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Preference: Surgery

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‘Everything presents at extremes…’ – a Solomon Islands experience

Pictgure: Dr Elizabeth Gallagher (second from left) with other staff and volunteers at the National Referral Hospital, Honiara

By Dr Elizabeth Gallagher, specialist obstetrician and gynaecologist, AMA ACT President

The mother lost consciousness just as her baby was born.

The woman was having her child by elective Caesarean when she suffered a massive amniotic fluid embolism and very quickly went into cardiac arrest.

We rapidly swung into resuscitation and, through CPR, defibrillation and large doses of adrenaline, we were able to restore her to unsupported sinus rhythm and spontaneous breathing.

But, with no equipment to support ventilation, treat disseminated intravascular coagulation, renal failure or any of the problems that arise from this catastrophic event, it was always going to be difficult, and she died two-and-a-half hours later.

Sadly, at the National Referral Hospital in Honiara, the capital of the Solomon Islands, this was not an uncommon outcome. Maternal deaths (both direct and indirect) average about one a month, and this was the second amniotic fluid embolism seen at the hospital since the start of the year.

I was in Solomon Islands as part of a team of four Australian practitioners – fellow obstetrician and gynaecologist Dr Tween Low, anaesthetist Dr Nicola Meares, and perioperative nurse and midwife Lesley Stewart – volunteering to help out at the hospital for a couple of weeks in October.

It was the first time I had worked in a developing country, and it was one of the most challenging, and yet satisfying, things I have ever done

Everything from the acuteness of the health problems to the basic facilities and shortages of equipment and medicines that we take for granted made working there a revelation.

The hospital delivers 5000 babies a year and can get very busy. As many as 48 babies can be born in a single 24-hour period.

The hospital has a first stage lounge and a single postnatal ward, but just one shower and toilet to serve more than 20 patients. The gynaecology ward is open plan and, because the hospital doesn’t provide a full meal service or much linen, relatives stay there round-the-clock to do the washing and provide meals.

From the beginning of our stay, it was very clear that providing training and education had to be a priority. I was conscious of the importance of being able to teach skills that were sustainable once we left.

The nature of the emergency gynaecological work, which includes referrals from the outer provinces, is that everything presents at the extremes…and late. Massive fibroids, huge ovarian cysts and, most tragically because there is no screening program, advanced cervical cancers in very young women.

When I first got in touch with doctors at the hospital to arrange my visit, I had visions of helping them run the labour ward and give permanent staff a much-needed break. But what they wanted, and needed, us to do was surgery and teaching.

To say they saved the difficult cases up for us is an understatement. I was challenged at every turn, and even when the surgery was not difficult, the co-morbidities and anaesthetic risks kept Dr Meares on her toes.

In my first two days, the hospital had booked two women – one aged 50 years, the other, 30 – to have radical hysterectomies for late stage one or early stage two cervical cancer. I was told that if I did not operate they would just be sent to palliation, so I did my best, having not seen one since I finished my training more than 12 years ago.

I also reviewed two other woman, a 29-year-old and a 35-year-old, both of whom had at least a clinical stage three cervical cancer and would be for palliation only. This consisted of sending them home and telling them to come back when the pain got too bad.

It really brought home how effective our screening program is in Australia, and how dangerous it would be if we got complacent about it.

We found the post-operative pain relief and care challenged. This was because staffing could be limited overnight and the nurses on duty did not ask the patients whether they felt pain – and the patients would definitely not say anything without being asked.

Doing our rounds in our first two days, we found that none of the post-operative patients had been given any pain relief, even a paracetamol, after leaving theatre.

We conducted some educational sessions with the nursing staff, mindful that the local team would need to continue to implement and use the skills and knowledge we had brought once we left. By the third day, we were pleased to see that our patients were being regularly observed and being offered pain relief – a legacy I hope will continue.

The supply of equipment and medicines was haphazard, and depended on what and when things were delivered. There was apparently a whole container of supplies waiting for weeks for clearance at the dock.

Many items we in Australia would discard after a single use, like surgical drains and suction, were being reused, and many of the disposables that were available were out-of-date – though they were still used without hesitation.

Some things seemed to be in oversupply, while others had simply run out.

The hospital itself needs replacing. Parts date back to World War Two. There were rats in the tea room, a cat in the theatre roof, and mosquitos in the theatre.

The hospital grounds are festooned with drying clothes, alongside discarded and broken equipment – including a load of plastic portacots, in perfect condition, but just not needed on the postnatal ward as the babies shared the bed with their mother.

It brought home how important it is to be careful in considering what equipment to donate.

The ultrasound machine and trolley we were able to donate, thanks to the John James Memorial Foundation Board, proved invaluable, as did the instruction by Dr Low in its use.

The most important question is, were we of help, and was our visit worthwhile?

I think the surgical skills we brought (such as vaginal hysterectomy), and those we were able to pass on, were extremely useful. Teaching local staff how to do a bedside ultrasound will hopefully be a long-lasting legacy. Simple things like being able to check for undiagnosed twins, dating, diagnosing intrauterine deaths, growth-restricted babies and preoperative assessments will be invaluable.

The experience was certainly outside our comfort zone, and it made me really appreciate what a great health system we have in Australia, and what high expectations we have. I want to send a big thank you to the John James Memorial Foundation for making it all possible.

[Correspondence] Primary chemotherapy versus primary surgery for ovarian cancer

We read with great interest the Article by Sean Kehoe and colleagues,1 in which they compare primary chemotherapy with primary surgery for patients with ovarian cancer. We agree that the median overall survival recorded in this trial is unexpectedly low. However, we disagree with the authors’ hypothesis that the slightly higher median age of the study population accounts for this low overall survival. Biological, rather than chronological, age predicts tolerance to stress. In geriatric oncology, patients who are not physically weak or frail and receive standard therapy have similar oncological outcomes compared with younger patients and live longer compared to those receiving less aggressive treatment because of their chronological age.

The 8 goals RACS have announced to stamp out bullying

The Royal Australasian College of Surgeons has launched an Action Plan to turn around the reputation of their profession.

The intention of their plan is to ‘promote respect, counter discrimination, bullying and sexual harassment in the practice of surgery, and improve patient safety’.

The Action Plan is a response to a draft report and recommendations released by an Expert Advisory Group commissioned by RACS in response to reports of bullying behaviour in the surgical field.

The report found there is culture of bullying that is considered a ‘rite of passage’ within the College with the intent to prepare trainees for surgery.

There are 8 goals in the Action Plan with a set of actions for each one to help the college monitor its progress.

The goals are:

  1. Build a culture of respect and collaboration in surgical practice and education
  2. Respecting the rich history of the surgical profession, advance the culture of surgical practice so there is no place for discrimination, bullying and sexual harassment (DBSH)
  3. Build and foster relationships of trust, confidence and cooperation on DBSH issues with employers, governments and their agencies in all jurisdictions
  4. Embrace diversity and foster gender equity
  5. Increase transparency, independent scrutiny and external accountability in College activities
  6. Improve the capability of all surgeons involved in surgical education to provide effective surgical education based on the principles of respect, transparency and professionalism
  7. Train all Fellows, Trainees and International Medical Graduates to build and consolidate professionalism including: fostering respect and good behaviour,   understanding DBSH: legal obligations and liabilities, ‘calling it out’/not walking past bad behaviour  and resilience in maintaining professional behaviour
  8. Revise and strengthen RACS complaints management process, increasing external scrutiny and demonstrating best practice complaints management that is transparent, robust and fair

Read the full action plan on the RACS website.

So far, responses from doctors have been positive. Dr Ashleigh Witt, who gained prominence in the mainstream media earlier this year for her comments on being a female surgeon, tweeted ‘I’ve only skimmed but so far very impressed by this. Excellent work @ ‘

St Vincent’s Health tweeted ‘Congratulations @ on this important announcement. We stand ready to work with you on its implementation.’

Senior surgeon and author on gender equality Dr Gabrielle McMullin told ABC Radio that she wasn’t sure it would change anything: “The problem is getting people, trainees, to believe that a complaint will not adversely affect their progression in their career and getting a job. That is the major reason why trainees don’t complain about harassment and bullying, is because you lose your career if you complain.”

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Latest news:

FBT cap: we are not entertained

Patients could face a blow-out in waiting times for elective surgery if the Federal Government pushes ahead with controversial plans to cap tax concessions on entertainment benefits for hospital employees, the AMA has warned.

The nation’s peak medical group had told Treasury its proposal to impose a $5000 cap on salary sacrificed meal and entertainment expenses that are eligible for fringe benefit tax exemptions would harm the ability of public hospitals and other not-for-profit health groups to attract and retain skilled medical staff, undermining the services they are able to provide.

In its May Budget, the Federal Government claimed the tax concession – currently worth around $17,000 a year – was being exploited and abused, and estimated its crackdown on the perk would raise $295 million over four years.

But AMA Vice President Dr Stephen Parnis said the Government had not provided any substantive evidence to back its claim FBT concessions were being used unfairly, and urged it to proceed with great caution in making any changes.

“The AMA is deeply concerned that the reforms canvassed in the exposure draft could significantly affect the ability of institutions, including public hospitals, to recruit and retain staff,” Dr Parnis said, warning this could cause treatment waiting times to blow out.

“If the current supply of medical specialists decreases, we believe it is reasonable to predict a lengthening of waiting lists for elective surgery and outpatient clinics.”

Public hospitals and not-for-profits have relied on the FBT concession to help them compete with the private sector for the services of doctors and other health workers.

Dr Parnis said that many practitioners chose to forego higher wages on offer in the private sector to work in public hospitals because of the chance to practice advanced acute care, undertake research and provide teaching and training.

But he said they still deserved to be fairly remunerated for their skills and experience, and the FBT tax concession helped to make the salaries hospitals could offer competitive.

The AMA has warned that putting a cap on the concession would have a number of serious unintended consequences for the health care system, particularly the supply of medical specialists.

In the short-term, any drift of medical specialists away from the public system will likely cause waiting lists for surgery to blow out.

In the longer term, because the health system relies on senior and experienced hospital medical staff to help train the next generation of practitioners, Dr Parnis said the loss of even some of these workers to the private sector because of reduced tax breaks would undermine teaching capacity.

He said this was particularly worrying because it was coming at a time when the pressure on hospital teaching capacity had never been greater as a result of rapid growth in the number of medical graduates.

Several organisations have written to Treasury urging that the $5000 cap on entertainment expenses that are eligible for FBT exemptions be raised.

St John’s Ambulance said it relied on the FBT exemption to help attract and retain skilled staff, and suggest the cap be increased to $20,000, while the Fred Hollows Foundation recommended it be set at $30,000.

The Salvation Army, meanwhile, warned a $5000 cap would hit the salaries of half its staff.

The Tax Institute recommended the bcap be set at $15,000.

The tax change is due to come into effect from 1 April 2016.

Adrian Rollins

 

Hospital cuts cloud reform outlook

The states are seeking to exert increasing pressure on the Federal Government over its $57 billion cut to public hospital funding amid speculation of a radical overhaul of Commonwealth-State health arrangements.

Queensland Health Minister Cameron Dick told a meeting of the nation’s health ministers last month that the Coalition Government’s decision to rip up the National Partnership Agreement on health services and reduce the indexation of Commonwealth hospital payments to population plus inflation would cut $11.8 billion from the State’s hospital system – the equivalent of 4500 doctors, nurses and allied health professionals.

This follows claims from the Victorian Government that the Commonwealth’s decision will rip $17.7 billion from its health system over the next decade, while New South Wales has figured a $16.5 billion loss, South Australia $4.6 billion, Western Australia $4.8 billion and Tasmania $1.1 billion.

Victorian health officials told a Senate inquiry the impact of the Federal Government’s cuts would be equivalent to shutting down two major hospitals and axing 23,000 elective surgery procedures every two years.

“[It] would equate to the level of service delivery of two health services the size of Melbourne Health [which operates the Royal Melbourne Hospital],” acting Victorian Health Department Secretary Kym Peake told the inquiry.

The big cuts form a challenging backdrop for discussions of reform to Federal-State relations that include proposals for Commonwealth public hospital funding to be replaced by a “hospital benefit payment” that would follow individuals, similar to Medicare.

Government discussions of changes to the private health insurance industry have included reference to option two in the Reform of the Federation Discussion Paper, which proposes a Medicare-style payment for hospital services, regardless of whether they are provided in the public or private system.

Under the arrangement, the price of hospital procedures would be set by an independent body and the Commonwealth would pay a proportion. For patients in the public system, the states would be expected to make up the difference, while in private hospitals the gap would be covered either by insurers or the patients themselves.

States would retain responsibility and operational control of public hospitals and would be able to commission services from the private sector, while the Commonwealth would discontinue the private health insurance rebate.

But the Federal Government is likely to encounter significant resistance to such a change from the states unless it comes up with more money.

The revenue raised from the GST, which is funnelled directly to the states, has been growing far more slowly than expenditure, tightening the squeeze on state budgets and their health funding.

When it was introduced in 2000, GST applied to 55 per cent of spending, but since then its share has shrunk to 47 per cent this year, and consultancy Deloitte Access Economics estimates it will apply to just 42 per cent by 2024-25.

The squeeze on funding has shown up in disappointing public hospital performance.

The latest report from the Australian Institute of Health and Welfare shows that hospitals are struggling to make headway in the face of increasing demand for emergency care.

The proportion of urgent patients receiving treatment within the recommended time fell back in 2014-15 to just 68 per cent – well short of the target of 80 per cent.

The goal for all emergency department visits to be completed within four hours, which was meant to be achieved this year, has also been missed.

The results bear out warnings made by the AMA earlier this year that the Commonwealth’s funding cuts for hospitals would undermine the delivery of care.

Launching the AMA’s annual Public Hospital Report Card, President Professor Brian Owler said the Federal Government’s cuts had created “a huge black hole in public hospital funding”.

“It’s the perfect storm for our public hospital system,” he said. “There’s no way that states and territories can even maintain their current frontline clinical services under that sort of funding regime, let alone build any capacity we actually need to address the shortfalls now.”

Health Minister Sussan Ley rejected the warnings at the time, but the latest evidence of declining performance are likely to make it increasingly difficult for the Government to win State backing for an overhaul of funding arrangements without more money on the table.

Adrian Rollins

Atlas charts course to improved care

The first detailed national appraisal of variations in health practice has found that Australians are among the world’s heaviest users of antibiotics and antidepressants, and within the country there are major differences in the use of common drugs and treatments for everything from colonoscopies and cataract surgery to antipsychotic medicines for the elderly and hyperactivity drugs for the young.

In what is seen as the first step toward addressing unwarranted variations in the care patients receive, the Australian Commission on Safety and Quality in Healthcare has released a report identifying wide discrepancies in the use of everyday medicines and procedures.

Among its findings, the Australian Atlas of Healthcare Variation has revealed that children in some parts of the country, particularly in NSW, are seven times more likely to be prescribed drugs for ADHD than those in other areas, while cataract surgery, hysterectomies, tonsillectomies were three times more common in some areas than others, and patients in some parts were 30 times more likely to undergo a colonoscopy.

AMA President Professor Brian Owler said that, by reflecting how the delivery of health care was organised, the Atlas provided a useful illustration of differences in access to care.

But he highlighted the fact that the Commission itself made no claim about the degree to which differences in care was unwarranted.

“The Atlas is a welcome starting point for further research and examination of health service distribution,” Professor Owler said. “It is not proof that unnecessary or wasteful care is being provided to Australians, and should not be interpreted that way.”

The Commission said that some variation was “desirable and warranted” to the extent that it reflected differences in preferences and the need for care.

It added that “it is not possible at this time to conclude what proportion of this variation is unwarranted, or to comment on the relative performance of health services and clinicians in one area compared with another”.

Senior clinical adviser to the Commission, Professor Anne Duggan, said the average frequency of various services and procedures provided in the Atlas were not necessarily the ideal, and observed that “high or low rates are not necessarily good or bad”.

Nonetheless, she said the weight of local and international evidence suggested much of the differences observed was likely to be unwarranted.

“It may reflect differences in clinicians’ practices, in the organisation of health care, and in people’s access to services,” Professor Duggan said. “It may also reflect poor-quality care that is not in accordance with evidence-based practice.”

Many of the variations identified in the Atlas have been linked to wealth and reduced access to health care in disadvantaged areas.

Professor Duggan said the less well-off tended to have poorer health and so a greater need for care, while some procedures are used more often in wealthier areas.

She said the Atlas showed that rates of cataract surgery were lowest in areas of disadvantage, and increased in better-off locales.

But Professor Owler said the example showed the need to be very careful in drawing conclusions about the reasons for variation.

He said the Atlas showed that the incidence of cataract surgery was highest in the remotest parts of far north Queensland.

“This is because there are no public services available, with private ophthalmologists delivering eye care to Indigenous communities, which is covered by Medicare,” the AMA President said.

He said identifying variation in health care was essential, but this was the first step before determining the causes of variation.

“The Atlas doesn’t tell us what should be the best rates for different interventions and treatments.”

In addition to identifying variations in health care within the country, the Atlas also explored how the care provided in Australia compared internationally.

While acknowledging that differences in the type and quality of data made it difficult to draw direct comparisons, the Atlas nonetheless reported that Australia has “very high” rates of antibiotic use compared with some countries, and Professor Duggan said that, among rich countries, Australia was second only to Iceland in the extant of use of antidepressants.

Professor Owler said that, with the publication of the Atlas, the challenge now was to develop a process to identify variations in practice that were “actually unwarranted, not just assumed to be” and to develop and fund strategies to reduce them by supporting clinically appropriate care, such as by providing clinical services where they are needed.

To view the Atlas, visit: http://www.safetyandquality.gov.au/atlas/

Adrian Rollins

[Correspondence] Letter from the future surgeons of 2030

The Lancet Commission on Global Surgery1 shows that the global burden of surgical disease is far higher than previously estimated. However, there is a sense of opportunity to do more to reduce this burden by 2030.1,2 As the surgeons of 2030, we wish to raise some concerns and suggestions to reduce global surgical inequality.

[Correspondence] Global surgery and the dilemma for obstetricians

The Lancet Commission on Global Surgery (Aug 8, p 569)1 contains a strong message that all people should have access to safe, high quality surgical care, especially in low-income and middle-income countries. Likewise, the 2015 Amsterdam Declaration on Essential Surgical Care identified accessibility to caesarean sections as one of the top priorities.2

[Comment] Crohn’s disease: REACT to save the gut

Crohn’s disease affects roughly one in 300 adults in Europe and North America, with a rising global incidence.1 The disease usually develops from a predominantly inflammatory phenotype to penetrating and fibrostenotic intestinal complications. It carries substantial morbidity, with frequent hospital admissions, surgery, and need for corticosteroids and immunosuppressive drugs, and often results in poor quality of life and loss of workplace productivity. The cumulative incidence of abdominal surgery is 33% at 5 years, and 47% at 10 years.