. If it is to improve surgical patient safety or to inform patient choice, it is not clear how it will improve on the current public reporting system supported by governments. If a national performance and reporting framework is being developed, it should be directed at metrics of surgical team and organisational performance.

It remains to be seen if Government will be surgical in its approach to patient safety.

___________________________________________________________________________

Dr Peter Subramaniam MBBS MSurgEd FRACS is a cardiothoracic surgeon in Canberra who is currently pursuing a Juris Doctor law degree at the Australian National University. He established the Australian and New Zealand Cardiac and Thoracic Surgeons national cardiac surgery database in the ACT as well as the multidisciplinary ACT Cardiac Surgery Planning Group. He also has extensive experience in undergraduate and postgraduate surgical education.

Views expressed in the opinion article reflect those of the author and do not represent official policy of the AMA.

Government launches online resource to fight antimicrobial resistance

The Federal Government has used Antibiotic Awareness Week in November to launch a new online resource for industry and the community, as part of Australia’s ongoing work to tackle the rise of antimicrobial resistance.

Antimicrobial resistance (AMR) occurs when microorganisms, like bacteria, that cause infections resist the effects of the medicines used to treat them, such as antibiotics.

As a result of antibiotic resistance, standard medical and veterinary treatments may become ineffective and infections may persist and spread to others.

The Government’s funding commitment to help tackle the rise of AMR is $27 million – including $5.9 million from the landmark Medical Research Future Fund.

The planned AMR website, is one of the first priority areas of the Implementation Plan. It will aim to provide information for the community, health professionals, animal health professionals, farmers, animal owners and the broader agriculture industry.

Australia is one of the developed world’s highest users of antibiotics – one of the main causes of AMR. In 2015, Australian doctors prescribed more than 30 million antibiotic scripts through the Pharmaceutical Benefits Scheme.

Many patients are not aware that antibiotics only work against infections caused by bacteria and should not be used to treat viruses like colds, flu, bronchitis and most sore throats.

AMA President Dr Michael Gannon said in a recent ABC interview that AMR is a concern and there needed to be: “Better stewardship in hospitals, better education for GPs, but perhaps most importantly better education for people in the community for them to understand when antibiotics are not only not required, but they’re potentially dangerous or risky.”

AMR has both a health and economic impact with infections requiring more complex and expensive treatments, longer hospital stays, and it can lead to more deaths.

The World Health Organisation (WHO) believes global urgent change is needed in the way antibiotics are prescribed and used because antibiotic resistance is one of the biggest threats to global health, food security, and development today. Antibiotic resistance can affect anyone, of any age, in any country, including Australia.

WHO also believes that even if new medicines are developed, without behaviour change, antibiotic resistance will remain a major threat. Behaviour changes must also include actions to reduce the spread of infections through vaccination, hand washing, practising safer sex, and good food hygiene.

“A lack of effective antibiotics is as serious a security threat as a sudden and deadly disease outbreak,” said Dr Tedros Adhanom Ghebreyesus, Director-General of WHO.

“Strong, sustained action across all sectors is vital if we are to turn back the tide of antimicrobial resistance and keep the world safe.”

A recent study published in the Medical Journal of Australia shows that antibiotic resistance is on the rise and is present in our communities in Australia.

Lead researcher Dr Jason Agostino from the ANU Medical School said about 60 per cent of drug-resistant staph infections were picked up in the community, so infection control needed to shift from hospitals to the community.

“The problem of infections resistant to antibiotics in our community is not just a theoretical problem that will happen some time in the future – it’s happening right now,” Dr Agostino said.

Until the early 2000s in Australia, staph infections resistant to antibiotics mostly occurred in hospitals. The researchers found hospital infection rates are improving, with decreased infections in two of the region’s largest hospitals.

The study found that patients most at risk of the drug-resistant staph infection in the community are young people, Indigenous Australians and residents of aged-care facilities.

“We also need to improve the way we share data on antibiotic resistance to staph infections and link this to hospitalisation across health systems,” Dr Agostino said.

You can find out more about the progress of the Implementation Plan actions in the National Antimicrobial Resistance Strategy Progress Report at www.amr.gov.au.

MEREDITH HORNE

Alcohol damage could start at conception

New research that examines alcohol consumption’s long-term negative health effects and how they could start even from the time of conception has been published.

Published in the Journal of Developmental Origins of Health and Disease and the American Journal of Physiology is one of the first studies to look at alcohol in preconception rather than during pregnancy.

Professor Karen Moritz from The University of Queensland’s Child Health Research Centre UQ said the research using animal models found that exposure to alcohol around conception made male offspring more likely to seek a high fat diet more often as they aged.

“We found that exposure to alcohol resulted in male offspring having a sustained preference for high-fat food, which indicated the reward pathway in the brain was altered by alcohol exposure around conception,” Professor Moritz said.

“Surprisingly we found alcohol exposure at this time had no effect on alcohol preference in offspring of either sex later in life.”

In the study, which was conducted on rats, the equivalent of four standard drinks was consumed every day for four days either side of mating. Male offspring which were exposed to alcohol in this way developed elevated preferences for foods high in fat.

The Australian Guidelines to Reduce Health Risks from Drinking Alcohol has been developed by the National Health and Medical Research Council. No alcohol consumption is their current recommendation for pregnant women, and those who planning a pregnancy.

The dangers of consuming alcohol whilst pregnant are well documented and widely acknowledged. The message that there is no safe level of fetal alcohol exposure has been widely disseminated for the best part of the last decade.

More is emerging about the impact of alcohol consumption prior to conception. A separate but related study by UQ found that male offspring of mothers who had consumed alcohol around conception had five per cent more body fat than offspring of mothers who had not consumed alcohol around conception.

Professor Moritz said the study also found both male and female offspring were more likely to suffer from fatty liver when exposed to alcohol at conception.

“Our results highlight that alcohol consumption, even prior to a fertilised egg implanting in the uterus, can have lifelong consequences for the metabolic health of offspring,” she said.

The research highlights the vulnerability of the developing embryo. Previous studies have identified a link between paternal alcohol consumption around conception and epigenetic alterations.

Given that half of all Australian pregnancies are unplanned, the challenge remains reducing alcohol exposure in the early stages of unplanned pregnancies, when the mother may not even know she is pregnant.

The AMA recently raised its concern that the Government’s new National Drug Strategy did not focus on alcohol – even though alcohol-related harm alone is estimated to cost $36 billion a year.

AMA President Dr Michael Gannon has called for a national alcohol strategy.

The AMA position statement on Fetal Alcohol Spectrum Disorder is available here: position-statement/fetal-alcohol-spectrum-disorder-fasd-2016

The 2009 Australian Guidelines to Reduce Health Risks from Drinking Alcohol can be found here: https://www.nhmrc.gov.au/guidelines-publications/ds10.

GEORGIA BATH AND MEREDITH HORNE

Helsinki for holidays if you are safety conscious

The newly released 2018 Travel Risk Map reveals threat levels across the globe in three categories – medical, security and road safety.

Produced by security specialists International SOS, the charted risks across the three categories shows that Finland is the safest place on the planet.

Also listed as ‘low’ threats for medical concern are Norway, Sweden as well as much of western Europe, the US, Canada and Australia.

International SOS say that their Medical Risk Ratings are determined by their assessment of a range of health risks and mitigating factors including: infectious diseases, environmental factors, medical evacuation data, the standard of available local emergency medical and dental care, access to quality pharmaceutical supplies, and cultural, language or administrative barriers.

Group Medical Director of Health Intelligence for International SOS Dr Doug Quarry said that there is an increased understanding of preventative agendas in medical and travel risk mitigation, however organisations need to do more to strategically support their travelling staff.

“A staggering 91 per cent of organisations have potentially not included their travel risk program in their overall business sustainability program and 90 per cent are seemingly ignoring the impact a wellbeing policy could have on their travelling workforce,” Dr Quarry said.

The Scandinavian countries also perform well for road safety, possessing a ‘very low’ risk of a road traffic accident. Countries that Australians visit in significant numbers that have a ‘high’ road risk include Thailand and South Africa.

Unfortunately the number of Australians who died while travelling overseas rose past 1600 last financial year according to the Australian Government’s Department of Foreign Affairs and Trade (DFAT).

DFAT updates their travel advice to countries continuously and urges any Australian travelling overseas to register on the DFAT’s Smart Traveller website. This will allow the government to immediately alert Australians of any changes to the situation and know where Australians were if an evacuation was necessary.

Travel insurance remains an area of concern for Australian consular officials. Travellers without travel insurance are personally liable for covering any medical and associated costs they incur. The Australian Government won’t pay for your medical treatment overseas or medical evacuation to Australia or a third country.

The latest survey results undertaken by DFAT that looks at how Australians use travel insurance reveals Australians are not adequately using travel insurance, especially when it came to cruises. Half (48 per cent) of recent cruise goers who took out insurance were exposed to the risk of being unknowingly uninsured. This was a combination of those (38 per cent) who took out a general travel insurance policy that may not have adequately covered them for a cruise, and / or those (30 per cent) who were not certain that their travel insurance covered them for all countries their cruise liner visited.

The Australian Government provides regularly updated travel advice to all Australians at http://smartraveller.gov.au/Pages/default.aspx.

MEREDITH HORNE

[Correspondence] To be a scientist in Mexico… or not to be?

We want to provide some clarifications regarding points discussed in previous letters, published in The Lancet (June 17, p 2373)1 and Science,2 that are related to government cuts to science and fellowships in Mexico. Once again, the Mexican Government has deceived the academic community with false promises.3

AMA – a voice of many

BY AMA SECRETARY GENERAL ANNE TRIMMER

Elsewhere in this edition of Australian Medicine is a report on the November meeting of Federal Council. One question often asked of the Federal AMA is to explain how policies are developed and position statements adopted. It can be seen from the report that Federal Council deals with some weighty issues. Major topics at the most recent meeting included a discussion to shape AMA advocacy on transparency of medical fees and a briefing on the roll out of the NDIS.

Policies and position statements are developed through the councils, committees and working groups of Federal Council, and are brought to the Council for debate and adoption. Many policies are subject to vigorous debate. Once they are adopted they provide guidance for the public commentary of the President and Vice President.

At its most recent meeting Federal Council adopted unanimously a resolution asking questions of the Federal Government about the management of the health of the asylum seekers and refugees on Manu Island. Issues such as this attract a lot of correspondence from members and non-members alike who see the AMA as the natural voice for its leadership of doctors.

This is consistent with the AMA’s mission of leading Australia’s doctors and promoting Australia’s health. I outlined in my last column the strategic objectives agreed to by the Federal AMA Board for the period 2018-2020.

Among those objectives is a commitment to member engagement. In keeping with that the Federal Council and the Board have resolved to change the way National Conference is structured in 2018 to open the floor of the Conference to debate on issues of interest and relevance to members and the broader community.

The middle day of the Conference will be given over to debate on issues that will be canvassed with the State and Territory AMAs and the Practice Group Councils within Federal AMA. Under the AMA’s Constitution the role of National Conference is advisory only. However these debates will provide an opportunity for direct input into policy development.

The debates will be coupled with the traditional soapbox session on the final morning of the Conference that precedes the election of the next Federal President and Vice President.

The change in structure will facilitate participation not only by the appointed delegates from the State and Territory AMAs, Federal AMA Practice Groups and Federal Council, but also those members who register to attend.

On a personal note, I have advised the Federal AMA Board of my decision not to renew my contract when it expires in August next year. The Board has commenced the search for my successor with advertisements published in early December. There is still plenty to do before then so it isn’t time for farewells yet!

Rural health in retrospect

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

As the second Chair of AMACRD, I feel that despite being a relatively new group within the AMA, we have much to be proud of. So, as 2017 turns into 2018, I look at the circumstances that surrounded us, and am glad to note that we have worked hard, we have little victories we can take credit for.

So, Rural Doctors, I invite you to commemorate all our work in the year 2017, but also to note the challenges that lay ahead.

First off, I want to address the slow internet in the Outback. We are getting attention concerning this slowly (but steadily) and have advocated consistently for improvements.

NBN Co attended an AMACRD meeting at the time of the rollout of Skymuster II and had a good opportunity to hear our stories. We advocated to end the data drought by increasing bandwidth, reducing the cost per gb to make our data needs more affordable. We know that NBNCo has now announced larger satellite data allowances and intends giving medical practice ‘public interest premises’ status, which should improve data allowances and speed even further.
We made a submission to the Productivity Commission for the Telecommunications Universal Service Obligation, some of which we were pleased to see was included in their Final Report
Council members appeared before the Joint Standing Committee on the NBN, making a case for improved access to superfast broadband by describing in vivid stories what internet is like for us. I am told the stories were received with amazement.

Workforce Distribution continues to be an issue. Despite the influx of new medical graduates, there are still unfilled workforce needs in rural Australia. The concept of maldistribution is on the minds of everyone who is trying to solve this problem.

AMA has been invited to the Distribution Workforce Working Group. This group will meet frequently to advise the Minister of Health and the Rural Stakeholders Forum with recommendations.
We have also updated the AMA Rural Workforce Initiatives Position Statement to reflect the current state of our workforce and to offer solutions: new wet behind the ears medical graduates, bewildered overworked International Medical Graduates (IMGs) feeling unappreciated, rural health still far behind but eager to catch up.
The Government has provided funding of up to $93.8 million from 2015-16 to 2018-19 to implement three components to support the rural pipeline that included: Regional Hubs; Rural Junior Doctor Training Fund; and Specialist Training Programme.

Infrastructure is an area where we have had some wins, but we cannot afford to relax on this front. Hospital, clinics and toilets all need walls, doors and privacy.

Following AMA advocacy, the Government, as part of the 2016/17 Federal Budget, announced a redesign of the Rural and Remote Teaching Infrastructure Grants (RRTIGP) to create a more streamlined Rural General Practice Grants Program (RGPGP) which intends to improve uptake. AMACRD provided input to inform the Department of Health revision of the RRTIGP. The AMA will push for continued infrastructure grant funding.
Closure of services in hospitals, especially maternity services is the trend. However there are some “wins” in Queensland with their Rural Generalist program bolstering rural obstetrics.

In the past, Rural Health has been pushed into the background, but we are beginning to see it given some attention by the Government.

Recently at an international rural medical conference I was eavesdropping on North American attendees. They were impressed with the focus that Australia has on rural health. To quote, “They think rural health is so important they have a Federal Minister for Rural Health!”
Now we have even gone a bigger step forward. We have a National Rural Health Commissioner, Professor Paul Worley. That should impress the International Rural community. It took an act of parliament to create this arms-length Commissioner separate from the governing bodies and he is one of us. We will have an advocate, speaking on our behalf. He will be rolling out a national Rural Generalist program and the AMA is keen to work with him.

The vexed issue of Bonded Placements has yet to be resolved, but we are seeing some developments here.

The Government is looking at potentially reforming Return of Service (RoS) obligations on doctors working in bonded placements. This issue will continue to be developed into the new year as well. AMA is in discussions concerning this.
We need to care for our young, as they are the next generation of doctors. If they are treated like prisoners they will rarely return voluntarily to their former jail cells.

Regarding 2018, AMACRD has additional areas it will be vigilant on including (but certainly not limited to) the following:

Support for IMGs and doctors who are struggling with Australian Medical Council and Fellowship exams
Monitor the development of the National Rural Generalist Pathway
Provide input to Health care Homes, Practice Incentives Program redesign, and Medicare Benefits Schedule Reforms
Invigilate the application of the Modified Monash Model for Rural Workforce Incentive programs
Support our new Rural Health Commissioner
Rural Aged Care
Foster team work amongst Rural health care providers both medical and allied health
Monitor the new Rural Junior Doctor Innovation Fund (a tweak on the former Prevocational GP Placement Program (PGPPP)) to see 60 Full time equivalents by 2019.

Although some of these discussions may be uncomfortable, it is essential that we keep rural health in the spotlight. I look forward to continuing to make advancements and am optimistic about AMACRD achieving more victories in 2018.

@drshirowatari

It’s about time

BY DR JOHN ZORBAS, CHAIR, AMA COUNCIL OF DOCTORS IN TRAINING

Wage theft. Let’s call it what it is. When you have a contract to do a job, and you do that job, and you don’t get paid… that’s wage theft. Every fortnight, tens of thousands of doctors-in-training have the work that they’ve done processed into government payment systems. And every fortnight, tens of thousands of dollars and hours go missing.

The way we pay the majority of our doctors-in-training, and for that matter almost every government employee in the country, is embarrassing. It shouldn’t be a hard task. Any organisation that employees people needs to know what these people are doing and how long they are doing it for. Seemingly, this simple calculation was left out of the design plans for almost every HR system I’ve come across in the public sector. Every fortnight, we face a gauntlet of timesheets and rosters that almost invariably result in everyone getting paid less than they’re worth. The system takes its Angel’s Share, and I guarantee you it’s more than 2%. After this tax is levied, you then receive a payslip. Well, you might receive a payslip. They often don’t find you, as was the case when for a quarter of my intern year, my payslips were sent to a regional hospital 600 kilometres away from where I worked in an entirely different health service. And when you do find them, they’re indecipherable. There’s a series of figures and digits that put the techniques that casinos use to confuse us to shame. If big tobacco ever wants to make a comeback in Australia, they need to talk to big hospital.

Of course, no doctor is going hungry in Australia tonight. These dollars aren’t going to decide between life and death. But the dollars aren’t the problem. They’re a surrogate marker for time, and in our vocation we know that time is more valuable than almost anything in this world. When our patients start talking about the “if only-ies” of their lives, we can’t help but reflect on ours. Every hour of your life should be an hour worked and paid, or an hour not worked and not paid; it’s not rocket surgery. When we allow unpaid hours to propagate, those are hours that you don’t get to spend with your family. They are hours you don’t have to prepare for your fellowship exams. They are hours that you don’t spend with your friends enjoying your life and theirs, in shared experiences that you’ll never forget. They are hours that are taken from you. Stolen from you. Lost to you. Make no mistake about it, there is no greater time vampire than your payslip.

This is a system that hides risk. If you can’t accurately capture what your staff are doing, then you can’t safely run a health care service. You will be staffed incorrectly. You will be insured incorrectly. Your leave liability goes through the roof, and your overworked underpaid doctors resign as their access to leave slowly erodes. The pennies you save on wages today multiply into the errors and catastrophes of the future. Morale falls while culture crumbles. Come to think of it, the single worst action you could take to harm patients is to shortchange your doctors, your nurses, and every other person that keeps healthcare ticking.

But the worst part of this tragedy is us. We’re the enablers. We’ve been bailing the system out for years, and for what? When the razor gangs make their rounds, it’s the ultrasound fellowships and the research posts that go missing. But never the run of the mill registrar and resident positions. And you want to know why? It’s because we’re cheap. We’re extremely efficient, we’re too busy to complain and we’re terrible at understanding our rights as employees. Meanwhile, everybody wants to talk about resilience and the inherent difficulties we face in medicine that make it ineffably hard to be a doctor. The irony! I can resuscitate a trauma patient with half a liver and no kidneys. I can hold a family meeting for my critically unwell and soon to be departed ICU patient. I can’t explain my payslip to you. Let that sink in for a moment, and remember it next time someone lectures you about the inherent difficulties in medicine.

This system isn’t the brainchild of some villainous mastermind. It isn’t even a direct effort of government to minimise costs. It’s just simply evolved in an environment in which we’ve stood back and allowed it to happen. And it’s hard to talk about. There’s always someone who wants to make you feel shameful. They want to make it about money, and not about time. Every email you send becomes a less and less wanted intrusion. You’re made to feel the villain, and that’s just for asking for what is rightfully yours! Every unpaid hour we’ve been guilted into letting slide just helps to make life harder for all of us, our patients included. We focus so much on the money that we see it as a dirty act, when really it’s about time. Let’s collectively stop talking about money and start talking about time. This is about fair and due process, and enabling a health system than can actually function.

So next time somebody steals from you, stand up and make yourself heard. If your problem isn’t resolved, call the AMA (of which you are no doubt a member, you fine medical citizen you!). If you employ doctors-in-training, take a look at the processes you have around overtime and staffing. If you are a board member for a health service, audit the real hours that your doctors-in-training are working, so that you can appreciate the quantum of the silent risks that your company or service is being exposed to.

When they steal your money every fortnight, they make your life marginally harder. But when they steal your time, they make your life impossible. And you shouldn’t stand for that. Your time is priceless.