more_vertWe read with interest the WOMAN trial (May 27, p 2105).1 Tranexamic acid is an antifibrinolytic drug used to reduce haemorrhage complications in trauma and elective surgery. The WOMAN trial originally planned to enrol 15 000 women with a composite primary endpoint of death from all causes or hysterectomy within 42 days of giving birth. The trial increased the number of participants to more than 20 000 “in the hope that the trial would have enough power to detect a reduction in post-partum haemorrhage death”.
Preference: Surgery
1175
[Series] Advances in paediatric urology
Paediatric urological surgery is often required for managing congenital and acquired disorders of the genitourinary system. In this Series paper, we highlight advances in the surgical management of six paediatric urological disorders. The management of vesicoureteral reflux is evolving, with advocacy ranging from a less interventional assessment and antimicrobial prophylaxis to surgery including endoscopic injection of a bulking agent and minimally invasive ureteric reimplantation. Evidence supports early orchidopexy to improve fertility and reduce malignancy in boys with undescended testes.
[Series] Advances in paediatric gastroenterology
Recent developments in paediatric gastrointestinal surgery have focused on minimally invasive surgery, the accumulation of high-quality clinical evidence, and scientific research. The benefits of minimally invasive surgery for common disorders like appendicitis and hypertrophic pyloric stenosis are all supported by good clinical evidence. Although minimally invasive surgery has been extended to neonatal surgery, it is difficult to establish its role for neonatal disorders such as oesophageal atresia and biliary atresia through clinical trials because of the rarity of these disorders.
[Articles] Partial pancreatoduodenectomy versus duodenum-preserving pancreatic head resection in chronic pancreatitis: the multicentre, randomised, controlled, double-blind ChroPac trial
No differences in quality of life after surgery for chronic pancreatitis were seen between the interventions. Results from single-centre trials showing superiority for DPPHR were not confirmed in the multicentre setting.
[Comment] Long-term implications and global impact of paediatric surgery
Irrespective of variations across geography, culture, and socioeconomic status, paediatric surgery differs from other surgical subspecialties. Children are not small adults. Surgery for infants and children is typically undertaken for congenital, rare, and complex conditions and the consequences of both the condition and its treatment can affect that individual for life. Above all, the surgical outcome needs to stand the test of time.
My gender and my degree
BY DR DANIKA THIEMT
The first documented English-speaking female doctor was Dr James Miranda Barry, a medical officer of the British Army between 1813 and 1865. Dr Barry devoted her life to the British Army, earning the highest medical rank available: Inspector General of military hospitals. In an era when academic professions were the sole privilege of male members of society, it was necessary for Dr Barry to conceal her gender, living and practising medicine as a man. Her sad reality was exposed only posthumously where examination revealed her secret. Even in death, she was denied her right to her true identity; her gender kept secret for a further 100 years.
In Australia, medical training was opened to women in the late 1800s, and our first female graduate was registered to practice in 1891. Female medical trainees are now thriving, with female medical graduates in Australia outnumbering men since the mid-1990s. Women currently make up more than two-fifths of vocational trainees, focused largely in obstetrics and gynaecology (74.5 per cent), paediatrics (72.8 per cent) and general practice (63.1 per cent). Contrast this to the figures from oral and maxillofacial surgery, intensive care and surgery and female trainees make up less than a third of trainees. How, when we see women making up half or more of medical graduates and provisional trainees, are we still seeing unequally representation in the ongoing workforce? What is happening along the way? How and why does a speciality that starts out gender-neutral result in a specialist workforce that is predominantly male?
Fixing gender inequity in medicine requires supporting women in leadership. Diversity in the boardroom enhances corporate performance and, to advance as a profession, we need to attract and retain female leaders. Female specialists, on average, earn 16.6 per cent less than their male counterparts. Although differences in average hours worked account for some discrepancies, other contributory factors include a lack of women in senior positions and a lack of part-time or flexible senior roles. There are already inspiring and engaged female leaders within our profession, leading the world in clinical practice, medical research and education. We should be harnessing their talent to inspire the next generation.
The changing demographic of our workforce could, in part, be to blame. Trainees are graduating from medical school later and spending more time in vocational training. This leads to greater family and social pressures on trainees and possibly an increase in the need for breaks or flexible training options. Evidence shows that access to flexible training helps to retain female trainees and is desired by both female and male trainees regardless of parental status. We need to dispel the belief that trainees must choose between career and family and instead focus on how we enable trainees to have both.
Gender inequity extends beyond medical workforce.Many of my female colleagues report being mistaken for nursing or allied health staff, a rare occurrence among my male colleagues. Similarly, senior female doctors are often overlooked by patients who prefer to talk to the male junior by her side. How do women thrive in medicine and become leaders when public perception seems to favour male doctors? I watch senior medical staff respond to “Miss” in conversation rather than the respectful “Dr”. Although this seems petty in the scheme of everyday practice, it is easy for female doctors to believe that our degrees come second to our gender. Although the actions of some do not make a rule, it is time that we stand together as a profession to advance women in medicine. It is time to advocate for female leadership not only in the eyes of the profession but also in the eyes of the public.
Equity isn’t about creating a false forced equality. We aren’t all equal and that should be celebrated. It certainly shouldn’t hold us back. Opportunities to become leaders won’t be taken by all of our trainees, but they should be provided to all, regardless of gender.
(A version of this article first appeared in Emergency Medicine Australasia in 2016.)
Medical Indemnity
BY ASSOCIATE PROFESSOR JULIAN RAIT
As previously covered in this publication, the profession’s concerns about medical indemnity insurance have re-ignited since the Government announced reviews of all Commonwealth funded medical indemnity schemes and the underpinning legislation.
At the height of the indemnity crisis in the 2000s, many practitioners faced uncertainty about the future of their practice, with some thinking about leaving the profession all together.
Everyone was vulnerable.
The AMA played a pivotal role in stabilising the industry by bringing the profession together, and working with Government, to design schemes that were more equitable and affordable for practitioners.
However, these protections put in place by then Health Minister Tony Abbott looked to be under attack of late – indeed a saving has already been garnered through the MYEFO in December, along with the announcement of the review.
Since December, we’ve had a new Minister and thankfully, as it appears, a new approach. Following extensive lobbying by the AMA, the Terms of Reference (ToR) for the reviews into the Medical Indemnity Schemes appear to be far more informed.
The review has just commenced and the ToR appear to be more focussed on stability, understanding the importance of affordable indemnity insurance and affordable health care, and considering the international experience.
From an AMA perspective the schemes have been a resounding public policy success. They should remain and be strenuously defended.
We’re also aware that Medical Defence Organisations (MDOs) have been discussing what they wish to achieve through the review – including insuring that the outcome continues to promote stability in the industry, and maintains affordable premiums.
It is also expected that the role of insurers in providing universal cover – that is the requirement to be an ‘insurer of last resort’ in a particular jurisdiction, will come under review.
From an AMA perspective, there is a strong belief in the importance of universal cover, and that all indemnity insurers should be required to provide it, and that the arrangements should be fair and equitable. The last thing we want to see is a situation where an insurer, rather than a regulator, decides who can effectively practise in the medical profession.
From an insurance perspective, there is a desire to be able to charge a premium that reflects the level of risk in providing coverage, and to have a mechanism to encourage a practitioner to engage with the MDO and improve their practice.
One of the issues related to the indemnity review is any legislation changes that may be considered as part of ongoing AHPRA and MBA work. This potentially includes requiring indemnity insurers to disclose civil claims to AHPRA.
As all members know, the AMA does not support poorly performing practitioners. However, in absence of any level of detail about how these proposals will work we remain highly wary. Furthermore, a civil claims settlement, and poor medical practice, are not necessarily one and the same thing.
However, it is clear that there is an appetite in some jurisdictions for looking at mechanisms to reveal potentially poorly performing doctors – this builds on previous attempts via the revalidation agenda.
It is therefore critical that the AMA continue to advocate on behalf of our members on the importance of indemnity insurance; the critical requirement for the insurer and the regulator to be separate; and to address any ill thought out or underdeveloped approaches that unfairly target practitioners.
To that end, the AMA will closely watch the forthcoming proposed legislative changes, and the revalidation work underway by AHPRA.
In the meantime, Federal Council has reaffirmed our support for universal cover arrangements, and work has begun on our submission to the indemnity reviews.
But in the immediate term, this review needs to hear from the whole profession. The AMA has written to the Colleges, Associations and Societies, and in this publication, encouraging contributions to the Government’s indemnity review.
Providing affordable insurance flows directly through to affordable care, which is an issue the profession is focussed on right now. We need to ensure our voices are heard. For those who wish to make a submission, please see:
AMA Members are also welcome to directly contact me via my email address as follows:
[Editorial] Pushing the boundaries in paediatric surgery
Aside from the difficult psychosocial aspects of illness in babies and children, paediatric surgery and paediatric surgical research face inimitable challenges. These include the consequences of anaesthesia and radiation exposure in children, the implications of long-term complications, and, in many cases, the necessity of long-term care despite the inevitability of a transition to adult services. Diseases requiring paediatric surgery are sometimes rare and heterogenous in nature, with complex cases requiring multidisciplinary management.
Australian Indigenous kids have the highest prevalence of impetigo
West Australian researchers at Telethon Kids Institute have confirmed dangerous skin infections in many Aboriginal children across northern Western Australia are too often unrecognised and under-treated.
This is despite untreated skin infections such as scabies and impetigo (school sores) can lead to life-threatening conditions such as kidney disease, rheumatic heart disease and blood poisoning.
About 45 per cent of Aboriginal children living in remote communities across northern Australia are affected by impetigo at any one time – the highest prevalence in the world – and scabies is endemic in some communities.
Telethon Kids paediatric infectious diseases specialist Dr Asha Bowen said the recently published study in Public Library of Science (PLOS)journal Neglected Tropic Diseases, found underlying skin problems aren’t always noticed or treated – paving the way for serious complications later on.
Dr Bowen said Aboriginal people in the north of Australia have some of the highest rates of skin infection in the world.
Yet it can be so common in these communities it is regarded as normal, both by health workers and the community.
“When Aboriginal children are assessed at hospitals, it’s often for a more acute condition like pneumonia or gastroenteritis, and that tends to be what the clinicians focus on,” she said.
It was something researchers had suspected but couldn’t previously demonstrate with solid data.
“Now, after conducting a clinical study where we assessed new hospital admissions and compared the results to past records, we have the data to back it up,” Dr Bowen said.
“And that means we’re in a better position to do something about it.”
There remains a need to address the problem by improving training and awareness, and providing tools to help doctors and other healthcare workers better recognise and treat skin infections early on.
The study, led by Dr Daniel Yeoh of the Wesfarmers Centre of Vaccines and Infectious Diseases at Telethon Kids Institute and the Department of Infectious Diseases at Princess Margaret Hospital, was facilitated and supported by WACHS Pilbara, and WACHS Kimberley.
The AMA recognises the terrible effect Rheumatic Heart Disease (RHD) is having on Indigenous people in Australia. The AMA also recognises that impetigo plays a deadly role in RHD. Every year, RHD kills people and devastates lives – particularly the lives of young Indigenous Australians. It causes strokes in teenagers, and requires children to undergo open heart surgery.
MEREDITH HORNE
The AMA’s 2016 Report Card on Indigenous Health can be found here: article/2016-ama-report-card-indigenous-health-call-action-prevent-new-cases-rheumatic-heart-disease
AMA calls for urgent Government action on junk policies
The community is losing faith in private health insurance, with health funds offering too many “junk” policies that provide no cover when people need it, AMA President Dr Michael Gannon says.
The AMA has called on the Government to legislate to ensure that all policies have a minimum level of cover, appropriate to the age of the person taking out the policy.
“Private medicine is under siege and, in many ways, that’s because, very quickly, the community is losing faith with their private health insurance, which underpins most visits to private hospitals,” Dr Gannon told ABC AM.
“We seem to be seeing an orchestrated campaign by the insurers – an industry which is increasingly a for-profit industry – to deflect the blame from the real problems, and the real problems are that patients are getting sick and tired of finding out when they’re sick that their insurance isn’t good enough.”
Almost 35,000 people dropped their hospital cover between March and June this year, latest figures show. More than half (17,685) were in the 20 to 24 age group.
The slide coincided with an average 4.84 per cent premium rise in April – three times the inflation rate – and a 15.5 per cent rise in health funds’ net profits in the 2016-17 financial year.
While the AMA is part of the Private Health Ministerial Advisory Council (PHMAC), which is due to report by the end of the year, Dr Gannon says enough is known about junk policies for the Government to act now.
“There are people who have carefully, dutifully, responsibly put aside money for private health insurance, over many years in many cases, and then when they get sick they find they’re not covered,” he said.
“Policies for people over the age of 60 that exclude them from having their hips or knees fixed, or having their eyes fixed, are silly.
“We’ve a proliferation of junk policies which are worth nothing more than the paper they’re written on, and are purely designed so people avoid the tax penalty.
“The Government has the power to legislate — to make sure that [the policies] are worthwhile for people who take them out.”
Dr Gannon rejected a call by former Health Department head, Professor Stephen Duckett, for doctors to be forced to publish their fees.
He conceded that doctors could do better when it comes to providing information, but said patients should make better use of their general practitioner.
“If you’ve got time to spend with your GP, if you’ve got your own trusted GP, they’re pretty clever,” Dr Gannon told ABC Radio Adelaide.
“They get to know you, they get to know which specialists might fit with your personality, which specialists bulk bill, which specialists work in which hospitals, which operations can be done where.
“They know this information, and if you really want to talk about value in the health system, it’s having a good relationship with your GP.
“A lot of the time, a good GP will save you a visit to the specialist to start with, and a lot of the time they’ll work out who the right specialist for you is.”
The AMA’s submission to the Senate Value and Affordability of Private Health Insurance and Out-of-Pocket Medical Costs in Australian Health Care inquiry points out that medical fees make up just 16 per cent of total benefit outlays for private health insurers, so it would take a substantial decrease in fees to have an effect on premiums.
But it argued that if doctors’ fees should be published in the interests of transparency, so should all components of private health insurance costs.
“Private health insurers, hospitals, and other key stakeholders should all provide details of costs to the system,” the submission said.
“This could include senior management remuneration and/or fully itemised hospital list of charges post-surgery, so the patient can see exactly how their insurance has supported them.”
The AMA is prepared to consider a proposal where specialists publicly reported on a Government website the fees they charge for the five most common procedures they carry out.
MARIA HAWTHORNE