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Preference: Surgery

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Political message in National Press Club speech

AMA President Dr Michael Gannon has called on all sides of politics to take some of the politicking out of health, for the good of the nation.

Addressing the National Press Club of Australia, Dr Gannon said some health issues needed bipartisan support and all politicians should acknowledge that.

“Some of the structural pillars of our health system – public hospitals, private health, the balance between the two systems, primary care, the need to invest in health prevention – Let’s make these bipartisan,” he said.

“Let’s take the point scoring out of them. Both sides should publicly commit to supporting and funding these foundations. The public – our patients – expect no less.”

During the nationally televised address, broadcast live as he delivered it on August 23, Dr Gannon warned political leaders that the next election was anyone’s to win and so they should pay close attention to health policy.

“Last year we had a very close election, and health policy was a major factor in the closeness of the result,” he said.

“The Coalition very nearly ended up in Opposition because of its poor health policies. Labor ran a very effective Mediscare campaign.

“As I have noted, the Government appears to have learnt its lesson on health, and is now more engaged and consultative – with the AMA and other health groups.

“The next election is due in two years. There could possibly be one earlier. A lot earlier.

“As we head to the next election, I ask that we try to take some of the ideology and hard-nosed politicking out of health.”

In a wide-ranging speech, the AMA President outlined the organisation’s priorities, while also explaining the ground it has covered in helping to deliver good outcomes for both patients and doctors.

The AMA’s priorities extend to Indigenous health, medical training and workforce, the Pharmaceutical Benefits Scheme, and the many public health issues facing the Australian community – most notably tobacco, immunisation, obesity, and alcohol abuse.

“I have called for the establishment of a no-fault compensation scheme for the very small number of individuals injured by vaccines,” Dr Gannon said.

“I have called on the other States and Territories to mirror the Western Australian law, which exempts treating doctors from mandatory reporting and stops them getting help.

“We also need to deal with ongoing problems in aged care, palliative care, mental health, euthanasia, and the scope of practice of other health professions.

“In the past 12 months, the AMA has released statements on infant nutrition, female genital mutilation, and addiction.

“In coming months, we will have more to say on cost of living, homelessness, elder abuse, and road safety, to name but a few.

“Then there are the prominent highly political and social issues that have a health dimension, and require an AMA position and AMA comment.

“All these things have health impacts. As the peak health and medical advocacy group in the country, the community expects us to have a view and to make public comment. And we do.

“Not everybody agrees with us. But our positions are based on evidence, in medical science, and our unique knowledge and experience of medicine and human health.

“Health policy is ever-evolving. Health reform never sleeps.”

The address covered, among other things, health economics: “Health should never be considered just an expensive line item in a budget – it is an investment in the welfare, wellbeing, and productivity of the Australian people.”

Public hospital funding: “The idea that a financial disincentive, applied against the hospital, will somehow ‘encourage’ doctors to take better care of patients than they already do is ludicrous.”

Private health: “If we do not get reforms to private health insurance right – and soon – we may see essential parts of health care disappear from the private sector.

The medical workforce: “We do not need more medical school places. The focus needs to be further downstream.

“Unfortunately, we are seeing universities continuing to ignore community need and lobbying for new medical schools or extra places.

“This is a totally arrogant and irresponsible approach, fuelled by a desire for the prestige of a medical school and their bottom line.

“Macquarie University is just the latest case in point.”

And general practice: “General practice is under pressure, yet it continues to deliver great outcomes for patients.

“GPs are delivering high quality care, and remain the most cost effective part of our health system. But they still work long and hard, often under enormous pressure.

“The decision to progressively lift the Medicare freeze on GP services is a step in the right direction.”

On even more controversial topics, Dr Gannon stressed that the AMA is completely independent of governments.

While sometimes it gets accused of being too conservative, he said, it was not surprising to see the reaction to the AMA’s position on some issues – like marriage equality.

“Our Position Statement outlines the health implications of excluding LGBTIQ individuals from the institution of marriage,” he said.

“Things like bullying, harassment, victimisation, depression, fear, exclusion, and discrimination, all impact on physical and mental health.

“I received correspondence from AMA members and the general public. The overwhelming majority applauded the AMA position.

“Those who opposed the AMA stance said that we were being too progressive, and wading into areas of social policy.

“The AMA will from time to time weigh in on social issues. We should call out discrimination and inequity in all forms, especially when their consequences affect people’s health and wellbeing.”

Last year, the AMA released an updated Position Statement on Euthanasia and Physician Assisted Suicide.

It came at a time when a number of States, most notably South Australia and Victoria, were considering voluntary euthanasia legislation.

There was an expectation in some quarters that the AMA would come out with a radical new direction. But it didn’t.

“The AMA maintains its position that doctors should not be involved in interventions that have as their primary intention the ending of a person’s life,” Dr Gannon said.

“This does not include the discontinuation of treatments that are of no medical benefit to a dying patient. This is not euthanasia.

“Doctors have an ethical duty to care for dying patients so that they can die in comfort and with dignity.”

The AMA also takes Indigenous health very seriously.

Dr Gannon travelled to Darwin last year to launch the AMA’s annual Indigenous Health Report Card, which focused on Rheumatic Heart Disease.

“In simple terms, RHD is a bacterial infection from the throat or the skin that damages heart valves and ultimately causes heart failure,” he said.

“It is a disease that has virtually been expunged from the non-Indigenous community. It is a disease of poverty.

“RHD is perhaps the classic example of a Social Determinant of Health. It proves why investment in clean water, adequate housing, and sanitation is just as important as echocardiography and open heart surgery.

“The significance of challenging social issues like Indigenous health, marriage equality, and euthanasia is that they highlight the unique position and strengths of the AMA.

“The AMA was recently ranked the most ethical organisation in the country in the Ethics Index produced by the Governance Institute of Australia.

“People want and expect us to have a view – an opinion. Sometimes a second opinion.” 

Chris Johnson 

 

A transcript of the full address can be found here:
media/dr-gannon-national-press-club-address-0

 

 

[Correspondence] George Gershwin’s death and Duret haemorrhage

George Gershwin (born Sept 26, 1898) was one of the greatest American composers in history. He died, aged 38 years on July 11, 1937, after surgery for his brain tumour. His olfactory hallucinations, a sign of temporal lobe epilepsy, had begun in early 1934,1–3 but he continued active musical works despite the gradual deterioration of his health status until several months before his premature death. His headaches, spells of blurred consciousness and abnormal behaviours, and other symptoms were ascribed to mental health problems.

Public Hospital Doctors role central to AMA

BY DR ROD McRAE, CHAIR, AMA COUNCIL OF PUBLIC HOSPITAL DOCTORS

I’d like to state my thanks for all the input and interest from PHD members at our recent National Conference. It was invigorating to experience your enthusiasm for the many issues directly affecting public hospital doctors. An important issue about which I do want to remind you is actually how you “describe” yourself for AMA membership purposes. In order to keep the CPHD vibrant and relevant to key issues, we must have a solid base.  Today we can choose our membership category more accurately.  I hope more doctors based in public hospitals, particularly those with a Specialist qualification, will choose to identify in the public hospital doctor membership category as opposed to their medical craft group if they have one, when it comes to identifying their AMA membership as you will be invited to do soon, and thus remain engaged with the CPHD.

Vale Dr Patrick Pritzwald-Stegmann

Multiple issues are before the CPHD.  None is more relevant than safety in the workplace.  On July 21, a Memorial Service was held for AMA member Dr Patrick Pritzwald-Stegmann, who died after substantial time ventilated in one of our ICUs after an alleged “coward’s punch” received in the foyer of a Melbourne metropolitan public hospital resulted in a profound brain injury.  This is now a Coroner’s and police matter.  I am regularly horrified at the experiences of violence in our community and our workplaces, but this is all the more poignant for me as Patrick was a recent close colleague of mine with whom I had worked extensively. 

There are many intersecting issues in our community, most of which lead to the public hospital system.  They include mental health issues, whether acute, chronic or acute-on-chronic, illicit drug use, perhaps loading up on mental health issues, increased passive tolerance of greater violence in and by the now metropolises (as opposed to tight-knit communities), and a general lack of respect for those providing any type of community service.  Emergency service providers and our colleagues and other healthcare workers in emergency departments face the brunt, but it is throughout the public hospital system.  I note that our population is growing remarkably, we have generated profound productivity improvements, but there remains a yawning gap of lack of public hospital capacity investment to match the essential hospital requirements of the complex, multi-system, elderly and/or obese, chronic illness sufferers.  It is readily observable how “house full” messages contribute to patient frustration, then anger and venting in our workplace.  It was equally offensive to see lauding of “this is what 182 blows to the head looks like” related to a recent violent “sport” designed to inflict brain injury.  It is easy to see some might link these ingredients, resulting in an unsafe workplace for us. 

In perhaps a curious coincidence, I am now chairing an Australian Standards committee revising the standard Security for Health Care Facilities.  It will be a template for consideration of security risks for any and all health care facilities in Australia.  Its origin related to large public hospitals, but changes in technology and hospital interventions means security issues are everywhere that medicine is practised, including hospital-in-the-home and all points travelling between, patient record security, medication and medical gas security, microorganism security, IT security, food security, let alone staff safety and security.  I will be pleased to receive your thoughts on this topic.  Obviously not everything will be totally relevant to all, but in these days of terrorism and bioterrorism, it will be a useful tool for risk analysis.  It will be a sad day if every part time medical point of care in a high rise tower through to our major teaching hospitals needs to have the same security we now take for granted on getting to the airside of an airport, surveillance cameras or requires trained and authorised security personnel with Tasers and policing powers comparable to Protective Service Officers. 

Of note, none of the above may have prevented Patrick’s injury, or some of them may have caused the alleged perpetrator to pause. 

Public Hospital Funding

It is clear an expansion and greater funding of public hospital’s is required to meet the increasing demand, separate to security investments.  This is about to accelerate in my view as more reduce private health insurance due to increasing premiums coupled with increasing mortgage, energy and education costs pressures.  An important discussion will be how best to use the now billions of tax dollars shoring up publically listed health insurance companies’ profits and employee bonus payments, whilst squeezing the marketplace and offering frequently inadequate products to bamboozled patients seeking a tax break. 

Recently the Government rejected a proposal to abolish the private health insurance rebate and effectively take funds it saves from that, along with hospital funding, to provide a standard benefit for services, regardless if they happen in a public or in a private hospital. This would effectively take Commonwealth funds from public hospitals and force patients to pay more for coverage. This would reduce the amount the Commonwealth contributes to the cost of public hospitals to a paltry 35 per cent.  The 42 or 43 per cent funding we’re getting from the Commonwealth now is not sustainable for future public hospital operation. 

A 35 per cent share would be a disaster in the super-stretched public system and in the private system for that matter.  In recent years we’ve seen the Commonwealth’s share of funding to public hospitals drop below 45 per cent with a formula that only relies on growth in CPI and population. The AMA’s Public Hospital Report Card shows that performance in the system, such as wait times in the emergency department or for elective surgery, are not improving, or indeed are going backwards. So we can be thankful that this reduction has been ruled out.

But with consideration of the way hospitals are funded, we need to focus on priorities and things that might work in the hospital system. This especially includes quality and safety initiatives as well as increasing the utility of secondary hospitals or in the community. We must put more resources into primary care prevention as a long-term strategy for reducing the rate of increase of pressure on public hospitals.

Let’s hope governments see sense and realise that proper health care is a sound investment and saves money in the long term, and that engaging with doctors is the only way to develop sound health policy.  I look forward to discussing these and other issues with you in upcoming CPHD meetings and other events.  

Report warns blindness set to rise

A new study published in Lancet Global Health warns the number of blind people across the world is set to triple within the next four decades.

The research predicts cases will rise from 36 million to 115 million by 2050, if treatment is not improved by better funding.

A growing ageing population is behind the rising numbers.

Some of the highest rates of blindness and vision impairment are in South Asia and sub-Saharan Africa.

Although the percentage of the world’s population with visual impairments is actually falling, according to the study, the global population is growing and so the number of people with sight problems will soar in the coming decades.

Analysis of data from 188 countries suggests there are more than 200 million people with moderate to severe vision impairment.

That figure is expected to rise to more than 550 million by 2050.

“Even mild visual impairment can significantly impact a person’s life,” said lead author Professor Rupert Bourne, from Anglia Ruskin University in Cambridge.

“For example, reducing their independence…as it often means people are barred from driving.”

He said it also limited people’s educational and economic opportunities.

The worst affected areas for visual impairment are in South and East Asia. Parts of sub-Saharan Africa also have particularly high rates.

The study calls for better investment in treatments, such as cataract surgery, and ensuring people have access to appropriate vision-correcting glasses.

Professor Rupert Bourne said that interventions provide some of the largest returns on investment in eye health.

“They are some of the most easily implemented interventions in developing regions because they are cheap, require little infrastructure and countries recover their costs as people enter back into the workforce,” he said.

In Australia, the CEO of the Fred Hollows Foundation, Brian Doolan, spoke to the research, saying that more needs to be done for social development, targeted public health agreements and accessible eye health facilities.

“The strategies being used around the world have been shown to work, all we need is to get them to the right scale to address the growing global need,” Mr Doolan said.

According to Mr Doolan, the leading cause of blindness worldwide is poverty, followed by gender.

The report also indicates Aboriginal and Torres Strait Islander people are still three times more likely to be blind than other Australians. Most blindness in Australia is due to readily preventable or treatable causes of vision loss, including cataract, diabetes, refractive error and trachoma.

The AMA continues to call on the Federal Government to correct the under-funding of Aboriginal and Torres Strait Islander health services, including programs to limit preventable blindness.

MEREDITH HORNE

[Seminar] Cataracts

An estimated 95 million people worldwide are affected by cataract. Cataract still remains the leading cause of blindness in middle-income and low-income countries. With the advancement of surgical technology and techniques, cataract surgery has evolved to small-incisional surgery with rapid visual recovery, good visual outcomes, and minimal complications in most patients. With the development of advanced technology in intraocular lenses, the combined treatment of cataract and astigmatism or presbyopia, or both, is possible.

Attending the House of Delegates meeting of the American Medical Association

BY ANNE TRIMMER AMA SECRETARY GENERAL

The annual meeting of the House of Delegates (HOD) of the American Medical Association (AmMA) is the only event in which all of “organised medicine” in the United States physically comes together at the same time and place.

The program for the annual HOD meeting is immense. There is a mix of open sessions and committee sessions in the lead in the HOD meeting itself. Eight committees meet over the course of two days to work their way through a comprehensive agenda of reports and resolutions that amend existing policy or introduce new policy. The result of the committees’ work is then caucused by the participating representative societies and associations in preparation for debate on the floor of the HOD.

The HOD opens with a formal speech by the President (who completes a one-year term at the close of the HOD meeting) and another by the CEO. The meeting then opens to debate on the reports and resolutions that have come forward from the committees. This takes two days and can continue into a third day of the business isn’t completed.

As an international guest at this year’s meeting in June, I was invited to observe all proceedings and I made the most of the invitation by attending an open forum of the Council on Ethics and Judicial Affairs, two committee meetings, and the HOD meeting.

The conduct of the debate is democracy in action. The Speaker and Deputy Speaker control the debate with great deftness and humour. Speakers line up, as they do at the AMA National Conference, waiting to be recognised to speak.

There were several recurring issues that resonated. The first, and most pressing, was that of access to health care, even more so with legislation introduced by the Trump administration to wind back the Affordable Care Act (ObamaCare) which would have the result that 23 million Americans would lose cover. The legislation (the American Health Care Act or AHCA) is causing deep concern within the AmMA about the likely outcome.

Delegates debated the acceptability of per capita caps under federal Medicaid funding, which are a key element of the AHCA and are being considered for incorporation into the Senate version of the legislation that is still being drafted. The delegates rejected any proposal for caps on the basis that they would weaken States’ ability to respond to enrolment changes, greater care needs or breakthrough treatments.

The tactics of health insurers to deny cover for patients, or to create delays for physicians in trying to secure approval, were raised on many occasions. One of the more interesting debates focused on a resolution for AmMA to advocate for a public option to provide health cover where no insurance cover exists. This aspect of the original ObamaCare legislation was removed as a compromise to get the majority of the legislation through the Congress. AmMA voted to support the inclusion of a public option. The Australian health system was cited in debate as an exemplar of a system where there is public cover but also a right to choose private cover.

The networks established by the insurers are shrinking, often with the result that patients lose the physician they have had all of their lives. The provision of out of network care carries significant cost for patients who are not covered if they need care at a hospital that is not within their insurer’s network. This has an impact on emergency doctors who won’t turn patients away if they present at an out of network emergency department. At times the patient may not even be aware that they are out of network.

The resulting “surprise bills” come about either because the patient has presented out of network or because the cover they have is inadequate for the procedure that is undertaken. Delegates were critical of “outlier” medical colleagues who levied significant bills in these circumstances, attracting the ire of patients and media.

This has led to consideration in several States of a “fair minimum benefit”. However as States have been ratcheting down the benefits paid under Medicare, doctors are concerned that any benefit that is tied to Medicare will be inadequate for the service that is provided. Delegates discussed the potential for an independent database to be used as a reference point for charging (which sounds not dissimilar to the AMA Fees List).

Another example of egregious insurer behavior occurs in emergency departments where the insurer withdraws cover on the basis that the reason for presentation is not an emergency. To overcome this the patient is forced to seek pre-approval.

The issue of physician health was raised on several occasions. The concern is with burnout, exacerbated by the frustrations of dealing with the health insurers in seeking pre-approval for patients, and the electronic health record. Speakers referred to the extensive delays created by the system. Reference was also made to depression and suicide among doctors.

The open session of the Council on Ethics and Judicial Affairs provided a forum for the AmMA to obtain member feedback in the development of a new policy on euthanasia and physician assisted suicide. Among the speakers from the floor were physicians from the five States where it is already legal for doctors to prescribe end of life pharmaceuticals. In California, for example, physicians can choose to opt into the process with 18 per cent currently doing so. The legislation provides multiple safeguards.

Colorado is the most recent State to introduce euthanasia. The State medical society undertook a two year consultation before changing its policy to accommodate the change. In that State a patient must be able to self-administer the medication. However the cost of effective medication can be a barrier to a patient carrying out the euthanasia.

In the State of Oregon where euthanasia has been legal for 20 years, the State medical society has maintained a neutral position.

Notwithstanding that euthanasia is legal in some States, the debate emphasised the need for a better understanding of the role of palliative care and the place of hospice care. Patients at the end of life were often ignorant of the benefits of palliative care.

The address by the outgoing President of the AmMA, Dr Andrew Gurman, highlighted the big issues faced by the AmMA over the previous 12 months. These included the requirements of the health insurers for pre-authorisation of drugs and medical devices before they could be prescribed or utilised in surgery; gun control as a public health issue; the defeat of proposed health fund mergers which would have further reduced access to health care; and physician burnout.

Dr Gurman highlighted what he described as “advocacy at its most basic, human level” when he met with medical trainees who had grown up in the US but now feared deportation under proposed changes announced by the Trump administration.

The Executive Vice President and CEO, Dr James Madara, highlighted that the AmMA recently celebrated its 170th birthday, having been established in 1847. He identified three strategic areas for current focus in the work of the AmMA: 

  • Practice satisfaction and professional practice;
  • Medical education; and
  • Patients with pre-diabetes.

This last point relates to the fact that a staggering 83 per cent of health services in the US are for chronic conditions.

Unsurprisingly an opinion poll released while I was in the US has health as the number one issue for the electorate.

The AmMA’s work on medical education centres on online learning to provide tools and resources to physicians, including the recent release of an online education program on best use of electronic health records. This is part of a project entitled health 2047 (for the 200th birthday of the establishment of the AmMA) which aims to return to the physician one hour per day of the working week. Many speakers identified that navigating the current EHR system currently consumes up to two days each working week.

The AmMA is also working to protect patients at risk of losing their health cover by expanding meaningful coverage and including safety nets.

Resident mental health is now mandated as part of every residency program.

The contributions from the medical students were among the most compelling. The medical student section put forward a motion calling on the AmMA to be a leader in advocacy on the social determinants of health. The National Academy of Medicine established a framework in 2016 to better understand the social determinants. As several delegates pointed out, without understanding the social context of a patient there may be impacts on the care that is given. Examples provided were a patient living in accommodation with no running water, or with no access to transport to attend a pharmacy to have a prescription filled.

Another significant public health issue that attracted debate is the opioid epidemic in the US which has arisen as a result of the over-prescribing of pain medication.

 The organisation

The AmMA’s revenue in 2016 was $323.7 million with a profit of $13.6 million.

The House of Delegates is the supreme policy making body and elects the office-holders, including the President-elect who then becomes President the following year. It also elects the members of the Board of Trustees.

The Board of Trustees is the principal governing body and takes actions based on the policy and directives of the HOD. It exercises broad oversight and guidance with respect to management systems and risk through the oversight of the Executive Vice President (the CEO).  It has 21 members who have fiduciary responsibility for the organization and select and evaluate the CEO. The members include a student, a resident, a young physician, and a public member.

The eight Councils are standing, domain based, expert bodies. They are: 

  • Council on Constitution and Bylaws
  • Council on Ethical and Judicial Affairs
  • Council on Legislation
  • Council on Long Range Planning and Development
  • Council on Medical Education
  • Council on Medical Service
  • Council on Science and Public Health
  • American Medical Political Action Committee.

The Sections and Special Groups represent the constituent groups and provide a channel for outreach and member insights. They are as diverse as the Advisory Committee on LGBT Issues, the International Medical Graduates Section, the Medical Student Section, and the Organised Medical Staff Section.

The HOD draws representation from the State and territorial medical associations (260 delegates) and national medical specialty societies (205 delegates). It has 528 delegates and the same number of alternate delegates. With Past Presidents and observers there are approximately 1200 attendees at the HOD annual meeting.

The rules for participation of a national medical specialty society are complex and are based on the number of its members who are members of the AmMA at the rate of one delegate per 1,000 AmMA members with every eligible national medical specialty entitled to at least one delegate. Similarly every State/territory is entitled to at least one delegate.

In addition delegates represent Federal Services (Air Force, Army, Navy, Department of Veterans Affairs, and the US Public Health Service); AMA Sections; other national societies; and professional interest medical associations.

AmMA represents approximately 25 per cent of American physicians. However as the umbrella body representing the entire profession it is the voice in Washington DC that speaks for all physicians.

Each policy that is put before the HOD has a fiscal note on the likely cost of the proposal if adopted. This is a good discipline in either reducing or refining some resolutions.

Every policy is recorded in PolicyFinder which is an electronic database available online and updated after each meeting of the HOD.

As a final note, every resolution or policy that is put forward is framed as ‘our AMA’ undertaking the specified action. This engenders a sense of ownership and pride in the organisation’s advocacy.

 

Parliamentarians scrutinise health issues from around Australia

The Australian Senate is continuing its inquiry into the number of women in Australia who have had transvaginal mesh implants, having had to extend the date for submissions has been extended until 30 June 2017. The reporting date is 30 November 2017.  The committee will examine the types and incidence of health the Committee plans to hold public hearings at locations around Australia.

The inquiry will scrutinise problems experienced by women who have had this surgery, and the impact this has had on their lives. The committee will also examine the information available to patients and doctors about this surgery; any incentives offered to medical practitioners in relation to the use of transvaginal mesh implants and the role of the Therapeutic Goods Administration’s role in regulating and monitoring the use of transvaginal mesh implants. 

The Senate is also responding to the reported incidents in the Makk and McLeay Aged Mental Health Care Service at Oakden in South Australia, by examining the current aged care quality assessment and accreditation framework in the context of these incidents. The reporting date of this inquiry is 18 February 2018.

The House of Representatives is using the committee process to look into the use and Marketing of Electronic Cigarettes and Personal Vaporisers in Australia. 

Committee chair Trent Zimmerman MP, said: “In recent years the use of e-cigarettes has grown rapidly and governments have taken very diverse approaches to dealing with their emergence.”

“Internationally e-cigarettes have been regulated either as consumer, tobacco, or medicine products and the Committee will be investigating these different international regulatory approaches,” Mr Zimmerman said.

A House of Representative Committee adopted an inquiry in March this year into how Australia’s federal family law system can better support and protect people affected by family violence. Hearings are currently being conducted around Australia and will hear evidence from those with personal experience at the intersection of family violence and the family law system, including Rosie Batty, 2015 Australian of the Year. 

Committee chair Sarah Henderson MP said family violence was an issue which required a response from all sections of the community, and across all levels of government.

“We must ensure that the family law system provides adequate support and protection in cases where family violence has occurred,” Ms Henderson said.

“In carrying out the inquiry, the Committee will consider what has been done so far—and what more can be done—to meet the needs of vulnerable people in family law proceedings.”

Other parliamentary inquiries looking into special health issues include hearing health and wellbeing; delivery of outcomes under the National Disability Strategy 2010-2020 to build inclusive and accessible communities; and value and affordability of private health insurance and out-of-pocket medical costs.

The AMA advocates to the Australian Parliament on many issues and submissions can be found at: advocacy/

MEREDITH HORNE

[Comment] Improving quality of life after treatment for rectal cancer

In rectal cancer, findings from large randomised trials have provided solid evidence that preoperative (chemo)radiotherapy decreases local recurrence rates by 50%, compared with surgery alone.1 This decrease, however, comes at the cost of an increased incidence of anorectal and urogenital dysfunction, and, based on better imaging methods of today, many clinicians advocate a more selective policy of neodjuvant radiotherapy, with the goal of maintaining better quality of life. At the same time, there is a reverse strategy with the same goal of maintaining a better quality of life: start with radiotherapy and tailor subsequent surgery according to the response: total mesorectal excision after little or no response, local excision after a very good response, or even no surgery after a complete response.

[Department of Error] Department of Error

Avidan MS, Maybrier HR, Abdallah AB, et al. Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. Lancet 2017; 390: 267–275—In this Article, the eighth author’s name should have read “Hilary P Grocott”. This correction has been made to the online version as of July 13, 2017, and the printed Article is correct.