more_vertThe National Institute for Health and Care Excellence (NICE) has published draft guidelines for the clinical management of pelvic organ prolapse and stress urinary incontinence. The guidelines, which are open for public consultation until Nov 19, recommend that women, first and foremost, be offered lifestyle interventions, physical and behavioural therapies, and medication before surgical options are considered. Women who do choose to have surgery must be fully informed of the risks and referred to a specialist.
Preference: Surgery
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[Correspondence] Essential need for quality in surgical health-care systems
We congratulate Donald Berwick and colleagues (July 21, p 194)1 for highlighting the need for health systems to achieve safe, effective, universal health-care coverage in the Era of Sustainable Development. The need is most apparent in surgery, obstetrics, and anaesthesia, in which adverse health-care events can have devastating consequences. Surgery can be deemed a reliable stress test for health-care facilities and indicative of overall quality as it requires the successful integration of multiple systems.
[Correspondence] Cautery in medieval surgery: a unique palaeopathological case
Cautery is a fundamental tool in ancient and medieval surgery. According to a aphorism of Hippocrates, the father of medicine, “Those diseases which medicines do not cure, iron cures; those which iron cannot cure, fire cures; and those which fire cannot cure, are to be reckoned wholly incurable”.1 This statement was accepted in Roman medicine and then by the Byzantine and Islamic surgical practices in the Middle Ages.2 Despite this widespread acceptance, the bioarchaeological evidence of the use of cautery is extremely rare.
[Correspondence] Interpretation of results of pooled analysis of individual patient data
We read with interest the meta-analysis by Stuart J Head and colleagues1 of individual patient data from randomised trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with multivessel or left main disease. The authors found variation in outcomes according to the anatomical complexity of coronary artery disease, as gauged by the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score,2 but reported negative tests for interaction between subgroups of patients in the low (<23), middle (23–32), and high (>32) SYNTAX score tertiles and hazard ratios of death.
Doctor Robot
The Guardian reports that robots could soon help hospital patients eat their meals, diagnose serious illnesses, and even help people recover from operations, in an artificial intelligence revolution in the NHS in the UK.
Machines could take over a wide range of tasks currently done by doctors, nurses, health care assistants, and administrative staff, according to a report prepared by the Institute for Public Policy Research (IPPR) and eminent surgeon and former Health Minister, Lord Darzi.
Widespread adoption of artificial intelligence (AI) and ‘full automation’ by the NHS could free up as much as £12.5 billion a year worth of staff time for them to spend interacting with patients, according to the report.
“Given the scale of productivity savings required in health and care – and the shortage of frontline staff – automation presents a significant opportunity to improve both the efficiency and the quality of care in the NHS,” the report says.
“Bedside robots could help patients consume food and drink and move around their ward, and even help with exercises as part of their rehabilitation from surgery.
“In addition, someone arriving at hospital may begin by undergoing digital triage in an automated assessment suite.
“AI-based systems, include machine-learning algorithms, would be used to make more accurate diagnoses of diseases such as pneumonia, breast and skin cancers, eye diseases, and heart conditions.
“Digital technology could also take over the communication of patients’ notes, booking of appointments, and processing of prescriptions.”
The report sought to allay fears of significant job losses, signaling that machines would work alongside human beings, not replace them, so patients would benefit.
[Comment] Should we screen women for abdominal aortic aneurysm?
In The Lancet, Michael Sweeting and colleagues1 report their estimate of the benefits, harms, and cost-effectiveness of screening women for abdominal aortic aneurysm (AAA) based upon their modelling study. A discrete event simulation model was set up and women-specific parameters were obtained from systematic literature reviews, national registry or administrative databases, major AAA surgery trials, and UK National Health Service reference costs. By use of the same screening strategy as used for men (age 65 years; 3·0 cm cutoff for diagnosis; 5·5 cm cutoff for surgery), there were three fewer AAA-related deaths, ten women overdiagnosed with AAA, and one woman overtreated for AAA per 10 000 invited over a 30-year period.
AMA members honoured in Mongolia
Last month, in a private audience with the Mongolian President, four Australian doctors were awarded the Mongolian Silver Friendship Medal (Nairamdal).
Medical specialists, and AMA members – Dr Kym Jansen, Dr Emma Readman, Dr Samantha Hargreaves, and Dr Philip Popham – were honoured for their contribution to health care in Mongolia.
The Medal is the highest honour bestowed upon a foreign citizen by the Mongolian Government, and is solely given to foreigners who have contributed to strengthening the collaboration between their country and Mongolia through their work.
These four doctors are the first Australians to be awarded the Friendship Medal. Dr Elizabeth Farrell AM, a member of the same group, was awarded a visiting Professorship from the Mongolian National University of Medical Sciences.
These amazing doctors have been visiting Mongolia annually for the past 10 years.
The group initially concentrated on promoting minimally invasive gynaecological surgery, but recently expanded their role to encompass all aspects of women’s health, including anaesthetic care. The affiliation has seen rapid advances in surgical, anaesthetic, and obstetric care.
Over the last two years, the Epworth Foundation has expanded this project by funding three-month scholarships for two doctors from Mongolia to visit Australia annually.
The group has recently formed the Mongolian Australian Medical Affiliation (MAMA) – Women’s Health, and plan to continue their collaboration.
*In Photo are left to right: Dr Samantha Hargreaves, Dr Philip Popham, Dr Emma Readman, Dr Kym Jansen, Mongolian President, Khaltmaagiin Buttulga and Dr Elizabeth Farrell
Doctors warn Aussies will pay more for less health care
Specialist physicians have sounded a warning that thousands of Australians face a lifetime of chronic pain and second-rate treatment options under the Federal Government’s private healthcare reform.
A group of concerned spine surgeons and other medical practitioners say the proposed policy bands of Gold, Silver, Bronze and Basic will leave thousands of patients having to choose between the spine surgery they need and the one they can afford.
Gold Coast orthopaedic surgeon Associate Professor Matthew Scott-Young said spine surgery was split between Gold and Silver bands under the reforms, with spinal stabilisation and fusion restricted to the top level of cover.
“Splitting funding for spinal conditions between Silver and Gold will result in a patient’s level of private health cover influencing clinical decision making,” Associate Professor Scott-Young said.
“Surgeons will be pressured into offering, and patients will be obliged to accept, suboptimal care based on their level of cover.”
Assoc Prof Scott-Young said the reforms would cause more people to live with chronic pain or to opt for less effective treatments simply because they were the ones they could afford.
“It will increase pressure on the already over-burdened public health system and, ultimately, lead to an increase in the impact of spine disease within the Australian community,” he said.
“There is level one evidence to show spinal fusion is the most effective treatment for a number of elective and emergency spinal conditions. Add to that our 20 years and 6000 patients worth of Patient Reported Outcome Measures data which demonstrates spinal fusion patients have clinically significant reduction in symptoms, with an overwhelming majority able to return to enjoying their everyday activities.”
Federal Health Minister Greg Hunt announced last week that the changes were to ‘empower’ the 13 million Australians with private health insurance by providing a simplified summary of their cover on a single page. Mr Hunt also said the reforms, effective from 1 April 2019, would not lead to a change in policies or a rise in price for private health customers. Private health insurers currently offer top hospital cover as well as spine fusion from as little as $42.70 a week.
Numerous professional medical associations lodged submissions to the Federal Government during its consultation process, highlighting risks and problems with the proposed changes. Concerns about splitting the treatment of a single condition across different levels of cover formed the focus of many submissions. A further round of consultation is underway with submissions due on August 3, 2018.
Dr Bill Sears, Immediate Past President of the Spine Society of Australia and a Sydney-based neurosurgeon, said health fund coverage for spinal surgery should be an all or nothing proposition – you should either be covered, or you should not.
“Australians who choose to take out cover for private spinal surgery are entitled to feel confident that they will receive the procedure that is best suited to their problem,” Dr Sears said. “Things may change at the time of surgery; patients must be assured that they are covered for whatever eventuates and that their care will not be compromised.
Their surgeon shouldn’t have one hand tied behind his or her back.”
Sydney neurosurgeon Dr Marc Coughlan warned the reforms could have ‘draconian consequences’ on thousands of Australians.
“It would potentially impact the lives of thousands of patients who would be precluded from having spinal fusions because of the high costs of the prostheses,” he said.
“Many of these people are younger patients with spinal conditions impacting on their ability to walk, work and remain productive in the workforce.
“My concern is that practitioners will be forced to opt for less effective procedures that in many cases will ultimately lead to multiple operations and increased costs.”
Sydney neurosurgeon Associate Professor Ralph Mobbs said the millions of Australians who have paid for private health insurance for decades – in the face of annual premium increases – deserved to receive the coverage they had been promised.
“Those who have invested for private health insurance for years have a legitimate right to expect the treatments they previously had for the same premium,” Dr Mobbs said.
An estimated 3.7 million Australians have chronic back problems and more than $1 billion in total health care expenditure in Australia is attributed to the condition, according to the Australian Institute of Health and Welfare (AIHW).
In a 2017 report, AIHW found back pain and back problems were the third leading cause of disease burden in Australia.
Gold Coast spine surgeon Assistant Professor Laurence McEntee said public hospitals would feel the weight of thousands of spine surgery patients who were no longer able to receive the care they needed in the private system under the reforms.
“There were about 12,000 people who had spinal fusions in the private system in the past year,” he said. “Offering spinal fusion only in the most expensive level of private health cover will trigger a massive cost shift to state governments because we will see a drastic increase in the number of people moving to the public system for treatment
where there are already waiting lists of up to three years for spine surgery in some regions.”
Like looking through a kaleidoscope
Family Doctor Week
Tasmania – Dr Jane Gorman
Variety is the spice of life for Tasmanian Dr Jane Gorman.
A general practitioner at the Augusta Road Medical Centre in Hobart’s northern suburbs, Dr Gorman has many strings to her bow – and that’s what keeps it real for her.
“I like flexibility. I’m a GP, I’ve been involved in travel medicine, family planning, diet, GP-land, and orthopaedics in my past life so I get called on for that a lot,” she said.
“I am eminently travelable. I’ve done two locums to Lord Howe Island in the past couple of years and I found it fantastic. You have to be prepared for trauma and such to that kind of work in those kind of locations, but I really enjoy the work.
“I do two days as a GP and two days as a private assistant and orthopaedic work. On an average day in my clinic I would see about 20 patients.”
Dr Gorman has been at her current practice for nine years, but previously she worked in orthopaedics in Sydney for four years, then two years advanced work in the area before moving onto a year working an Emergency Department.
“Then I met a dentist from Tasmania and eventually we moved here, and we now have three kids together,” she said with a smile.
“I love living and working in Tasmania and I really love treating the patients I have.
“I have quite a few families where I am treating generations. I really enjoy that because it gives me a great insight into them. Hearing what parents say about their kids and what kids say about their parents can be very helpful.
“I find working with families really very rewarding. I love seeing what happens to them, which is something you don’t get in orthopaedics – you do the surgery and then they’re gone. But as a GP you get to see how your patients develop and you’re with them two years down the track.
“I love watching kids grow up and I love watching older people grow older.
“I was once asked to use a prop to describe what being a family doctor is like and I turned up with a kaleidoscope. With a kaleidoscope, you get to look down this little hole where you get insights you wouldn’t experience anywhere else.
“There are jewels and patterns that no one else sees. That’s what it’s like being a doctor. It’s quite a privilege.”
CHRIS JOHNSON
More than just writing a script
Family Doctor Week
Western Australia – Dr Simon Torvaldsen
Dr Simon Torvaldsen is Chair of the AMA WA Council of General Practice, and he is also one of the owners of Third Avenue Surgery in Mt Lawley, just a few kilometres north-east of Perth’s city centre.
In an area that overall has a somewhat middle-class flavour, his patient demographic is quite mixed.
“It’s mainly mortgage belt and professionals – I have quite a few doctor patients – but also a significant number of elderly, less wealthy patients who have lived in the area for many years, plus some tenants of cheap unit accommodation,” he said.
“We are privately billing, although we bulk bill most pensioners. Our standard appointment is 15 minutes and most doctors see four patients per hour or somewhat less, as we do not discourage longer appointments and have a focus on quality care and patient satisfaction.”
Third Avenue Surgery has 10 consulting rooms.
“The work is so varied. From parents worried about their small children with fevers, to depressed and anxious teenagers,” Dr Torvaldsen said.
“My oldest patient died recently aged 104. I managed the sudden and somewhat unexpected deterioration, counselled family, provided palliative care, arranged nursing support and she passed away peacefully at her low-care aged care facility. It avoided hospital admission, which would have been expensive, futile, and most likely a poor quality, undignified end to a long and worthwhile life.
“Also recently, I had to gently nag an ophthalmologist who came in with wax impacted in his ear, jammed in by his attempts to remove it using various eye surgery instruments. Fortunately, it was easily removed by me. We doctors are not good at self-care, and general practice is a specialty in its own right. He will get me to do it next time.
“It is certainly not all coughs, colds and minor illnesses. Although we see plenty of that and the real skill is in picking the more serious conditions from the minor illnesses, especially as they often present to us in the very early stages.
“So much of what we do in general practice is about ensuring good communication and good understanding. It is not enough to just write the script.
“The reward is in the long-term care and seeing people through all sorts of things, as well as seeing the results of our medical care and the difference we make to people’s lives.
“We sometimes forget the degree of trust they put in us. And for me, the sheer variety keeps the day interesting and the brain nimble.”
CHRIS JOHNSON