Subscribe
×

Preference: Obstetrics and gynaecology and women's health

663

This bondage isn’t right

BY DR JOHN ZORBAS, CHAIR, AMA COUNICL OF DOCTORS IN TRAINING

There’s a key difference between bondage and bonding. One is a contract between two or more parties, requiring informed consent, and designed for the mutual benefit of all involved. The other is a terribly flawed stick that the Australian Government seems intent on bashing medical graduates with, in a poorly informed attempt to provide a rural workforce.

In Australia, we have two medical bonding programs: the Bonded Medical Places (BMP) scheme and the Medical Rural Bonded Scholarship (MRBS). There are several different versions of these schemes, if you count the number of different contracts that now exist since their inception, but they can broadly be summarised as follows. The BMP scheme provides participants with a Commonwealth Supported Place (CSP) in medical school in exchange for a return of service of one to six years in rural and regional Australia. The MRBS scheme provided participants with a CSP in medical school and by the time it was axed a scholarship of $26,310 a year in exchange for six continuous years of work as a specialist in rural and regional Australia. Sounds simple enough, but the more you dig, the more you realise just how bad a deal this is for these future doctors and the patients they’re supposed to be serving.

You see, the first major flaw in this plan is that bonding just doesn’t work. Funnily enough, if you force someone to do something on your terms in an uncertain and inflexible manner, it turns out that people don’t appreciate the experience and they don’t come back. When bonding in medical school was first conjured up, the AMA provided evidence that similar schemes overseas, especially in North America, had failed to provide any form of sustainable medical workforce. More than 13 years have now passed and an exceedingly small number of scheme participants have completed their return of service. In fact, more participants have withdrawn or breached their agreement than those who have completed their return of service. Not exactly a ringing endorsement.

Compare this with the other measures and programs that are supported by the AMA. We know that having a rural background significantly increases your chance of going rural, and we have strongly supported increasing the quota of students from rural backgrounds. We floated the idea of Regional Training Networks in 2014, to help allow those who wanted to work and stay rural obtain fellowship in a more sustainable manner and reduce infrastructure duplication in what is already a resource poor area of medical training. We supported the Prevocational General Practice Placements Program and, following its abolition by the Abbott Government, subsequently developed an alternative proposal for a Community Residency Program (CRP), to enable doctors to have meaningful rural experiences in their pre-vocational years, while they work out exactly what career they want to pursue. And we have long supported an increased rural focus in the Specialist Training Program (STP), allowing registrars to be adequately funded to work in rural areas on progression to fellowship. It’s a suite of measures that encourages positive experiences and supports trainees along their often complicated and difficult path.

But the Government has chosen to focus on draconian bonding schemes. Let’s explore the MRBS for a second, mostly as initially on paper it looks very attractive. You take a 17-year-old undergraduate student and you promise them $26,310 tax free and a place in medical school for a return of service. Sounds reasonable. Except what 17-year-old understands Medicare? Hell, how many healthcare workers and bureaucrats even understand Medicare? Do we adequately explain to them that leaving the scheme will result in a 12-year ban from Medicare, effectively killing their medical career there and then, simply because of a change in their life situation and circumstances? Do we explain to them that as they train to become a rural general practitioner, they will be effectively forbidden from working in the city for short periods of time, preventing them from upskilling in crucial rural skill sets such as emergency medicine, obstetrics and anaesthetics? Do we explain to the orthopaedic trainee that they only have 16 years from the start of medical school to complete their requirements? Caveat emptor is one thing, but conscriptive blackmail is another.

And even if you are one of the few to complete your return of service, just how happy will you be at the end of it all? What doctor, having had to deny themselves the opportunities of personal and professional development at the behest of such an authoritarian scheme, will look kindly on rural Australia? When you take away mastery, autonomy and purpose, you’re left with a bitter, angry human. That’s not the kind of person that rural Australia deserves.

The AMA Council of Doctors in Training is continuing to lobby government to adjust the BMP and MRBS for the good of its participants and the Australian public that it purports to serve. Nobody is arguing that a return of service isn’t owed, but it certainly shouldn’t function like this. If you or someone you know is affected by these schemes, we’d like to hear about it. Please contact me at cdt.chair@ama.com.au and let’s see if we can’t loosen the bureaucratic nipple clamps, just a little bit.

 

Processed meats need a closer look

OPINION
By Dr Alphonse Roex and Dr Heleen Roex-Haitjema

In October 2015, the authoritative International Agency for Research on Cancer (IARC) confirmed that processed meat causes cancer and red meat is a probable carcinogen (Table 1.1,2 ).

IARC Carcinogenic Classification Groups

Likelihood to cause cancer in humans

Type of meat

Examples

1

Causes cancer

Processed meats

Bacon, ham, sausages, hot dogs, hamburgers, ground beef, mince, corned beef, beef jerky, canned meat, offal and blood

2a

Probably causes cancer

Red meats

Meat from mammals: pork, veal,  beef, bull meat, sheep, lamb, horse meat and,

Meat from hunting: wild boars, deer, pigeons, partridges, quail and pheasants

Table 1. Based on the IARC’s data on the carcinogenicity of processed meat and red meat.1,2

The IARC assessed more than 700 epidemiological studies regarding red meat and more than 400 provided data on processed meat. The IARC estimates that worldwide the consumption of diets high in processed meat results in approximately 34,000 deaths annually and diets high in red meat in 50,000 avoidable cancer deaths per year. Eating an extra portion of 50 grams of processed meat daily increases the relative risk of colorectal cancer by 18 per cent.

The strength of evidence that processed meat is a carcinogen is comparable with tobacco smoking and asbestos.3,4

Diets high in animal protein show a 75 per cent increase in total mortality, a 500 per cent increase in diabetes, a 400 per cent increase in cancer risk, and produce significantly higher levels of IGF1, a potent cancer-promoting hormone.5

Chronic diseases are responsible for considerable human suffering and contribute heavily to the burden of disease nationally. Australia’s ever increasing total healthcare expenditure has in 2016 for the first time surpassed 10 per cent of its Gross Domestic Product. It is estimated that 55-60 per cent of this total is spent on chronic disease management.

Nearly two years have passed since the World Health Organisation’s report on the categorisation of processed animal products as carcinogenic. The time has come that we doctors take the initiative to inform our citizens and create systems, processes and policies to protect our patients and communities from further harm from such known carcinogens. We were finally moved to show united leadership 60 years ago in regards to smoking. Ultimately, after roughly 7000 scientific publications showing the relationship between smoking and lung cancer, healthcare providers became advocates for the best available medical evidence trumping the lures of a treasured habit for many of their patients (and indeed, fellow colleagues).

The American Medical Association in the USA has led the way by calling on hospitals there to improve the health of patients, staff and visitors by (1) providing a variety of healthful food, including plant-based meals that are low in fat, sodium and added sugars, (2) eliminating processed meats from menus and (3) providing and promoting healthful beverages.6,7,8

Springmann et al. estimated the effects of consuming less – or no – animal products on global population health should a transition to a more plant-based diet be made leading up to 2050. Conclusions reached were a reduction in premature deaths, abundant economic benefits and reduced greenhouse gas emissions. Table 2.9

Healthier diets compared to present omnivorous diet

Characteristics diets

Human health benefits:

millions of premature deaths avoided

Economic valuation: value-of-statistical life approach.

Trillion of AUD saved per year

Healthy Global Diet (WHO)

Less meat and sugar; More vegetables and fruit

5.1

27.6

Vegetarian

Minimal animal products: dairy and eggs only

 

7.3

36.8

Vegan

No animal products: plant-based only

8.1

39.4

 

Table 2. Human lives and money saved in 2050 if the world population would adapt more healthful diets. Based on publication M Springmann et al.9

We understand that our AMA is aware of the issue and we are engaging with its Public Health team.

The time for compassionate action and leadership on this important issue by the Australian medical profession has arrived. All medical administrators, procurement officers, caterers and doctors (in association with registered dietitians) should then feel encouraged, empowered and supported to play a role in implementing the elimination of processed meats in medical institutions.

 

Views expressed in the above Opinion piece are those of the authors and do not reflect official policy of the AMA.

The authors’ credentials are listed below:

Dr Alphonse Roex MD PhD, FRANZCOG

Senior Consultant Obstetrics and Gynaecology The Lyell McEwin Hospital South Australia
Senior Lecturer, The University of Adelaide
Medical degree: Utrecht University, the Netherlands
Specialist degree and PhD: Free University Amsterdam, The Netherlands
Member PCRM (Physicians Committee for Responsible Medicine (Washington DC USA)
International presenter on Nutrition and Health

 

Dr Heleen Roex-Haitjema, Paediatrician (not practising)
Certificate in Plant-Based Nutrition, Cornell University, New York
Certified Food for Life Instructor, The Physicians Committee for Responsible Medicine, Washington DC
Medical degree: Utrecht University, The Netherlands
Specialist degree: Free University Amsterdam, The Netherlands.
Member PCRM (Physicians Committee for Responsible Medicine (Washington DC USA)
International presenter on Nutrition and Health.

References

  1. Bouvard V, Loomis D, Guyton KZ et al. on behalf of the IARC Monograph Working Group. Carcinogenicity of consumption of red and processed meat. Lancet Oncology 2015.
  2. http://publications.iarc.fr/Book-And-Report-Series/Iarc-Monographs-On-The-Evaluation-Of-Carcinogenic-Risks-To-Humans. Volume 114 (2015).
  3. IARC Monographs on the Evaluation of Carcinogenic Risks to humans. Volume 83 (2004) Tobacco Smoke and Involuntary Smoking.
  4. IARC Monographs on the Evaluation of Carcinogenic Risks to humans. Volume 100C. (2012) Asbestos.
  5. Levine ME et al. Low Protein Intake is Associated with a Major Reduction in IGF-1, Cancer, and Overall Mortality in the 65 and Younger but Not Older Population. Cell Metabolism 2014;19:407-17.
  6. https://janeunchained.com/2017/06/23/ama-comes-out-against-serving-processed-meats-in-hospitals/
  7. http://www.pcrm.org/nbBlog/american-medical-association-passes-healthy-food-resolutions
  8. https://wire.ama-assn.org/ama-news/ama-backs-comprehensive-approach-targ…
  9. Springmann M. et al. Analysis and valuation of the health and climate change co-benefits of dietary change PNAS doi:10.1073/pnas. 2016; 1523119113.

 

 

 

[Comment] Offline: NCDs—why are we failing?

Why is the global health community failing to respond effectively to the rising burden of non-communicable diseases (NCDs)? The answer can be summed up in one word—fear. Fear of a species-threatening pandemic. A pervasive fear that has displaced all other health concerns. Anxiety among political elites is causing a recalibration of priorities among global health leaders. In his first speech to staff in Geneva this month, WHO’s new Director-General, Tedros Adhanom Ghebreyesus, named four urgent issues: health emergencies; universal health coverage; women’s, children’s, and adolescents’ health; and climate change.

[Viewpoint] The medical education system in Israel

During the British administration of the Palestine Mandate, before the foundation of Israel in 1948, the Jewish community built hospitals, developed a network of clinics, and established a fairly extensive coverage of health care.1 Yet not until 1949 was the first medical school founded at the Jerusalem-based Hebrew University of Jerusalem. Although much of the funding came from the Hadassah, the Women’s Zionist Organization of America, most of the teaching staff were, at first, refugees who had received their medical training in Germany before migrating to Palestine.

[Viewpoint] Women and health in Israel

WHO defines health as “a complete state of physical, mental and social wellbeing, and not merely the absence of disease or infirmity”.1 This broad definition includes physical and mental health, but also socioeconomic standing and access to resources such as health care and safety. In this Viewpoint, we present a holistic picture of women’s health within the Israeli societal and cultural context, taking these factors into account.

Medical role models honoured at AMA National Conference

AMA Woman in Medicine

Dr Genevieve Goulding, an anaesthetist with a strong social conscience and a passion for doctors’ mental health and welfare, has been named the AMA Woman in Medicine for 2017.

Described by her colleagues as a quiet achiever, ANZCA’s fourth successive female President, Dr Goulding has used her term to focus on professionalism, workforce issues, advocacy, and strengthening ANZCA services for Fellows and trainees.

Dr Goulding is a founding member of the Welfare of Anaesthetists Group, which raises awareness of the many personal and professional issues that can affect the physical and emotional wellbeing of anaesthetists throughout their careers.

Dr Michael Gannon, who presented the award at the AMA National Conference, said that Dr Goulding was a role model for all in the medical profession.

“She has raised the profile and practice of safe and quality anaesthesia. She is committed to ensuring patients – no matter their background or position – can rely on and benefit from our health system,” Dr Gannon said.

Dr Goulding continues to effect change with her work on the ANZCA Council and on the Queensland Medical Board, her numerous positions with the Australian Society of Anaesthetists, and her current work with the Anaesthesia Clinical Committee of the MBS Review.

Excellence in Healthcare Award

This year, AMA recognised a true medical leader Dr Denis Lennox, who has made an outstanding contribution to rural and remote health care in Queensland, and to the training of rural doctors.

Dr Lennox has had an extraordinary career since starting as a physician and medical administrator in his home town of Bundaberg in the 1970s. 

Dr Gannon said that Dr Lennox had earned this award through his vision and revolutionary training of rural general practitioners and specialist generalists.

“Dr Lennox has been responsible for real workforce and healthcare improvements in all parts of Queensland, particularly through the Queensland Rural Generalist Program which has delivered more than 130 well-prepared Fellows and trainees into rural practice across Queensland since 2005 – an incredible achievement,” Dr Gannon said when presenting the award.

An Adjunct Associate Professor at James Cook University and Executive Director of Rural and Remote Medical Support at Darling Downs Hospital Health Service, Dr Lennox prepares to retire from 40 years of public service.

AMA Women’s Health Award

A nurse and midwife in Darwin, Eleanor Crighton has been awarded the Women’s Health Award – an award that goes to a person or group, not necessarily a doctor or female, who has made a major contribution to women’s health.

Ms Crighton won the award for her outstanding commitment to Indigenous women’s health. 

Dr Gannon when presenting the award to Ms Crighton said that she had made a real difference to the lives of Aboriginal women in the greater Darwin region through them gaining access to affordable family planning.

“As an obstetrician, I know the importance of the work of women’s health teams, particularly in Aboriginal community-controlled organisations like Danila Dilba,” Dr Gannon said.

As the Women’s Health Team leader at Danila Dilba Health Service, Ms Crighton has shown her commitment to Indigenous health by pursuing additional studies and gaining personal skills with the aim of filling gaps in health care services.

Ms Crighton has also worked tirelessly to raise awareness of Fetal Alcohol Spectrum Disorder, and has started training Danila Dilba’s first home-grown trainee midwife, at the same time as pursuing her own Nurse Practitioner studies. 

Meredith Horne 

13 Reasons Why – suicide the last taboo

13 Reasons Why is a Netflix TV drama about a troubled teenager who takes her own life, having beforehand recorded 13 tapes explaining the ‘reasons’ for her suicide. The show is based on ayoung adult best-selling novel by Jay Asher.

This TV show has generated controversy over its theme of teen suicide, depicting suicide ‘method’, and the graphic depiction of rape. Debate on the program content, and the reaction from suicide prevention and mental health organisations, has created an international furor. Headspace, the National Youth Mental Health Foundation providing early intervention mental health services to 12-25 year olds, issued a warning about the show’s “dangerous content” and labelled the program irresponsible for depicting suicide methods. Headspace said it “exposes viewers to risky suicide content and may lead to a distressing reaction by the viewer, particularly if the audience is children and young people.” A critic on MamaMia, Australia’s largest independent women’s website, described the show as “a suicide manual”.

Other critics point out that 13 Reasons Why does not conform to the guidelines on safe and responsible reporting on suicide. Mindframe, who provide information to support the reporting, portrayal and communication of suicide, said the TV drama “sends the wrong messages about suicide risk and the show does nothing to encourage help-seeking.”

There is no question that 13 Reasons Why is confronting viewing; with graphic messages and imagery of suicide methods. Most troubling for many suicide and mental health experts, it does not present options for troubled teens. This is the view of leading cultural magazine Rolling Stone: “Had 13 Reasons Why showcased other forms of outreach, like therapy, teens watching it might realize that there is always an option that doesn’t include self-harm.”

In a Vanity Fair interview, scriptwriter Nic Sheff (who incidentally has spoken of his own suicide attempts) defended the show’s direct approach: “Facing [suicide] head-on … will always be our best defense against losing another life. We need to keep talking, keep sharing, and keep showing the realities of what teens in our society are dealing with every day. To do anything else would be not only irresponsible, but dangerous.”

Many websites discussing the pros and cons of this controversial series agree that it is leading to a wider discussion about teenage issues and how parents can talk with the children about suicide and self-harm. The Sydney Morning Herald reviewer described the show as an “unflinching but unexploitative portrayal … 13 Reasons Why is extremely tough viewing at times … It’s strong stuff that works hard to shatter pernicious assumptions.” The New York Times commented: “The overall message — one that probably appeals to teenagers — is that it’s possible to figure out why someone takes her own life, and therefore to guard against it happening to others.” The Guardian, by contrast, deplored the series as “horrifying”. The New Yorker, in a scathing assessment, raised a crucial issue, namely that the series does not address mental illness, and presents “suicide as both an addictive scavenger hunt and an act that gives … glory, respect, and adoration that was denied in real life.”

The debate over 13 Reasons Why is, in essence, whether teenage suicide is a subject matter to be graphically depicted in a popular teen drama, whether the modern appetite for ‘binge’ watching allows young viewers to properly understand and discuss the issues (and seek appropriate counseling and guidance), and whether a slick, glossy TV series can inadvertently present suicide as ‘normal’, even glamorous.

Conversely, as others have advanced, we shouldn’t make suicide, especially youth suicide, a taboo issue. By bringing it out into the open (and the show is based on a popular book that caused few ripples when it was released) we open a gateway into a most confronting and all too real issue for young people.

It’s too early to assess the impact of this show on young viewers, but it does appear that how we discuss youth suicide has been changed.

Simon Tatz
Director, Public Health   

[Case Report] Targeted enrichment sequencing in two midterm pregnancies with severe abnormalities on ultrasound

A 29-year-old woman, with a history of medically justified termination for severe fetal anomalies at 23 weeks’ gestation in 2014 and a miscarriage at 9 weeks’ gestation in 2015, presented to our obstetric department in April, 2016, at 20 weeks’ gestation. Ultrasonography showed several fetal anomalies including polyhydramnios, nuchal and general oedema, hepatomegaly, and general growth restriction. The patient and her partner had no similarly affected relatives and no history of consanguinity. After discussion with the gynaecologist, human geneticist, and a specialist medical psychologist from the department of obstetrics and gynaecology, and patient counselling, the pregnancy was terminated at 23 weeks because of the fatal prognosis.

[Correspondence] Health professional associations and industry funding—reply from Talukder et al

A breast milk substitutes (BMS) act has been in existence in Bangladesh since 1984. Even before this BMS act was strengthened in 2013, the Bangladesh Paediatric Association, the Bangladesh Neonatal Forum, the Bangladesh Perinatal Society, as well as the Obstetric Gynaecology Society of Bangladesh had stopped taking financial support from BMS producers. This is despite the fact that Bangladesh is a low-to-middle-income country with a gross domestic product per capita that is 36-times less than that of the UK.