Rich countries have been urged to reduce their reliance on overseas-trained doctors and improve workforce planning to help address severe shortages of medical practitioners in developing nations.

A dramatic upsurge in the number of doctors has averted fears of a world-wide doctor shortage, but the Organisation for Economic Cooperation and Development said large numbers were flocking to wealthy nations from Africa, exacerbating problems with access to care among the poor.

According to the OECD report Health Workforce Policies in OECD countries: Right Jobs, Right Skills, Right Places, there were 3.6 million doctors practising among its member countries in 2013, up from 2.9 million in 2000 – a 24 per cent increase in just 13 years.

Much of this increase has been driven by a sharp expansion in medical school intakes and training programs.

Australia has been part of a global trend toward boosting medical school intakes – since 2004, the number of medical school places has soared by 150 per cent to reach more than 3700, creating problems further along the training pipeline, where there has not been a commensurate increase in capacity.

But the growth in doctor numbers has also been fuelled by recruitment from overseas.

The report found that 17 per cent of all active doctors working in OECD countries came from overseas, and though a third originated in other OECD nations, “large numbers also come from lower-income countries in Africa that are already facing severe shortages”.

While the United States and the United Kingdom are the two most popular destinations for overseas-trained doctors, Australia is among the most heavily reliant on them to help plugs gaps in the medical workforce.

They comprise about a quarter of all doctors working in Australia, and make up more than 40 per cent of those practising in rural and remote regions.

The OECD said this reliance was coming at a heavy cost to poor countries that were training doctors, only to see many of them emigrate rather than ease the local shortage.

OECD Secretary-General Angel Gurria said that with the threat of a global doctor shortage averted, it was time to focus attention on improving the distribution of the medical workforce to ensure all had access to high quality care.

“The evolving health and long-term care needs of ageing populations should stimulate innovation in the health sector, where attention should focus on creating the right jobs, with the right skills, in the right places,” Mr Gurría said. “Countries need to co-operate more to ensure that the world gets the strategic investments in the health workforce that are necessary to achieve universal health coverage and high-quality care for all.”

The AMA has anticipated the OECD’s call, late last year releasing a Position Statement recommending that Australia not recruit doctors from countries which have an even greater need for them.

Australia is already a signatory to the World Health Organisation’s Global Code of Practice on International Recruitment of Health Personnel, which calls for improved workforce planning to allow nations to respond to future needs without relying “unduly” on the training efforts of other countries, particularly low-income ones.

But some researchers have argued that not only would it be unfair to constrain the ability of doctors from poorer countries to choose where they would like to practice, but such restrictions could also have the perverse effect of discouraging people in these locations from considering a career in medicine, exacerbating the shortage of medical workers.

AMA Vice President Dr Stephen Parnis said that improved workforce planning was an “urgent priority”.

The Abbott Government abolished Health Workforce Australia and absorbed its functions within the Health Department, a move Dr Parnis condemned as short-sighted.

In its final report, the HWA confirmed that Australia had sufficient medical school places, and instead urged attention on improving the capacity and distribution of the medical workforce – a task that the AMA hopes the National Medical Training Advisory Network will be able to fulfil.

A particular concern is difficulties in recruiting and retaining doctors in rural and regional areas.

The OECD has urged countries to use a mix of financial incentives, regulations and technologies such as telemedicine to help reduce regional disparities in access to care.

The Federal Government has announced the establishment of 30 regional training hubs and an expansion of the Specialist Training Program, but the AMA has voiced doubts that these initiatives on their own will be enough, and has instead called for a third of all domestic medical students to be recruited from rural areas.

The Government has so far resisted the suggestion, and Health Minister Sussan Ley told the AMA Federal Council last month that she was “not interested” in imposing regulations that would tie doctors to practice in a particular geographic area.

Adrian Rollins

In December, the AMA issued a Position Statement on Tobacco Smoking and E-Cigarettes in which it called for nationally consistent controls on the marketing and advertising of e-cigarettes, including a ban on sales to children. The AMA has raised concerns that e-cigarettes are appealing to young people, undermining tobacco control efforts, and says there is no evidence to support their use as an aid to quitting smoking.

Below, AMA member Dr Colin Mendelsohn, a tobacco treatment specialist, raises objections to the AMA’s current position on e-cigarettes, and the AMA responds.

Is the AMA statement on e-cigarettes consistent with evidence?

By Dr Colin Mendelsohn, tobacco treatment specialist, The Sydney Clinic*

* Dr Colin Mendelsohn has received payments for teaching, consulting and conference expenses from Pfizer Australia, GlaxoSmithKline Australia and Johnson and Johnson Pacific. He declares to have no commercial or other relationship with any tobacco or electronic cigarette companies.

The recent AMA statement on smoking takes a very negative position on electronic cigarettes (e-cigarettes). While there is still much to learn about e-cigarettes, there is growing evidence to support their effectiveness and safety for smoking cessation and harm reduction. Many experts feel that e-cigarettes are a potentially game-changing technology and could save millions of lives. ¹

The AMA position statement does not reflect the current evidence in a number of areas. For example, there is currently no evidence for the AMA’s statement that ‘young people using e-cigarettes progress to tobacco smoking’ (the gateway effect). In the UK for example, regular use of e-cigarettes by children is rare and is confined almost entirely to current or past smokers. ² Research in the US has found that increased access to e-cigarettes is associated with lower combustible cigarette use, rather than the opposite being true. ³

Understandable concerns are raised that increasing the visibility of a behaviour that resembles smoking may ‘normalise’ smoking and lead to higher rates of tobacco use. However, since e-cigarettes have been available, smoking rates have continued to fall. In the US, daily smoking by adolescents has dropped to a historic low of 3.2%.  Adult smoking rates in the US and UK are also at record lows.

A recent independent review of the evidence commissioned by the UK Public Health agency, Public Health England (PHE), concluded that e-cigarettes are around 95% less harmful than smoking.⁴ This assessment includes an estimate for unknown long-term risks, based on the toxicological, chemical and clinical studies so far. Any risk from e-cigarettes must be compared to the risk from combustible tobacco, which is still the largest preventable cause of death and illness in Australia.

Three meta-analyses and a systematic review ^5-8 suggest that e-cigarettes are effective for smoking cessation and reduction. The evidence indicates that using an e-cigarette in a quit attempt increases the probability of success on average by approximately 50% compared with using no aid or nicotine replacement therapy (NRT) purchased over-the-counter.  

Most of the research to date has used now-obsolete models with low nicotine delivery. Newer devices deliver nicotine more effectively and have higher quit rates.

In the UK, e-cigarettes are now the most popular quitting method and are used in 40% of quit attempts. ⁹ In the UK alone there are currently over one million smokers who have quit smoking and are using e-cigarettes instead, with considerable health benefit.¹⁰ It has been estimated that each year in England many thousands of smokers quit using e-cigarettes and would not otherwise have quit if e-cigarettes had not been available. ¹¹

Many organisations disagree with the AMA’s view that ‘currently there is no medical reason to start using an e-cigarette’. The Australian Association of Smoking Cessation Professionals, Public Health England and the UK National Centre for Smoking Cessation and Training recommend e-cigarettes as a second-line intervention for smokers who are unable or unwilling to quit smoking using approved first-line therapies. In the healthcare setting there is empirical evidence that combining e-cigarettes with counselling and other pharmacotherapies such as varenicline and NRT can improve outcomes further.¹²

The regulatory agency in the UK (MHRA) recently licensed an e-cigarette which will be available on the National Health Service in 2016. It can be prescribed by doctors to help smokers quit and will be provided free.

In Australia, we need to have an evidence-based debate on the potential benefits and risks of e-cigarettes. Careful, proportionate regulation of e-cigarettes could give Australian smokers access to the benefits of vaping while minimising potential risks to public health. The popularity and widespread uptake of e-cigarettes creates the potential for large-scale improvements in public health.

The AMA has made a major contribution to reducing smoking rates in the past. It is well placed to take a leadership role in this debate to ensure that the potential benefits from e-cigarettes are realised.

References

1.  Hajek P. Electronic cigarettes have a potential for huge public health benefit. BMC Med. 2014;12:225

2.  Bauld L, MacKintosh AM, Ford A, McNeill A. E-Cigarette Uptake Amongst UK Youth: Experimentation, but Little or No Regular Use in Nonsmokers. Nicotine Tob Res. 2016;18(1):102-3

3.  Pesko MF, Hughes JM, Faisal FS. The influence of electronic cigarette age purchasing restrictions on adolescent tobacco and marijuana use. Prev Med. 2016

4.  McNeill A, Brose LS, Calder R, Hitchman SC, Hajek P, McRobbie H. E-cigarettes: an evidence update. A report commissioned by Public Health England. PHE publications gateway number: 2015260  2015. Available at https://www.gov.uk/government/publications/e-cigarettes-an-evidence-update (accessed February 2016)

5.  McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev. 2014;12:CD010216

6.  Rahman MA, Hann N, Wilson A, Mnatzaganian G, Worrall-Carter L. E-cigarettes and smoking cessation: evidence from a systematic review and meta-analysis. PLoS One. 2015;10(3):e0122544

7.  Lam C, West A. Are electronic nicotine delivery systems an effective smoking cessation tool? Can J Respir Ther. 2015;51(4):93-8

8.  Khoudigian S, Devji T, Lytvyn L, Campbell K, Hopkins R, O’Reilly D. The efficacy and short-term effects of electronic cigarettes as a method for smoking cessation: a systematic review and a meta-analysis. Int J Public Health. 2016

9.  West R, Brown J. Electronic cigarette use for quitting smoking in England: 2015. Public Health England., 2016. Available at http://www.smokinginengland.info/latest-statistics/ (accessed March 2016)

10.  Use of electronic cigarettes (vapourisers) among adults in Great Britain. Action on Smoking and Health, UK., May 2015  Contract No.: Fact sheet 33. Available at http://ash.org.uk/information/facts-and-stats/fact-sheets (accessed June 2015)

11.  West R. Estimating the population impact of e-cigarettes on smoking cessation and smoking prevalence in England. 2015 [(accessed 30 October 2015)]. Available from: http://www.smokinginengland.info/sts-documents/.

12.  Hajek P, Corbin L, Ladmore D, Spearing E. Adding E-Cigarettes to Specialist Stop-Smoking Treatment: City of London Pilot Project. J Addict Res Ther. 2015;6 (3) http://dx.doi.org/10.4172/2155-6105.1000244

Clarification on the AMA’s position

The recently updated AMA Position Statement Tobacco Smoking and E-Cigarettes – 2015 states:

that the AMA has significant concerns about e-cigarettes. E-Cigarettes and the related products should only be available to those people aged 18 years and over and the marketing and advertising of e-cigarettes should be subject to the same restrictions as cigarettes.  E-cigarettes must not be marketed as cessation aids, as such claims are not supported by evidence.

As noted in the background to the Position Statement, the evidence supporting the role of e-cigarettes as a cessation aids is mixed and low-level.

The stance taken by the AMA on e-cigarettes is consistent with that of the World Health Organisation, Cancer Council Australia, the National Heart Foundation, the National Health and Medical Research Council (NHMRC) and the Therapeutic Goods Administration (TGA) – the latter two organisations being the key decision makers on whether or not e-cigarettes have a role in smoking cessation in Australia.

It is worth noting that a number of smoking cessation aids, backed by evidence, are already available through the Pharmaceutical Benefits Scheme.

The assertion that there is no evidence that e-cigarettes are a potential gateway for young people to progress to tobacco smoking is incorrect.

The AMA’s Position Statement refers to international research [1] showing that some young people who use e-cigarettes do in fact progress to tobacco smoking. Given the risk, the AMA supports a precautionary approach for children and young people.

E-cigarettes will continue to be topical. Research is being published regularly and the AMA will continue to monitor the issue.

The AMA Position Statement, which covers a range of issues, can be viewed at: position-statement/tobacco-smoking-and-e-cigarettes-2015