News briefs

One-handed people point way to new brain theory

In people born with one hand, the brain region that would normally light up with that missing hand’s activity lights up instead with the activity of other body parts — including the arm, foot, and mouth — that fill in for the hand’s lost function, according to an international study published in Current Biology. Scientists from Israel and the UK say that the discovery could change fundamental understanding of how the brain is organised. The researchers studied 17 people who lacked a hand from birth along with 24 matched, two-handed controls. A video of each participant was recorded while they completed five everyday tasks, such as wrapping a present or handling money, to see how they went about it. Participants were also asked to move various parts of their bodies while their brains were scanned using functional magnetic resonance imaging. “We found that the traditional hand area gets used up by a multitude of body parts in congenital one-handers,” said researcher Tamar Makin, from University College London. “Interestingly, these body parts that get to benefit from increased representation in the freed-up brain territory are those used by the one-handers in daily life to substitute for their missing-hand function — say when having to open a bottle of water. In intact participants, all this is carried by the non-dominant hand,” she continued. “But the fact that we see such a strikingly different representation in that area in congenital one-handers may suggest that this is not actually the hand area. If true, this means we’ve been misinterpreting brain organisation based on body part, rather than based on function. The implications, if this interpretation is correct, are massive.” Her hope is to find a way to encourage the brain to represent and control artificial body parts, such as a prosthetic arm, using the brain area that would have controlled the missing hand.

doi: http://dx.doi.org/10.1016/j.cub.2017.03.053

Australian ad linking alcohol with cancer is a winner

Australian-led research published in BMJ Open has found that the effectiveness of alcohol harm reduction campaigns may be improved by directly communicating alcohol’s long term harms to the general adult population of drinkers, along with drinking guidelines. Researchers from the Cancer Council Victoria, Curtin University and Ohio State University in the US, randomly assigned 2174 Australian adult weekly drinkers to view three of 83 English-language alcohol harm reduction ads. Each ad was viewed and rated by a mean of 79 participants. After viewing each ad, participants reported the extent to which they felt motivated to reduce their drinking. Ads were ranked from most to least motivating using predicted means adjusted for demographic characteristics and alcohol consumption. The researchers then compared the characteristics of the top-ranked 15% of ads (most motivating) with the middle 70% and bottom 15%. An Australian ad about the link between alcohol and cancer (“Spread”) was most motivating, whereas an ad that encouraged drinking water instead of beer (“Add nothing”) was least motivating. Top-ranked ads were more likely than other ads to feature a “why change” message and less likely to carry a “how to change” message, more likely to address long term harms, more likely to be aimed at the general adult drinking population and more likely to include drinking guidelines. There was substantial overlap in top-ranked ads for younger versus older adults, men versus women and high risk versus low risk drinker subgroups. With a mean score of 3.77, the highest ranked ad was “Spread”, developed and funded by the Western Australian state government as part of their Alcohol and cancer mass media campaign. The second most effective ad — “What you can’t see” (mean score of 3.62) — was from the same Western Australian campaign. The authors acknowledge that further research is needed to determine whether the motivation measure predicts subsequent reduced alcohol consumption.

doi: http://dx.doi.org/10.1136/bmjopen-2016-014193

Budget 2017-18 from a public health perspective

Analyses of federal budgets are typically couched in clichés. Government’s talk about jobs and growth, initiatives, priorities and investments; while oppositions and minor parties respond with the language of not enough, missed opportunities, disappointments and failures.

In regard to public health and health prevention, the 2017-18 Coalition Budget is all of these things.

There are many welcome and positive public health initiatives in the Budget. The Government has listened to the AMA and is investing $5.5 million into an immunisation awareness campaign. There is a further $14 million to expand the National Immunisation Plan to provide catch-up vaccinations to 10-19 year-olds who missed out on childhood vaccinations. These are measures the AMA has been advocating directly with the Government for.

New mental health funding is also welcome. There is $9 million for a telehealth initiative to improve access to psychologists for people living in rural and remote areas, and an extra $15 million for mental health research initiatives. The big ticket item is $80 million of additional funding to maintain community psychosocial services for people with mental illness who do not qualify for the NDIS. This is a very good measure and shows that Health Minister Greg Hunt has taken on-board concerns the AMA and others raised about people falling through the cracks that exist between the NDIS and State and Territory community services.

However, this funding is contingent on the States and Territories matching the Commonwealth’s commitment. The Government said it will allocate the entire $80 million, even if some States or Territories do not sign up to the matched funding offer. In other words, the money will only go to those jurisdictions who offer a matched dollar-for-dollar commitment. What we don’t know is how these funds will be allocated and what happens if a State or Territory does not sign up or provide new money for psychosocial services. Will the people in those jurisdictions be left with no psychosocial supports? I suspect that the Australian Health Ministers’ Advisory Council (AHMAC), the advisory and support body to the COAG Health Council, may be the entity that negotiates this funding measure.

The mental health sector has been encouraged by this Budget and Minister Hunt’s dedication to mental health reform. Preventative health didn’t get the same attention as mental health in this budget. The Prime Minister told the National Press Club in February: “In 2017, a new focus on preventive health will give people the right tools and information to live active and healthy lives.”

There was, therefore, an expectation that this Budget would deliver in key areas of preventative health, most importantly in tackling obesity. The AMA has been calling for a range of initiatives and measures that are urgently needed to address the rise in obesity, and in this respect the cliché of ‘missed opportunity’ is applicable.

There is a $10 million initiative to establish a Prime Minister’s Walk for Life Challenge and a further $5 million for a GPs Healthy Heart partnership with the RACGP to support GPs to encourage patients to lead a healthy lifestyle. These are small but good measures. The AMA has been calling for a national obesity prevention strategy that recognises obesity as a complex problem that can only be addressed through a broad range of measures. The measures announced in the Budget are a start, but fall well short of the funding for community-based initiatives and restrictions on the marketing of junk food and sugary drinks to children that we say are needed to address obesity.

There was no National Alcohol Strategy or any measures that help Australians manage the misuse and abuse of alcohol, and the alcohol-fuelled violence that emergency department staff know all too well.

There were no measures or initiatives that address climate change and health.

The Government has indicated that there will be a ‘third wave’ of preventative health measures, possibly in the next budget. We hope so, because investment in preventative and public health initiatives is smart, cost-efficient and a benefit to future generations.

Simon Tatz
Director, Public Health

Budget at a glance

Significant health measures in the Budget

Lifting the freeze on the indexation of the Medical Benefits Schedule.
National Disability Insurance Scheme to be fully-funded by a 0.5 percentage point Medicare Levy increase from 2019.
Legislation to guarantee Medicare and the PBS.
Hospital funding increased by $2.8 billion over four years.
$1.4 billion to be invested in health research over four years.
$1.2 billion in new medicines to be made available

Other big measures in the Budget

Levy on big banks’ liabilities to raise $6.2b.
Negative gearing and depreciation changes to raise $2.1b.
First home buyers can get a deposit by salary sacrificing into super.
$300m to the Australian Federal Police to fight terrorism.
$10b to establish a National Rail Program.
Foreign worker levy to raise $1.2b over four years.
$18.6b for Gonski education funding.
$5.3b over 10 years for Western Sydney Airport Corp.
$8.4b for Melbourne to Brisbane Inland Rail Project.
$4b tax crackdown on multinationals.
$1b National Housing Infrastructure Facility for new homes
Federal Government to take control of Snowy Hydro
$90m to secure gas resources for domestic use

The Budget deficit is $29.4 billion in 2017-18, with the Government forecasting a return to surplus by 2020-21.

More health measures in the Budget

The following is extracted from the Government’s Budget overview document

Budget 2017-18 Guaranteeing the essentials for Australians

A healthy Australia

Providing affordable medicines and investing in mental health and public hospitals. Continuing to provide access to new medicines. Australians will continue to have affordable access to new medicines, with the Government meeting its commitment to list cost-effective medicines on the PBS. In this Budget, $1.2 billion will be provided for new and amended listings on the PBS, including more than $510 million for Sacubitril with valsartan (Entresto®).

Since 2013, the Government has listed more than 1400 new or amended medicines on the PBS averaging 32 new and amended listings a month. These new listings include breakthrough medicines to treat breast cancer, Hepatitis C, cystic fibrosis and severe asthma. Investing in mental health More than $115 million will be invested in mental health, including $80 million for psychosocial services, $9.1 million in funding for rural telehealth psychological services, $15.0 million for priority mental health research and $11.1 million to address suicide hotspots. The Government is providing further mental health support for veterans and their families, by investing $9.8 million to fund pilot programs to improve mental health services and support suicide prevention efforts for veterans.

The Government will also provide $33.5 million to ensure anyone who has served a single day in the fulltime Australian Defence Force can seek treatment for mental health conditions and $8.5 million to expand access to counselling services for veterans’ families. Funding public hospitals Record levels of financial assistance will be provided to State Governments to deliver the public hospital services Australians need. Commonwealth payments to the States for public hospitals continue to grow strongly, from $13.8 billion in 2013-14 to an estimated $22.7 billion in 2020-21. On current Budget forecasts, an additional $7.7 billion will be provided to the States and Territories from 2016-17 to 2020-21 giving effect to the Heads of Agreement on public hospital funding signed by COAG on 1 April 2016. Medical Research In this Budget the Government has committed new funding for medical research, $65.9 million will be provided from the Medical Research Future Fund to support preventative health research, clinical trials and breakthrough research investments. In addition, $5.8 million will be provided for research into childhood cancer.

Full and sustainable funding for the National Disability Insurance Scheme

The Commonwealth will fully fund its contribution to the National Disability Insurance Scheme, giving Australians with permanent and significant disability, and their families and carers, certainty that this vital service will be there for them into the future. To help fund the scheme, the Government is asking Australians to contribute, with the Medicare levy to be increased by half a percentage point from 2 to 2.5 per cent of taxable income. This means that one-fifth of the revenue raised by the Medicare levy, along with any underspends within the NDIS, will be directed to the NDIS Savings Fund. The Government’s decision to increase the Medicare levy from 1 July 2019 reflects the fact that Australians have a role to play, in accordance with their capacity, to ensure this important program is secure for current and future generations. The NDIS is on track to be fully rolled out from 2020. States and Territories will be expected to maintain their commitment and contribution to the NDIS and continue to support mainstream services for people with disability. More than $200 million will be provided to establish an independent NDIS Quality and Safeguards Commission to oversee the delivery of quality and safe services for all participants of the NDIS. The Commission will support NDIS participants to exercise choice and control, ensure appropriate safeguards are in place, and establish expectations for providers and their staff to deliver quality supports. The Commission will perform three core functions: regulation and registration of providers; complaints handling; and reviewing and reporting on restrictive practices.

The Government will also invest $33 million over three years to help existing service providers in the disability and aged care sectors grow their workforce. This package will deliver jobs for Australians in rural, regional and outer suburban areas that require strong workforce growth as a result of the NDIS roll out. The scheme’s cost sustainability is being examined in the Productivity Commission’s review of NDIS costs. Due to be released in September 2017, it will examine factors affecting costs and will help inform the final design of the full scheme.

Medical Students say Budget missed opportunity for workforce investment

The Australian Medical Students’ Association (AMSA) welcomes certain elements of the federal budget, but is concerned by the Government’s lack of investment in medical education.

While the Budget will continue to fund the Specialist Training Program and support rural background recruitment, cuts to funding will impact quality of medical education.

AMSA President Rob Thomas said he was pleased to see there will be no increases in medical student places from new medical schools, and also that funding will continue for the Commonwealth Medical Internships Program.

“However, this Budget was a real opportunity for the Government to contribute to the future health workforce by increasing specialist training in regional and rural areas and ensuring medical schools are adequately funded,” he said.

“AMSA has called for more places in the Specialist Training Program to be delivered in rural and regional areas, as this is required to ensure a sustainable rural medical workforce.

“The Budget delivers no net increase overall, and a marginally increased proportion from 39 per cent rural places currently to 45 per cent by 2021.

“This means that those who want to work rurally will continue to have to undertake the majority of their training in metropolitan areas, decreasing the likelihood that they will be rural doctors in the long-term.”

Mr Thomas said AMSA was relieved university fee deregulation is off the table, but that the higher education reform announcement posed new concerns.

“According to the Medical Deans of Australia and New Zealand, funding for medical education falls short by $23,500 per student per year. This discrepancy places major strains on the training of future doctors in Australia,” he said.

“By reducing Commonwealth base funding for medical education by 2.5 per cent in each of 2018 and 2019, this figure will only expand, impacting the quality of basic medical education.”

AMSA welcomes the Government’s commitment of $5 million over the next two years to Orygen, the National Centre of Excellence in Youth Mental Health, and a further $10 million to the Black Dog Institute and Sunshine Coast Mind and Neuroscience.

“With medical students facing a disproportionate burden of mental illness, the Government’s increased funding for mental health research is to be applauded,” Mr Thomas said

“We are hopeful that a proportion of this funding will be devoted to the research of university student mental health.”

Chris Johnson

Changing our professional culture – what can we do as individuals?

BY DR KATHERINE KEARNEY

Culture is defined as the “total of human behaviour patterns and technology communicated from generation to generation” (New Webster’s Dictionary). How do you define yourself within the broad umbrella of medicine? Are you a doctor, and connect broadly with other doctors as colleagues, or do you feel a stronger association with your fellow nephrologists, cardiothoracic surgeons or general practitioners? Who do you consider your peers and your fellow professional representatives to the broader community? How does that influence your interaction with other doctors, other healthcare professionals and healthcare delivery systems?

Healthcare delivery is a team sport. Broadly speaking, our teams can be as large as our entire hospital operational staff, to “geriatrics team C” with a few consultants, a registrar and an intern. To make it easier for ourselves, we often choose to identify with those closest to us in personality and in daily interactions. I believe it is important to think about the broader profession and our professional culture. What is our professional culture, and what impact is it having on the health and wellbeing of doctors, broadly speaking?

Undoubtedly, medicine is a culture of high achievement and has always been so. High stakes selection processes are becoming universal given the enormous numbers of doctors in training entering the prevocational system as interns, approximately 3,300 in 2015 (MTRP report). It is becoming the norm that trainees have committed early, and committed fully to pursuing a wide range of extracurricular activities such as research, audits, extra qualifications like graduate diplomas or masters, sit on committees relevant to their future goals and have lofty achievements outside of medicine in their hobbies; climbing mountains, volunteer work, high level sporting achievements.

The pressure is immense, amongst a group that is naturally incredibly high achieving. I’ve certainly heard statements from tremendously successful senior colleagues that they would never have gotten onto their training pathway in the current era. Relentless accumulation of accomplishments does not necessarily make for a happy, fulfilled person nor a superior clinician – we see this in disconnects between CVs full of achievements and a lack of correlation with clinical success. I’m as guilty as anyone else at relieving my anxiety about the future of my career by punishing schedules of extracurricular activities. What are truly important achievements to us individually, and how can we bring clarity by appropriately setting personal and professional goals?

Throughout most training pathways, there are high stakes barrier assessments – some of which, such as physicians college exams, are only held on an annual basis. A failed assessment reverberates around hospital and medical community and has a huge impact on the trainee. With this increasingly competitively environment for training positions, as well as failing being challenging personally for those who’ve failed at little in their lives, it can feel like the this stumble means heading to the back of the pack. Differentiating clinical competence from assessment success is very important.

What can we do as individuals to change this perception? Firstly, challenge our own preconceptions about what the journey to success looks like. There are always dead ends and wrong turns, in choosing training pathways or places of employment.

There are many doctors with happy, fulfilled lives and careers who took the opportunity to change tack from surgical training or physician training to pursue general practice or radiology. These stories aren’t talked about enough. We can help each other raise our sights, see the forest for the trees, and change paths to something that is more fulfilling.

We can advocate for complete training programs in rural and regional areas. We can advocate for linking training pathways to workforce requirements, as well as better production and availability of data on what the actual workforce looks like – so we might be able to see our place within it.

Being a doctor is a lot more than just practicing medicine. We are part of a profession, and it’s up to all of us to contribute to making our profession a more supportive place to learn and grow.

[Editorial] Research integrity—have we made progress?

This month there will be two important anniversaries related to research integrity. The first is the 20 year anniversary of the Committee on Publication Ethics (COPE), celebrated at COPE’s European annual meeting in London, UK, on May 25. The second marks 10 years since the first World Conference on Research Integrity (WCRI) in Lisbon, Portugal, in 2007—to be held at the fifth WCRI in Amsterdam, Netherlands, May 28–31. More than 600 delegates will gather and present research on research integrity and debate current policies and initiatives, progress, and difficulties.

[Correspondence] What can WHO do to support research in LMICs?

To achieve improvements in global health, research is necessary to identify novel solutions to major public health issues. Implementation research is particularly relevant in view of the history of evidence-based practices being poorly or never implemented. Efforts spearheaded by The Lancet have demonstrated the potential impact of implementing practices shown to reduce mortality, alleviate and prevent morbidities, and improve quality of life.1–4

[Correspondence] The INFANT study—a flawed design foreseen

During the INFANT Study1 (March 21) application process in 2006–07 and since, concerns were formally raised regarding study design weaknesses by myself and some of the clinical investigators, clinical collaborators, and the National Institute for Health Research (NIHR) referees.2 The source of the concerns were two-fold.

Gender stereotypes not good enough to support embryo gender selection

A recent paper published in the Journal of Bioethical Inquiry fully supports the updated Assisted Reproductive Technology (ART) guidelines to not support the use of sex selection techniques for non-medical purposes.

Dr Tamara Kayali Browne, a lecturer in health ethics and professionalism at Deakin University, who wrote the paper, believes that: “Professional organisations and policymakers like the NHMRC should stand for evidence-based policy which promotes rather than undermines gender equality, and which promotes rather than undermines autonomy.”

The National Health and Medical Research Council (NHMRC) release of their revised Ethical guidelines on the use of assisted reproductive technology in clinical practice and research, 2017 (ART guidelines) maintained their advice that in Australia parents can only select the sex of their embryo if it is to prevent the transmission of a serious genetic condition.

The reasons are clear, Dr Browne believes.

“The evidence currently available has not succeeded in showing that the gender traits and inclinations sought are caused by a ‘male brain’ or a ‘female brain’,” Dr Browne said.

“Sex selection is not merely a symptom of gender essentialism but serves to perpetuate it.”

The ART guidelines provide contemporary ethical guidance and framework for the conduct of ART in the clinical setting and was overseen by the Australian Health Ethics Committee (AHEC), with advice from an expert working committee to oversee a number of complex ethical issues including sex selection for non-medical purposes and surrogacy.

The AHEC notes in the report that Victorian and Western Australian legislation currently prohibits sex selection for non-medical purposes.

All other jurisdictions are silent on the issue. The report expresses support for states and territories to enact uniform legislation

Meredith Horne