Physician – care for thine own health

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

The suicides of several young doctors recently have activated concerned discussion about how to do better in preserving and protecting the health of caring professionals. If there were a simple solution it would have been applied decades ago.

It is not only mental health that is a concern, complicated by illicit drug use or not, identity crisis or relationship upheavals. Doctors’ health more generally is a worry. That such is the case is clear testimony to the insufficiency of knowledge about health and illness alone to empower the individual to choose wisely.

Recently I spent 10 days in a Sydney teaching hospital receiving intravenous antibiotics for a nasty episode – my first – of diverticulitis. The literary genre of ‘I am a doctor and I got sick and I will tell you all about it’ contains the occasional interesting account but much dross, so I won’t bang on about my experience. But reflecting on my illness confirms insights. I doubt that I took action soon enough and instead used symptom-denial and fantasy to justify delay. It was lucky I did not have an enteric rupture.

I discussed this experience with my friend Peter Arnold, a retired general practitioner who has served on boards and committees concerned with doctors’ health and impairment. Writing in Australian Medicine in 1997, Dr Arnold put the proposition that every doctor should have their own general practitioner.

“Despite regular advice to this effect to the profession at large, from bodies concerned with doctors’ health, it is patently difficult for doctors to accept another doctor as their GP. It is, of course, more difficult for doctors in small towns, but, in an age of modern telecommunications [to which may now be added Skype] and air travel, it is possible to have a one-to-one relationship with a GP, distance notwithstanding.”

Why does this not happen? Arnold advanced several reasons derived from his experience with doctors who were impaired or ill. A fear of ridicule if the ailing doctor’s own diagnosis is wrong, a denial of the import of symptoms (I can identify with that one), a loss of ‘doctor authority’ as one becomes a patient, the question as to whether one doctor can trust another who may not be as expert, making an appointment and sitting in the waiting room, and concerns about the confidentiality of my record in a group practice.

“Each of the reasons has some validity,” Arnold wrote. “Added together, they constitute a formidable obstacle to having your own GP. But against this, the downside must be considered carefully.

“By not having a GP, you leave yourself open to a lack of preventive care, missing the onset of insidious illness and the opportunity of early intervention, objective assessment and appropriate management of your problems, psychological support when under stress and all the other ‘good things’ about having that continuing, monitoring relationship with a GP which makes you recommend them to all your patients.

“If there is one universal piece of advice which we give to doctors presenting with problems at the NSW Medical Board, it is: ‘Get yourself a GP’.”

I was embarrassed, when I fronted up to my GP with my discharge papers in hand, to realise how irregularly I had attended. Was my most recent colonoscopy five years ago? “Actually seven!” I was told politely. The list of meds in my record was wildly out of date.

A further barrier to seeking medical assistance for our own ills has been the requirement for mandatory reporting of impairment. This is a two-edged sword, the self-destructive edge being that it may prevent doctors from seeking necessary care because of fear. Recent changes to the law have diminished this problem and Minister Greg Hunt is taking positive action,

Another trick I used when ill was an imaginative reinterpretation of my symptoms that I think owed more to my interest in poetry than in rational prose! In retrospect I was surprised that I could have spun such a confected set of interpretations around apparently minor bodily dysfunctions. In reality they weren’t! I swear that I will not fall into this trap again – but then…

The message is clear. Don’t treat your family and don’t treat yourself. When it comes to your own health seek external interpretation and treatment, preferably from a practitioner who knows you well. Try your GP.

Democracy Inaction

BY ROB THOMAS, PRESIDENT AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

“The tyranny of a prince in an oligarchy is not so dangerous to the public welfare as the apathy of a citizen in a democracy.” – Montesquieu

The position of AMSA President has been rewarding in many ways for me. I’ve had the opportunity to learn and be inspired by those around me, and come to high-level meetings, often several decades younger than the next person in the room. I get to hear the many views of my peers and on my best days, hope to represent 17,000 young people.

It’s fair to say that this year has been an incredible learning curve, beyond that of an average medical school year. I’ve learnt more about health and the education systems and have advocated for improvements in both. But perhaps most interestingly, I’ve learnt much more about leadership and the democratic process.

I find young people in general get a bad rap when it comes to political engagement. It’s true, there is less identification with traditional party politics among young people, but engagement through petition-signing or demonstrations is much higher. I find this very interesting in an age where political leaders are torn down just as quickly as they emerge. Perhaps we demand too much from our leaders, particularly if we’re not engaging them in traditional ways.

With the information revolution also comes the need to be discerning, and to protect oneself. I’ve seen this myself in the marriage equality debate, one that I have a stake in and at times need to actively block from my mind. On issues such as climate change and health inequity overseas and at home, young people can be discouraged by inaction from our leaders and in so doing disconnect.

One very interesting thing I’ve found about the advocacy sphere is how lonely it can be. Organisations such as the AMA and AMSA, and of course the Government, rely on facts and opinions from their constituents. We do this through survey or election, but often we only get half the picture. Worse still, some representatives receive feedback only when it’s negative, and I feel for those who don’t get the thanks they deserve.

On the other hand, representing any large group of people will involve strong differences of opinion, especially when it may involve life and death. The success of the National Rifle Association in America depends on the simplicity of their message – “no” to any information or regulation on gun ownership. The larger the organisation and more diverse its mandate, the more power it may hold; but it may start to represent more differences of opinion than similarities. On leadership, it’s important to be aware of these differences, as I believe it only legitimises your stance to show respect to the other side. As health professionals, we need to be able to flex and adapt to new information, and that only comes when we refuse to switch off. By our very nature we should challenge our assumptions and our preconceived notions to achieve the best for the public.

At the top I left a quote about the danger of apathy. Yes, democracy has its flaws, as we seem to witness time and time again. However, the only answer I can come up with is to engage in it – for those in power to make themselves available to opinion, and for those not in power to realise that there is power in that too. There is no good in burying one’s head in the sand. Democracy inaction is democracy in disaster.

Email: rob.thomas@amsa.org.au
Twitter: @robmtom

Rec leave rewards for non-smokers in Japan

Japan currently comes in last on the World Health Organisation’s ranking of nations’ anti-smoking regulations, rated according to the type of public places entirely smoke-free.

So, it is quite remarkable that Japanese marketing company Piala Inchas announced it is granting its non-smoking staff an additional six days of holiday a year to make up for the time off smokers take for cigarette breaks.

“I hope to encourage employees to quit smoking through incentives rather than penalties or coercion,” Chief Executive Officer Takao Asuka said in regards to his company’s decision.

Hirotaka Matsushima, a spokesman for the company, said the idea came about following a message in the company suggestion box earlier in the year saying that smoking breaks were causing problems.

Other companies are also pushing for change. Convenience store chain Lawson Inchas introduced an all-day ban on smoking at its head office and all regional offices in June with an eye toward lowering the ratio of smokers in its entire workforce by around 10 percentage points in fiscal 2018.

“The company is willing to take an even tougher anti-smoking measure in the future,” a public relations officer for Lawson Incsaid.

A recent government survey in Japan showed that the number of smokers nationwide has fallen below 20 percent of the population for the first time on record, estimating about 18 per cent of Japanese are believed to smoke. Both genders recorded a decrease. The rate of male smokers fell 2.6 points to 31.1 per cent, while smoking among women declined 1.2 points to 9.5 per cent.

The Japanese health ministry is seeking new restrictions on smoking in public places before the 2020 Tokyo Summer Olympics. But the proposal is likely to encounter strong opposition from Japan Tobacco, which is one-third government owned.

MEREDITH HORNE

Lead poisoning a top risk factor for pre-eclampsia

More than a century since a Brisbane doctor found that lead in paint destroyed children’s lives, new research from Griffith University concludes that it is a major risk factor for pre-eclampsia.

Pre-eclampsia is a disease which kills more than 75,000 women around the world each year and is responsible for 9 per cent of all fetal deaths.

Scientists from Griffith University have published their findings in Environmental Research, which measured blood lead levels of pregnant women who experienced pre-eclampsia and control groups of women who did not experience preeclampsia.

“We combined the data from a number of clinical trials to conduct a powerful analysis of pre-eclampsia research,” said Dr Arthur Poropat from Griffith Health.

Along with Dr Mark Laidlaw from RMIT University, the team found that blood lead levels are the strongest predictor of whether a pregnant woman will develop pre-eclampsia, with even relatively low levels of lead increasing the risk of the condition.

“There is a clear dose-response relationship between maternal blood lead and pre-eclampsia: doubling the blood lead level results also doubles the risk of pre-eclampsia,” Dr Poropat said.

Pre-eclampsia is a potentially fatal disease, in which pregnant women develop high blood pressure and protein in their urine due to kidney malfunction, potentially leading to cardiac and/or kidney failure, and eventual disability or death.

Reducing exposure to lead remains an important health issue in Australia because lead can be found in various sources throughout the environment.

Dr Poropat said women are exposed to lead in many ways, including lead paint, lead contaminated soils, lead water pipes, shooting lead bullets at firing ranges and other sources. Women can even be exposed by handling or washing lead contaminated clothes.

“Fortunately, most people in Australia are not at risk of lead poisoning as they are not commonly exposed to lead via their occupation or the environment. However there are certain well-documented risk areas within the country including the industrial regions of Broken Hill (NSW/SA), Mount Isa (QLD) and Port Pirie (SA).

“Regardless of where women are located or their lifestyle, women should be aware of the risks associated with lead poisoning if they are preparing to become pregnant or are currently pregnant,” Dr Poropat said.

Lead, a naturally occurring metal found in the earth’s crust, has a wide variety of uses in manufacturing. Unlike many other naturally found metals, lead and lead compounds are not beneficial or necessary for human health, and can be harmful to the human body. Infants, children and pregnant women are at the greatest risk of harm from lead.

Professor Mark Taylor from Macquarie University in Sydney led a study that was published earlier this year which was the first comprehensive snapshot of industrial lead contamination in Australia.

This study found that while concentration of lead in the air in major cities is now largely below limits of detection, contaminated soil and dust is causing problems in backyards.

Professor Taylor believes that regulation has reduced concentrations of lead in air largely below limits of detection in our major cities. However, he warns homeowners need to be careful, especially if they live in the inner city or have homes built before the 1970s.

MEREDITH HORNE

Compliance with the advertising provisions under the National Law

As part of the Australian Health Practitioner Regulation Agency’s (AHPRA) ongoing work to ensure compliance with the National Law’s advertising requirements, it has commenced contacting medical practitioners who AHPRA has assessed as having non-compliant website, social media and/or print advertising by letter.

While only a small number of medical practitioners will receive correspondence about non‑compliant advertising, it is important that practitioners ensure that they meet the requirement under the National Law and that the profession maintains and upholds the best standards as an exemplar amongst the regulated professions.

Medical practitioners who are contacted have 60 days to check and correct their advertising to ensure they comply with the National Law. AHPRA will check that the advertising content has been amended. If AHPRA remains concerned, it may take further action. Further non-compliance may result in a condition being placed upon a practitioner’s registration or the relevant National Board taking disciplinary action.

If you are advertising a regulated health service, your advertising must not:

be false, misleading or deceptive, or likely to be misleading or deceptive;
offer a gift, discount or other inducement, unless the terms and conditions of the offer are also stated;
use testimonials or purported testimonials about the service or business;
create an unreasonable expectation of beneficial treatment; or
directly or indirectly encourage the indiscriminate or unnecessary use of a regulated health service.

Examples of unacceptable advertising include:

“When I was first diagnosed, I felt there was no hope for me to survive. I had constant pain and was unable to care for myself. But then I saw Dr Smith at Wonders Day Surgery. Dr Smith agreed with my diagnosis and was able to provide treatment which saved my life. Dr Smith cured me and I have no more pain.”

“As an incentive to my existing patients to introduce their friends and family to our work, I am offering a $20 discount on their first visit! Just fill in the forms on our new website, present them to reception and get a $20 discount.”

“At the Rose Street Clinic, cosmetic and reconstructive procedures are an area of care we can provide. These simple procedures are completely safe and can be done on site. Our cosmetic surgery procedures are guaranteed to provide consumers with the desired result. Improve your happiness through the wonderful work at the Rose Street Clinic.”

AHPRA has published resources on its website to support practitioners to comply with the advertising requirements. The correspondence sent to identified practitioners includes a direct link to a check, correct and comply webpage (www.ahpra.gov.au/Publications/Advertising-resources/Check-and-correct.aspx), which provides links to several resources for practitioners including common examples of non-compliant advertising and how they can be fixed. This site also provides more details about the process for managing advertising complaints.

Complaints about advertising rose by 237.7 per cent and accounted for 75.2 per cent of all offence complaints[1] between 2014/15 and 2015/16. Almost 57.3 per cent of these complaints related to chiropractic services. However, while most of the complaints relate to chiropractic advertising, medical practitioners also attracted some complaints. As such, the AMA advises that practitioners should make themselves aware of the guidelines.

The Medical Board of Australia has guidelines for advertising regulated health services, which can be found here http://www.medicalboard.gov.au/Codes-Guidelines-Policies.aspx

There are also specific guidelines for medical practitioners who perform cosmetic medical and surgical procedures, which can be found here http://www.medicalboard.gov.au/News/2016-09-29-revised-registration-standards.aspx

The AMA will monitor this compliance program as it develops.

Jodette Kotz
AMA Senior Policy Advisor

[Comment] The British 1967 Abortion Act—still fit for purpose?

Oct 27, 2017, marks the 50th anniversary of the British Abortion Act, written “to amend and clarify the law relating to termination of pregnancy by registered medical practitioners”.1 Amended in 1990 to include selective reduction of a multiple pregnancy, the Abortion Act governs abortion in England, Scotland, and Wales, the first law in western Europe to formally legalise abortion for several indications.

[Health Policy] The global health law trilogy: towards a safer, healthier, and fairer world

Global health advocates often turn to medicine and science for solutions to enduring health risks, but law is also a powerful tool. No state acting alone can ward off health threats that span borders, requiring international solutions. A trilogy of global health law—the Framework Convention on Tobacco Control, International Health Regulations (2005), and Pandemic Influenza Preparedness Framework—strives for a safer, healthier, and fairer world. Yet, these international agreements are not well understood, and contain gaps in scope and enforceability.

Victoria’s assisted dying legislation: how it would work

Supporters of voluntary assisted dying are becoming increasingly convinced that they have the numbers to pass a controversial bill currently before the Victorian parliament.

The bill, to be debated next week, would make Victoria the first state to legislate for voluntary euthanasia in Australia if successful. But other states are not far behind: New South Wales has introduced draft legislation into parliament, and Western Australia has set up a joint select committee on end-of-life choices, due to report next year. In South Australia, voluntary euthanasia legislation was knocked back last year by a single vote.

But the momentum may have shifted since then, and Victorian Labor MPs, who are supportive of the legislation, think they may be able to peel off enough Nationals MPs to score a victory.

The legislation, which Victorian premier Daniel Andrews says is more conservative than any other current euthanasia laws currently in force across the globe, would allow terminally ill patients access to lethal medication within 10 days of a request, following a three-step process involving two independent medical assessments. The legislation covers patients who are considered to have a life expectancy of less than 12 months.

If legislation passes, there will be an 18-month period to work out how it would be implemented. One issue would be with the Medicare benefits schedule, which explicitly excludes the use of drugs for euthanasia.

Here’s how the Victorian legislation would work:

Only the patient can ask for assistance to die, but a doctor can refuse to be involved.
The patient can change their mind at any time throughout the process.
The clinician decides whether the patient fits the criteria, and can refer to a specialist if in doubt.
The doctor must verify that the patient’s request is “voluntary and enduring”.
A written declaration must be signed and witnessed by two non-relatives in the presence of the doctor.
A final request must be made, at least ten days after the initial request. It is then certified by the doctor.
Prescription of the lethal drugs is overseen by the department of health and human services.
The patient must take the medication unaided. If physically unable to do so, the doctor must seek an additional permit to assist.
If the doctor is administering the medication, another witness must be present.

The proposed NSW legislation is similar, although the age at which a patient can request assisted dying is 25 rather than 18. The NSW bill also requires referral to a psychiatrist. Neither of the proposed state legislations permit assisted dying for people with dementia or mental illness.

Doctors’ medical defence organisation Avant, which recently hosted a forum to explore medicolegal issues with voluntary euthanasia, says that it believes legislation will eventually be passed in one state or another, but that such legislation will pose a number of questions about how a scheme would work. These include:

How to determine eligibility;
How a treating doctor would negotiate a decision not to participate;
How to identify and refer to another practitioner for a second opinion;
How to ensure privacy and security of information;
How to manage assisting healthcare providers’ distress;
How to manage potential liability in a number of scenarios.

Six US states currently allow some form of voluntary euthanasia, as does Canada. In Europe, Switzerland, the Netherlands, Belgium and Luxembourg all have euthanasia laws.

The AMA, in its position statement, has maintained its opposition to physician-assisted euthanasia.

[Essay] Mental health and human rights in Russia—a flawed relationship

When the Soviet Union disintegrated in 1991, new independent psychiatric associations were established in many of the former Soviet republics, and groups of reform-minded psychiatrists initiated projects to discard the old Soviet psychiatric system, a system notorious for its political abuse of psychiatry and characterised by an almost exclusively biological orientation and institutional form of care. Russia was no exception and even boasted some of the most prominent mental health reformers, such as psychiatrist Yuri Nuller in St Petersburg1 and the Moscow-based lawyer Svetlana Polubinskaya, an associate of the Institute of State and Law who formulated the Soviet Union’s last law on psychiatric help and Russia’s first law on psychiatric care, which was adopted in 1992.

RACGP’s spectacular backflip on marriage equality

The Royal Australian College of General Practitioners (RACGP) executed a dramatic U-turn on marriage equality this week, which it now backs after initially claiming to be neutral on the issue.

Over the past few months, the number of medical colleges and associations officially coming out in support of marriage equality has grown to include the Australian Medical Association, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the Royal Australian and New Zealand College of Psychiatrists and the Royal Australasian College of Physicians, to name a few.

And yet the RACGP remained curiously silent, until last Wednesday, when RACGP President Dr Bastien Seidel wrote that the college’s council “acknowledged that the organisation has a diverse membership” and that it believed that in regard to marriage equality, “members should consider the issues involved carefully for themselves.”

But the college’s carefully neutral position unleashed a storm of criticism on social media and elsewhere, with many GPs expressing deep disapproval of their college’s stance. Former AMA President Dr Kerryn Phelps expressed her “surprise” at the RACGP’s neutrality. The college, she said, “should be a thought leader. This is unequivocally a health issue so the RACGP should take a stand.”

After around 750 GPs signed a petition demanding that the college change its position, its council hastily convened an emergency meeting on Monday.

The outcome of that meeting was a new statement from Dr Seidel, in which he acknowledged that marriage equality “is a human rights issue”.

“When I became RACGP President a year ago, I clearly outlined that the RACGP could no longer afford to sit on the fence when it came to any issue that affected our members or our patients. I deeply regret that I did not meet my own standard,” Dr Seidel wrote.

He said that the RACGP acknowledged that discrimination, bullying and harassment of LGBTIQ people has a severe and damaging effect on their mental and physical health.

“As part of valuing diversity and inclusion, RACGP Council supports marriage equality,” he wrote.

He said the council acknowledged the right of all members to hold and express their own views on marriage equality. However, the council urged all members “to provide particular care and consideration to LGBTIQ groups during this trying period.”

The turnaround comes as the latest figures from the Australian Bureau of Statistics show around 60% of eligible Australians have already returned their marriage equality postal surveys, with the announcement of the results set for November 15th.