more_vertOver two decades ago a surgeon told me the story of a young man with a spinal injury. The young man had a potentially catastrophic injury and either having surgery, or not, was risky. He had the surgery and recovered, but subsequently the surgeon was informed that the young man’s sexual function was entirely lost. The patient fell into depression and despair. The surgeon was devastated and blamed himself. The senior ward nurse on the Nightingale ward observed all this. She listened to her patient’s anguish and the surgeon’s distress.
Preference: Surgery
1175
[Articles] Outcome and undertreatment of mitral regurgitation: a community cohort study
In the community, isolated mitral regurgitation is common and is associated with excess mortality and frequent heart failure postdiagnosis in all patient subsets, even in those with normal left-ventricular ejection fraction and low comorbidity. Despite these poor outcomes, only a minority of affected patients undergo mitral (or any type of cardiac) surgery even in a community with all means of diagnosis and treatment readily available and accessible. This suggests that in a wider population there might be a substantial unmet need for treatment for this disorder.
SERENDIPITY ?
LETTER TO THE EDITOR
I well know anecdotal and personal stories are anathema to the scientific process. However, ‘my accurate story is different’. In 2012, I developed severe life endangering throat cancer, successfully treated at RPAH as a public patient, with radiotherapy and cetuximub. In 2017, I sustained colon cancer, also successfully treated by surgery. I am aged 90. Never used alcohol, never smoked, vegetarian, weight 60 kg, walked 30 minutes every day for a lifetime. Regular prophylactic medical checks by a specialist twice a year for more than 20 years.
I worked in my same GP surgery at North Ryde, a Sydney suburb that abutted directly onto a public laneway. Along the laneway were electrical cables, also on the same poles for cable television. Now, I sat for 60 years within roughly three metres (possibly less) of the wires and cables. All such wires carry an electromagnetic field – always with the query of whether it possibly being carcinogenic. I never considered that though (even after having watched the Australian made film The Castle several times). I believe this possibly caused or contributed to my two unrelated cancers. I would appreciate views of your readers, as this has always been a highly contentious issue among doctors and medical statisticians. I wonder how many other people ‘out there’ have similar exposure, with a ‘cancer diagnosis’ just waiting to be made?
Dr John F Knight AM
NSW Senior Australian of the Year 2017
Founder and Chairman Medi-Aid Centre Foundation
North Ryde, NSW
A stitch in time: the fine art of suturing
Suturing is one of the oldest of medical arts. Its practice goes back at least 5,000 years, with evidence from mummies showing that Ancient Egyptians used plant fibres, hairs and tendons to sew up wounds. Today, basic suturing is something that all doctors are expected to master, and practically all GPs will have to perform at some stage.
The scariest part of learning how to suture, says Perth-based GP Dr Alison Soerensen, is when you’re presented with your very first patient.
“Up until then, you’ve practised on pig skin or pig trotters, but that’s not a perfect substitute for the real thing. ‘You’re my first one’ doesn’t necessarily go down well with the patient!” she laughs.
But Dr Soerensen says she was relatively lucky with her first experience, which involved a very elderly patient without too many concerns about cosmetic outcomes, and who had a very good relationship with the GP who was supervising the intervention.
“The GP said something like: ‘It’s her first time, but don’t worry, I won’t let her sew your foot to your elbow or anything’, and the patient was OK with it.”
Dr Soerensen says an easier first-time experience for med students might arise if they’re doing a surgical rotation, with the patient under general anaesthetic. The surgeon might do most of the suture and then let the student finish it.
“The advantage in that scenario is the patient is asleep and you’re not having the added pressure of them watching what you’re doing. And if you make a mistake it’s very easy for the surgeon to correct it.”
Dr Soerensen says that in many medical disciplines, “you’d struggle without some suturing skills”. A common issue is getting the skin edges to come together, which can be particularly difficult with elderly patients whose skin is fragile and tears easily. Scarring is not an issue with the actual intervention, but it’s a risk you should discuss with patients.
Another issue, says Dr Soerensen, is non-compliant patients. It could be an elderly patient with dementia who has cut her head in a fall and doesn’t understand the need to keep still during the intervention.
“Or, on the other end of the age scale, you’ve got the two-year-old with laceration. You might normally think about glueing, but then you’d worry the child might pick at it and you’d have an open wound again. So it’s a question of do you suture, and do you look at sedation to try and get a good result.”
Often the decision whether to suture or not can be a bit of a grey area, with different doctors having different opinions.
“You have to discuss it with the patient. For example, a lot of biopsies will heal fine by themselves, but you’ll get a little circular scar. Suturing might minimise the scar, but then you’ve got another needle going in. You have to talk to the patient to see what they want.”
Dr Soerensen says there’s a lot of variation among GPs as to how much suturing they do, although most would at least have one case per month.
“The more you do, the more confident you are, and that’s why you have GPs that essentially end up subspecialising in skin work, because it’s what they’re good at and they enjoy it. The more you do, the quicker you get, and the better results you get. Like everything else, there’s a learning curve.”
Want to sharpen your suturing skills? Sign up to doctorportal’s online Basic Suturing module to learn about wound assessment and cleaning, suturing technique and post-suturing wound care.
This one-hour course is designed for beginners and is accredited with ACEM, ACRRM, CICM and ANZCA.
[Perspectives] Medical 3D printing and the physician-artist
It was psychologically impossible to prepare for the first patient I met who had catastrophic facial deformity. Medical training helped me respond to his sensory defects: sight, sound, smell, and taste. However, when one person meets another, we connect via, and then later recognise, one another’s face. When I met that first patient—one of many wounded soldiers with severe facial injuries—I was challenged to help artfully repair the damage. Had the injury occurred in the mid-20th century, surgery would have been greatly limited by the paucity of options in plastic surgery.
Impact of frailty on outcomes after discharge in older surgical patients: a prospective cohort study [Research]
BACKGROUND:
Frailty is a state of vulnerability to diverse stressors. We assessed the impact of frailty on outcomes after discharge in older surgical patients.
METHODS:
We prospectively followed patients 65 years of age or older who underwent emergency abdominal surgery at either of 2 tertiary care centres and who needed assistance with fewer than 3 activities of daily living. Preadmission frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale as “well” (score 1 or 2), “vulnerable” (score 3 or 4) or “frail” (score 5 or 6). We assessed composite end points of 30-day and 6-month all-cause readmission or death by multivariable logistic regression.
RESULTS:
Of 308 patients (median age 75 [range 65–94] yr, median Clinical Frailty Score 3 [range 1–6]), 168 (54.5%) were classified as vulnerable and 68 (22.1%) as frail. Ten (4.2%) of those classified as vulnerable or frail received a geriatric consultation. At 30 days after discharge, the proportions of patients who were readmitted or had died were greater among vulnerable patients (n = 27 [16.1%]; adjusted odds ratio [OR] 4.60, 95% confidence interval [CI] 1.29–16.45) and frail patients (n = 12 [17.6%]; adjusted OR 4.51, 95% CI 1.13–17.94) than among patients who were well (n = 3 [4.2%]). By 6 months, the degree of frailty independently and dose-dependently predicted readmission or death: 56 (33.3%) of the vulnerable patients (adjusted OR 2.15, 95% CI 1.01–4.55) and 37 (54.4%) of the frail patients (adjusted OR 3.27, 95% CI 1.32–8.12) were readmitted or had died, compared with 11 (15.3%) of the patients who were well.
INTERPRETATION:
Vulnerability and frailty were prevalent in older patients undergoing surgery and unlikely to trigger specialized geriatric assessment, yet remained independently associated with greater risk of readmission for as long as 6 months after discharge. Therefore, the degree of frailty has important prognostic value for readmission.
Trial registration for primary study
ClinicalTrials.gov, no. NCT02233153
AMA shines in Australia Day Honours
Former Australian Medical Association President Dr Mukesh Haikerwal has been awarded the highest honour in this year’s Australia Day awards by being named a Companion of the Order of Australia (AC).
He is accompanied by the current Editor-in-Chief of the Medical Journal of Australia, Laureate Professor Nick Talley, as well as longstanding member Professor Jeffrey Rosenfeld – who both also received the AC.
The trio top a long and impressive list of AMA members to receive Australia Day Honours this year.
AMA Federal Councillor, Associate Professor Julian Rait, received the Medal of the Order (OAM).
A host of other members honoured in the awards are listed below.
AMA President Dr Michael Gannon said the accolades were all well-deserved and made he made special mention of those receiving the highest Australia Day Honours.
“They have dedicated their lives and careers to helping others through their various roles as clinicians, researchers, teachers, authors, administrators, or government advisers – and importantly as leaders in their local communities,” Dr Gannon said.
“On behalf of the AMA, I pay tribute to all the doctors and other health professionals who were honoured today for their passion for their profession and their dedication to their patients and their communities.
“The great thing about the Honours is that they acknowledge achievement at the international, national, and local level, and they recognise excellence across all avenues of human endeavour.
“Doctors from many diverse backgrounds have been recognised and honoured again this year.
“There are pioneering surgeons and researchers, legends across many specialties, public health advocates, researchers, administrators, teachers, and GPs and family doctors who have devoted their lives to serving their local communities.
“The AMA congratulates all the doctors and other health advocates whose work has been acknowledged.
“We are, of course, especially proud of AMA members who are among the 75 people honoured in the medicine category.”
Dr Haikerwal, who was awarded the Officer in the Order of Australia (AO) in 2011, said this further honour was “truly mind-blowing” and another life-changing moment.
“To be honoured on Australia Day at the highest level in the Order of Australia is beyond imagination, beyond my wildest dreams and extremely humbling,” Dr Haikerwal said.
“For me to be in a position in my life and career to receive such an honour has only been made possible due to the unflinching support and unremitting encouragement of my closest circle, the people who have been with me through every step of endeavour, adversity, achievement, and success.”
CHRIS JOHNSON
AMA MEMBERS IN RECEIPT OF HONOURS
COMPANION (AC) IN THE GENERAL DIVISION
Dr Mukesh Chandra HAIKERWAL AO
Altona North Vic 3025
For eminent service to medical governance, administration, and technology, and to medicine, through leadership roles with a range of organisations, to education and the not-for-profit sector, and to the community of western Melbourne.
Professor Jeffrey Victor ROSENFELD AM
Caulfield North, Vic
For eminent service to medicine, particularly to the discipline of neurosurgery, as an academic and clinician, to medical research and professional organisations, and to the health and welfare of current and former defence force members.
Professor Nicholas Joseph TALLEY
Black Hill, NSW
For eminent service to medical research, and to education in the field of gastroenterology and epidemiology, as an academic, author and administrator at the national and international level, and to health and scientific associations.
OFFICER (AO) IN THE GENERAL DIVISION
Emeritus Professor David John AMES
East Kew, Vic
For distinguished service to psychiatry, particularly in the area of dementia and the mental health of older persons, as an academic, author and practitioner, and as an adviser to professional bodies.
Dr Peggy BROWN
Sanctuary Cove, Qld
For distinguished service to medical administration in the area of mental health through leadership roles at the state and national level, to the discipline of psychiatry, to education, and to health care standards.
Professor Creswell John EASTMAN AM
St Leonards, NSW
For distinguished service to medicine, particularly to the discipline of pathology, through leadership roles, to medical education, and as a contributor to international public health projects.
Professor Suzanne Marie GARLAND
Docklands, Vic
For distinguished service to medicine in the field of clinical microbiology, particularly to infectious diseases in reproductive and neonatal health as a physician, administrator, researcher and author, and to professional medical organisations.
Dr Paul John HEMMING
Queenscliff, Vic
For distinguished service to higher education administration, to medicine through contributions to a range of professional medical associations, and to the community of central Victoria, particularly as a general practitioner.
Professor Anthony David HOLMES
Melbourne, Vic
For distinguished service to medicine, particularly to reconstructive and craniofacial surgery, as a leader, clinician and educator, and to professional medical associations.
Dr Diana Elaine O’HALLORAN
Glenorie, NSW
For distinguished service to medicine in the field of general practice through policy development, health system reform and the establishment of new models of service and care.
MEMBER (AM) IN THE GENERAL DIVISION
Dr Michael Charles BELLEMORE
Croydon, NSW
For significant service to medicine in the field of paediatric orthopaedics as a surgeon, to medical education, and to professional medical societies.
Dr Colin Ross CHILVERS
Launceston, Tas
For significant service to medicine in the field of anaesthesia as a clinician, to medical education in Tasmania, and to professional societies.
Associate Professor Peter HAERTSCH OAM
Breakfast Point, NSW
For significant service to medicine in the field of plastic and reconstructive surgery as a clinician and administrator, and to medical education.
Professor Ian Godfrey HAMMOND
Subiaco, WA
For significant service to medicine in the field of gynaecological oncology as a clinician, to cancer support and palliative care, and to professional groups.
Dr Philip Haywood HOUSE
WA
For significant service to medicine as an ophthalmologist, to eye surgery foundations, and to the international community of Timor Leste.
Adjunct Professor John William KELLY
Vic
For significant service to medicine through the management and treatment of melanoma, as a clinician and administrator, and to education.
Dr Marcus Welby SKINNER
West Hobart, Tas
For significant service to medicine in the field of anaesthesiology and perioperative medicine as a clinician, and to professional societies.
Professor Mark Peter UMSTAD
South Yarra, Vic
For significant service to medicine in the field of obstetrics, particularly complex pregnancies, as a clinician, consultant and academic.
Professor Barbara S WORKMAN
East Hawthorn, Vic
For significant service to geriatric and rehabilitation medicine, as a clinician and academic, and to the provision of aged care services.
MEDAL (OAM) IN THE GENERAL DIVISION
Professor William Robert ADAM PSM
Vic
For service to medical education, particularly to rural health.
Dr Marjorie Winifred CROSS
Bungendore, NSW
For service to medicine, particularly to doctors in rural areas.
Associate Professor Mark Andrew DAVIES
Maroubra, NSW
For service to medicine, particularly to neurosurgery.
Dr David William GREEN
Coombabah, Qld
For service to emergency medicine, and to professional organisations.
Dr Barry Peter HICKEY
Ascot, Qld
For service to thoracic medicine.
Dr Fred Nickolas NASSER
Strathfield, NSW
For service to medicine in the field of cardiology, and to the community.
Dr Ralph Leslie PETERS
New Norfolk, Tas
For service to medicine, and to the community of the Derwent Valley.
Associate Professor Julian Lockhart RAIT
Camberwell, Vic
For service to ophthalmology, and to the development of overseas aid.
Mr James Mohan SAVUNDRA
South Perth, WA
For service to medicine in the fields of plastic and reconstructive surgery.
Dr Chin Huat TAN
Glendalough, WA
For service to the Chinese community of Western Australia.
Dr Karen Susan WAYNE
Toorak, Vic
For service to the community of Victoria through a range of organisations.
Dr Anthony Paul WELDON
Melbourne, Vic
For service to the community, and to paediatric medicine.
PUBLIC SERVICE MEDAL (PSM)
Dr Sharon KELLY
Yeronga, Qld
For outstanding public service to the health sector in Queensland.
Professor Maria CROTTY
Kent Town, SA
For outstanding public service in the rehabilitation sector in South Australia.
Medicare Benefits Schedule Review update
The MBS Review Taskforce continues its work into 2018, with the next round of public consultations expected for release in February.
In the meantime, a number of clinical committees have yet to begin. The Department of Health’s MBS Review team is currently accepting nominations from medical practitioners with the relevant background to participate on the following reviews:
Aboriginal and Torres Strait Islander Health, Neurology, Pain Management, Urology, Allied Health, Colorectal Surgery, Consultation Services, General Surgery, Mental Health Services, Nurse Practitioner & Participating Midwife, Ophthalmology, Optometry, Oral & Maxillofacial Surgery, Paediatric Surgery, Plastic & Reconstructive Surgery, Thoracic Surgery, Vascular Surgery
The MBS Review Taskforce also has an interest in participants (both specialists and consultant physicians) for the review of specialist consultation items.
The success of the MBS reviews is contingent on the reviews being clinician-led and the AMA encourages medical practitioners with the relevant skillset to consider nominating to the clinical committees. Follow the online links to learn more about the individual items under review by each committee.
For more information or to submit a nomination, contact the MBS Review team.
The AMA’s approach has always been to defer recommendations relating to specialty items to the relevant Colleges, Associations and Societies (CAS) and comment on the broader policy. As such, the AMA does not have direct representation on individual clinical committees but supports the commitment made by members who do contribute their expertise to the review.
Through feedback mechanisms involving the CAS, a member-based AMA Working Group and the Medical Practice Committee, the AMA has responded to every single MBS review consultation – raising issues from across our membership, while stressing where systematic improvements need to be made. The AMA Secretariat and the President have done this through direct representations with the Health Minister, the Department of Health and in writing to the Chair of MBS Review Taskforce.
Recent submissions highlighted a number clear deficiencies and significant variations in the MBS review process, signalling a need for absolute transparency from the Taskforce and leadership on the clinical committees through early engagement of the relevant CAS.
This year, the AMA will continue to press Government to ensure the reviews result in sensible reinvestment into the MBS while protecting clinical decision making. It is therefore crucial that each committee has the input of practicing clinicians and consistent, practical advice from the CAS.
The AMA continues to monitor the reviews with interest and update members along the way. The profession and the wider CAS are encouraged to do the same by engaging early with the clinical committees and public consultations. The full schedule of MBS reviews can be found on the Department of Health website: http://www.health.gov.au/internet/main/publishing.nsf/content/MBSR-about
For more information on AMA’s advocacy with the MBS reviews, contact Eliisa Fok
Senior Policy Adviser, Medical Practice efok@ama.com.au
Eliisa Fok
AMA Senior Policy Adviser
Enthused about Indigenous Medical Scholarship
It is pretty hard to imagine someone being more inspirational than Associate Professor Kelvin Kong.
Australia’s first Indigenous surgeon – having qualified as the first Aboriginal Fellow of the Royal Australasian College of Surgeons and specialising in otolaryngology, head and neck surgery – he is passionate about bridging the health gap between Indigenous and non-Indigenous Australians.
Hailing from the Worimi people of Port Stephens, he now practices paediatric and adult ear, nose and throat surgery at Newcastle, NSW. He also lectures there.
His career to date is impressive and he is hugely committed to helping others pursue their own goals. Describing Dr Kong as enthusiastic would be an understatement.
Included in his long list of accolades is the AMA Indigenous Medical Scholarship.
A young Kelvin was the scholarship’s recipient in 1997.
Australian Medicine asked Dr Kong how important it was then to receive the award and how it seems now in retrospect.
“At the time it was extremely important,” he said.
“It wasn’t a huge amount of money, but for me it was. It certainly wasn’t a little amount of money, but I wouldn’t have cared if it was five bucks.
“The biggest impact it had on me was being recognised by my colleagues and the medical fraternity as someone who is legitimate.
“I was being told that I can make a contribution. I stand very proud as a recipient of this scholarship. I hope it has paid off and I hope those who sponsored it believe their contribution was worthwhile.
“I was mid-career with my studies, year 3-4, and at a time when we are pouring beers, waiting tables and all that kind of stuff just trying to get through.
“This meant I could pay my bills and put food on the table and spend more time trying to feel normal.
“It is important in retrospect to acknowledge the pure fact that the AMA thought that this was a big enough issue to get its Board to recognise and seek to fund.
“That was huge. It says a lot about the AMA as an organisation that it had that vision.
“Medicine is hugely competitive, so to get some acknowledgement is very important. It gave me a lot of inroads into mentorship and leadership and allowed me to contact people with similar values to me.
“Australia is a diverse community and so is its medical community. This was normalising that it’s ok to achieve.
“In the Aboriginal community and in the wider community there can be this misconception that people are ‘getting in’ on the back of them being Aboriginal. The actual fact is, there are a lot of hugely talented people in the Aboriginal community who will make an enormous contribution to medicine.
“That was a great vision and I am eternally grateful for being given that morale boost.”
Dr Kong has used his scholarship, and all of the honours that followed, to help him play his part in addressing the disparity – not only in health outcomes, but in career opportunities – between Indigenous and non-Indigenous Australians.
“It is important to acknowledge the disparity of opportunities for people who live in the same country,” he said.
“We have a very robust medical industry. I know there is talk of maybe awarding two of these scholarships each year. I think it would be fabulous if there were ten.
“I was asking myself ‘how can the AMA enhance this more?’ and I thought that maybe one way is by increasing the number of scholarships – increasing the number of donors.
“There is a greater awareness among Australia and the medical community that this is genuinely important and we give value to it. It gives me that boost. It must give donors that boost too.
“We have this disparity in health outcomes, but there is a genuine desire in governments, in associations like the AMA, and in the community to address this.
“I am extremely lucky, first and foremost. I love my profession. I love my work. I love coming to work.
“As a Worimi man, I am heartened that we are as an Australian community seeking to address this disparity.
“I live a fantastic lifestyle. But my mother never had this opportunity, my Nan never had this opportunity.
“They would have done a better job.”
He says with a smile.
CHRIS JOHNSON
Information about donations towards the Indigenous Medical Scholarship can be found at: donate-indigenous-medical-scholarship
How good are you at basic suturing?
Are you a junior medical officer looking for a refresher in basic suturing? Are you up to date with your basic surgical skills? Suturing is an essential skill in the everyday practice of medicine. Although suturing technique is important, as a junior doctor you’re also expected to have a thorough understanding of wound management in general to effectively care for a patient with a laceration.
Whether in primary health or in an emergency environment, junior doctors will encounter many types of wounds requiring closure. The decision to close a wound and the technique used are influenced by many factors, including location, depth and contamination of wound, age of patient and resources or time available.
Designed in response to feedback from junior doctors and accredited for CPD by ACRRM, ACEM, CICM and ANZCA, the Basic Suturing learning module will help doctors bolster their competence in the basic techniques of minor surgery. Doctorportal Learning, in partnership with Osler, have created an easy to understand, well-structured module with step-by-step instructions and streaming video demonstrations of basic knot tying and suturing techniques for beginners. The module covers:
- Wound assessment
- Wound cleaning
- Suturing technique
- Post suturing wound care
- Knowledge and assessment.
Click here for more information and add basic suturing to your skills.