Advocating for the rights of our patients; core business

By Professor Brad Frankum, Chair of the AMA Working Group on Gender Identity and Sexual Diversity/ President of AMA (NSW)

“Get back in your box”, “it’s not your place”, “look after your own backyard” are just a few of the responses slung our way when our position statements dare to venture beyond the biomedical realm. I like to see it as a sign of defeat; your critics cannot provide a rational rebuttal to your stance, so instead, they question your right to take it. I am sure that the AMA coming out in support of marriage equality is likely to elicit similar responses, and I, for one, am ready.

I do not pretend to know how much courage it takes to place your hand in the palm of your partner’s and walk down the street, knowing full well that your simple display of affection may be met with absolute contempt or even violence. I could never understand how exhausting it must be to have to censor your every word to ensure that one of the most significant parts of your identity remains concealed from relatives and colleagues alike. I have never had to fathom what it must be like to live and grow beside someone for decades without ever having the opportunity to formalise your commitment to them, with the full blessing of the law of the land and the people you love.

What I, and hopefully all Doctors, can understand is the tragic consequences of these realities. It is evident in the suicide rate of LGBTIQ people just as clearly as it manifests in the mental illness and substance abuse patterns among LGBTIQ populations. All of the evidence points to a need for change.

Many opponents of marriage equality question the significance of the impact of marriage denial, particularly when a civil union provides many of the legal benefits of a marriage. I cannot fully explain the reasons that the right to marry is so significant for LGBTIQ people, nor do I believe that it can ever be fully understood by somebody for whom marriage was a simple birthright.

The United States achieved marriage equality incrementally; initially deemed to be the responsibility of individual States, different jurisdictions arrived at marriage equality at varying points. The inconsistency in access to marriage rights for LGBTIQ Americans essentially laid the foundations for the perfect social experiment. We now know that health outcomes and access to healthcare improved significantly for LGBTIQ individuals who lived in states that had legislated for marriage equality. All things being equal, access to a simple piece of paper made the world of difference to thousands of LGBTIQ Americans.

Thankfully, the marriage equality social experiment in the United States came to an end in 2015 when the Supreme Court ruled that the US Constitution provides same-sex couples the right to marry. I have not travelled there recently but I hear that the sky has not fallen in.

I am proud that the AMA has taken a stand to support marriage equality and when the detractors come, I am armed and ready with a slew of peer-reviewed, empirical and anecdotal evidence to justify our reasons for doing so. LGBTIQ people are telling us that this is important to them, and we need to start listening before we lose any more young lives to suicide.

President highlights AMA influence

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

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

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

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

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

“The AMA’s political influence is significant.”

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

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

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

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

The freeze was bad policy that hurt doctors and patients.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Chris Johnson

AMA urges bipartisan approach to enshrining marriage equality in law

The Australian Parliament should legislate for marriage equality and end the divisive public debate over same-sex marriage, says AMA President Dr Michael Gannon.

The AMA has called on the Government and the Opposition to work together to bring about marriage equality in Australia.

The AMA has written to Prime Minister Malcolm Turnbull and Opposition Leader Bill Shorten, urging a bipartisan approach to the issue.

Releasing the AMA Position Statement on Marriage Equality 2017, Dr Gannon said that excluding same-sex couples from the institution of marriage has significant mental and physical health consequences for lesbian, gay, bisexual, transgender, intersex, and queer/questioning (LGBTIQ) Australians.

“Discrimination has a severe, damaging impact on mental and physiological health outcomes, and LGBTIQ individuals have endured a long history of institutional discrimination in this country,” he said.

“This discrimination has existed across the breadth of society; in our courts, in our classrooms, and in our hospitals.

“Many of these inequalities have been rightly nullified. Homosexuality is no longer a crime, nor is it classified as a psychiatric disorder. The ‘gay panic’ defence is no longer allowed in cases of murder or assault, and same-sex couples are allowed to adopt children in most jurisdictions.

“However, LGBTIQ-identifying Australians will not enjoy equal treatment under Australian law until they can marry.

“It is the AMA’s position that it is the right of any adult and their consenting adult partner to have their relationship recognised under the Marriage Act 1961, regardless of gender.

“There are ongoing, damaging effects of having a prolonged, divisive, public debate, and the AMA urges the Australian Parliament to legislate for marriage equality to resolve this.”

Former AMA President, and long-time same-sex marriage campaigner, Kerryn Phelps said the medical profession has carefully considered the health consequences of continued discrimination and has now made an “emphatic statement” that it should end.

“I think politicians now have a duty of care to the community to make sure marriage equality is introduced as soon as possible,” Dr Phelps said.

While there is no definitive data on the number of Australians who identify as LGBTIQ, same-sex couples made up approximately 1 per cent of all Australian couples in the 2011 Census, and more than 3 per cent of respondents to a 2014 Roy Morgan survey identified as homosexual.

People who identify as LGBTIQ have significantly poorer mental and physiological health outcomes than those experienced by the broader population. They are more likely to engage in high-risk behaviours such as illicit drug use or alcohol abuse, and have the highest rates of suicidality of any population group in Australia.

“These health outcomes are a consequence of discrimination and stigmatisation, and are compounded by reduced access to health care, again due to discrimination,” Dr Gannon said.

“The lack of legal recognition can have tragic consequences in medical emergencies, as a person may not have the right to advocate for their ill or injured partner, and decision-making may be deferred to a member of the patient’s biological family instead.

“Marriage equality has been the subject of divisive political and public debate for the best part of the past decade.

“It is often forgotten that, at the core of this debate, are real people and families. It’s time to put an end to this protracted, damaging debate so that they can get on with their lives.

“As long as the discrimination against LGBTIQ people continues, they will continue to experience poorer health outcomes as a result.

“LGBTIQ Australians are our doctors, nurses, police officers, teachers, mothers, fathers, brothers, and sisters. They contribute to this country as much as any Australian, but do not enjoy the same rights.

“It is time to remove this discrimination.”

The AMA Position Statement on Marriage Equality 2017 is at position-statement/marriage-equality-2017.

Chris Johnson

World body upholds Australian law on tobacco plain packaging

Following a five-year legal battle, the World Trade Organisation (WTO) has upheld the landmark Australian law on restrictive tobacco packaging, better known as plain packaging.

Tobacco firms claimed their trademarks were being infringed, while Cuba, Honduras, Dominican Republic and Indonesia complained at the WTO that the rules constituted an illegal barrier to trade.

Australia was the first country to sign on to the World Health Organisation’s (WHO) Framework Convention on Tobacco Control. Bipartisan support in the federal parliament enabled the introduction of legislation so that all tobacco products sold, offered for sale, or otherwise supplied in must be in plain packaging.

Evidence demonstrates that changes to tobacco packaging there led to more than 100,000 few smokers in Australia in the first 34 months since implementation in 2012.

Former Australian Health Minister Nicola Roxon, who oversaw the introduction of plain packaging for cigarettes, said the decision should encourage other countries to follow suit.

“We’ve already seen a large number of countries introduce or take steps to introduce plain packaging, so it’s a really significant international outcome,” Ms Roxon said.

As laid out in the WHO Framework Convention on Tobacco Control, the plain packaging of tobacco products entails restricting or prohibiting the use of logos, colours, brand images or any promotional information other than brand and product names displayed in a standard colour and font.

The objectives of tobacco plain packaging as set out in the Tobacco Plain Packaging Act 2011 are to improve public health by discouraging people from using tobacco products, encouraging people to give up using tobacco products, discouraging relapse of tobacco use and reducing exposure to tobacco smoke.

The United Nations continues to advocate for the use of plain packaging of tobacco products in an effort to save lives by reducing demand for such products, which kill nearly 6 million people every year.

Six nations have legislated for and have implemented or will shortly be implementing plain packaging (Australia, France, UK, Norway, Ireland and Georgia) and a more are set to follow.

Tobacco smoking is the single largest preventable cause of premature death and disease in Australia. Smoking contributes to more deaths and hospitalisations than alcohol and illicit drug use combined. While smoking prevalence in Australia has declined over time, the 2010 National Drug Strategy Household Survey found that 2.8 million Australians aged 14 years or older still smoke daily (15.1 per cent). Continued effort is therefore necessary to maintain the decline and reduce the social and economic costs of tobacco use to the community.

The AMA recognises that tobacco is unique among consumer products in that it causes disease and premature death when used exactly as intended. There is no safe level of tobacco smoking.

The AMA also believes that all forms of public promotion and marketing of tobacco products should be banned.

Meredith Horne

[Editorial] UK air pollution and public health

The UK Government released its latest consultation documents for controlling air pollution on May 5. Under European law, the UK has a legal obligation to protect public health by minimising the impact of environmental pollutants, including particulate matter and nitrogen dioxide. The UK has been in breach of the European directive since 2010, and has been the target of legal action by environmental groups.

Government had to reassure Australians about Medicare

After almost losing last year’s federal election over cuts to Medicare, the Government has used this Budget to display its commitment to the national health scheme.

It is setting up a Medicare Guarantee Fund and from July this year money from the Medicare Levy as well as from personal tax receipts, will be poured into the fund to cover the costs of Medicare and the Pharmaceutical Benefits Scheme.

(A 0.5 percentage point Medicare Levy rise in 2019 will help fund the National Disability Insurance Scheme.)

Labor hammered the Coalition during the 2016 election with its so-called Mediscare campaign, requiring a clear message on Budget night from the Government.

“Tonight, we put to rest any doubts about Medicare and the Pharmaceutical Benefits Scheme,” Treasurer Scott Morrison said in his Budget address.

“We are lifting the freeze on the indexation of the Medicare Benefits Schedule. We are also reversing the removal of the bulk billing incentive for diagnostic imaging and pathology services and the increase in the PBS co-payment and related changes.

“The cost of reversing these measures is $2.2 billion over the next four years

“Tonight, I also announce we will legislate to guarantee Medicare and the PBS with a Medicare Guarantee Bill.

“This new law will set up a Medicare Guarantee Fund to pay for all expenses on the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme.

“Proceeds from the Medicare Levy will be paid into the fund. An additional contribution from income tax revenue will also be paid into the Medicare Guarantee Fund to make up the difference.

“The Bill will provide transparency about what it really costs to run Medicare and the PBS and a clear guarantee on how we pay for it.”

But Shadow Health Minister Catherine King said the Budget was an insult directly from Prime Minister Malcolm Turnbull to every Australian who relies on Medicare.

She said instead of a staggered lifting of the rebate freeze, it should have been removed across the board immediately.

“When it comes to health, the Liberals haven’t learned a thing. The Turnbull Medicare freeze remains in place across the health system for years to come,” Ms King said.

“The failure to drop the freeze immediately will impact on many of Australia’s most vulnerable patients – such as those needing critical oncology treatment, obstetric services, and paediatric treatment.

“Australians will have to wait more than 12 months for relief and will be left waiting more than two years for the freeze on specialist procedures and allied health to be lifted.”

Greens leader Richard Di Natale described the Budget as a missed opportunity for health.

“The Medicare Guarantee Fund is a glorified bank account and ending the Medicare freeze just undoes a bad decision,” Senator Di Natale said.

“We should be investing more in prevention and redirecting the Private Health Insurance rebate into the public health system.”

Health Minister Greg Hunt said all Australians can be assured Medicare was not only here to stay, but will be strengthened into the future.

“This Budget includes a $2.4 billion additional investment in Medicare over the next four years,” he said.

“Partnerships have been struck with the nation’s GPs, specialists, pharmacists and the medicines sector. These are key to the Turnbull Government’s initiatives that will support the long-term future of Australia’s health system.

“As part of our compacts with Australia’s GPs and specialists, the 2017-18 Budget restores indexation of the Medicare rebate at a cost of $1 billion, starting with GP bulk-billing incentives from 1 July 2017.

“With GP bulk-billing at a record high 85.4 per cent, more Australians are visiting the doctor without having to reach into their pockets. This Budget will help ensure that continues with our indexation commitment to GPs alone worth $543.1 million over 4 years and around $2.2 billion over ten years.

“Indexation of standard GP and specialist consultations will resume on 1 July 2018, and specialist procedures and allied health from 1 July 2019.”

Chris Johnson

Technology set to change children’s health

A national initiative, My Health Record, has been designed to help the access and sharing of information to improve children’s health outcomes by using a digital platform.

The new children’s digital health network, the National Collaborative Network for Child Health Informatics, is a collaborative project between eHealth NSW, Sydney Children’s Hospital Network and the Australian Digital Health Agency (ADHA).

My Health Record’s aim is to be patient centred and clinician friendly so as to support integrated care for children and their families. It will also enhance the quality of clinician care through improved decision making tools, including a child’s safety in an emergency.

My Health Record will be a digital summary of a patient’s medical information including diagnosis, outcomes, medications, reactions and allergies. Clinical documents added by healthcare providers could also include Shared Health Summaries and Hospital Discharge Summaries.

Parents choose what information gets loaded onto their child’s record. They also control what information stays on their child’s record and who can access the information. The patient’s record will be part of a national system that will travel with each child.

Accessing and sharing information about their children’s health using a new technology platform will enable parents to accurately keep track of their children’s healthcare that can be easily shared with healthcare providers.

“This can improve their ability to access health services and enhance their experience of health services because their providers have real-time information about each child’s health status, immunisation status, and interaction across the entire health system. The work of the Network will help us realise this vision,” said ADHA Chief Executive Tim Kelsey.

Because My Health Record is a part of the Australian Government’s Digital Health Agency it is protected by security and safety laws at a nationally recognised level.

Meredith Horne

Why sexual advances towards a patient are never OK, even if ‘consensual’

In a recent independent review, I recommended chaperones no longer be used as an interim protective measure to keep patients safe while allegations of sexual misconduct by a doctor are investigated.

The review was commissioned by the Medical Board of Australia and the Australian Health Practitioner Regulation Agency (AHPRA), following media reports that a Melbourne neurologist was facing criminal charges for sexually assaulting a patient.

Dr Andrew Churchyard was allowed to keep practising after the alleged sex abuse. But this was subject to a condition on his registration that an approved chaperone be present for all consultations with male patients.

The Medical Board of Australia and AHPRA have accepted my recommendations that the current system of using chaperones is outdated and paternalistic. In future cases where a doctor is accused of sexual misconduct, and interim protection is considered necessary, restrictions may be imposed after an assessment of the allegations by a specialist board committee.

They will include prohibitions on contact with patients of a specified gender, prohibitions on any patient contact, or suspension from practice.

Sadly, cases of sexual misconduct are likely to continue. It’s important patients know the warning signs and where to seek help if they suspect their doctor is behaving inappropriately.

Ethical boundaries

The Hippocratic Oath states that in their professional lives, doctors will:

abstain from all intentional wrongdoing and harm, especially from abusing the bodies of man or woman.

The oath frames sexual contact with patients as a type of intentional harm that is forbidden. Much has changed in medical practice since the days of the ancient Greeks, but Hippocrates’ clear-eyed prohibition on sexual contact with patients, and categorisation of such conduct as a form of abuse, remains apt.

It seems likely that the disciplinary findings and criminal convictions that come to media attention are only the tip of the iceberg of doctor-patient sexual contact.

International studies indicate that the prevalence of sexual boundary violations by health practitioners may be as high as 6 to 7%. A Canadian survey of 8,000 members of the public in 1992 found that 4.1% of respondents (4.7% of women, 1.3% of men) reported touching of a private body part by their doctor “for what seemed to be sexual reasons”.

During my review, I heard first-hand accounts of the harm sexual contact from their doctor causes patients. The harrowing stories from abused patients and their families confirm what the literature says.

Patients who are sexually exploited by their doctor suffer from major depressive disorders, suicidal and self-destructive behaviour, and relationship problems. They experience feelings of shame, guilt, isolation, poor self-esteem and denial. They may also delay seeking medical help.

Their trust in their doctor, and in the consultation room as a safe place to share problems and seek advice, is shattered.

Consensual relationships?

The impact on patients who have been indecently assaulted – by being subjected to unnecessary and inappropriate clinical examinations – has much in common with the effects of sexual abuse on victims in other, non-clinical contexts.

But patients who engage in “consensual” sexual relations with their doctor also suffer harm. Issues of vulnerability, transference and breach of trust are well recognised for current patients. Yet even former patients may be harmed by entering a sexual relationship with their former doctor.

Critics of a “zero tolerance” approach to doctor-patient contact suggest notions of vulnerable patients being exploited by their doctor are old-fashioned. They argue that a mature, consenting adult should be free to enter a consensual sexual relationship with their doctor, once the doctor-patient relationship has ended. Such views are misguided.

It is one thing to accept that a doctor may later become romantically involved with a patient after fleeting professional contact. But if the doctor-patient relationship has endured for some time, and has involved confidential disclosures and advice, any subsequent sexual relationship risks harm to the patient, and damaging professional consequences for the doctor.

Warning signs

It may be very difficult to discern whether an examination of the genitalia is warranted. For all the rhetoric about empowered patients, when we are unwell and consulting a doctor (especially someone new) for diagnosis and treatment, it can feel awkward to ask whether it is really necessary to disrobe for a full examination.

During my review, one patient recalled seeing a specialist about his severe migraines. He thought a full body examination was unusual, but said: “How was I meant to know what was normal?”

Ideally, patients will know that it’s always ok to ask why an examination or procedure is necessary, to request to have a support person present, and to raise any concerns with a practice manager after a consultation.

Patients concerned that their doctor may have acted improperly can contact support services such as CASA House in Victoria, which provides information and counselling to victims of sexual assault.

Patients should be alert to signs that their doctor’s interest is more than professional. Scheduling appointments for the end of the day, asking personal questions unrelated to the presenting problem, and providing their mobile number may all be warning signs.

Doctors should always be willing to question their own motives and, if in doubt, to seek advice from a professional mentor.

Sexual advances or sexual assault by doctors causes significant harm. A strict “zero tolerance” approach protects patients and doctors.

Ron Paterson, Professor of Health Law and Policy, University of Auckland

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

DIY injuries

‘Do-it-yourself’ (DIY) refers to making, mending or maintaining something oneself, instead of hiring a professional or tradesperson. This factsheet looks at DIY injuries that occurred as a result of falls (for example, from ladders and buildings), and while using tools and machinery (for example, hand tools and lawnmowers) at home. In 2013–14, men aged 65+ were the most commonly hospitalised group due to 1 of these types of DIY injuries.

[Series] The Affordable Care Act: implications for health-care equity

Inequalities in medical care are endemic in the USA. The Affordable Care Act (ACA), passed in 2010 and fully implemented in 2014, was intended to expand coverage and bring about a new era of health-care access. In this review, we evaluate the legislation’s impact on health-care equity. We consider the law’s coverage expansion, insurance market reforms, cost and affordability provisions, and delivery-system reforms. Although the ACA improved coverage and access—particularly for poorer Americans, women, and minorities—its overall impact was modest in comparison with the gaps present before the law’s implementation.