Profession united in approach to MBS Reviews

The AMA last month convened a high-level Roundtable of the medical colleges, associations, and societies to discuss the profession’s involvement in, and response to, the Government Reviews of items on the Medicare Benefits Schedule (MBS).

The meeting was attended by over 70 people, representing 53 organisations.

Professor Bruce Robinson, Chair of the MBS Review Taskforce, made a presentation to the meeting and responded to questions from the floor.

Following the meeting, AMA President Professor Brian Owler wrote to Health Minister Sussan Ley to inform her that the profession would be united in its response to the Reviews, and outlined some of the major concerns arising from the meeting.

Here is the text of that letter …

I am writing to you to set out broad concerns with the Medicare Benefits Schedule (MBS) Reviews: the broadened scope that will impact long standing arrangements; the composition of the review working groups; and that new items are out of scope.

The AMA is concerned that the Reviews will be undertaken in the absence of an overarching vision and specific direction for the Australian healthcare system to guide the final outcomes.

In addition, as there are no specific and quantifiable aims, other than delivering better patient outcomes, there is a risk that the scope of the reviews will extend into dangerous territory, whereby the fundamental structure of our healthcare system will be interfered with.

The latter was highlighted in Professor Bruce Robinson’s presentation to a forum of the medical colleges, specialist associations, and societies convened by the AMA on 19 August 2015 to discuss the medical profession’s involvement in the MBS Reviews. Professor Robinson made a presentation to the group and very generously answered all of the participants’ questions.

We learnt that the Reviews will now also consist of groups to review “macro issues and rules”, and that this will consider issues such as referral arrangements and the potential removal of surgical assistance fees. We heard that patients find it inconvenient to visit their GP for a referral to a specialist. Given that the referral arrangements are the most fundamental feature of our healthcare system, providing the gateway to clinically necessary tertiary care, it is incredible that such a change might be contemplated in an environment where Government wants to reduce expenditure.

In addition, the surgical assistance fees support the very basis of vocational training in Australia. Removal of them will have a significant impact on the training opportunities and therefore the future medical workforce. It is equally incredible that a change to these arrangements is being contemplated.

On both these issues it is not clear what the objective is, and therefore why they would even be on the table for review.

The 70 participants representing 53 medical organisations at the AMA forum were extremely vexed by this latest turn of events.

Working groups

The profession is very concerned that the working groups will not comprise a representative from the relevant specialist college, association or society. While working group members will be able to “confer with colleagues”, it is more appropriate for professional organisations to be formally included in the working groups. We believe this is critical to professional buy‑in to the outcomes of the Reviews, as well as continuity of the professions’ participation in the ongoing maintenance and management of the MBS into the future.

Further, there are potential problems with the members of the in-scope speciality discipline comprising less than 50% of the working group numbers, with decisions to be made using a >60% majority. The equation has the potential to arrive at incorrect outcomes because the members of the speciality discipline with the knowledge and expertise will be in the minority. We appreciate the need to transparently manage conflicts of interest, but this should not be at the expense of arriving at sensible outcomes in the decision making process.

New items

The medical profession supports an MBS that facilitates patient access to evidence based modern medical procedures and practice. This cannot occur if the review process is limited to removing obsolete and infrequently used items, and working groups are not able to consider and recommend the inclusion of new items on the MBS. While there is scope to update items, this may not always be the best way to bring the MBS up to date, and the objectives of the Reviews will be only partly achieved.

In many cases, completely new items for procedures that have evolved in the 20+ years since they were first included on the MBS will be the only sensible outcome. If this is not resolved, the Reviews could thwart patient access to services that have been provided for several years even though they are not explicitly catered for in existing items. If the rapid review questions are appropriately framed, these services should be substantiated by the relevant literature.

There must be capacity to include new items on the MBS as a result of the reviews, which does not involve a full health technology assessment and consideration by the Medical Services Advisory Committee.

Professor Brian OwlerAMA President

Based on discussions at the MBS Roundtable, the AMA compiled the following list of issues for medical colleges, associations and societies to consider and discuss in preparing for the Reviews.

1. Identify how the MBS should be changed to reflect current practice

Identify current practice for specific services.
Describe those services and the clinical circumstances for which they are intended.
Identify how the MBS currently covers those procedures.
Determine what is needed for the MBS to properly reflect current practice.
Identify services that are new due to ‘evolution’ and therefore require an update to the item descriptor compared to ‘novel’ services where there is new technology used.
Identify the time period in which the ‘novel’ service/s was introduced in your practice.
Identify items that can be deleted and the reasons for deleting them.
Frame the questions that will form the literature review.
Determine what data you need to demonstrate/inform the changes.

2. Identify the key participants

Identify who of your colleagues is best placed to represent you.
Identify the craft groups that also provide the services.
Identify the craft groups that do not provide the services, but whose clinical practice might be affected.
Anticipate how they might respond.

3. Identify other issues

Are there quality considerations?
Are there compliance issues?
What are the likely impact on business structures of the changes and what transition is needed?

4. Guiding principles for participating in the reviews

Ensure services support best practice, provides value for public expenditure and supports quality, safe and effective care that is appropriate to the patient’s needs and circumstances.
Avoid limiting services to specific specialties, expertise, scope of practice, credentialing, and/or endorsement arrangements. If there are safety and quality issues, consider how these can be best dealt with i.e. medical registration and/or hospital credentialing arrangements.
Accept the MBS rebates are inadequate. The reviews are not the vehicle to address inadequate rebates, and certainty not at the expense of another specialty group.
Share information about the reviews to ensure consistent outcomes and clinician participation throughout the review process.

The MBS Review Taskforce is seeking nominations from clinicians to participate in clinical committees and working groups. The Taskforce is seeking people who have sound clinical knowledge and experience, are committed to interpreting evidence and research, and are interested in furthering the objectives of the Review. Nominations can be made to MBSReviews@health.gov.au providing the name, position, clinical expertise, and email contact.

Information about the reviews can be found at

http://www.health.gov.au/internet/main/publishing.nsf/Content/healthiermedicare

John Flannery

Can a medical researcher have too many publications?

The most prolific researchers may not be adhering to authorship guidelines

Medical research is a very competitive business, with a low success rate for grants and fellowships. To survive the competition, a researcher needs strong performance indicators, chief of which is the number of publications and associated citations. With publications, more is generally seen as better. However, I argue that very high publication rates should be seen as indicating poor authorship practices and should be discounted in evaluating track record.

The reason is that some researchers are claiming authorship on an extraordinary number of publications. To illustrate, using Publish or Perish software (Harzing, http://www.harzing.com/pop.htm), I did a publication count of the 27 Australian health and medical researchers listed on the Highly Cited Researchers 2014 website (Thomson Reuters, http://www.highlycited.com). In 2014, their median number of publications was 32, with eight individuals having more than 50 publications (more than one per week) and one author having more than 100 publications (more than two per week). I question whether it is possible to meaningfully participate as an author on one or more publications per week.

How many publications are feasible?

The Australian Code for the Responsible Conduct of Research, which is endorsed by the National Health and Medical Research Council (NHMRC), the Australian Research Council and Universities Australia, states:

Attribution of authorship depends to some extent on the discipline, but in all cases, authorship must be based on substantial contributions in a combination of:

conception and design of the project

analysis and interpretation of research data

drafting significant parts of the work or critically revising it so as to contribute to the interpretation.

The right to authorship is not tied to position or profession and does not depend on whether the contribution was paid for or voluntary. It is not enough to have provided materials or routine technical support, or to have made the measurements on which the publication is based. Substantial intellectual involvement is required.1

To get an indication of how many publications per year might be feasible while still adhering to the Code, I conducted a straw poll of 10 full professors at the University of Melbourne who are active in clinical or public health research. I asked them: “Imagine a person who is a full-time researcher funded by an NHMRC Research Fellowship. This person is named as an author on a certain number of publications per year. Let the person’s average number of publications per year be X. What do you think is the maximum feasible value of X if the person adheres to the authorship criteria above?” Answers ranged from 10 to 30, with a mean of 17.5. While this is based only on a straw poll, it has been shown that averaged estimates of experts can be surprisingly accurate.2

Based on these figures, and allowing considerable latitude for differences between disciplines and extremes of productivity, I suggest that it is not plausible that a researcher could author 50 or more publications a year and still adhere to the NHMRC authorship criteria.

Why should we be concerned?

Claiming authorship that is not due is on the spectrum of scientific misconduct. If an author has not contributed at the required level, we cannot trust that there has been adequate oversight of the quality of the work. Unfortunately, such behaviour is likely to be rewarded, except in rare instances where the research is found to be fraudulent or incompetent. There may also be a misuse of power. It has been pointed out that senior researchers can achieve high publication rates by exerting pressure on more junior researchers, who may do most of the work, to be listed as an author.3

What should be done to promote more responsible authorship?

First, I propose that producing an implausibly large number of publications per year should be counted negatively by grant review, appointment and promotion committees. This should be made explicit in the criteria for awarding grants and positions. Sometimes researchers are asked to list their “best X publications”, emphasising quality rather than quantity, but this is not enough, because a person with a large number of publications has more to choose from.

Second, employing institutions should do spot audits on the authorship contributions of staff, particularly those exceeding feasible publication rates for their discipline, similar to what occurs with medical overservicing.

Third, journals could do more to check the role of authors in producing a publication. Some require that each author state what his or her specific contribution is, but this is not universal and editors may not query whether the stated contribution is sufficient.

If action is not taken on this issue by the medical research community, funding bodies, institutions and journals, we are in danger of seeing an escalation of implausible authorship claims as researchers compete with each other for scarce resources.

Medicines Australia’s new Code of Conduct – what it means for medical practitioners

From 1 October 2015, pharmaceutical companies who are members of Medicines Australia will begin collecting information about payments they make to individual health practitioners so that they can start publishing it on their websites next year.

The Medicines Australia Code of Conduct now requires its members to publicly report details of certain categories of payments made to practitioners.

Medical practitioners who receive payments or benefits from pharmaceutical companies should ensure they fully understand the new requirements and any implications for them. For example, practitioners should be aware that the public reports will be published in a format to allow data to be downloaded and analysed.

Reporting will commence in two stages.

From 1 October 2015, pharmaceutical companies will collect data on the relevant categories of payments so that they can publicly report on the payments made to individual health practitioners.

In line with Australian privacy legislation, companies will need to seek consent from individuals before this can be published. Individual practitioners will be able to withhold consent.

From 1 October 2016, pharmaceutical companies will only be able to enter into relationships with practitioners who consent to this information being published as a condition of accepting the payment.

The AMA supports transparency of pharmaceutical company relationships with practitioners.

The AMA lobbied hard – starting in 2012 – to make sure a US-style transparency system was not imposed in Australia. This would have required the collection of information about every industry-practitioner ‘transaction’ equal to or more than $10 in value, such as providing tea and biscuits at a meeting.

The Medicines Australia Code increases the transparency of industry-practitioner relationships for the public without creating an unnecessary red tape burden.

The final model is similar to codes of conduct adopted in Europe by focusing on significant transactions most likely to provide meaningful information to patients about their practitioners’ relationships.

The AMA also made strong representations to the Australian Competition and Consumer Commission which resulted in the public reporting requirements being phased in over 12 months, so that all parties will have the opportunity to understand, plan for, and fully comply with the new requirements.

Unfortunately, although the AMA strongly opposed the ACCC’s reporting requirement, all information will be reported in a form that can be downloaded and analysed.

The AMA argued that the public should only be able to search for one practitioner name at a time, consistent with its use by patients seeking information about their health practitioner.

A full list of the categories of payments that will be publicly reported, and the detail of the information included in the reports, is available on the AMA website.

Further information is also available on the Medicines Australia website.

Georgia Morris

Negotiating the complex maze of claims of dietary cures for cancer

How can we help our patients make sensible decisions?

In this increasingly internet-connected world, vulnerable and desperate patients with life-threatening illnesses such as cancer are often advised or motivated to negotiate their way through a seemingly expanding maze of “dietary cures”.1 As an example, a woman claimed to have cured herself of thyroid cancer by eating pineapples.2

Many negotiate their way through and make sensible choices, but my oncology colleagues and I continue to see patients who choose extreme dietary and alternative treatments for potentially curable cancers and don’t turn to us until they are quite ill and their cancer has spread and become incurable. To see patients with early disease, who would have an excellent prognosis if standard treatment protocols were followed, return with advanced disease after eschewing this standard treatment for dietary cures is extremely distressing for the patients, their loved ones and their treating doctors.

Why is this occurring and how can we as physicians and health professionals help our patients navigate this maze and make sensible decisions?

Problem: Patients with cancer are often terrified and feel out of control

Strategy: Form a trusting, empathic and therapeutic relationship with the patient

We must acknowledge and validate the patient’s values and feelings.3 We must guide and advise, but we must also empower patients in their treatment choices. This will encourage open dialogue with the patient about any alternative treatments that they may be considering using as ancillaries or replacements for standard treatments. This will also acknowledge that patients base their treatment refusals mainly on personal values and/or experience. In contrast, physicians mainly emphasise the medical perspective when evaluating patients’ treatment refusals. Our ability to accept and understand the patients’ values-orientated perspective and form a consensus with them will help them to feel understood and respected, and thus help form a better physician–patient relationship.4

Problem: Distrust of hard science combined with sophisticated online marketing and celebrity testimonials

Strategy: Education and careful explanation of the goals, benefits and adverse effects of treatments

When I started practising oncology in the early 1980s, it was a new speciality and there were far fewer effective treatments than there are now. Surgery, radiotherapy and chemotherapy were less sophisticated and far more debilitating, and many patients suffered toxicities without deriving benefits. Some patients at that time became naturally curious about individuals claiming to have had advanced cancer and to have cured themselves with diet and meditation.5,6 The dissemination of these natural cures relied on books in the self-help sections of bookshops. As more and more patients use online search engines to research their disease, their treatment options and their health generally, they find themselves being constantly beckoned, assailed and seduced by a rapidly rising number of sites, celebrities and personalities providing glowing testimonials about extraordinary new dietary “breakthroughs” that will cure their cancer (and their arthritis or multiple sclerosis), and make them more youthful, virile and joyful. More of these claims appear to be coming from individuals with implausible claims of advanced cancer and “self cure”. Some of these claims are wrapped in a cloak of pseudoscientific tests and research to give them greater credibility.7

In our current era, in which a distrust of hard scientific data appears to be finding greater voice on the many available online platforms and discussion sites, some of the practitioners and spruikers of these claims also invoke conspiracy theories that doctors don’t want patients to know about these simple, non-toxic (but often expensive) treatments because it will either reduce our role or the incomes of doctors and the pharmaceutical companies that we are “in collusion with”. We should endeavour to base our treatment recommendations on robust evidence-based medicine, to collaborate in multidisciplinary teams and to emphasise that there have been dramatic recent advances in cancer treatments, including organ-preserving treatments for many cancers such as cancers of the breast, rectum, oesophagus, larynx and bladder. Surgery can now cure many patients with colon or lung metastases from bowel cancer, and targeted radiation is now dramatically more effective for many cancers and far less toxic. The benefits and adverse effects of chemotherapy have become far better understood, and treatment choices and doses are far better tailored to the goals of therapy. Well tolerated and effective targeted therapies are replacing many chemotherapy treatments for advanced cancers. We now understand better that many cancers, such as low-grade non-Hodgkin’s lymphoma, chronic lymphocytic lymphoma and early-stage prostate cancer, often behave very indolently and require no treatment.

Problem: Alternative treatments are regarded as simple, natural and non-toxic

Strategy: Carefully warn the patient that there is no credible evidence that any patient with cancer has been cured by diet or a combination of alternative treatments

The reverse of this is true — recent studies have shown that high-dose vitamin therapy can worsen the prognosis of some cancers. This is not surprising as vitamins are growth factors and are required for the integrity of cell growth and division.7,8 They may also partly repair otherwise lethal DNA damage, allowing some aberrant cells to survive and proliferate. Also, these treatments can be time-consuming and can reduce quality of life.9

I also suggest that interested patients review their local Cancer Council website and read the article about cancer myths on the Cancer Research UK website.10

Problem: The claims of cures by diet are either of patients whose clinical course is within the expected natural history of the disease or are deliberately false

Strategy: Carefully explain that you and your colleagues have never observed cures by diet

I emphasise that my colleagues and I have carefully observed many patients pursue various purely dietary treatments over the past 30 years and are yet to see one whose progress has been outside the expected natural history of their particular cancer.

Problem: Some patients are reluctant to return to us after unsuccessfully pursuing alternative treatment, as they already feel ill enough without us adding any encouragement of feelings of guilt

Strategy: Try to avoid all guilt and blame

I regard guilt and blame in cancer patients as negative emotions, and try always to look ahead and to treat the patient with the compassion, care and skill that they require.

Problem: Some patients are given incorrect and overly pessimistic prognoses and feel they are being drained of all hope and/or denied the possibility of setting realistic life goals

Strategy: Emphasise the frequent difficulty of providing a very accurate prognosis

I try to answer the patient’s and family’s questions as honestly, sensitively and fully as possible, but advise them that making a prognosis, even for oncologists with 30 years of experience, is very difficult. I tell them that I am giving them a realistic range of possible prognoses based on my experience and all the available evidence about their particular circumstance and type of cancer. I try to provide the necessary time and detailed information that the patient seeks to enable them and their family to set realistic goals and plan their lives appropriately. This goal setting often entails making the necessary arrangements for their work, travel, family and financial affairs. Very often, a calm and trusting acceptance can be created by carefully and regularly assessing, reassessing and communicating any genuine possibility of cure, of a period of remission or of improvement of a symptom based on the patient’s current and sometimes constantly changing situation. This reassurance and calm that can develop from such an ongoing and open conversation between the patient, the family, the oncologist and the treating team is a vital part of maintaining the patient’s quality of life, as well as the psychological health of both the patient and their family members.

Problem: Some patients benefit from an opportunity to debrief and unpackage their thoughts and beliefs with a skilled third person

Strategy: Encourage a consultation with a skilled psycho-oncologist, psychologist or other skilled counsellor

I have been fortunate throughout my career to have worked with highly skilled psycho-oncologists, psychologists, social workers and other counsellors. They are integral to the creation of a trusting, therapeutic relationship between the patient and the health care team. Their assistance should be offered and encouraged for all patients who are searching or struggling emotionally, as should the early assistance of a specialist palliative care team for patients with advanced, incurable disease.

General practitioner understanding of abbreviations used in hospital discharge letters

The transition from hospital to the community is a potentially dangerous time for patients.1 It often involves a change in medical management, with potential for error. Hospital discharge letters aim to facilitate safe transition of patients into the community. To be effective, discharge letters must reach the general practitioner in a timely manner and contain easily understandable information. These are essential ingredients in effective continuity of care.

Deficits in discharge letters can contribute to a failure of information transfer. Studies have found high rates of omissions and errors in such letters.2–4 This contributes to errors in care after discharge. One study found that 49.5% of patients discharged from a large academic medical centre experienced at least one medical error relating to change of care on discharge.2

In this article, we focus on the potential danger of using abbreviations (shortened forms of words or phrases5) in medical communication. Abbreviations used in medical communications are either acronyms or initialisms. Acronyms use the initial letters of words and are pronounced as words (eg, ASCII, NASA); initialisms use initial letters pronounced separately (eg, BBC).5 Abbreviations are commonly used in medical specialties, but may not be understood by the broader profession. Doctors are under pressure to complete discharge letters in a timely fashion, and abbreviations may be used to facilitate this process.

We identified few published studies of the frequency of abbreviations in discharge letters.6,7,8 Some reported that abbreviation use is increasing and identified this as a concern. A recent audit at Royal Melbourne Hospital reported that 20.1% of all words in discharge letters were abbreviations.8 Another study audited abbreviation use in inpatient medical records and surveyed members of an inpatient multidisciplinary team for their understanding of abbreviations.9 The mean correct response rate was 43%, with Postgraduate Year 1 doctors posting the best scores (57%) and dietitians posting the worst (20%).

However, we identified no published studies determining whether the abbreviations used in hospital discharge letters are understood by GPs, who are usually the recipients of discharge letters.

Methods

We retrospectively analysed 200 electronic hospital discharge letters (eDLs) of patients discharged from Nepean Hospital, Sydney, a tertiary referral centre, from 31 December 2012, working backwards to 18 December 2012. We stopped at this point because few new abbreviations were being identified. To be included in the audit, an eDL had to be addressed to a GP.

We chose 31 December to begin the analysis to provide a representative sample of junior doctors who had a minimum of almost a year of hospital experience.

The meaning of each abbreviation was inferred from the surrounding text, and abbreviations were categorised as shown in Box 1.

Survey of GPs

From the audit, we developed a survey using the 15 most commonly used abbreviations plus five less frequently used but clinically important abbreviations. We determined that abbreviations of investigations, management or services were likely to be most clinically significant, based on our clinical experience and the potential consequences of misinterpretation. We defined commonly used abbreviations as those that were used at least 20 times in the audit. In the resulting survey of GPs, each abbreviation was provided in the context of a phrase in which it had been used in a discharge letter (Appendix).

To provide adequate precision, we aimed for 100 GP responses. The survey was mailed to all 240 GPs listed in the 2014 edition of the Medical Practitioners’ Directory for the Nepean, Blue Mountains and Hawkesbury areas. This was the most extensive directory of GPs in this area available to us. Responses were returned in a coded envelope inside a postage-paid envelope. GPs who did not respond were resent surveys on up to two additional occasions.

Outcome measures

Survey responses were analysed to determine what proportion of GPs understood each abbreviation.

Ethics approval

The study was approved by the Nepean Blue Mountains Local Health District Human Research Ethics Committee.

Results

Electronic discharge letter audit

We found 321 different abbreviations in the 200 eDLs audited (a rate of 1.6 new abbreviations per eDL and 7.1 total abbreviations per eDL); most were initialisms. The frequency of abbreviations in eDLs is shown in Box 2.

Hospital coding-approved abbreviations accounted for 62.6% of all abbreviations identified. Seven unapproved abbreviations (2.2%) were in common use (ie, found more than 20 times in the audit).

GP survey

The response rate was 55% (132 of 240 GPs). No abbreviation was correctly interpreted by all GPs, but 10 abbreviations (50%) were interpreted correctly by 97.0% of GPs (128).

The frequency of incorrect interpretation of all abbreviations in the survey is shown in Box 3. Box 4 shows the range and frequency of individual GP scores.

Discussion

The results of our survey show that there is poor understanding among GPs of abbreviations used in hospital discharge letters. The response rate to our survey was fair, so our results are likely to be representative of GPs in the area.

Worryingly, more than half of the abbreviations we found related to investigations, management or services that we considered to be the most clinically significant categories. Misinterpretation of abbreviations by GPs can adversely affect patient care through duplication of investigations, failing to institute treatment based on investigation results or failing to follow up with recommended management. We could find no studies that identified which types of abbreviations confer the worst outcomes if misinterpreted. Also of concern is that almost half of the abbreviations we identified were used only once in the 200 eDLs.

The difference identified in the use of abbreviations by junior doctors and understanding of abbreviations by GPs suggests a lack of consistency between the language commonly used in hospitals and that used by GPs. It is uncertain how well understood these same abbreviations are by hospital doctors in different specialty areas. The language of abbreviations may also vary between hospitals. Common abbreviations found previously in Royal Melbourne Hospital discharge letters8 were different from those we found. The five most common inappropriate ambiguous or unknown abbreviations in the Royal Melbourne Hospital audit were not found in any eDL in our audit. Their abbreviation rate was higher, with a mean of 10.5 new abbreviations per discharge letter compared with our rate of 1.6. Widespread use of abbreviations in paediatric medical notes with no standardisation and difficulty in interpretation by health care professionals has also been previously reported.11

Our study has some limitations. Non-responding GPs might have scored differently on the survey compared with those who responded. Also, we did not ascertain GP demographic characteristics such as length of career outside the hospital setting. GPs with more recent hospital practice may better understand these abbreviations. In addition, we could not assess GPs’ understanding of most abbreviations we identified in the eDL audit because of the large number identified. However, we expect that understanding of these less frequently used abbreviations would be poorer than for the 20 we included in our survey. Also, this study was conducted in a single centre, so the results may not be generalisable to other centres. However, junior doctors are drawn from many universities and it is likely that discharge practices are similar in other hospitals.

Conclusion

Discharge letters are an essential means of communication between hospitals and GPs to facilitate optimal care of patients when they return to the community. All abbreviations used should be understood by all GPs. Strategies to improve communication by means of discharge letters are urgently needed. Potential solutions include banning the use of abbreviations in eDLs or using only a limited number of hospital-approved abbreviations and providing GPs with an approved abbreviation list. Another option would be use of computer software to auto-complete mutually exclusive abbreviations (ie, allowing only one possible meaning for each).

1
Categorisation of the 321 abbreviations used in 200 sequential electronic hospital discharge letters

Type of abbreviation	Number	% of total	Representation of the types of abbreviation in the survey

Investigations	102	31.8%	30%
Physical examination finding	56	17.5%	30%
Management	56	17.5%	5%
Service*	22	6.9%	5%
Patient history	20	6.2%	30%
Other	65	20.1%	0
Total	321	100.0%	100%

*A hospital outpatient service such as outreach or outpatient clinics.

2
Frequency with which the 321 abbreviations were used in 200 sequential electronic hospital discharge letters

Frequency	Number (%)

> 20 times	17 (5.3%)
15–19 times	5 (1.6%)
10–14 times	14 (4.4%)
5–9 times	32 (10.0%)
0–4 times	253 (78.8%)

3
Frequency of incorrect interpretation by general practitioners of 20 common or clinically significant abbreviations

Abbreviations

GPs misinterpreting abbreviation

Number

Percentage (95% CI)10

SNT

47.0% (38.5%–55.5%)

TTE*

33.3% (25.3%–41.3%)

EST*

33.3% (25.3%–41.3%)

NKDA

32.6% (24.6%–40.6%)

CTPA*

31.1% (23.2%–39.0%)

ORIF*

28.0% (20.4%–35.7%)

HSDNM

23.5% (16.3%–30.7%)

B/G

23.5% (16.3%–30.7%)

GCS*

18.2% (11.6%–24.8%)

ADLs

13.6% (7.8%–19.5%)

PMHx

3.0% (0.1%–6.0%)

ECG

3.0% (0.1%–6.0%)

CXR

3.0% (0.1%–6.0%)

O/E

3.0% (0.1%–6.0%)

2.3% (0–4.8%)

GORD

2.3% (0–4.8%)

1.5% (0–3.6%)

1.5% (0.–3.6%)

ADLs = activities of daily living. B/G = background. BP = blood pressure. CT = computed tomography. CTPA = computed tomographic pulmonary angiography. CXR = chest x-ray. ECG = electrocardiogram. ED = emergency department. EST = exercise stress testing. GCS = Glasgow coma scale. GORD = gastro-oesophageal reflux disease. HR = heart rate. HSDNM = heart sounds dual and no murmur. NKDA = no known drug allergies. O/E = on examination. ORIF = open reduction and internal fixation. PMHx = past medical history. RR = respiratory rate. SNT = soft, non-tender. TTE = transthoracic echocardiogram.
*Less common but clinically significant abbreviations.

4
Proportion of general practitioners receiving particular survey scores for correct interpretation of abbreviations

Big Food’s resistance to health stars crumbling

Food industry resistance to the front-of-packet nutrition star rating system is crumbling, with cereal giant Kellogg’s the latest to adopt the labelling scheme for its products.

Almost two years after the Health Star Rating system was approved by the nation’s food and health ministers, Kellogg’s has announced that, from June, the labelling scheme would be introduced across all 37 of its cereal products.

Under the system, which the AMA was involved in developing, food is awarded between a half and five stars depending on its nutritional value. The label also includes a panel detailing sugar, saturated fat, sodium and energy content.

While some Kellogg’s products, including All Bran and Guardian, have been awarded five stars under the scheme, and the majority have four or more stars, several varieties aimed at children, including Coco Pops, Fruit Loops, Crunchy Nut and Nutri-Grain have just two stars and one, Crispix, has earned just 1.5 stars.

Assistant Health Minister Fiona Nash said that Kellogg’s adoption of the voluntary scheme meant that soon the vast majority of breakfast cereals would carry a Health Star Rating, making it easier for “time-poor parents [to] make quick, informed choices…without taking precious time reading labels”.

Monster Health Foods Company was an early adopter of the scheme, and other manufacturers has since joined them, including Sanitarium, Nestle/Uncle Toby’s, Food for Health, Goodness Superfoods, Freedom Foods, Greens General Foods, Coles home brand and Woolworths’ ‘Macro’ brand.

The increasing adoption of the scheme by industry has despite fierce resistance from some manufacturers.

Major food companies including McCain, Mars, PepsiCo, Mondelez, George Weston and Goodman Fielder are yet to implement the scheme.

A Mondelez spokeswoman told Fairfax Media the company, which owns of Kraft, Belvita and Philadelphia, was resisting the scheme because it was flawed.

“Our view is that the concept and formula underpinning the voluntary system fails to account for individuals’ dietary requirements and takes an unrealistic view of portion sizes,” she said.

The resistance has come despite industry’s close involvement in developing the scheme over a two-year period prior to its adoption by the nation’s food and health ministers.

Industry representatives publicly expressed dissatisfaction soon after the system’s formal adoption, and a Federal Health Department website promoting the Health Star Rating system was controversially taken down in early 2014 at the direction of Senator Nash’s office.

The Minister’s then-Chief of Staff, Alistair Furnival, who had directed the take-down, was subsequently forced to resign after it was revealed he co-owned a consultancy that had major food manufacturers among its clients.

The website was reinstated last December, a move welcomed at the time by AMA Vice President Dr Stephen Parnis, who said giving consumers quick and easy nutritional information was an important tool in helping improve food choices and reducing obesity.

Estimates suggest that almost two-thirds of adults, and a quarter of children, are overweight or obese, meaning a huge proportion of the population will be at risk of diabetes, heart disease, stroke and other complex, chronic and expensive health problems unless more is done to trim the nation’s waistline.

Dr Parnis said he hoped that the Health Star Rating scheme would encourage manufacturers to reformulate their products and make them more nutritious in order to earn more stars.

Manufacturers have four years to voluntarily adopt the system, and Dr Parnis said the AMA would support a move by the Government to subsequently make it mandatory.

The Health Star Rating System website can be viewed at:

http://www.healthstarrating.gov.au/internet/healthstarrating/publishing.nsf/content/home

Adrian Rollins

Peer review: maintaining trust in research funding decisions

Ensuring that the peer-review process adapts as medical research changes

Researchers in Australia have recently criticised peer review of applications for grant funding, arguing that the process involves too much work, is too arbitrary and is too conservative in identifying the best grants.1

These criticisms need to be addressed, but they must also be balanced by other considerations, especially the interests of the wider community.

Public research funding bodies like the National Health and Medical Research Council (NHMRC) and the Australian Research Council rely on peer review when deciding who and what to fund. Because Australians’ taxes pay for the funding, funders have responsibilities to ensure that peer review is able to identify the most valuable research to fund, and to do so fairly, free from bias and self-interest.

The NHMRC’s funding decisions depend almost entirely on researchers’ peer review. It is remarkable that the public trusts us researchers with towards a billion dollars a year of their money, and we have a responsibility to maintain this trust.

Peer reviewing is an essential part of being a scientist, and we can expect to spend a sizeable amount of our time providing reviews of other researchers’ applications for funding (and publishing). It is a type of mutual obligation — participation in the peer-review process is our reciprocal duty towards other researchers.

To maintain public and researcher trust, it is essential that processes are fair and provide applicants natural justice. There is never enough money to fund all worthwhile research. Therefore, it is important to ensure that the playing field is level. As far as possible, applicants need to be aware of the assessment criteria, and be given a chance to respond to the views of reviewers, including possible misconceptions or errors. Over a decade ago, the NHMRC introduced specific criteria for the assessment of applications and assigned specific weighting to each of these. Applicants’ understanding of what they will be assessed on also allows them to write their applications accordingly — a general principle now generally agreed on in the San Francisco declaration on research assessment (http://www.ascb.org/dora-old/files/SFDeclarationFINAL.pdf)

Peer review is a human activity, so any two researchers are likely to have different views. For funders, it is essential to bring as many experts as possible to the review and to ensure that interests (scientific or material) are transparent and taken into account. Peer review is inherently tied up with the values and knowledge of the individuals involved. It follows that it is important to have knowledgeable and ethical researchers involved. Peer review can never be reduced to a simple number that does not require human judgement.

Humans do err in their judgements, and there are few researchers who would be willing to leave a decision on their application to a “lottery”, a political process or the decision of a single superior (eg, a deputy vice-chancellor or institute director). In the 21st century, few researchers will tolerate “I know a good grant when I see one — just trust me”.

We can always do better. Funders need to constantly assess their processes and the outcomes. More training and mentoring in quality peer review would also help. Most of us learn about peer review informally as early career researchers through departmental and research group seminars, and as we begin to be asked to assess grants and papers submitted for publication.

Can peer review ever be a precise instrument? No, but we should strive to make it as good as possible, in order to identify the best research to fund, fairly and without bias.

Health and medical research grows and changes. It is becoming more diverse, complex, multidisciplinary and collaborative across institutions and around the world. We all need to ensure that the peer-review process adapts and evolves to meet the challenges that these changes are bringing.

The G20, human health and sustainability: an interview with Jeffrey D Sachs

To the Editor: I am both amazed and disappointed that the Journal would assault the goodwill and common sense of its readership by publishing uncritical barracking for the unproven thesis of human-induced climate change,1,2 at a time when we expect evidence-based medical practice as a maxim.

To suggest that there is any consensus on climate science is an untruth that disenfranchises the many genuine physicists, geophysical scientists, climate engineers and astrophysicists who refute the anthropogenic proposition (consensus is not a scientific discipline). Neither Jeffrey D Sachs1 nor the eminent signatories petitioning the Prime Minister2 are entitled to any more scientific credibility than Joe Blow in urging massive changes to our economy and society on the basis of an unproven precautionary principle. One would hope that their climate prognostications are more accurate than those of Tim Flannery, who stated that we would never see worthwhile rain again (http://www.abc.net.au/landline/content/2006/s1844398.htm), before Australia-wide flooding left a several billion dollar legacy of rusting desalination plants. We need not mention pink batts and their resultant death and destruction.

For someone who expresses concern for the impoverished, Sachs makes no mention of the opportunity cost of misguided low-CO2 emission (not carbon) policies that have wasted billions of dollars which could have been used more productively in health, infrastructure, education and aid. Direct investment in dams, levees, vaccine development, improved agriculture and technology to reduce genuine pollution (not CO2 levels) are more effective than chasing the CO2 phantom. Alarmists do not acknowledge the enormous contribution that cheap energy has made to lifting billions of people throughout the world out of poverty and pestilence. The resultant development of a middle class in China, India and elsewhere will lead to a better environment both socially and physically. Interestingly, the alarmists are the same people who vehemently reject large-scale replacement of fossil fuel sources with advanced nuclear power plants or dam building for hydroelectric power. A combination of green evangelism and condescending paternalism seeks to rob the poor of developing countries of equal opportunity in power generation. While Sachs despairs of continuing poverty in Africa because of climate change, many would argue that endemic corruption is a greater threat to African nations.

Sachs’s trajectory for global warming of 4–6ºC by the end of the century flies in the face of the absence of global warming over the past 17 years, acknowledged by the Intergovernmental Panel on Climate Change, and the recent controversy over the homogenising of the Australian temperature record by the Bureau of Meteorology to convert a slight cooling trend to a warming trend (http://jennifermarohasy.com).

Sachs has spent too long at the United Nations. His reference to the immorality of greed and power is misguided, and code for the massive economic redistribution that socialism failed to achieve but seeks to realise through the deep-green (and red) politics embedded in the UN. Sachs’s gratuitous demonising of a major public figure such as Rupert Murdoch is unworthy of a true professional.

A social conscience is no excuse for outsourcing opinion to the socialist left and green movements. Most readers of the Journal would prefer to see debate rather than pronouncements. I hope that the Journal wakes up to itself before it is too late.

Decolonising practices: can journalism learn from health care to improve Indigenous health outcomes?

Efforts to decolonise health care practice and research also hold lessons for journalists and the media industry

The ongoing effects of colonisation are widely acknowledged as contributing to intergenerational trauma, disadvantage and poor health among Aboriginal and Torres Strait Islander peoples.1–3 Colonisation disrupted peoples’ connection to country, to culture, to communities and to families through policies that sought to control, stigmatise and intervene in people’s lives. Historically, doctors and other health professionals have been involved in colonising practices that have been detrimental to Aboriginal and Torres Strait Islander communities and peoples.4 Health and medical research also has a longstanding record of perpetuating rather than mitigating the impacts of colonisation, for example, by portraying Aboriginal and Torres Strait Islander peoples as “passive, powerless victims”.5

Indigenous researchers, health professionals and organisations have been at the forefront of efforts to decolonise health care practice and research in order to tackle harmful attitudes and practices that continue to contribute to poor health and lack of access to culturally respectful and appropriate care.1–3 These approaches stress the importance of acknowledging the role of one’s own profession and related institutions in colonisation. Awareness of one’s own values and biases is an important part of culturally competent practice, as well as an understanding of other peoples’ world views.1–3 Decolonising practices include reorientation away from problematising Indigenous peoples to a focus on strengths, capacity and resilience, and stress the importance of proper process, including allowing the time and opportunity to develop relationships and trust.

Health care practitioners and researchers are encouraged to be aware of the historical context of contemporary health issues, and to understand that “the present and the future are absolutely bound up in the past”.6 Decolonising practices also include respect for Indigenous knowledge and stress the importance of reciprocity — that research and practice should reflect community priorities and explicitly aim to provide useful service.

Many parallels can be drawn between the mainstream health and media sectors, including their powerful roles in contributing to a discourse about Indigenous Australians that is based on a deficit model and reflects Western ethnocentric assumptions and institutionalised racism. This discourse dominates much public debate, despite a vibrant Indigenous community media sector, the emergence of new platforms like the Twitter account @IndigenousX, and the innovative use of social media by the National Aboriginal Community Controlled Health Organisation to disseminate Indigenous health news and to develop networks and influence.7 Efforts have been made in journalism education and practice to improve media reporting of Indigenous affairs in the wake of numerous inquiries and research reports that have raised concerns over some decades.8–10 While acknowledging the diversity of media practice, particularly in this era of proliferating digital communication channels, the colonising, harmful impact of much mainstream coverage remains apparent.11

Journalism, journalism education and the media industry can learn from efforts to decolonise health care research and practice, with a view to producing journalism that better serves the interests of Aboriginal and Torres Strait Islander peoples. Indeed, it is noteworthy that Juanita Sherwood, an Aboriginal academic who began an innovative new course at the University of Technology, Sydney, in 2012, teaching decolonising methods to undergraduate communications students, has a background in the health sector.3 We believe there is potential for more widespread efforts for journalism to adapt decolonising practices from the health sector, including a greater inclusion of decolonising practices in journalism education and practice. This would result in increased awareness of institutionalised racism and concerted efforts to ensure greater representation of Indigenous peoples — whether in newsrooms and media management, or as sources in stories, including and beyond those directly related to Indigenous affairs. It would encourage a reframing of journalistic work towards more emphasis on solutions-focused reporting, and coverage that humanises, rather than portraying Aboriginal and Torres Strait Islander people as “the other”.

As can be seen with community media like the Koori Mail, decolonising practices offer the possibility of journalism that better reflects the diversity and humanity of Aboriginal and Torres Strait Islander peoples. It also would lead to the revision of media style guides that continue to perpetuate terminology viewed as offensive by many Aboriginal and Torres Strait Islander peoples, from easily addressed issues such as “indigenous” (lower case “i”) to the more insidious problems of racist stereotyping.12 In the sphere of health journalism, it would reframe the narrative so that Indigenous health is reported in a much wider context. Connections to country and culture, the importance of social and emotional wellbeing, and the impact of racism and stigma would receive far more attention as important health issues.13

Efforts to decolonise journalism thus have the potential to reframe public debate in ways that might directly benefit the health of Aboriginal and Torres Strait Islander peoples. A mainstream media discourse that acknowledges the strengths, culture and knowledge of Aboriginal and Torres Strait Islander peoples may bring benefits for the social and emotional wellbeing of individuals and communities, as well as encouraging a focus on culturally appropriate and safe health care practices and services. Given that the limited news frames of much mainstream media coverage have been associated with a narrowing of policy options in Indigenous affairs,14 decolonising practices may also result in journalism that encourages healthier policy outcomes for Indigenous Australians.

Why old people talk about their operations

Because the body is vocal as it nears the end

with its querulous list of aches and pains

that makes relatives squeamish.

Because the body doesn’t care;

everything grumbles and complains.

The ground has become perilous.

Because our bowels are slow, the bladder stings

and the body is a mulish obstinate thing,

whose hipbones jut out beneath flaps of skin.

Because our log-jammed senses no longer grasp

the complexity of things; sharp, subtle-edged.

Birdsong is a smudge on soft-torn wings.

Because sentences meander and lose their way

though we circle well-trod, familial terrain.

Visitors get restless — we forget their names.

Because the heart anticipates that vital day

when it can at last take rest and refrain

from its incessant loyal pumping.

Because the roof has long begun to leak

the pointing crumbles as soon as it’s fixed

and nothing else prevails but this.