[Editorial] Prophesying in surgery

Predicting the future is a human preoccupation but not one without risks. Predictions tend to expand on current trajectories, missing the big disrupters and barriers, and rendering them inaccurate. In 1930, The Lancet published an editorial on the future of surgery discussing the forecasts of A F Hurst, a surgeon at Guy’s Hospital, who had recently published his deliberations in the hospital gazette. He considered cancer and gallstones were likely to be “only a very small problem to the future surgeon” and was convinced that the prevention of cancer would be in sight within 25 years.

AIHW reports confirm public hospitals strained

Australia’s public hospitals are under considerable funding pressure and are struggling to meet patient demand, according to two reports released by the Australian Institute of Health and Welfare (AIHW).

The reports, Emergency Department Care 2017-18 and Elective Surgery Waiting Times 2017-18, highlight ongoing and growing pressure on public hospitals.

AMA President Dr Tony Bartone said the AIHW reports send a clear message to the major parties that public hospital funding will be a major issue at the next year’s Federal election.

“Our world-class public hospitals – and the dedicated health professionals who work in them – are required to meet the needs of more and more Australians every year,” Dr Bartone said.

“But these reports show that the current level of public hospital capacity is falling behind patient demand. Patients are joining public hospital waiting lists for elective surgery at rates faster than public hospitals can admit them.

“And the data does not consider the hidden waiting list and the hidden waiting time – the time that it takes for a patient to be seen in the out-patient department before being placed on the list. This can be as long, or even longer, than the elective waiting list time.

“Patient presentations in emergency departments continue to increase year on year. The doctors, nurses, and other staff who work in our hospitals are some of the most skilled in the world, but they can only do so much with the funding and resources available.

“There are not enough additional beds, staff, or capacity within hospital wards to admit every patient who presents in emergency and needs urgent care. There are insufficient resources to admit elective surgery patients who wait too long in pain, at risk, or with too little mobility.”

Dr Bartone said that the AMA will increase its advocacy for public hospital funding ahead of the 2019 election.

And he said it might also be time to seriously review whether the current activity-based funding settings are adequate.

“The AMA shares the ambitions of Ministers, bureaucrats, and academics that public hospitals must lift their efficiency, improve the safety and quality of care, provide better patient discharge and care integration, embed electronic health records, and even prevent avoidable admissions,” Dr Bartone said.

“But this will take more than words to achieve. It requires funding, planning, good policy, cooperation, and commitment.”

Key findings of the reports include:

Over the most recent 12-month period, between 2016-17 to 2017-18, the growth in elective surgery admissions from public hospital elective surgery waiting lists is virtually stagnant – an increase of only 0.1 per cent.
The backlog of people waiting for elective surgery is building, not reducing. Over the last four years, 2012-14 to 2017-18, the rate that patients are joining public hospital elective surgery waiting lists outstrips the rate that patients are removed from waiting lists.
Between 2013-14 and 2017-18, the median waiting time (50 per cent of patients admitted for the awaited procedure) across all public hospitals has increased from 36 days in 2013-14 to 40 days in 2017-18.
As usual, there is variation in time waited for elective surgery between jurisdictions.
- NSW is treading water – elective surgery waiting times are relatively unchanged – but slightly worse over the last 12 months.
- Victoria, Tasmania, and NT – show improvement – especially at the 90th percentile (number of days waited to admit 90 per cent of all patients waiting for elective surgery).
- Patients in Queensland, WA, SA, and ACT are waiting longer.
The number of patients presenting in Australian public hospital emergency departments is increasing year on year. There were more than 8 million presentations in 2017-18. This equates to 22,000 patients in Emergency Department per day.
Nationally, the number of ED presentations in 2017-18 jumped by 3.4 per cent on the previous year. This is a definite spike compared to the 2.7 per cent per annum average growth in emergency presentations over the last four year (2013-14 – 2017-18).
The growth in ED presentations in most jurisdictions over the last year hovers around the national average growth rate of 3.4 per cent in most jurisdictions. Tasmania has had the highest increase in ED presentations – 3.9 per cent.
Only 72 per cent of all ED presentations in 2017-18 were completed within the recommended four hours.

“In light of these reports, the AMA repeats its call for strong public hospital funding policies for the election,” Dr Bartone said.

“We must fully fund hospitals so they can improve patient safety and build their internal capacity to deliver high value care in the medium to long term.”

Brain mapper finds hidden region

World-renowned cartographer of the brain, Scientia Professor George Paxinos AO from Neuroscience Research Australia (NeuRA), has discovered a hidden region of the human brain.

The region is found near the brain-spinal cord junction and Professor Paxinos has named it the Endorestiform Nucleus.

Professor Paxinos suspected the existence of the Endorestiform Nucleus 30 years ago but has only now been able to see it with better staining and imaging techniques. Commenting on this discovery, Professor Paxinos said it’s like finding a new star.

“There is nothing more pleasant for a neuroscientist than identifying a hitherto unknown area of the human brain. In this case, there is also the intrigue that this area is absent in monkeys and other animals,” said Professor Paxinos, adding, “there have to be some things that are unique about the human brain besides its larger size, and this may be one of them.”

The discovery of new brain regions helps researchers to explore cures for diseases including Alzheimer’s, Parkinson’s disease and motor neuron disease.The Endorestiform Nucleus was noticed when Professor Paxinos introduced the use of chemical stains, combined with imaging techniques, in the production of his latest atlas.

The Endorestiform Nucleus is located within the inferior cerebellar peduncle, an area that integrates sensory and motor information to refine our posture, balance and fine movements.

“I can only guess as to its function, but given the part of the brain where it has been found, it might be involved in fine motor control,” said Professor Paxinos.

Many neuroscientists researching neurological or psychiatric diseases, in humans or animal models, use Professor Paxinos’ maps as guides for their work.

An increasingly detailed understanding of the architecture and connectivity of the nervous system has been central to most major discoveries in neuroscience in the past 100 years.

“Professor Paxinos’ atlases, showing detailed morphology and connections of the human brain and spinal cord, provide a critical framework for researchers to test hypotheses from synaptic function to treatments for diseases of the brain,” said Professor Peter Schofield, CEO at NeuRA.

“It is truly an honour for Elsevier to be continuing Professor Paxinos’ legacy of publishing with us,” said Natalie Farra, Senior Editor at Elsevier. “His books are world-renowned for their expertise and utility for brain mapping, and for their contributions to our understanding of the structure, function and development of the brain.”

Professor Paxinos is the author of the most cited publication in neuroscience and another 52 books of highly detailed maps of the brain. The maps chart the course for neurosurgery and neuroscience research, enabling exploration, discovery and the development of treatments for diseases and disorders of the brain.

The discovery of the Endorestiform Nucleus, is detailed in Professor Paxinos latest book titled Human Brainstem: Cytoarchitecture, Chemoarchitecture, Myeloarchitecture.

[Comment] Where are the women in academic cardiology?

Women are a minority of cardiologists. Despite gender parity among medical students and internal medicine residents in the USA and in Europe, only 21% of cardiology fellows in the USA and 16·8% in the UK are women.1,2 This drop-off has been labelled the “residency to fellowship cliff” by Pamela Douglas, Chair of the American College of Cardiology (ACC) Taskforce on Diversity, and former ACC president.3 These proportions are comparable to US female trainees in thoracic surgery (21%), neurosurgery (17%), and orthopaedic surgery (15%).

[Comment] Twice the benefits with twincretins?

Rising global numbers of patients with obesity and diabetes and a scarcity of approved medical therapeutics with curative potential are major challenges for physicians, biomedical researchers, and health-care systems worldwide. Scientific breakthroughs such as discovering gut hormone-based polyagonists with preclinical efficacy and action profiles similar to gastric bypass surgery suggest that transformative medicines for obesity and type 2 diabetes might be within reach.1 Remaining uncertainties are the inclusion of glucagon receptor agonism as a driving factor in the promotion of energy expenditure and weight loss in some of the leading candidates for unimolecular coagonism targeting obesity and type 2 diabetes, because this action requires substantial buffering by incretin action to prevent detrimental effects on glucose metabolism.

[Comment] Potential harms of isolated arthroscopic partial meniscectomy

Meniscal tears are common in middle-aged and older adults,1 and most patients with osteoarthritis have concomitant meniscal tears. When a meniscal tear is judged to be a source of symptoms, arthroscopic partial meniscectomy is often done to remove the damaged meniscal tissue. This procedure is the most common orthopaedic surgery in countries with available data.2

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.

When the doctor becomes the patient

Former Federal AMA President, Dr Steve Hambleton, fell ill suddenly and unexpectedly last week in Canberra.

He flew in to Canberra early on Wednesday, November 7 for a meeting of an MBS Review Committee. He made it to the meeting, but not for long. By midday, he was in the ED at Canberra Hospital.

After tests and care and an overnight stay in Canberra Hospital, he was on a 6.00am Thursday flight home to Brisbane and straight back in to hospital in his home town.

He underwent surgery later that day, and remains in hospital recovering.

In a brief window of opportunity during his transition from robust doctor to vulnerable patient, Steve found time to write a ‘Thank You’ note to all his carers, which is also an emotive account of his patient journey.

Thank you all …

Dr Steve Hambleton

Thank you to all the people who made my stay in the Canberra Hospital a little more bearable.

Thank you to Dr Eleanor who, when I asked for help, was decisive and supported my need to seek help. Thank you to Dr Andrew for making that call to the hospital to smooth the way for me.

Thank you to the staff at the triage desk, to whom I was just another person. I was treated with care and compassion. I was not that well, and not at my best, but very grateful. I wasn’t the only one there. Around me were people from all walks of life, with a bandage here or there, and their own personal stories to tell. Some were impatient. But if it bothered them, they did not show it.

Thank you to the cleaners. Your work behind the scenes makes a huge difference. My body told me it was time to vomit, which is always a bit awkward when wearing a suit and tie. On one knee on the floor in a clean toilet rather than a soiled one made all the difference to me. I am sorry if I made your next run a little bit harder.

Thank you to the triage nurse who kept me informed while I was in the waiting area, and for showing me to my bed.

Thank you to the emergency nursing staff. You don’t know how much comfort the sight of you in your uniform brings to those of us feeling helpless.

Getting changed out of my suit (which makes me feel important) into that gown confirmed that I was truly the patient on this occasion, totally dependent on the kindness and skills of others.

Thanks to the Emergency Physician who took a history from me. You asked me to describe my pain and I could not. It was pain, bad pain. It was waxing and waning every few minutes, and I was struggling to find an adjective that would help you. You smiled and were patient as you gently probed and questioned.

I was not a very good historian. In that moment there was a lot of my history I could not remember. Certainly not dates and times, and what happened in what order, and I don’t really have any chronic diseases. It made me think about how much harder it must be for those that do.

Thank you for putting in that intravenous line, which sort of validated for me that I was not a fraud and did need to be there.

Thank you to the student nurse, who recorded my observations and administered the first of the medications. I was not well, and probably did not express my thanks all that well.

Thank you to your Senior, who was quietly guiding you as you administered the analgesia. The pain did not go away immediately, but the warm feeling on my skin was reassuring that something was being done.

I wondered how the meeting that I left was going, and what my colleagues were thinking about my sudden departure.

Thank you to the wardsmen who transported me to the radiology department on two occasions. For your light-hearted banter as we weaved our way along the corridors in my bed, which seemed to have lost its steering. We need to get that trolley fixed – it just wouldn’t go straight. Sorry about the rubbish bin. It was a welcome distraction to take my mind off the way I was feeling.

Thank you to the ultrasound operator who was gently efficient – his job was to be in that darkened room, applying his knowledge of anatomy to help answer the clinical questions.

Thank you to the CT scan nurse and the radiographer for your part of the diagnostic journey.

I spent a long time in your emergency department. I love the reference to the flight deck, which is your central point. I was there long enough to hear shift changes and the handovers.

I heard you gently managing the patient with the mental illness, whose understanding and connection with our reality was tenuous at best.

I heard you keeping the patients’ relatives informed about the next steps on their journey.

I heard you manage the man with dementia who was someone’s brother/husband/father. He was loud, and he was angry as he fought his demons. Despite that, he was treated with the same kindness as all your other patients. Do you remember telling me that by the time he left the Department that he was “the nicest old man”. I hoped that you would be around if ever I was that man in the future.

I wanted to go home but needed to stay. I needed help and you gave it to me willingly and I am so grateful. When I leaned on the call button accidentally or when I needed extra help, you were there quickly.

Did you know that if you hold your breath you can watch your oxygen “sats” go down and make the alarm go off? The machines beep to tell you when things are going well, and when they are not.

Thank you for letting me use the phone to keep my family informed. It seemed every time you came into my room, I was talking to someone else.

Thank you for letting me go home when you knew that I was still not quite right. I know you worried about whether it was the right decision. Thank you for tolerating that uncertainty.

Nothing in medicine is absolute – it’s all about trade-offs.

As I walked through the Department on the way out, I could not believe the patient load you were facing.

Thank you to the night registrar who, even at the end of his shift, had a smile for me.

Dr Steve Hambleton is a former President of the Federal AMA and AMA Queensland.

[Series] Hip replacement

Total hip replacement is a frequently done and highly successful surgical intervention. The procedure is undertaken to relieve pain and improve function in individuals with advanced arthritis of the hip joint. Symptomatic osteoarthritis is the most common indication for surgery. In paper 1 of this Series, we focus on how patient factors should inform the surgical decision-making process. Substantial demands are placed upon modern implants, because patients expect to remain active for longer. We discuss the advances made in implant performance and the developments in perioperative practice that have reduced complications.

[Series] Knee replacement

Knee replacement surgery is one of the most commonly done and cost-effective musculoskeletal surgical procedures. The numbers of cases done continue to grow worldwide, with substantial variation in utilisation rates across regions and countries. The main indication for surgery remains painful knee osteoarthritis with reduced function and quality of life. The threshold for intervention is not well defined, and is influenced by many factors including patient and surgeon preference. Most patients have a very good clinical outcome after knee replacement, but multiple studies have reported that 20% or more of patients do not.