Let’s be clear eyed while moving forward on private health insurance

BY ASSOCIATE PROFESSOR JULIAN RAIT, CHAIR, COUNCIL OF PRIVATE SPECIALIST PRACTICE

On October 11, Health Minister Greg Hunt announced the final rules that support the new private health insurance clinical categories and the Gold, Silver, Bronze and Basic classification system.

CPSP and the AMA have called on these reforms to deliver simplified, better value private health insurance products for consumers. A system that offers more comprehensive coverage, with clear definitions, and less caveats and carve outs. Will the new system deliver total clarity and transparency? Not quite, but it is going to be a lot simpler for consumers than trying to navigate through the current 70,000 policy offerings.

The AMA has always supported, two key aspects of these reforms:

Clarity about what medical conditions are covered in each tier of benefits; and
The use of standard clinical categories across all private health policies.

The new classification system categorises existing policies into easier to understand tiers. These tiers, in combination with new Private Health Information Statement (which includes mandatory information about what each policy covers), should make it easier for people to compare policies, to shop around and actually see what they are covered for.

This should enable consumers to know that when they book in for a procedure they are covered now and not have to wait an additional 12 months or try the public system.

The tiers outline minimum requirements, but they still allow insurers to add additional cover. The legislation clarifies that insurers can move people onto new products, closing old products, but introduces new protections about warning and information for consumers. Additionally, the Minister is on the record stating that “importantly consumers will not be forced to change their policy cover if they are happy with it”.

There are also some more hidden benefits that will come in with the new system.

That the system provides full mandatory cover for the medical conditions in each tier; partial cover is not permitted (except in Basic cover and for Psychiatry, Rehabilitation, and Palliative Care – except in Gold cover where there are no exclusions allowed at all);
The inclusion of gynaecology, breast surgery, cancer treatment, and breast reconstruction in bronze tier products;
That a clinical category covers the entire episode of hospital care for the investigation or treatment;
That an episode of hospital treatment covers the miscellaneous services allied to the primary service; and
Patients with limited cover for psychiatric care can upgrade their cover (once) to access higher benefits for in-hospital treatment without serving a waiting period.

While these look obvious, they haven’t always been included in policies. From next year they will be.

The Minister has called for an April 1, 2019 commencement to coincide with the annual announcement of new premiums. However, as with most major changes, not all groups can adapt as quickly as others. So, while the reforms start next year, insurers have a further 12 months to ensure that each of their products is compliant and to move people onto new products if required. This is not ideal, but the transition for the smaller insurers is likely to be very resource intensive. The Minister has stated that his expectation is that the great majority of policies will be ready to go by April 1 next year. He has also stated that these reforms will have an overall neutral to -0.3 per cent impact on premiums compared with current policy settings.

But we also need to be clear eyed here. This will not solve the wider issue of how to bridge the ongoing premium increases in the 4-5 per cent range, and wages growth at 2 per cent range. That fundamental paradox to a long-term, sustainable private health insurance system remains. These reforms will not address the concerns around private health insurer behavior, nor will they address the variation in rebates. These reforms are about making life a little easier for our patients, and our practices. But the AMA will need the support of all our members going forward – for clearly, the bigger problem is yet to be addressed.

Our new Medicare Billing Compliance online learning module

Medicare billing errors and healthcare fraud are significant factors in the cost of the Australian health care system. Irrespective of different payment models, challenges exist at the interface of medical billing and medical practice across the system. Inappropriate Medicare billing resulted in $29 million of debts against doctors and healthcare providers last year, which led to reputation and legal penalties.

From 1 July 2018, the Professional Services Review Committee was empowered to make findings of inappropriate practice against persons or officers of body corporates who employ “or otherwise engage” doctors. This includes practice owners and officers of corporate practices. The consequences of a provider found guilty of inappropriate practices can lead to the repayment of the whole or part of the Medicare benefits paid for a service. Practices, hospitals and others with administrative responsibility for the submission of documents to Medicare should ensure documents are not inaccurate or misleading. Those with a responsibility for the direction of more junior providers such as supervisors, practice principals and senior hospital administrators should ensure their directions to junior providers are appropriate. Doctors are responsible for unsubstantiated claims regardless of who does the billing or receives the benefit.

Medical billing education is an effective measure to improve compliance, reduce incorrect claiming and improve programme integrity of health systems. doctorportal Learning has launched a new Medicare Billing Compliance accredited self-paced online learning module where you can gain critical insights on compliance regulations and legislation, procedures and record keeping obligations that helps you be responsible and remain compliant. Offered for free by the Australian Government Department of Health, there are six key topics addressing information on the role of compliance in the Medicare system, relevant regulations and legislation, obligations with regards to claiming under Medicare, and processes and procedures should payments be non-compliant after a compliance activity. CPD points are awarded following completion of the module. Click here and get started.

Your Learning is closer than you think! Sign-up or login now to view our latest learning opportunities and start your medical learning from anywhere, anytime. For more information please email our friendly member services team on: memberservices@ama.com.au

Portugal competition winner announced

We’re pleased to announce a winner for our Portugal and Spain Medical Conference competition.

Dr Gregory Katsoulotos, a Sydney-based adult respiratory and sleep physician, wins our $23,000 package, which includes seven nights on board a luxury riverboat on the Douro River in northern Portugal, including all meals and drinks plus a 20-hour accredited medical education program.

Contacted by phone, Dr Katsoulotos said having recently been to America and also other parts of Europe, he’d actually been thinking about visiting somewhere on the Iberian peninsula.

“So the timing really is perfect!” he said.

Dr Katsoulotos has a PhD in asthma, immunology and allergy problems and has a keen interest in allergy and all forms of airways disease, including asthma and COPD. He has appointments at several hospitals in South Sydney and is a Senior Lecturer at the University of NSW. Dr Katsoulotos also helps run the undergraduate medical student teaching program at The Sutherland Hospital.

The conference organiser, Unconventional Conventions, is an accredited education provider for the Royal Australian College of General Practitioners. The conference will provide an opportunity for local professional contribution and cultural exchange through workshops and structured visits to local clinics. You can access the program here.

The role of pharmacists should be overhauled, taking the heat off GPs

A Grattan Institute report released earlier this week, Cutting a better drug deal, calls for a major shake-up of pharmacies and pharmaceutical pricing.

The market for retail pharmacies is highly regulated. States regulate who can own pharmacies – essentially prohibiting anyone other than pharmacists owning them – and how many pharmacies one person can own. The Commonwealth regulates where pharmacies can be located, and have used that regulation to slow the growth of big discount pharmacies.

The current rules prevent competition in a way that benefits pharmacy owners more than consumers. International evidence suggests deregulation, allowing more pharmacies in urban market areas, actually improves access. The regulations in Australia restricting the number of pharmacies need to be changed.

The role of pharmacists

Pharmacists could also do more than they currently do. If there are more pharmacies in competition with each other, the hope is they would compete on prices and the services they provide. Pharmacists could take some of the load off doctors, allowing GPs to concentrate on more difficult diagnostic problems.

The role of pharmacists should be expanded so they become part of a coordinated team providing health care to their local community. In particular, local pharmacies, as part of a team with GPs, should be empowered to:

administer vaccinations
give drug information to patients, review their medication and adjust doses when required
prescribe repeat medications for patients with simple and stable medical conditions such as some cases of asthma, or straightforward drug requirements such as the contraceptive pill
work with GPs to manage treatment for patients with chronic diseases.

Pharmacists are highly skilled health care professionals. With appropriate further training, they could safely perform these additional tasks. And giving pharmacists wider roles such as the authority to administer vaccinations and provide repeat prescriptions has been found to improve patient outcomes.

Better pricing of PBS-listed medications

The Grattan report also shows Australian taxpayers could save half a billion dollars a year from better pricing of medications listed on the Pharmaceutical Benefits Scheme (PBS). Most of these savings come from strengthening and extending an existing policy known as Therapeutic Group Premiums.

This policy applies to seven “therapeutic groups” – groups of similar drugs such as angiotensin II receptor antagonists used for the treatment of high blood pressure – and dictates that if a drug has a similar effect, the PBS should pay a similar price for it. The devil is in the detail, of course, and the implementation rules for this policy mean it is full of loopholes.

The current rules set generous standards about how different prices are allowed to be from the benchmark medication. Tightening these rules, by revising how to calculate if the price of a drug is different from another, could ensure many more drugs were scoped into the policy. Our report shows that just this one change – which may not even need any legislative approval – would save taxpayers A$240 million each year.

Other countries apply their equivalent policy much more broadly. Germany, for example, has more than 30 therapeutic groups to Australia’s seven. If Australia extended its existing seven groups to 18, adding new groups such as one for insulin, more drugs would come within the scope of the therapeutic group premium policy. With additional medications in scope, taxpayers could save a further A$205 million each year from these 11 new groups.

Benchmarking drug prices

Still more savings could be made if Australia benchmarked the prices it pays for drugs against prices paid overseas. This would cut prices in Australia by more than the current policy of “price disclosure”.

Under price disclosure, drug companies are forced to disclose to the PBS the prices they actually charge pharmacies for their products. Where that price is less than the price the PBS currently pays, the PBS drops its price accordingly. This policy has been quite successful; the prices paid by the PBS for many drugs have now dropped, in some cases quite substantially (as in the graph below).

In 2013, for example, the PBS paid almost 30 times the world best practice benchmark price for the anti-psychotic medication, Olanzapine. It is now six times the international benchmark. Similar improvements have occurred across almost all generic drugs.

In a 2013 report, Grattan estimated benchmarking could save Australian taxpayers more than A$600 million dollars a year. Since then there have been several rounds of price disclosure, each bringing the prices of drugs covered by the policy closer to international benchmarks. So in our new report, we estimate savings from benchmarking at A$93 million a year. That $93 million is worth saving. The PBS should benchmark its prices regularly, and publish the results.

The savings identified in this new Grattan report could be used to meet the costs of new drugs with proven benefit, or to kill off one of the zombie measures sitting outside the Senate door such as the one designed to increase PBS co-payments.

Improved pricing for the PBS is a much more equitable policy. Relaxing location rules for pharmacies in metropolitan areas and enhancing the role of pharmacists will also benefit consumers through lower prices and better access to vaccinations and medication management.

Stephen Duckett, Director, Health Program, Grattan Institute

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

Season’s Greetings from doctorportal

The team at doctorportal would like to wish you a happy and festive holiday season, and thank you for your support this year.

Since the launch of doctorportal in May last year, the team has aimed to provide informative and engaging content to help you, the busy medical professional, stay abreast of the current issues and opinions shaping the Australian health landscape. It has also endeavoured to publish useful updates in clinical practice, and noteworthy developments in medical research and politics.

The doctorportal website has also proven to be a useful resource this year, offering a range of tools and information, including GP Desktop, Find a Doctor, doctorportal Jobs, the online bookshop, and the events page.

Readers can look forward to updates to the doctorportal Learning space in the new year, where members can:

track all CPD points and activities in one place
access 24/7 online, mobile-friendly, medical education
receive assistance in meeting MBA CPD reporting obligations
find guidance on CPD requirements
upload and track external learning

We look forward to returning in 2017 with more exciting launches and products.

We wish you all a joyous, restful and safe holiday period.

Mellow yellow? The mood and cognitive effects of curcumin from turmeric

Curcumin is the component of turmeric (Curcuma longa) that gives the spice its bright yellow colour. It is one of more than 5,000 flavonoids, a group of plant-based compounds thought to contribute to the health benefits of fruit and vegetables.

The purported medical effects of curcumin have a long history, going back at least to the 18th century. In 1937, a paper in the Lancet medical journal described successful case studies using curcumin in the treatment of inflamed gall bladders.

Around 150 curcumin studies are under way to investigate the effects of curcumin (alone or in combination with other drugs) on cancer, heart disease, diabetes and dementia. While any meaningful clinical effects are far from proven, at least the trials have a scientific foundation.

There are already some promising results from studies of curcumin in healthy people. For example, one study in healthy middle-aged volunteers showed that taking 80mg of curcumin a day for four weeks reduced markers of inflammation and oxidative stress. These are implicated in a number of disease processes, including those observed in cardiovascular disorders, diabetes and dementia, among others.

While half a tablespoon or so of turmeric might contain 80mg of curcumin, gaining these health benefits is not as simple as ingesting this amount of the spice every day. First, there is large variability in the levels of curcumin in commercial turmeric. Second, native turmeric has low bioavailability. This means that, under normal circumstances, little is absorbed from the gut into the body.

Various methods have been used to try to increase bioavailability. The preparation used in the study above is lipid-conjugated. This means that the curcumin molecules are bound to lipids (molecules which make up cell membranes), allowing the curcumin to pass through tissue much more readily. This makes it up to 60 times more bioavailable.

Our lab is researching the cognitive and mood effects of a range of bioactive nutrients. Unlike many pharmaceuticals, which are often aimed at single targets, these may affect multiple biological processes involved in cognitive decline and dementia.

Compounds that increase the activity of certain neurotransmitters (chemical signalling molecules) or the delivery of the basic energy substrates (glucose and oxygen) to the brain have the potential to improve aspects of cognitive function. Those that, like curcumin, decrease inflammation and oxidative stress may have longer-term benefits for the ageing brain.

Indeed, there is converging evidence from both human population and animal studies that curcumin may help prevent age-related cognitive decline.

One study of around 1,000 Singaporeans found that those who ate more curry had higher scores on a broad measure of cognitive ability.

While such findings need to be interpreted with caution, they suggest that some component of curry may contribute to the effect. The possible role of curcumin as the key ingredient is supported by numerous animal and test tube studies which show that the compound possesses a host of properties, including many relevant to brain function.

Our placebo-controlled, double-blind study examined the effects of 80mg of the lipid-conjugated curcumin in a cohort of healthy older people. For full transparency, note the study was funded by a grant from the company that makes the extract – though it had no input into the design, interpretation or publication of the study.

We randomly allocated 60 participants (with mean age 69 years) to receive curcumin capsules (the intervention) or a matching placebo (a dummy). Neither group knew whether they were receiving curcumin or a placebo.

The volunteers underwent a training day to familiarise themselves with the computerised cognitive and mood tests. Then they undertook the tests before taking the capsule, then one and three hours after a single dose. They underwent testing at the same three time points following 28 days on curcumin or placebo.

We found that, compared with the placebo group, those in the curcumin group performed better on working memory tasks one hour after the first dose. This effect disappeared by the third hour, by which time blood levels of curcumin would have dropped.

After 28 days, the participants’ working memory was still significantly better than those in the placebo group. Those taking curcumin were also significantly less fatigued at the 28-day assessment.

Sitting computerised cognitive tests for any length of time has negative effects on mood for people in their 60s and 70s. It makes them significantly less alert, content and calm, while increasing stress and fatigue. These mood effects were significantly reduced in the curcumin group, suggesting they were protected to some degree against mental workload stress.

These are early results from a single trial but are encouraging and merit further exploration. We are conducting a replication study, which includes additional measures such as brain imaging to try to better understand the effects of curcumin as a cognitive and mood enhancer.

In the absence of effective new pharmaceutical interventions to treat cognitive decline, it is important that we continue to explore the potential for bioactives like curcumin, and other nutritional interventions, to improve mental function.

Andrew Scholey, Professor and Director of the Centre for Human Psychopharmacology, Swinburne University of Technology and Katherine Cox, PhD Candidate, Centre for Human Psychopharmacology, Swinburne University of Technology

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

Latest news

Richard Nesbit Evans, MB BS, MRCP(UK), FAFOM

Richard Nesbit Evans was born on 14 May 1944 in Birmingham, United Kingdom. A natural all-rounder, he attended Winchester College from 1957 to 1962, where he excelled at athletics and won the science prize. He studied politics, philosophy, economics and natural sciences at the University of Cambridge in the early 1960s and joined The Economist, where he worked as an investigative journalist from 1964 to 1967.

Richard then changed career paths, studying medicine at King’s College London, where he served as president of the Medical Students’ Association. After graduating in 1972, Richard worked at hospitals in London, Coventry and Epsom and became a member of the Royal College of Physicians of the United Kingdom in 1975.

From 1975 to 1979, Richard was the chief medical officer for several airlines including British Caledonian, Laker Airways, British Airways and Cathay Pacific. His interest in aviation came from his father, who was a de Havilland Mosquito test pilot during the Second World War. During this time, Richard organised the dispatch of chemotherapy medications to various African nations and was involved in aeromedical retrieval missions. He was also a regular contributor to the “from the doctor” column of the Cathay Pacific in-flight magazine.

He moved to Perth, Western Australia, in 1979. He was the medical officer at the BP Kwinana Refinery and at Cockburn Cement from 1980 to 1985. He was then appointed medical registrar at the Royal Perth Hospital from 1985 to 1988 and became a Fellow of the Australian Faculty of Occupational Medicine in 1985.

Richard ran a general practice in Leederville for 7 years and subsequently spent the next 20 years working across rural and urban Australia as a locum, becoming well known in towns such as Coober Pedy, Boddington and Halls Creek. He was also surveyor of general practice in Western Australia from 2002 to 2007.

Richard wore many non-medical hats: fisherman, birdwatcher, gold-fossicker and master handyman. He played for the international Ghanaian rugby union team while on medical student elective and followed the San Francisco 49ers in American football and Aston Villa in soccer. He was also an active member of the Australian Baha’i community and of the Men of the Trees society.

Richard died in Perth on 22 December 2015, just 4 months after being diagnosed with glioblastoma multiforme. He was a gentle, patient and kind doctor and a man of great humility. He is survived by his wife Faeghe, sons James, Matthew, Stephen and Eric, and grandsons Oliver and Leo.

Medicinal cannabis can now be prescribed by NSW GPs

New regulation means that from 1st August 2016, NSW doctors can seek approval to write up scripts of medicinal cannabis for patients who need it.

Previously, patients could only legally access cannabis-based medicines through clinical trials. However thanks to changes under the Poisons and Therapeutic Goods Amendment (Designated Non-ARTG Products) Regulation 2016 (under the Poisons and Therapeutic Goods Act 1966), the drugs can now be prescribed for patients who have exhausted their standard treatment options.

“People who are seriously ill should be able to access these medicines if they are the most appropriate next step in their treatment,” NSW Premier Mike Baird said on Sunday.

How do doctors get approval to prescribe?

In order to prescribe the drugs, doctors will need to get approval from both the Commonwealth Therapeutic Goods Administration and NSW Health.

According to NSW Health, in making their decision, the Commonwealth “will consider the prescriber’s expertise, the suitability of the product to treat the patient’s condition, and the quality of the product.”

A committee of medical experts from NSW Health will review the prescriber’s application, and will consider “whether the unregistered cannabis-based product is being appropriately prescribed for the patient’s condition.”

What can be prescribed?

Some cannabis-based products have already been assessed for quality, safety and efficacy by the medicines regulator. These include:

Nabiximols (Sativex®) – registered in Australia with the Therapeutic Goods Administration for managing spasticity associated with multiple sclerosis.
Dronabinol – registered by the US Food and Drug Administration for anorexia in patients with AIDS and chemotherapyinduced nausea and vomiting, where standard treatment has failed.
Nabilone – registered by the US Food and Drug Administration for chemotherapyinduced nausea and vomiting.

Although applications aren’t limited to the above products, the products applied for must be legally produced and manufactured to appropriate quality standards. There must also be evidence that supports use for that product for the patient.

How do doctors apply?

For more information and to apply for authority to prescribe and supply cannabis products, visit NSW Health’s Pharmaceutical page. More information can also be found at their Cannabis and cannabis products information site.

Latest news:

No strong evidence bicycle helmet legislation deters cycling

A focus on helmet legislation detracts from concerns about cycling infrastructure and safety

Opponents of helmet legislation often argue that mandatory bicycle helmet legislation (MHL) is the primary impediment to an increase in cycling.1 The public debate regarding MHL recently flared up with the Leyonhjelm Senate inquiry2 and the Australian Capital Territory proposing a relaxation of their MHL in low speed areas.3 As there are numerous health and social benefits to cycling, such arguments need to be evaluated with rigour against the highest quality evidence available.

Victoria was the first jurisdiction in the world to adopt MHL in July 1990. Other Australian states and territories adopted similar legislation by July 1992. Around this time, the governments of New South Wales, Queensland, South Australia, Victoria and Western Australia commissioned research to assess the impact of their state-specific laws on helmet wearing.4–8 In SA and WA, stratified random sampling surveys were employed to estimate cycling frequencies before and after the introduction of MHL.6,8 The results of these surveys suggest that there was no real impact on cycling frequencies following MHL (Box 1). Cycling frequencies were not estimated for NSW, Queensland or Victoria.

Recent evidence suggests that active travel modes (ie, walking, cycling and public transportation) steadily declined following World War II because more Australians used cars as their primary transportation mode.9 In a 2011 survey regarding barriers to cycling, over 50% of the responses from current cyclists and non-cyclists related to lack of cycling infrastructure and concerns about safety (Box 2).10 Dislike of helmets constituted only 6% of the responses for both groups and was the tenth and 13th most cited response among cyclists and non-cyclists respectively. Yet, MHL is sometimes proposed as a major barrier to cycling.11

Complex study designs, such as the stratified random samples discussed above, are essential for estimating cycling frequencies to ensure that the sample is representative of the population. Stratified random sampling surveys have long been used in countries with an entrenched cycling culture, such as the Netherlands,12 and also recently in Australia since 2011 through the National Cycling Participation Survey conducted by Australian Bicycle Council (http://www.bicyclecouncil.com.au/publication/national-cycling-participation-survey-2015). There is a lack of international evidence using such methods to support the case that MHL acts as a deterrent to cycling. A Canadian study, in which participants were randomly identified from three sampling frames with elements of stratification and clustering, found no evidence that MHL deters cycling.13

Although complex survey designs are important for obtaining reliable data, they also require many resources and are not always feasible. On the other hand, convenience sampling often requires fewer resources, making it attractive for some studies. However, the cost of convenience is a biased sample. In NSW and Victoria, convenience sampling was used to collect data at various roadside locations in each state over one time period before the introduction of MHL and multiple time periods after its introduction. In addition to bias from convenience sampling, these studies were designed to estimate helmet wearing not cycling frequency. Nonetheless, some authors have used the cyclist counts from these surveys to demonstrate a reduction in the number of cyclists following the introduction of helmet legislation. There is an argument that convenience samples taken over time are representative of population trends; however, such an argument involves many assumptions that are almost always violated.14

In summary, there are reports indicating a decline in cycling based on convenience sampling data following the introduction of helmet legislation in Australia. However, there is also evidence based on better quality data which shows no significant impact on cycling participation. When faced with conflicting evidence, it is important to consider differences in study design and data quality. When these parameters are taken into account, the best evidence suggests that MHL has never been a major barrier to cycling in Australia. In addition, the focus on helmet legislation detracts from more important discussions around the uptake of cycling. These include concerns for personal safety, which can be addressed by the construction of dedicated cycling infrastructure,15 education of all road users, and supportive legislation to protect cyclists, such as minimum passing distances.16

Box 1 –
Frequency of cycling before and after the introduction of helmet legislation in South Australia and Western Australia, according to stratified random sampling surveys6,8

	Frequency	1990	1993
		1989	1993

South Australia	At least weekly	21.8%	21.0%
	At least monthly	5.2%	6.0%
	At least every 3 months	3.9%	4.4%
	Less often or never	69.1%	68.6%
Western Australia	At least weekly	26.6%	27.7%
	At least every 3 months	11.1%	11.6%
	At least once per year	10.3%	11.5%
	Never	52.0%	49.2%

Box 2 –
Percentage of responses for reasons for not riding a bike for transport more frequently (current cyclists) or for transport (non-cyclists), 2011*

Response category	Current cyclists (n = 158/386)	Non-cyclists (n = 515/1289)

Lack of infrastructure^†	30.6%	25.0%
Concerns about safety^‡	27.7%	25.8%
Uncontrollable issues^§	26.9%	24.4%
Do not like wearing a helmet	6.5%	6.3%
Miscellaneous^¶	8.3%	18.6%

* Adapted with permission from the National Heart Foundation of Australia (numbers of respondents/responses).10 † Speed/volume of traffic, lack of bicycle lanes/trails, no place to park/store bicycle, no place to change/shower, nowhere to store clothes. ‡ Unsafe road conditions, do not feel safe riding, do not feel confident riding. § Weather conditions, destinations too far away, too hilly, not enough time, health problems. ¶ Not fit enough, none, unsure of best route, other, do not own a bicycle, need to transport other people (eg, children), do not know how to ride a bike.

Chicken or beef?

Runner-up — Practitioner category

The spirit of adventure came upon me one Tuesday morning. I was battling to stay awake during a particularly tedious preamble. I knew my patient would get to the point eventually — she usually did, but experience had taught me that resistance was futile. By focusing my attention on the wall calendar hanging strategically behind her head, I could feign undivided attention while dreaming of an escape to this month’s exotic location. It was March. The Andes.

By August — at an age when convention would have me taking up golf or bridge instead — I found myself wedged between a bull-necked businessman and a tattooed hipster with a bushy beard. The monotonous tshh-tshh-tshh of the bass-line from his headphones rendered fresh insight into the misery of my chronic tinnitus patients. I was trapped, with ready access neither to the stunning view of the mountains below nor to the toilets. I wasn’t sure which worried me more. The static from the nylon airline blanket had sent my hair into a silver halo and the neck pillow was already aggravating my psoriasis. It was going to be a long flight. Luckily, I was prepared and reached for the white pill bottle in my bag.

I kicked my brand new hiking boots off under the seat in front and pulled down my tray table in anticipation. A glass of Sauvignon Blanc would be an excellent choice to wash down my temazepam.

I generally have no need for medication. But ahead of me lay the inevitable slide into a world of specialists, prescriptions and podiatrists. There would come a time when I would rely on my Webster-pak for the correct day of the week. I shuddered and picked up the duty-free catalogue for distraction. I’d barely made it past the mini-perfume collections, when the captain made an announcement.

Ironically, in the many years since I qualified, I’d never been called upon to perform a Good Samaritan act. Now that I’d retired, however, it appeared my luck had run out. I barely had time for his words to sink in before the captain made a second announcement. This time there was no mistaking the urgency in his voice. I could make out his thinly veiled alarm, even above the wailing of the fractious toddler in the row behind me. If there was a doctor on board, could they please make themselves known to the cabin crew?

By now, a plastic tray containing my dinner had materialised. I froze, torn for a microsecond between a sense of vocation and the green chicken curry sitting in front of me. I sighed and pressed the call button.

A young stewardess appeared, panic etched into her perfect make-up. “Follow me, please,” she said, her pencilled eyebrows tangled in a frown.

Somehow, I managed to extricate myself from the blanket that had lassoed my ankles together. Stumbling into the aisle like a drunk evicted from a bar, I straightened my non-crease walking trousers and attempted to tame my wayward hair. So much for a professional persona. They’d have to take me as they found me. I casually flicked a piece of chicken curry from my left breast and hoped no-one would notice my bunions, tented beneath my elastic flight socks.

A knot began to tighten in my stomach as I followed the stewardess towards the back of the plane. Relax, I tried telling myself. Someone will have splashed hand soap in their eye or stubbed a toe on the drinks trolley. If I timed it right, I would arrive just behind a team of emergency physicians, all travelling on the same flight to a conference.

A small crowd had gathered in the aisle. As I arrived, they parted like a shoal of startled fish to reveal a pair of feet emerging across the threshold of the toilet cubicle. But instead of the proverbial traveller left robbed and beaten on the road to Jericho, I found a young backpacker slumped altogether less biblically over the pan of the economy class toilet. His bloated face — what I could see of it above the white porcelain bowl — was the colour of a boiled lobster and his gastrointestinal system was attempting to expel his in-flight meal simultaneously from both ends.

“He had the beef,” the stewardess added.

“The beef is trying to kill him,” I muttered.

“What? Am I going to die?” wheezed the backpacker, terror briefly prising his oedematous eyelids apart.

“Of course not,” I replied. Not if I could pull myself together and focus.

I was painfully aware how long it had been since I’d handled a life-threatening medical emergency, let alone an acute anaphylaxis aboard a 747-400. Perhaps I’d become complacent lately, signing sick notes and writing referrals to other doctors. I could perform a Pap smear with my eyes closed. Fat lot of good that would do me right now. I had to go back to basics.

Airway, breathing, circulation.

I tried to avoid the anxious glances from the cabin crew as they manoeuvred their trolleys around the makeshift resuscitation area. The backpacker’s body continued to swell and his fingernails tore at angry welts, leaving vivid red trails of blood down his forearms. I tried taking his blood pressure, but all I could hear was a thud-thud-thud that I recognised as my own galloping pulse.

The plane’s medical kit turned out to be surprisingly well equipped. My relief was short-lived, however, as I examined several identical glass vials. The dim light of the toilet cubicle was woeful and I struggled to read the drug names on the outside of the vials. The letters danced in front of my eyes like twerking insects. With a man’s life hanging in the balance, I turned to the audience and with all the authority of a surgeon demanding a scalpel, I held out my hand.

“Reading glasses!”

The elderly gentleman who was next in line for the toilet plucked a pair of half-moon spectacles from his face and placed them into my outstretched palm. The magnification was much stronger than I needed and, as I fought to regain my equilibrium, I had a sudden urge to curl up on the floor next to my patient.

With valuable seconds ticking away, I managed to identify the adrenaline vial, broke off the lid and started to draw up the clear liquid into a syringe.

How many millilitres was 0.3 mg again?

A doctor had once saved a passenger’s life on a flight by improvising with a coat hanger and a ballpoint pen. Here, I was struggling with the simplest of mental arithmetic. It was time to face facts. I was past my best, capable of little more than totting up the score on a par 4.

Yet medicine had been the one constant in my life. Two husbands and three children had come and gone. I’d formed more enduring relationships with some of my patients than with either of my spouses. My own narrative was written in the lives of people who had never even used my first name. Exchanging a lifetime of knowledge and wisdom for a world of coffee mornings and daytime television filled me with despair.

“0.3 mg of 1:1000 is 0.3 mL,” whispered a tiny voice inside my head.

I plunged the needle into the backpacker’s thigh. Almost immediately, the wheezing subsided and the rash began to fade. A smile crept into the corners of the young man’s swollen lips.

“Thank you, doctor,” he said.

I slumped back against the cubicle door next to my patient. There was a ripple of muted applause from the other passengers, no doubt relieved to find another toilet cubicle free at last. Presently, the backpacker returned to his seat and I realised that I would never see him again. By the time he made it home with a head full of adventures and a pile of dirty laundry, the episode on the plane would be nothing more than an amusing travel anecdote. For me, however, it spelled out what it meant to be a doctor. The lives touched in a moment of shared intimacy. The trust, the duty and, above all, the privilege.

Returning to my seat, I climbed over the hirsute hipster and slipped in next to the snoring businessman. His crescendo of porcine rumbles was punctuated by periods when he appeared to stop breathing altogether. I debated whether to wake him and recommend a sleep study, but thought better of it. Instead, I picked up the duty-free brochure and pressed the cabin crew call button once more.

“I’d like a bottle of this, please,” I said pointing to a special edition champagne bottle.

It was time to celebrate. Not my retirement, nor even the imminent arrival of my first grandchild, but a new beginning. A fresh chapter. Far from winding down, I now realised it was time for a real adventure. Besides, I’d always fancied the idea of a career in expedition medicine. All I had to do was squeeze my bunions back into those hiking boots.