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Preference: Law

558

The flabby country

Children are continuing to pack on the pounds even though the pace of weight gain among adults appears to be slowing, underlining concerns that a combination of poor diet and inactivity is putting millions at heightened risk of heart disease, diabetes and other serious lifestyle-related health problems.

There has been a small but notable slowing in weight gain among adults – particularly women – since the global financial crisis struck in 2007-08. The proportion considered overweight or obese increased by just 0.6 of a percentage point to 63.4 per cent in the last three years after jumping more than 6.5 percentage points in the previous 15 years.

But Australian Bureau of Statistics figures show that children are putting on weight much more rapidly. The proportion who are overweight or obese leapt 1.7 percentage points in the last three years.

Overall, the country continues to have a severe weight problem.

Last financial year, more than 63 per cent of adults were overweight or obese, including more than 70 per cent of men, while more than a quarter of all children (27.4 per cent) are carrying too much weight.

The results mean Australia retains the unenviable status of having some of the highest rates of overweight and obesity in the world. By comparison, the World Health Organisation calculates that 39 per cent of adults worldwide are overweight, and 13 per cent obese.

The nation’s waistline has continued to bulge against a background of poor eating and exercise habits.

The ABS found that although half of all adults, and 70 per cent of children, eat two or more serves of fruit a day, Australians are not getting enough vegetables in their diet – just 7 per cent of adults and 5.4 per cent of children meet dietary guidelines for the consumption of vegetables.

Just as concerning, a large proportion of Australians are not getting enough exercise. While 55 per cent of adults reported doing at least two-and-a-half hours of moderate physical activity or 75 minutes of vigorous exercise each week, 30 per cent did not manage to do even this much, and almost 15 per cent said they did none.

AMA Vice President Dr Stephen Parnis said the findings showed much more needed to be done on health prevention.

“The message from this survey is clear – Australians have to get moving,” Dr Parnis said.

He said while it was heartening that rates of smoking and risky drinking were declining, the incidence of preventable disease highlighted the need to do more.

The ABS, which surveyed 19,000 people for its report, found that just 14.5 per cent of adults smoke on a daily basis – down from 16 per cent in 2011-12 – while the proportion who drink excessively has slipped to 17.4 per cent, a 2 percentage point decline over the same period.

Dr Parnis said the results showed the effectiveness of Australia’s tobacco control measures, including its plain packaging laws, but warned that alcohol continued to “wreak havoc” on families and communities.

“We cannot be complacent about alcohol because one in four men and one in 10 women are still exceeding the lifetime risk guidelines [for consumption],” he said.

The effects of excessive drinking, poor diet and relative inactivity are showing up in persistent rates of lifestyle-related illnesses identified in the ABS report, National Health Survey: 2014-15.

It found that rates of diabetes and heart disease (both affecting about 1.2 million people) are continuing to grow, while 2.6 million have hypertension and 1.6 million suffer from high cholesterol.

Dr Parnis said that, amidst the flurry of reviews of Medicare, primary care and private health insurance, the ABS report showed the “urgent need” for greater attention on preventive health measures.

“Investing in prevention pays big dividends. It keeps people healthy and away from costly hospital care,” he said. “We need to do more to make Australians more aware of their diets, their exercise regime, and the serious health risks of smoking and excessive or irresponsible alcohol consumption.”

Adrian Rollins 

 

[Perspectives] Lawrence Gostin: legal activist in the cause of global health

In the mid-1970s, and for a decade, Larry Gostin was an American in London. To anyone living in the UK with an interest in public affairs, Gostin’s name, voice, and words became familiar. First as the legal director of the mental health charity Mind and subsequently as the General Secretary of the UK’s National Council for Civil Liberties (NCCL), he was to be heard pronouncing on knotty issues from psychiatry to surveillance. When he returned to the USA in 1985, Gostin went from taking on the British establishment to taking on the world as he forged a stellar career at the interface between law and public health.

National licensing scheme for medicinal cannabis: Ley

Minister for Health Sussan Ley has announced there will be a nationally controlled licensing scheme regulating the cultivation of medical marijuana.

This scheme would reduce the need for states and territories to set up individual schemes and ensure laws are consistent for growers.

“Allowing controlled cultivation locally will provide the critical “missing piece” for a sustainable legal supply of safe medicinal cannabis products for Australian patients in the future,” she said.

Related: MJA – Medical cannabis: time for clear thinking

There has been consultation with state and territory governments and law enforcement agencies over the past month,

“We want to not only ensure these legislative amendments are rock solid, but that we can all work together to pass them in a bipartisan fashion as quickly as possible,” Ms Ley said.

“The important point is legislative changes are drafted and we’ve hit the start button for change.”

Latest news:

 

Medicare safety net back down

Health Minister Sussan Ley has been forced to back down on proposed changes to the Medicare Safety Net after failing to convince crossbench Senators to back the savings measure.

In a decision that blows a $267 million hole in the Turnbull Government’s Budget, Ms Ley has pulled legislation that would have made it harder for patients to get financial assistance with medical expenses.

The changes, announced in the ill-fated 2014 Federal Budget and introduced to Parliament in October this year, were to have come into effect from 1 January 2016. But the Minister’s decision means that the reforms will be held over until at least next year – raising the risk that they become an issue in the lead-up to the next Federal election, due by late 2016.

Ms Ley tried to put a positive spin on the reversal by arguing she was unwilling to compromise on key aspects of the proposal in order to secure the support she needed to get it passed.

“This is a good measure that aims to address significant inequities in a system failing to help the very people it’s designed to protect – our most vulnerable patients with complex and costly medical needs,” she said.

Despite what she described as “constructive” discussions with the Greens and crossbench Senators, Ms Ley said she was “unwilling to compromise over the fundamental integrity of the policy’s intention and design in favour of a quick political solution”.

“Cutting and dicing good policies might result in short-term political fixes, but is not the way governments should manage a $65 billion health care system,” the Minister said.

Related: MJA – With talk of Medicare reform, let’s not neglect vertical equity

The Federal Government wanted to replace the Original Medicare Safety Net, the extended Medicare Safety Net and Greatest Permissible Gap with a single Medicare Safety Net, increase the out-of-pocket costs patients pay before being eligible for assistance, and impose a universal cap on safety net benefits.

AMA President Professor Brian Owler said the proposed changes would have hurt the sickest and most disadvantaged the hardest, and called on the Government to scrap them altogether.

“The Government’s changes would have created a financial and emotional burden for Australian families with considerable and unavoidable health needs,” Professor Owler said. “We recommend that the Government scrap the proposed changes altogether.”

While the Minister’s decision will add to the pressure on the Budget, the AMA President urged her not to seek to fill the savings gap by turning the multiple reviews she has commissioned into the MBS, primary care and private health insurance into cost-cutting exercises.

“The Government must not be tempted to use the reviews to recoup the almost $267 million in Budget savings it was pursuing with the Safety Net changes,” Professor Owler said.

The safety net changes were expected to hit patients in need of complex and ongoing treatment, including cancer sufferers and those with mental illness, particularly hard, increasing Australia’s already high level of out of pocket costs.

Shadow Health Minister Catherine King said the Government’s back down was a vindication of Labor’s opposition to the changes.

Ms King said that although the Opposition was prepared to discuss what it considered to be sensible reforms, “we could not support this unfair and flawed legislation in its original form”.

Related: Worrying trend in MBS review

But Ms Ley hit back, saying that changes made by Labor while in government had not worked.

“Labor’s own failed safety net reforms taught us that tinkering around the edges by placing inconsistent caps on the claiming of some Medicare items, such as IVF, but not others, will not solve the problem,” the Minister said, and indicated that the Government had not given up on the reform proposal altogether.

The Minister said the Government would look to revisit the changes as part of its broader overhaul of Medicare and primary health care.

“The current measure will remain on the table while we continue to work…on an agreeable solution as part of our broader discussions on Medicare and primary care reform,” she said.

Adrian Rollins

Latest news:

 

Cut Indigenous imprisonment to help close health gap

Sky-high rates of Indigenous incarceration need to be dramatically reduced if the nation is to close the health gap blighting the lives of Aboriginal and Torres Strait Islander people, according to AMA President Professor Brian Owler.

Launching the AMA’s Indigenous Health Report Card 2015, Professor Owler said being imprisoned had devastating lifelong effects on health, significantly contributing to chronic disease and reduced life expectancy.

“Our Report Card recognises that shorter life expectancy and poorer overall health for Indigenous Australians is most definitely linked to prison and incarceration,” the AMA President said.

Aboriginal and Torres Strait Islander people are hugely over-represented in the nation’s prisons – almost 30 per cent of all sentenced prisoners are Indigenous.

While some progress has been made in recent years in improving infant and maternal health, the AMA President said that imprisonment rates were rising, and the country was set to reach a “grim milestone” next July when, on current trends, the number of Indigenous people in custody will reach 10,000, including 1000 women.

In its Report Card, launched by Rural Health Minister Fiona Nash, the AMA has urged Federal, State and Territory governments to set a national target for cutting rates of Indigenous imprisonment.

The call has come just days after disturbing details of the death of a young Aboriginal woman who was being held in police custody for failing to pay $3622 of fines.

A West Australian coronial inquest has been told the 22-year-old woman, known as Miss Dhu for cultural reasons, was in a violent relationship and using drugs at the time of her arrest last year. While in the South Hedland Police Station she collapsed after complaining of pain and difficulty breathing.

It was later found she had several broken ribs following an attack by her partner, and died from a lethal combination of pneumonia and septicaemia.

Miss Dhu’s death has fuelled calls for WA to overhaul laws regarding the imprisonment of fine defaulters.

But the AMA has said a much broader approach needs to be taken.

Indigenous adults are 13 times more likely to be jailed than other Australians, and among 10 to 17 year-olds the rate jumps to 17 times.

Professor Owler said it was possible to isolate the health issues that led to so many Aboriginal and Torres Strait Islander people landing in prison, and they included mental health conditions, alcohol and drug use, substance abuse disorders and cognitive disabilities.

He said the “imprisonment gap” was symptomatic of the health gap, and the high rates of imprisonment of Aboriginal and Torres Strait Islander people, and the resultant health problems, needed to be treated as a priority issue.

In particular, he said, the health issues identified as being the most significant drivers of Indigenous imprisonment “must be targeted as a part of an integrated effort to reduce Indigenous imprisonment rates”.

Professor Owler said the evidence showed that Aboriginal and Torres Strait Islander people continued to be let down by both the health and justice systems, and firm and effective action was required.

“It is not credible to suggest that Australia, one of the world’s wealthiest nations, cannot solve a health and justice crisis affecting 3 per cent of it citizens,” he said.

Reconciliation Australia Co-Chair Professor Tom Calma said the AMA’s “very substantial” Report Card was latest in a long list of reports identifying the need for action, and urged governments to “get on with it”.

Professor Calma said there had been “some really good outcomes” from recent initiatives to improve prisoner health, particularly moves in many states to ban smoking in jails.

But he said more needed to be done to tackle recidivism, citing figures showing 50 per cent of Indigenous prisoners reoffended.

The Indigenous leader said that this was not surprising because often people getting out of prison returned to the same situation that got them into trouble in the first place, and urged action to tackle the causes of offending in the place, such as alcohol and drug abuse.

Among its recommendations, the AMA has called for funds freed up from reduced rates of Indigenous incarceration to be reinvested in diversion programs; for governments to support the expansion of chronic health and prevention programs by Aboriginal Community Controlled Health Organisations; for such organisations to work in partnership with prison health authorities to improve health and reduce imprisonment rates; and to directly employ Indigenous health workers in prison health services.

Adrian Rollins

Early drinks call as alcohol toll hits 500,000

Emergency doctors are calling for the nationwide adoption of early closing and pub lock-out laws amid estimates that 500,000 people a year end up in hospital because of the effects of alcohol.

Echoing AMA calls for a national strategy to tackle alcohol-related harm, the Australasian College for Emergency Medicine has urged other states and territories to follow the lead of the New South Wales government in cracking down on the availability of alcohol in late-night entertainment districts.

The College made its call after conducting a study which showed a high proportion of emergency department patients are affected by alcohol.

The study, which involved screening 9600 patients presenting at eight emergency departments in Australia and New Zealand during a one-week period in December last year, found that 8.3 per cent of all visits were related to alcohol, and the proportion jumped to one in eight presentations during peak periods.

Chair of the College’s Public Health Committee, Associate Professor Diana Egerton-Warburton, said the scale of the problem was surprising and disturbing.

“That equates to more than half a million alcohol-related patients attending EDs every year across Australia and New Zealand,” A/Professor Egerton-Warburton said. “It confirms that alcohol is having a huge impact on our emergency departments.”

Last year, a National Alcohol Summit organised by the AMA heard that the damage caused by alcohol – ranging from street violence, traffic accidents and domestic assaults through to poor health, absenteeism and premature death – cost the community up to $36 billion a year.

AMA President Professor Brian Owler told the Summit that alcohol misuse was one of the major health issues confronting the country: “Alcohol-related harm pervades society. It is a problem that deserves a nationally consistent response and strategy.”

While the Queensland Government has joined NSW in pushing for earlier closing times and lock-outs, Professor Owler said the Commonwealth needed to take the lead in developing a coherent and comprehensive strategy to tackle alcohol-related harm that went well beyond calls for individuals take more personal responsibility to address the nation’s drinking culture and increase investment prevention.

Previous studies by the College of Emergency Medicine have shown the high prevalence of alcohol among patients seeking treatment at inner-city hospital emergency departments on Friday and Saturday nights.

But A/Professor Egerton-Warburton said the most recent study was aimed at gaining a broader understanding of the role played by alcohol in ED presentations by extending the time-frame to a week, and including outer metropolitan, rural and regional hospitals in the sample.

She said the results underlined just how pervasive alcohol-related harms were, and how the effects of this ripple through the health system.

“One drunk person can disrupt an entire ED,” A/Professor Egerton-Warburton said. “They are often violent and aggressive, make staff feel unsafe and impact negatively on the care of other patients.”

She said the sheer volume of alcohol-affected patients going through emergency departments meant that they were much more disruptive than patients on the drug ice.

A/Professor Egerton-Warburton said evidence showed that early closing and lock-out laws worked, resulting in a 38 per cent reduction in serious injuries related to alcohol.

“This is a rare opportunity to take policy action that we know works.

“Other jurisdictions should follow NSW, and now Queensland, in introducing early closing times and reducing the availability of alcohol.

“Policy makers have the power to reduce the tide of human tragedy from alcohol harm.”

The AMA National Alcohol Summit Communique can be viewed at: media/ama-national-alcohol-summit-communique

Adrian Rollins

Unprofessional behaviour on social media by medical students

Social media are defined as a group of internet-based applications that allow the creation and exchange of user-generated content within a virtual community or network.1 Their rapid growth over the past decade has caused a paradigm shift in the way people communicate. The social media service Facebook reported 1.19 billion active users in 2013, and as early as 2008 the site was used by 64% of medical students,2 increasing to 93% of Australian first-year health professional students in 2013,3 suggesting that Facebook and other social media services form a growing part of students’ lives.

Earlier research has examined the use of social media by medical students and doctors for personal purposes and discussed the implications for medical professionalism.4 One study5 explored American medical schools’ experience of medical students posting improper content online, including profanity, discriminatory language, depictions of alcohol intoxication, and sexually suggestive material. Such cases have led to disciplinary action and even expulsion.6 In response to the growing use of social media and concerns about its effect on professionalism, the Australian Medical Association published a guideline on online professionalism for medical students and practitioners in 2010.7

Some behaviours are clearly unprofessional, such as the posting of patient information or any content that involves illegal activity. Depending on the context, depicting alcohol use may also be unprofessional.

We hypothesised that social media usage would be high among medical students, and that unprofessional material would be commonly posted and publicly available online. Additionally, we anticipated that medical students would know the relevant guidelines,7,8 and that they would moderate their online behaviour accordingly.

The aim of our study was to assess social media use patterns among medical students, and to identify factors independently associated with reporting evidence of unprofessional behaviour on social media. We specifically investigated whether being exposed to guidelines on social media professionalism was associated with reduced prevalence of such behaviours.

Methods

An online survey comprising 35 questions with a skip-logic design was developed using the SurveyGizmo platform. Not every question was put to every respondent, as not all were applicable. The survey was conducted between 29 March and 12 August 2013.

Any student who was currently enrolled in a medical degree (undergraduate or postgraduate) at an Australian university was eligible to respond; 16 993 students were potentially eligible, including international students.9 Students were recruited by contacting student organisations and Australian Medical Students Association (AMSA) representatives from each medical school and asking them to disseminate the recruitment information. The assistance of medical school deans was sought for internal promotion of the survey on online learning management systems (eg, Blackboard and Moodle). The study was also promoted by these groups through Facebook and Twitter.

A standard consent page that detailed the purpose of the study was displayed before the survey was delivered. All responses were recorded, although only complete responses were included in the final analysis. As an incentive to complete the survey, students were offered the chance to win a prepaid debit card to the value of $500, to be allocated randomly to one respondent; contact details were collected for this purpose in a separate form to ensure that identifying details could not be linked to the survey data. Vendor-provided duplicate protection technologies were used to prevent multiple responses by an individual. Funding was not received from any external body, with all costs borne by the authors of this article.

“Unprofessional content” was defined as an online depiction of illegal activity, overt intoxication or illicit drug use, or the posting of patient information. If students had removed unprofessional content posted by themselves or others on their account, it was not assessed as evidence of unprofessional behaviour.

Data were exported from the platform and analysed with SAS 9.4 (SAS Institute). Univariate comparisons were performed using χ2, Student t– and Wilcoxon rank-sum tests as appropriate, according to the type and distribution of the data. Parametric data are reported as means and standard deviations, non-parametric data as medians with interquartile ranges (IQR), and categorical variables as numbers and percentages. Multivariable logistic regression of “unprofessional behaviour” was performed using backwards elimination techniques, with univariate P < 0.25 as the cut-off for inclusion; results are reported as odds ratios (OR) with 95% confidence intervals. Multicollinearity was assessed by evaluating coefficient changes between univariable and multivariable models and using variance inflation factors. P < 0.05 (two-sided) was defined as statistically significant.

The study was approved as a low-risk project by the Monash Health Research Ethics Committee (MUHREC LR 2012001495).

Results

It was not known how many of the 16 993 students enrolled at Australian medical schools received notification about the survey, but 1027 from 20 medical schools (21 at the time of study enrolment) initially responded. Of these, 880 students fully completed the survey (85.6%) and thus comprised the study cohort.

Of the 880 students who submitted complete responses, 534 (60.6%) were undergraduates, 391 (44.4%) were from Victorian medical schools, and 875 (99.4%) used Facebook. The next most commonly used social networks were YouTube (853 students, 96.9%) and blogging platforms (399 students, 45.3%). Every student used at least one social network, with a mean of 5.5 networks per student (95% CI, 5.31–5.67). Online professionalism teaching had been received by 305 students (34.9%). Other demographic data are included in Box 1.

Unprofessional content was reported by 306 students as (34.7%) being present on their accounts. Evidence of intoxication was reported by 301 students (34.2%), evidence of illegal drug use by 14 (1.6%), depiction of an illegal act by 10 (1.1%), and the posting of patient information by 14 (1.6%). The proportion of students who reported seeing unprofessional content on other medical students’ accounts was much higher than that of those who reported it being present on their own account (Box 2).

Most students were aware of social media guidelines, with 475 (53.9%) aware of a professional body guideline, 363 (41.2%) of a university or clinical school guideline, and 584 (66%; 95% CI, 63%–69%) of at least one of the two. There was no association between knowledge of social media guidelines and unprofessional behaviour on social media (OR, 0.77; 95% CI, 0.54–1.11; P = 0.16). Most respondents (796, 90.5%) agreed or strongly agreed with the statement that they were held to a higher standard of professionalism than the general community; 27 (3.1%) disagreed and four (0.5%) strongly disagreed (Box 3 and Box 4).

Of the 875 students who used Facebook, 848 (96.9%) had changed the default security settings and 744 (85.0%) had a private profile; 618 students (70.6%) had increased their privacy and security settings by restricting content to groups or specific individuals.

After adjusting for covariates, unprofessional content was associated with students reporting that they had posted to their accounts evidence of alcohol use (OR, 6.50; 95% CI, 4.42–9.56; P < 0.001) or racist content (OR, 2.45; 95% CI, 1.15–5.20; P = 0.02), that they had used MySpace (OR, 1.51; 95% CI, 1.09–2.1; P = 0.01), and planned to change their profile name after graduation (OR, 1.61; 95% CI, 1.12–2.31; P = 0.01). Behaviours less likely to be associated with reporting of unprofessional content included believing that videos depicting medical events with heavy alcohol use are inappropriate (OR, 0.73; 95% CI, 0.63–0.85; P < 0.001), and being happy with their social media portrayal (OR, 0.57; 95% CI, 0.45–0.74; P < 0.001) (Box 4). Exposure to guidelines had no effect on students reporting unprofessional behaviours. The act of completing the survey itself caused 493 students (56.0%) to check their privacy settings, and 307 (34.9%) to change them.

Discussion

Our study found that social media use by the study population of medical students was nearly universal; further, 34.7% of respondents reported evidence of unprofessional content on their accounts. More students reported viewing unprofessional content on other students’ accounts than on their own. Unprofessional content was reported despite exposure to guidelines and education about online professionalism.

Medical students are held to higher standards of professionalism than general university students, and we found that most students are aware of this. This is relevant, as unprofessional conduct (online or offline) by a student may lead to disciplinary action, and has also been found to be associated with lapses during later professional practice.6,10

Factors associated with unprofessional content

Several factors were associated with the presence of unprofessional content, including evidence of alcohol use or racist content, and planning to change one’s profile name after graduation. Conversely, being happy with their social media portrayal appears to reduce the posting of unprofessional content by students. The implications of the association of unprofessional content with MySpace use are uncertain, and may now be weaker, given the decline in use of this platform.

The association between posting unprofessional content and the intention to change social media profile names on graduation suggests that students were aware that they had unprofessional content on their accounts but were not intending to remove it. This is despite knowing about the relevant guidelines and believing they are subject to a higher expectation of professionalism than the general public. As changing one’s profile name may not effectively conceal an individual’s identity, such strategies provide a false sense of security and, paradoxically, encourage unprofessional behaviour.11

Professionalism guidelines

Medical associations and professional organisations have published guidelines and other literature7,8 in response to earlier research and reports in the media. Our results suggest that, despite the widespread dissemination and awareness of professional body guidelines in Australia, there appears to have been only a minimal impact on medical students’ behaviour.

There is a distinction between disseminating guidelines and formally integrating social media instruction into medical curricula. Senior clinicians and teachers who have not used social media may teach professionalism “largely in the context of the physician–patient relationship”,12 and be ill-equipped for teaching their juniors about professionalism in a social media context.13 Our findings show that reducing the unprofessional use of social media will require more than providing guidelines.

Privacy settings

The finding that 71% of students who used Facebook had set their account to “private” was higher than the 37.5% among US medical students reported in a 2008 study.2 Private profiles allow a medical student to partition “personal” information from their public persona. However, they do not provide a completely safe sanctuary for unprofessional behaviour. Data leaks, changes to terms and conditions, and public dissemination of previously private information mean that private content posted to social media may still become more widely available.

Reading and interpreting online content is highly subjective, and the level of professionalism expected in both public and private spaces varies between individuals. Completing the survey led 35% of students to adjust their privacy settings, suggesting that being prompted to do so, combined with their reflecting on a desirable public image, may be an effective intervention. The higher proportions of participants who reported having seen rather than posted unprofessional behaviour also highlight an intrinsic attribute of social networks: that a single example of unprofessional content may be seen by a large number of medical students. While use of a private profile may not reduce the incidence of unprofessional content, it does reduce the size of the potential audience for that content.

Strengths and limitations

There are some limitations to our study. Participation was voluntary, and many participants were recruited through social media; each factor introduces selection bias. Our survey included only a small proportion of the 16 993 Australian medical students in 2013; we were unable to estimate the number of students who were actually aware of the study. A large proportion of participants were from a small number of Victorian universities, the state in which the authors of this article reside, and this may limit extrapolation of the results to other medical student populations. The survey was conducted in 2013, and the time that has elapsed between collecting and publishing our data is also acknowledged.

Our study relied on the self-reporting of specific content on social media, and did not record the prevalence of unprofessional behaviour itself. This has the potential for introducing both information and recall bias, as students may report their own behaviour differently to their perception of others’. In addition, the accuracy of participants’ responses could not be verified. The findings of this study cannot be extrapolated to qualified medical practitioners or to other allied medical staff.

Nevertheless, our study is the largest to examine medical student professionalism on social media, and has identified factors that may predict and protect against future unprofessional behaviour. It also showed that the act of completing the study was sufficient to change some behaviours, so that introspection itself may be a beneficial tool for educators seeking to address this problem.

Conclusion

The use of social media by the surveyed students was almost universal, and unprofessional behaviours on social media were exhibited by a significant proportion of medical students, despite widespread awareness of guidelines about professionalism. Content posted online is effectively in the public domain, and management of their online identity is therefore now part of a student’s professional responsibility. Medical educators should consider approaches beyond simply providing guidelines or policies, and students should be regularly prompted to reflect on their activities, to evaluate their online behaviours, and to temper them if appropriate.

Box 1 –
Demographic characteristics of students reporting or not reporting evidence of unprofessional behaviour∗

All students

Students reporting no evidence of unprofessional behaviour

Students reporting evidence of unprofessional behaviour

P

Number

880

574

306

Median age (IQR), years

22 (20–24) [range, 16–40]

22 (20–24)

22 (21–24)

0.95

Enrolment type

Undergraduate

534 (60.6%)

359 (67.4%)

174 (32.6%)

0.11

Previous health care degree†

98 (28%)

66 (67%)

32 (33%)

0.65

Domestic‡

826 (94.1%)

527 (63.8%)

299 (36.2%)

0.001

Year of study

1st

184 (20.9%)

122 (13.9%)

62 (7.0%)

0.79

2nd

173 (19.7%)

117 (13.3%)

56 (6.4%)

0.48

3rd

189 (21.5%)

124 (14.1%)

65 (7.4%)

0.93

4th

169 (19.2%)

103 (11.7%)

66 (7.5%)

0.21

5th

93 (10.6%)

55 (6.3%)

38 (4.3%)

0.21

6th

71 (8.1%)

53 (6.0%)

18 (2.1%)

0.09

University attended

Monash (Victoria)

278 (31.6%)

190 (21.6%)

88 (10.0%)

0.19

Western Australia

116 (13.2%)

73 (8.3%)

43 (4.9%)

0.60

Melbourne (Victoria)

113 (12.8%)

79 (8.9%)

34 (3.9%)

0.29

Deakin (Victoria)

78 (8.9%)

49 (5.6%)

29 (3.3%)

0.71

Queensland

48 (5.5%)

30 (3.4%)

18 (2.0%)

0.75

New England (NSW)

48 (5.5%)

25 (2.8%)

23 (2.6%)

0.06

Western Sydney (NSW)

39 (4.4%)

29 (3.3%)

10 (1.1%)

0.30

Others

160 (18.1%)

99 (61.9%)

61 (38.1%)

0.36

Received instruction about online professionalism

Yes

305 (34.9%)

199 (22.8%)

106 (12.1%)

0.45

No

421 (48.2%)

268 (30.7%)

153 (17.5%)

Not sure

147 (16.8%)

102 (11.7%)

45 (5.2%)

∗ All values reported as number (and column percentage) unless otherwise stated. † Percentage refers to medical postgraduates only. ‡ Australian and New Zealand citizens, and Australian permanent residents.

Box 2 –
Unprofessional behaviours on medical students’ social media accounts, self-reported (own account) v observed (others’ accounts)

* Posted by self v posted by others: P < 0.001.

Box 3 –
Characteristics of students reporting or not reporting evidence of unprofessional behaviour∗ (univariate analysis)

Students reporting no evidence of unprofessional behaviour

Students reporting evidence of unprofessional behaviour

P

Do you use:

Facebook

566/567 (99.8%)

304/305 (99.6%)

1.0

Twitter

208/574 (36.2%)

145/306 (47.4%)

0.002

Reddit

107/574 (18.6%)

93/306 (30.4%)

0.01

Do you think it is appropriate to be Facebook “friends” with:

Allied health staff

333/570 (58.4%)

213/302 (70.5%)

< 0.001

Junior doctors

443/571 (77.6%)

263/304 (86.5%)

0.0016

Nurses

322/568 (56.7%)

209/303 (70.0%)

< 0.001

Patients’ families

17/570 (3.0%)

7/303 (2.3%)

0.67

Patients

12/570 (1.38%)

3/303 (0.34%)

0.33

Have you ever posted content which could be interpreted as:

Racist

16/566 (2.8%)

25/302 (8.3%)

< 0.001

Sexist

225/568 (39.6%)

166/301 (55.2%)

< 0.001

Containing frequent swearing

58/569 (10.2%)

91/301 (30.2%)

< 0.001

Discussing a clinical site in a negative light

88/568 (15.5%)

93/302 (30.8%)

< 0.001

What guides your professionalism on social media?

Concerns about appearing unprofessional to friends, family, or peers

407/574 (70.9%)

192/306 (62.8%)

0.01

Belief that as a medical student I am held to a higher standard of professionalism

522/570 (91.6%)

274/304 (90.1%)

0.53

University social media guidelines or policy guides my behaviour

148/574 (25.8%)

58/306 (19.0%)

0.02

Concern about appearing unprofessional to general public

414/574 (72.1%)

198/306 (64.7%)

0.03

Do you believe professionalism extends to social media presence?

516/568 (90.8%)

246/306 (80.4%)

0.0001

Do you feel you have control over social media portrayal?

454/567 (80.1%)

218/303 (71.9%)

0.008

Are you happy with your social media portrayal?

504/569 (88.6%)

228/305 (74.7%)

0.0001

Do you use a pseudonym for your profile name?

46/566 (8.1%)

40/306 (13.1%)

0.02

Do you plan to change your Facebook profile name after graduation?

138/574 (24.0%)

110/306 (36.0%)

0.0001

Are you a domestic student?

527/572 (92.1%)

299/306 (97.7%)

0.0008

Have you read or been instructed about a social media guideline?

412/574 (71.8%)

219/306 (71.7%)

0.95

∗ All values reported as number and percentage of responders.

Box 4 –
Reported factors independently associated with unprofessional behaviours (multivariate analysis)

OR (95% CI)

P

Evidence of any alcohol use (not intoxication)

6.50 (4.42–9.56)

< 0.0001

Evidence of posting racist content

2.45 (1.15–5.20)

0.02

MySpace use

1.61 (1.09–2.10)

0.01

Planning to change profile name upon graduation

1.61 (1.12–2.31)

0.01

Believing that recording videos of medical events depicting heavy alcohol use are inappropriate

0.73 (0.63–0.85)

< 0.0001

Happy with social media portrayal

0.57 (0.45–0.74)

< 0.0001

Read or been educated on social media guidelines

0.77 (0.54–1.11)

0.16

OR = odds ratio. Hosmer–Lemeshow H statistic for goodness of fit, 5.31; P = 0.72; area under receiver–operator characteristic curve, 0.80.

Food stars changing habits

The nation’s food ministers are hailing the success of the breakthrough front-of-packet health star labelling system amid evidence that it is changing eating habits and encouraging the production of healthier foods.

The Australia and New Zealand Ministerial Forum on Food Regulation was told that 55 companies have adopted the voluntary Health Star Rating system since it was introduced last year, and it is now displayed on more than 1500 food products.

In a sign that the labelling system is exerting an influence, the health ministers noted that “a number of major companies have reformulated some of their most popular products to make them healthier, achieving a higher star rating”.

They were also encouraged by evidence it may be leading to better food choices.

The results of a consumer study presented to the ministers found one in six consumers were changing their shopping behaviour based on the system, and awareness of it had grown from 33 per cent in April to 42 per cent in September.

The system was introduced in controversial circumstances last year when Chief of Staff to the-then Assistant Health Minister Fiona Nash ordered the system’s website pulled down just hours after it was launched.

It was later revealed that at the time he retained an interest in a consultancy that had major food manufacturers among its clients, and he was forced to resign.

The website was eventually reinstated late last year.

But although the system is considered to be an advance in food labelling standards, the AMA has said that it should be mandatory, and public health experts are critical of its central message that “the more stars, the healthier the food”.

Professor of Public Health Nutrition at Deakin University, Mark Lawrence, and Christina Pollard of the Curtin University School of Public Health argue that, because it only applies to packaged foods, the system misses the fresh foods, particularly fruits and vegetables, that people should eat most.

And, in an article in The Conversation, they warned that it encouraged food manufacturers to make minor tweaks to their products which would earn them more stars without making significant difference to nutritional value, while avoiding using the system altogether for products that would rate poorly.

Adrian Rollins  

 

[Comment] Offline: Gender equality—the neglected SDG for health

“Wives should have the same rights and should receive the protection of law in the same manner as all other persons…the defenders of established injustice do not avail themselves of the plea of liberty but stand forth openly as the champions of power.” John Stuart Mill’s 1859 essay, On Liberty, may not be the cri de coeur those working for gender equality today would hope for in a post-2015 world. But Mill’s link between liberty, the rights of women, and universal education was one of the first and most striking modern statements advocating greater gender empowerment (at least by a man).