War zone gynaecologist named AMA Woman in Medicine

AMA Woman in Medicine 2018, Professor Judith Goh AO, has described receiving her award as a great honour and privilege.

Adding that it was acknowledgement for the work of a dedicated team of health professionals, Professor Goh told Australian Medicine the award would also help build awareness for the plight of women’s health.

“We often live quite comfortably in Australia but for most women around the world, surviving their pregnancy is not taken for granted,” she said.

“So this is great recognition. But we don’t do these things to be recognised. We do it because we want to do it.”

Professor Goh is a dedicated gynaecologist who volunteers her time treating women in war zones and Third World countries.

She was named the AMA Woman in Medicine 2018 at the AMA National Conference in May.

She is a urogynaecologist who has devoted her career to women’s health. Her next stops are Bangladesh, Myanmar, and some African countries.

A world-renowned surgeon who has spent approximately three months every year for the past 23 years training doctors in Third World countries in repairing vesico-vaginal fistula – a devastating injury that can occur following prolonged, obstructive labour – Professor Goh was noticeably touched by the honour.

In presenting her the award, outgoing AMA President Dr Michael Gannon noted that Professor Goh’s nominators – colleagues from the Australian Federation of Medical Women and the Queensland Medical Women’s Society – have described her career as both humbling and inspirational.

“Since 1995, Professor Goh has donated her time and expertise, working abroad several times a year as a volunteer fistula surgeon in many parts of Africa and Asia, including Bangladesh, Sierra Leone, Ethiopia, Tanzania, Uganda, the Democratic Republic of Congo, and Liberia,” Dr Gannon said.

“Professor Goh runs the twin projects, Medical Training in Africa and Medical Training in Asia, via the charity, Health and Development Aid Abroad (HADA), using funds raised to help pay for women’s surgeries such as the correction of genital tract fistulae and prolapse, while training the local staff in these areas.

“To carry out her work within a dedicated team of professionals, Professor Goh often has to brave political unrest, and perform surgery in challenging environments, as well as deal with the emotional and social injuries to her patients due to war, rape, domestic violence, poverty, shame, and grief.

“Her work has changed lives for the better for hundreds of affected women, correcting their often long-standing and preventable obstetric trauma, including vesico-vaginal and recto-vaginal fistulae, with the minimum of overhead costs to maximise the reach of her services.

“Professor Goh uses her time abroad to upskill local practitioners in this area of medicine, and to raise awareness of the underlying causes of chronic complications of birth trauma, including poverty, lack of education, lack of awareness, and the subordination of women in some cultures.

“In 2012, she was made an Officer of the Order of Australia (AO) ‘for distinguished service to gynaecological medicine, particularly in the area of fistula surgery, and to the promotion of the rights of women and children in developing countries’.

“Her humble dedication within this field of women’s medicine, and her brave and generous service to women all over the world, is inspirational, and very worthy of recognition as a recipient of the AMA Woman in Medicine Award.”

Professor Goh said many women felt ashamed after delivering stillborn babies.

“In some places it is seen as a failure. There is even violence against them in some communities. We are building a community where lot of women can come together and feel supported,” she said.

“In our country we no longer really say ‘mother and child are well’ after a baby is born. It’s taken for granted, so the first question is how much did the baby weigh.

“But there are so many places in the world where this cannot be taken for granted.”

The AMA Woman in Medicine Award is presented to a woman who has made a major contribution to the medical profession by showing ongoing commitment to quality care, or through her contribution to medical research, public health projects, or improving the availability and accessibility of medical education and medical training for women.

CHRIS JOHNSON

[Comment] Pathology and laboratory medicine in partnership with global surgery: working towards universal health coverage

Pathology and laboratory medicine (PALM) is the backbone of high-quality care across many specialties, particularly surgery. In surgery, PALM provides the cross-match to keep patients with bleeding ectopic pregnancies alive, the histopathology that differentiates a benign colonic polyp from a malignancy, the biochemistry that allows safe titration of anaesthetics, and the forensic pathology that quantifies the burden of disease.

[Correspondence] PRIMA, non nocere: a reply from the authors

We thank John Harvin and Lillian Kao for their Comment1 on our Article.2 Harvin and Kao stated, on the basis of the results of the PRIMA trial, that we cannot conclude that there are no increased short-term risks associated with use of prophylactic mesh. The short-term results were published in Annals of Surgery in 2015,3 and it is true that we did not specifically power our study with the short-term outcomes in mind.

[Perspectives] Plastic perfection

At a time of increasing dissatisfaction with the natural body, people are ever more likely to call for the sculptor with the scalpel. Two-thirds of young people and adults in the UK are unhappy about how they look, and cosmetic surgery is big business. British artist Jonathan Yeo’s new exhibition shows his long-held interest in ideas of bodily perfection and their shaping by new technologies. Self-taught as a portraitist while recovering from Hodgkin’s lymphoma as a young man, Yeo achieved fame with paintings of celebrities such as Damien Hirst, Nicole Kidman, and Dennis Hopper.

[Articles] Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study

Despite a low-risk profile and few postoperative complications, patients in Africa were twice as likely to die after surgery when compared with the global average for postoperative deaths. Initiatives to increase access to surgical treatments in Africa therefore should be coupled with improved surveillance for deteriorating physiology in patients who develop postoperative complications, and the resources necessary to achieve this objective.

[Comment] A snapshot of surgical outcomes and needs in Africa

It is estimated that two-thirds of the world’s population do not have access to safe, affordable, and timely surgical care.1 Around 16·9 million people die from conditions that require surgical care each year, most of them in low-income and middle-income countries (LMICs).2 In 2014, Jim Kim, President of the World Bank, challenged the global community to address this injustice, and to develop targets to measure progress on effective coverage of surgical interventions.3 In response, the global surgery community developed a set of core surgical indicators that measure timely access, provider density, operative volume, surgical safety, and financial effects.

Communiqué from March Federal Council meeting

DR BEVERLEY ROWBOTHAM, CHAIR, FEDERAL COUNCIL

Federal Council met in Canberra on March 16 and 17. Debate was robust as always and productive, with numerous Position Statements approved for adoption. These will be released to members and the public over coming weeks.

The President reported, as is our usual practice, in a town hall format, with questions of the President from Councillors and some debate. The President reported that the AMA had maintained a very high media profile over the summer period, with many press releases on summer lifestyle issues. These included avoiding heat stress, drinking in moderation, and driving safely. There were also significant Position Statements released, including the AMA Position Statement on Mental Health, which attracted a lot of positive interest from the mental health community.

In the week prior to the Federal Council meeting, the President had released the Public Hospital Report Card, highlighting the need for continued investment by Federal and State Governments in our public hospitals.

The major focus of discussion at this meeting was the recent actions of Bupa in announcing changes to its cover, which will impact doctors and patients alike. Federal Council urged the President to maintain his advocacy on the issue.

The Secretary General’s report again highlighted the scope of activity underway within the Federal AMA secretariat and the success of AMA advocacy on behalf of members; workforce initiatives; the granting by the ACCC of a further authorisation to permit certain billing arrangements to benefit general practices; discussions with the Department of Health on its review of medical indemnity insurance schemes; the raft of reviews relevant to reforms to private health insurance; the ongoing MBS reviews, and much more.

Federal Council considered a proposal for the introduction of post nominal letters to denote membership of the AMA, a move that has been long in the gestation. Further work is required before the Board considers amendments to the By Laws to make provision for the introduction.

Another key discussion was the change to the format of National Conference this year with the introduction of a day of policy debate. This change is being made in response to feedback from delegates that the opportunity for debate on issues by delegates needed to be enhanced. Federal Council considered a number of draft policy resolutions put forward by the membership, which will be further refined before distribution to delegates attending National Conference. Participation in the debate on the resolutions will be open to all AMA members attending the Conference, whether as an appointed delegate or fee-paying member.

Public health working groups brought forward a Position Statement on Men’s Health, and on Drugs in Sport. Council debated the issue of funding of access to bariatric surgery in the public health system. It also agreed to establish two new working groups to look at the issues of child abuse and neglect, and health literacy.

The Ethics and Medico Legal Committee tabled a revision to the Guidelines for Doctors on Managing Conflicts of Interest in Medicine, which was approved by Council. It is part of a wider piece of work before the Committee, looking at relationships between medical practitioners and industry.

Federal Council approved a new Position Statement on Diagnostic Imaging; and another on Resourcing Aged Care. The latter is one of the many advocacy documents in development or under review as part of the AMA’s expanded work on aged care issues. Council noted the report on the recent AMA survey of doctors’ views about providing care in aged care settings, noting the anticipated decline in the number of practitioners providing care.

A recent meeting of the Health Financing and Economics Committee had considered the issue of value based care as a model with the potential to concurrently increase hospital efficiency and improve patient outcomes. Quality data is needed to inform this work within public hospitals.

The Task Force on Indigenous Health, which advises the President on issues relevant to Indigenous health, continues its close involvement with Close the Gap initiatives. Its 2017 report card on ear health continues to be well received.

The various Councils of Federal Council provided their reports. The Council of Private Specialist Practice is monitoring the various reviews of private health insurance, including out of pocket costs and options to manage low value care in mental health and rehabilitation.

The Council of Doctors in Training (DiTs) discussed proposed reforms to bonded medical workforce schemes. The AMA has been active in influencing changes to the schemes which the Council of DiTs has strongly endorsed. The Chair of the Council of DiTs reported on the very successful AMA Medical Workforce and Training Summit held on 3 March 2018. The Summit brought together more than 70 important stakeholders in medical workforce and training to discuss the concerns of the AMA and many others in the profession with the distribution of the medical workforce, the long-standing imbalance between generalist training and sub- specialisation, the workforce position of different specialties and the growing evidence of a specialty ‘training bottleneck’ and lack of subsequent consultant positions.

The Council of General Practice tabled two Position Statements for approval. The first dealt with General Practice Accreditation and the second provides a Framework for Evaluating Appropriate Outcome Measures.

Federal Council supported a motion put forward by the Council of General Practice to endorse funding of universal catch-up vaccines through the National Immunisation Program for anyone living in Australia wishing to become up to date with clinically appropriate NIP vaccinations, irrespective of age, race, country of origin and State or Territory of residence.

The Council of Rural Doctors reported on its recent meeting with the new Rural Health Commissioner, Professor Paul Worley and discussions on the national rural generalist pathway.

The final item of business, but by no means the least important, was the adoption by Federal Council of a position statement on the National Disability Insurance Scheme, which followed a detailed discussion on the Scheme at the November meeting of Council.

Federal Council now prepares for the National Conference and its last meeting with its current membership in May. Elections are underway for several positions on the Council, evidence of increased member interest in its work.

Graduate supply and public hospital funding – when will Government get this the right way around?

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

As I write, Victorian salaried doctors are voting on its recommended Enterprise Bargaining Agreement, and other jurisdictions are in advanced negotiations in the new industrial relations frameworks. Relevant reports will follow.

My attendance at the sobering March 3 AMA Workforce and Training Summit convened in Melbourne, together with inspection of AMA’s 2018 Public Hospital Report Card, explains my continued exasperation at the consistent failure of Government to introduce realistic, necessary policy responses that deal with the now clearly apparent multiple medical training pipeline obstacles and poor public hospital access. Currently we have too much medical graduate supply and insufficient funding for appropriately training our junior colleagues in a manner that will meaningfully lead to reasonable public access to public hospital services.

The Summit attitude was constructive with about 80 national stakeholders combining to produce many broadly supported actions which AMA can prosecute. The Summit’s challenge was to consider what measures are needed further ‘downstream’ in training provision to ensure sufficient high quality training places in all medical specialties as they are needed for community benefit. While I fear the problems we now face are actually fast becoming too entrenched to solve, the Summit made it apparent that the medical profession is looking to the AMA, and within it your Council of Public Hospitals Doctors (CPHD), to lead the case for major reform. Accordingly, CPHD will be guided by the outcome strategies of the Summit, and will press to further inform and influence our health policy makers.

Two certain consensus points emerged from the Summit: stop opening new medical schools, and start rationalising resources towards regions and specialties where they are most needed. Government has regularly failed to fully listen to AMA’s advance warnings that there is real structural constraint to training capacity and that substantial ongoing investment is necessary to maintain training standards. Additionally, we need to urgently find sustainable, equitable paths to tackle the maldistribution of doctors (particularly across rural settings) and the shortages or bottlenecks arising in some craft areas.

I observe that it was AMA advocacy that achieved for most medical school graduates (and including many International Medical Graduates) guaranteed internship after graduation when, incredibly, Government had not actually originally factored this in to its expansion decision. Just another Federal/State divide. And, let’s not forget, the massive increase of new graduates doesn’t actually have true tsunami characteristics of quick destruction by ingress then receding as fast as it came, enabling an early, planned, rebuild. Instead, there is actually a permanent rising of the water table, overwhelming teaching infrastructure capacity, which means patients in public hospital beds.

The point is, we are graduating medical students in numbers far in excess of the OECD average without ensuring the adequate provision of the essential training places, both prevocational and specialist. This is at the same time that Commonwealth funding investment is not keeping pace with population growth. Any economist would reel.

In my December 2017 Australian Medicine piece, I discussed the ‘doing more with less’ implications of the Commonwealth financially penalising public hospitals who report acquired conditions, sentinel events and avoidable readmissions, otherwise known as possible healthcare outcomes (as if we are exercising choice to not provide optimum care now!). Added to that is the idea of penalising ‘low value care’ based on what are imposed and unsophisticated definitions, all with the aim of minimising financing, and a country mile from favourable health outcomes. This Commonwealth approach is in conjunction with them not offering any additional long term hospital funding via its 2020 State Agreement.

So, we have no additional funding despite AMA’s 2018 Public Hospital Report Card establishing there has been a 3.3 percent year-on-year average increase in separations (that’s called increased productivity), that one third of urgent emergency department patients are not seen within the recommended 30 minutes and that most States’ urgent elective surgery is not performed within the 90 day clinically indicated timeframe (that’s called increased demand). Don’t get me started on the sometimes years of a patient waiting to be seen in outpatients before actually being counted on an elective waiting list! And they want to claw back already insufficient funding when a complication happens. That economic management is called madness. If only health care really was like slapping a motor vehicle together on a production line; but it just is not.

The Summit’s Report will help us work together to develop initiatives to build a sustainable, well-trained, well-qualified and accessible medical workforce. The AMA’s Report Card is true evidence-based advocacy about hospital performance and the need for Government funding support to improve public access. Both suggest the public health climate is ominous with Government offering less funding but at the same time pressing for improved outcomes and offering more graduates but with no clear, coordinated, training pipeline management. Government must listen to us because of the implications for the community’s fair access to appropriate public hospital services, and for the career aspirations of our best and brightest.

How weight loss surgery affects marriage and relationships

People who have undergone bariatric surgery are more likely to divorce if they were married before the intervention, and more likely to get married if they were previously single, a first-of-its-kind study has found.

The finding shows that although improving physical health is the key motivator for weight loss surgery, it often impacts on the patient’s personal life as well, the Swedish study authors say.

The study, published in JAMA Surgery, looked at two large cohorts, the first with nearly 2000 bariatric surgery patients plus matched obese controls, and the second with nearly 30,000 patients matched with general population controls.

In the first group, those who were single at the time of the surgery were twice as likely to be married or in a new relationship after four years, compared with obese controls, and were still substantially more likely to be in a relationship at ten years. And in the second group, new marriages and relationships were 24% more likely than in the single general population.

But separations and divorces among those in a relationship at the time of surgery were also more common than in both obese and general population controls.

The authors argue that the two findings are probably the result of a new-found self-confidence that patients have after their intervention. For those who are single, that confidence allows them to engage in social activities that they would have shunned before and opens up the possibility of new relationships. For those already married or in a relationship, the surgery may change the power dynamics of that relationship, giving people more confidence to exit a relationship that isn’t working or making them happy.

In a linked commentary, two US-based surgeons say the new research has important implications.

“From a research perspective, we must continue to explore the causes of relationship disruption and initiation so that health care professionals can support patients before and after surgery,” they write.

This will help reassure patients that bariatric surgery is not only the most effective treatment for severe obesity, but also “an extremely powerful tool for positive transformation in their lives”.

You can access the full study here.

[Review] Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions.