tag:theconversation.com,2011:/id/topics/clinical-care-19452/articlesClinical care – The Conversation2022-04-27T07:19:56Ztag:theconversation.com,2011:article/1819412022-04-27T07:19:56Z2022-04-27T07:19:56ZPatients leaving hospital sometimes need opioids. Doctors can reduce risks of long-term use and dependence<figure><img src="https://images.theconversation.com/files/459924/original/file-20220427-18-8sbhf7.jpg?ixlib=rb-1.1.0&rect=50%2C76%2C5597%2C3599&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/illness-asia-patient-women-hospital-concept-540969166">Shutterstock</a></span></figcaption></figure><p>Hospital patients are often given strong, opioid pain medicines when discharged home after surgery and other treatments. This can sometimes lead to <a href="https://link.springer.com/article/10.1007/s40429-018-0227-6">long-term use and dependence</a>. </p>
<p>New <a href="https://www.safetyandquality.gov.au/publications-and-resources/resource-library/opioid-analgesic-stewardship-acute-pain-clinical-care-standard">national standards</a>, released today by the <a href="https://www.safetyandquality.gov.au/">Australian Commission on Safety and Quality in Health Care</a>, aim to reduce prescribing that increases the risk of dependence. </p>
<p>The standards encourage hospital doctors to consider prescribing alternative pain relief such as paracetamol and ibuprofen for mild to moderate pain where possible. </p>
<p>When stronger pain relief is required – and medicines such as oxycodone, morphine, fentanyl, tramadol and codeine are prescribed – the standards recommend discharging patients with up to seven days’ supply, depending on their circumstances. </p>
<p>So what are the risks of dependence? And how can clinicians ensure pain is adequately managed? </p>
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<a href="https://theconversation.com/2-200-deaths-32-000-hospital-admissions-15-7-billion-dollars-what-opioid-misuse-costs-australia-in-a-year-137712">2,200 deaths, 32,000 hospital admissions, 15.7 billion dollars: what opioid misuse costs Australia in a year</a>
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<h2>Treating pain is a human right</h2>
<p>Acute pain isn’t just unpleasant to experience. Pain causes the body to enter a <a href="https://linkinghub.elsevier.com/retrieve/pii/S0007-0912(17)36344-4">stress response</a>. This can have wide-ranging effects on the body, from raising your heart rate, to reducing the functioning of your immune system. </p>
<p>Uncontrolled pain in hospital may lead to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5626380/">poorer patient outcomes</a>: people in pain take longer to recover and may experience longer hospital stays. </p>
<p>Uncontrolled acute (short-term) pain may even <a href="https://pubmed.ncbi.nlm.nih.gov/16698416/">progress to chronic pain</a>, which is much harder to manage and can have significant impacts on a person’s quality of life. </p>
<p>Treating pain is also ethical, and access to adequate pain management has been recognised as a <a href="https://www.apsoc.org.au/PDF/Publications/DeclarationOfMontreal_IASP.pdf">fundamental human right</a>.</p>
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<img alt="Man sits on the edge of a hospital bed in the dark." src="https://images.theconversation.com/files/459953/original/file-20220427-14-d1swmt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/459953/original/file-20220427-14-d1swmt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/459953/original/file-20220427-14-d1swmt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/459953/original/file-20220427-14-d1swmt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/459953/original/file-20220427-14-d1swmt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/459953/original/file-20220427-14-d1swmt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/459953/original/file-20220427-14-d1swmt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Patients have a right to adequate pain management.</span>
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<p>There are several reasons why people may experience pain in hospital, including injury, illness or surgery. Internationally, <a href="https://pubmed.ncbi.nlm.nih.gov/26778249/">84% of hospital patients</a> report experiencing pain. And up to <a href="https://pubmed.ncbi.nlm.nih.gov/24237004/">three-quarters</a> of patients experience moderate to severe pain after surgery. </p>
<p>Opioid medicines are commonly used to manage pain in hospital. But with hospitals encouraged to get patients home earlier, many people may still be experiencing pain when they’re discharged. So opioids are also often prescribed on discharge.</p>
<h2>Opioids are high-risk medicines</h2>
<p>Although opioids are effective in treating many types of pain, they are considered “high risk medicines”. They can cause <a href="https://www.painphysicianjournal.com/current/pdf?article=OTg1&journal=42">multiple unwanted effects</a> which <a href="https://pubmed.ncbi.nlm.nih.gov/12891220/">range in severity</a> from nausea and constipation, to life-threatening breathing problems and loss of consciousness. </p>
<p>Prescription opioid use has increased internationally over the past 30 years. In Australia, we’ve seen a <a href="https://www.publish.csiro.au/ah/AH18245">15-fold increase</a> in opioid prescriptions dispensed on the Pharmaceutical Benefits Scheme between 1995 and 2015. </p>
<p>Over the same time period, <a href="https://www.mja.com.au/journal/2011/195/5/prescription-opioid-analgesics-and-related-harms-australia">harms</a> from <a href="https://link.springer.com/article/10.1007/s40429-018-0227-6">opioids</a> have <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/summary">also risen</a>. Between 2001 and 2012, deaths from pharmaceutical opioid overdoses in Australia rose from <a href="https://pubmed.ncbi.nlm.nih.gov/28826104/">21.9 per million population to 36.2 per million population</a>: an increase of 6% per year. </p>
<p>Prescription opioids are now involved in <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/summary">more deaths than illicit opioids</a> such as heroin. </p>
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Read more:
<a href="https://theconversation.com/opioids-continue-to-be-the-leading-cause-of-overdose-deaths-in-australia-what-else-can-we-do-144422">Opioids continue to be the leading cause of overdose deaths in Australia. What else can we do?</a>
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<p>To address these issues, government bodies have <a href="https://www.tga.gov.au/hubs/prescription-opioids">introduced strategies</a> to <a href="https://theconversation.com/smaller-pack-sizes-from-today-could-new-opioid-restrictions-stop-leftover-medicines-causing-harm-139558">improve the safety</a> of opioid use. Although many focus on addressing opioid use in the community, opioids are also commonly used in acute care settings such as hospitals. </p>
<h2>Finding a balance between benefits and risks</h2>
<p>Good pain management aims to ensure pain is well managed while making sure the risk of any unwanted effects is low. </p>
<p>One of the risks is that short-term opioid use may become long-term opioid use. Studies <a href="https://journals.lww.com/annalsofsurgery/Abstract/9000/Postoperative_Opioid_Prescribing_and_New.93116.aspx">have found</a> that among people who receive opioids <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1108765">after surgery</a>, 1-10% are <a href="https://pubmed.ncbi.nlm.nih.gov/32584407/">still using</a> them <a href="https://jamanetwork.com/journals/jamasurgery/fullarticle/2618383?resultClick=1">up to one year later</a>. </p>
<p>Existing opioid <a href="https://www.anzca.edu.au/resources/college-publications/acute-pain-management/apmse5.pdf">treatment guidelines</a> recommend <a href="https://journals.lww.com/jorthotrauma/fulltext/2019/05000/clinical_practice_guidelines_for_pain_management.11.aspx">doctors prescribe</a> the <a href="https://pubmed.ncbi.nlm.nih.gov/22227789/">lowest dose</a> of opioids needed for sufficient pain relief, for the shortest amount of time possible. </p>
<p>However, this does not always occur in practice. There is <a href="https://journals.lww.com/annalsofsurgery/fulltext/2017/04000/wide_variation_and_excessive_dosage_of_opioid.15.aspx">wide variation</a> in what patients are prescribed at discharge, even within the <a href="https://pubmed.ncbi.nlm.nih.gov/30049481/">same hospital or surgical unit</a>. </p>
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<img alt="Doctor in scrubs shows patient a form." src="https://images.theconversation.com/files/459952/original/file-20220427-22-sgqx43.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/459952/original/file-20220427-22-sgqx43.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/459952/original/file-20220427-22-sgqx43.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/459952/original/file-20220427-22-sgqx43.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/459952/original/file-20220427-22-sgqx43.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/459952/original/file-20220427-22-sgqx43.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/459952/original/file-20220427-22-sgqx43.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Good pain management means balancing the risks and benefits of medicines.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-consulting-her-female-patient-sitting-633840107">Shutterstock</a></span>
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<h2>Guiding principles for clinicians</h2>
<p>Clinical care standards are a set of quality statements written by an expert writing group for consistent and high-quality health care. They aren’t rules; they’re guiding principles that inform patients and clinicians about “best practice” for a clinical area. </p>
<p>In many ways, the new opioid standards aren’t new – they’re consistent with current guidelines and research. However, they provide “indicators” for health care organisations to measure their performance against. Given ongoing issues with opioids, indicators may provide important feedback on how opioids are being used. </p>
<p>Building on <a href="https://theconversation.com/smaller-pack-sizes-from-today-could-new-opioid-restrictions-stop-leftover-medicines-causing-harm-139558">regulatory changes implemented in 2020</a>, such as smaller pack sizes when filling prescriptions from community pharmacies, these <a href="https://www.safetyandquality.gov.au/standards/clinical-care-standards">new standards</a> come at a good time and will play an important role in ensuring opioids and other analgesic medicines are used appropriately and safely for short-term pain. </p>
<p>However, they don’t cover chronic pain, cancer pain, palliative care, or patients with opioid dependence. </p>
<p>It’s now up to clinicians to ensure they’re implemented, with patients given adequate pain relief and prescribed the lowest dose for the shortest time possible.</p>
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Read more:
<a href="https://theconversation.com/smaller-pack-sizes-from-today-could-new-opioid-restrictions-stop-leftover-medicines-causing-harm-139558">Smaller pack sizes from today: could new opioid restrictions stop leftover medicines causing harm?</a>
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<img src="https://counter.theconversation.com/content/181941/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ria Hopkins receives funding from the Australian National Health and Medical Research Council.</span></em></p><p class="fine-print"><em><span>Natasa Gisev does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New national standards aim to change doctors’ prescribing habits for hospital patients with pain when they’re discharged home. But clinicians also need to ensure patients’ pain is well managed.Ria Hopkins, PhD Candidate, National Drug and Alcohol Research Centre, UNSW SydneyNatasa Gisev, Clinical pharmacist and Scientia Senior Lecturer at the National Drug and Alcohol Research Centre, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/677682017-03-10T04:21:13Z2017-03-10T04:21:13ZMy doctor says there’s a guideline for my treatment – but is it right for me?<figure><img src="https://images.theconversation.com/files/159415/original/image-20170305-29012-v83khc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Reviewing guidelines with your doctor is important, because guidelines are just one part of decision making</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/109017980?src=giucV4D6jFA5qk77uaheBQ-1-81&size=huge_jpg">From www.shutterstock.com</a></span></figcaption></figure><p>Health care guidelines are produced in ever-increasing numbers. The <a href="https://www.guideline.gov/">National Guideline Clearinghouse</a>, a U.S.-based public website compiling summaries of “clinical practice” (health care) guidelines, has over 1,000 entries and is updated weekly. The <a href="https://www.nice.org.uk/">National Institute for Health and Care Excellence</a> in the U.K. has over 180 clinical guidelines. </p>
<p>Health care guidelines cover all aspects of medicine, from <a href="https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer">using aspirin to prevent heart attacks and colon cancer</a> to <a href="http://www.entnet.org/?q=node/334">managing earwax</a> and <a href="https://www.aan.com/Guidelines/Home/GetGuidelineContent/586">caring for athletes with concussions</a>. </p>
<p>Health care guidelines impact policy decisions and care for individuals. Recent research, though, suggests that <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1319-4">the public has only a vague understanding of what guidelines are and how they are developed</a>. </p>
<p>This is consistent with my own experience as a physician studying best practices for patient engagement in guideline development. Most of my patients and focus group participants are unfamiliar with how guidelines are developed. This can lead to uncertainty for patients and contributes to controversy, such as <a href="http://www.npr.org/sections/health-shots/2016/01/11/462693737/federal-panel-finalizes-mammogram-advice-that-stirred-controversy">debates about mammography guidelines</a>. </p>
<h2>What are guidelines?</h2>
<p>Before widespread internet access allowed people to search systematically for scientific evidence, “guidelines” often reflected suggestions from groups of experts on how to best manage — or prevent — a medical condition. </p>
<p>Current high-quality clinical practice guidelines, though, are anchored in a thorough review of available medical evidence.</p>
<p>This has led some organizations to revisit recommendations made in older guidelines less firmly based on medical evidence. Last year the Departments of Agriculture and Health and Human Services <a href="https://www.nytimes.com/2016/08/03/health/flossing-teeth-cavities.html?_r=0">dropped recommendations for flossing of teeth</a> from their dietary guidelines, though <a href="http://www.ada.org/en/press-room/news-releases/2016-archive/august/statement-from-the-american-dental-association-about-interdental-cleaners">debate about this remains</a>. </p>
<p>In this era of evidence-based medicine, various standards exist for developing clinical practice guidelines. These include standards from <a href="http://annals.org/aim/article/1103747/guidelines-international-network-toward-international-standards-clinical-practice-guidelines">the Guidelines International Network</a> and the U.S.-based <a href="http://www.nationalacademies.org/hmd/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx">Institute of Medicine</a>. The Appraisal of Guidelines Research & Evaluation Enterprise (AGREE) publishes a <a href="http://www.agreetrust.org/agree-ii/">tool</a> to assess the quality and reporting of clinical practice guidelines.</p>
<p>While different in some nuances, international standards agree on core elements. Guidelines summarize what is known (and not known) about different tests and treatments for health problems. They then make recommendations for expected best care, with specific descriptions of how confident guideline developers are in the research and recommendations. </p>
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<img alt="" src="https://images.theconversation.com/files/159416/original/image-20170305-29017-1u7zwfa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/159416/original/image-20170305-29017-1u7zwfa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/159416/original/image-20170305-29017-1u7zwfa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/159416/original/image-20170305-29017-1u7zwfa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/159416/original/image-20170305-29017-1u7zwfa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/159416/original/image-20170305-29017-1u7zwfa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/159416/original/image-20170305-29017-1u7zwfa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">General guidelines may not work for all, and they may not be practical for all.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/lose-weight-checklist-clipboard-eat-exercise-432690439?src=F0TmjwpzcN-zYERQYG3C4A-1-31">From wwww.shutterstock.com</a></span>
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<p>High quality guidelines are developed by groups of patients and other public representatives, professional subject experts (physicians and other health professionals) and guideline specialists. These individuals decide what questions to ask, examine all the available research, grade the research quality, consider other issues (such as risks, benefits, availability, personal preferences and sometimes cost), and then make recommendations about best medical care. </p>
<p>Some guideline developers, such as the <a href="https://www.uspreventiveservicestaskforce.org/">U.S. Preventive Services Task Force</a>, seek <a href="https://www.uspreventiveservicestaskforce.org/Page/Name/us-preventive-services-task-force-opportunities-for-public-comment">public comment</a> on plans for upcoming guidelines, draft evidence reviews, and recommendation statements to give the public a voice in the development process.</p>
<p>The reliance of guidelines on the best medical evidence means the recommendations are now less likely to be driven by panel members’ opinions and personal experiences. Practicing health professionals and the public can be more confident that recommendations are based largely on unbiased reviews of medical research and transparent weighing of benefits and harms. </p>
<h2>Limitations</h2>
<p>The term “clinical practice guideline” is reserved to describe <a href="http://www.nationalacademies.org/hmd/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx">“recommendations intended to optimize patient care</a> that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.” </p>
<p>However, some recommendations labeled (by developers or the media) as “guidelines” are actually policy or expert consensus statements provided without a full systematic review of medical research or offered in the absence of helpful studies. For example, recent <a href="https://theconversation.com/no-limits-can-the-new-guidelines-on-kids-and-screens-work-67635">screen time recommendations from the American Academy of Pediatrics</a> are an <a href="http://pediatrics.aappublications.org/content/early/2016/10/19/peds.2016-2591">American Academy of Pediatrics policy statement</a> rather than a formal clinical practice guideline. </p>
<p>Even when guidelines are based on systematic grading of the medical evidence, sometimes <a href="https://academic.oup.com/jnci/article/105/1/2/878630/Conflicting-Clinical-Guidelines">different developers make different recommendations</a>. These conflicts are confusing for patients and for health professionals. Inconsistencies may reflect different approaches to panel composition, reviewing and grading medical evidence, interpretation of the evidence and/or weighing of risks and benefits. The inconsistencies may also represent more concerning possibilities such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4887051/">contributions from conflicts of interest</a>. </p>
<h2>Putting guidelines to good use</h2>
<p>A common misunderstanding about clinical practice guidelines is that they tell patients and health professionals what to do. Rather than identifying one “best” answer, clinical practice guidelines summarize what is known about medical options and describe anticipated benefits and risks. This information can then be used by patients and health professionals during <a href="https://theconversation.com/the-most-important-thing-youre-not-discussing-with-your-doctor-67766">shared decision making</a>, which combines patients’ values and preferences alongside the best medical evidence to make an individualized decision. </p>
<p>Many clinical practice guidelines are now publicly available on websites. One resource for this is the <a href="https://www.guideline.gov/">National Guideline Clearinghouse</a>, which accepts only guidelines meeting certain quality standards and which summarizes key elements of their development. </p>
<p>Understanding <a href="http://www.npr.org/sections/health-shots/2016/01/03/461777229/what-to-think-about-conflicting-medical-guidelines">guideline debates</a> can also inform decision making, helping patients and health professionals know when there is uncertainty in the field. </p>
<p>Every medical decision is a personal one, and rarely is there a single “right answer.” Trustworthy clinical practice guidelines are an important tool for improving the delivery of high quality health care to a broad audience. Individual decisions, though, are best made when patients partner with their health professionals to understand the evidence and incorporate their own medical history and values to make the best decision in that unique circumstance.</p><img src="https://counter.theconversation.com/content/67768/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melissa J. Armstrong receives funding from the Agency for Healthcare Research and Quality (AHRQ K08HS24159) for research on patient engagement in clinical practice guidelines and she serves an evidence-based medicine methodology consultant for the American Academy of Neurology clinical practice guideline program. </span></em></p>Guidelines galore suggest how we can take care of ourselves in concert with our doctors. Here’s why it’s not as easy as it may seem (and how those guidelines get written)Melissa J. Armstrong, Assistant Professor, Neurology, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/680472016-11-09T19:06:38Z2016-11-09T19:06:38ZAre we expecting too much of our junior doctors?<figure><img src="https://images.theconversation.com/files/144969/original/image-20161107-4708-f0tu2p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There's much we can do to stop our junior doctors from feeling devalued, demoralised and depressed, like this junior doctor protesting in London earlier in 2016.
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-412020307/stock-photo-london-united-kingdom-april-26-2016-march-and-rally-by-the-junior-doctorsthe-junior-doctors-with-the-support-of-teachers-and-other-unionist-marched-on-downing-street-in-their-thous.html?src=8I8Vcvsv44tSUiKud6pGiw-1-20">from www.shutterstock.com</a></span></figcaption></figure><p>“When will the proper doctor see me? You know, the one who wears the suit.”</p>
<p>This is what junior doctors hear from patients and their families every week.</p>
<p>Who do you trust to provide the medical care you need when you are unwell in hospital? There is the person who sees you every day, orders the x-rays, chases up the blood results, prescribes the medicines you need onto the hospital medication chart and writes the discharge letter. That’s the junior doctor. Or perhaps you prefer the medical specialist who arrives occasionally, stays briefly and is followed by an entourage of other doctors and nurses.</p>
<p>Junior doctor is a term used to describe recent medical graduates, usually in their first three postgraduate years. They are also called interns, resident medical officers or basic trainees. They are still learning and honing their clinical and professional skills.</p>
<p>So when things go wrong, it is very easy to blame the junior doctor; criticism of junior doctors is routine, especially in the media. There is also a perception, unsupported by evidence, that successive cohorts of junior doctors are <a href="http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2923.2003.01611.x/full">clinically worse or less professional</a> than their predecessors.</p>
<p>Perpetuating this stereotype disempowers junior doctors, encourages colleagues to undervalue their contribution and erodes public confidence in our health system. This is harsh and unfair.</p>
<p>Our society’s aspirational goal for a world-class health system increases the pressure and expectation on junior doctors. High quality, efficient, safe, timely and personalised care <a href="https://www.nap.edu/html/quality_chasm/reportbrief.pdf">is expected</a> for all individual patients and their families.</p>
<p>Although better educated and better prepared than ever before, junior doctors are less equipped now than 20 years ago to meet the demands and expectations in the workplace. The medical landscape has changed profoundly.</p>
<h2>How things have changed</h2>
<p>Twenty years ago medical practice was simpler. We treated one disease at a time, had very few administrative and regulatory requirements and could make decisions relying on our clinical judgement. The community were also more likely to accept the limitations of health care.</p>
<p>Now, medical practice is much better because of dramatic improvements in how we use information technology, imaging, pathology, more effective medications with fewer side effects and the advent of non-invasive procedures, such as keyhole surgery.</p>
<p>The most profound is the cultural shift that rightly promotes patient-centred care and <a href="http://www.nationalacademies.org/hmd/%7E/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf">safer care</a>, that is, eliminating harm due to how health care is provided.</p>
<p>So now, in an ordinary day, a junior doctor must understand and manage a patient with multiple diseases, and comprehend, balance and navigate treatments that could make one disease better but another one worse. </p>
<p>A junior doctor must choose, order and interpret from the huge range of highly specialised and technical blood tests and imaging techniques while remaining calm, empathetic, compassionate and explaining everything to patients in plain language. </p>
<p>This is as well as completing and meeting all the additional administrative and regulatory requirements introduced to improve the health care system.</p>
<p>Junior doctors work in an environment that demands efficiency and fast turnarounds. The <a href="http://www.audit.vic.gov.au/publications/20160210-Length-of-Stay/20160210-Length-of-Stay.pdf">average length of stay</a> in hospital is 5.9 days with an emphasis on reducing this. This drives a form of anticipatory and defensive practice.</p>
<p>The pace of work leads to over-ordering tests to avoid the possibility of “missing something”. This perversely leads to not ordering tests that <em>are</em> needed because doctors are so overwhelmed chasing up what does not need to be done.</p>
<p>A profound and desirable shift in practice was the arrival of <a href="http://www.cochrane.org">evidence-based medicine</a>. However, this has created doubt where there was once certainty. Evidence-based medicine requires gathering, consolidating and critically appraising research evidence so we know what to do or, what not to do. It improves consistency in decision-making and reduces doctors doing “their own thing”. </p>
<p>What we now know is there is not always enough evidence to inform practice and it does not always directly apply to a specific patient situation. We now also know what was once a “fact” <a href="http://www.sciencedirect.com/science/article/pii/S0025619613004059">becomes “fiction”</a> when it is found not to be true. These concepts are confronting and challenging for senior medical specialists, let alone a junior doctor.</p>
<h2>Why we need junior doctors</h2>
<p>We need junior doctors, not only because they are the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3308637/">future leaders</a> for a better health system, but because they – along with the graduate nurses and allied health professionals – <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129546076">contribute substantially</a> to the smooth operation of our hospitals.</p>
<p>We also <a href="http://www.emeraldinsight.com/doi/abs/10.1108/14777261311321824">need</a> junior doctors because they bring new ideas and new skills, better reflect the values of a progressive contemporary society (such as the importance of transparency, patient-centred care) and need for integration of technology into health care.</p>
<p>Reducing the pressures on junior doctors is possible. Showing appreciation for their contribution to the overall health system should be a simple matter. We only need to reflect on the <a href="https://www.bma.org.uk/collective-voice/influence/key-negotiations/terms-and-conditions/junior-doctor-contract-negotiations">recent experiences</a> in the UK’s National Health Service – where junior doctors marched on the streets to protest their pay and conditions – to be reminded what happens if we fail to do so. </p>
<p>Another step is to think of a better title, one that recognises junior doctors’ potential as <a href="http://www.vifmcommuniques.org/?page_id=4296#home">future leaders</a>, to listen to their ideas and ask them to engage their peers to improve patient safety. </p>
<p>The terms “young”, “junior”, “beginner” and “novice” fail to recognise the skills the person who recently graduated bring to the work place.</p>
<p>Perhaps the most challenging is to stop comparing and recognise junior doctors have strengths and that senior doctors have their limitations. A world class health system requires working together. Wearing a suit is a personal choice, not a marker of medical competency.</p><img src="https://counter.theconversation.com/content/68047/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joseph Ibrahim works for Monash University in an academic role involving teaching and research. H receives funding from Victorian Managed Insurance Authority, Department of Health and Human Services (Victoria). He is affiliated with the Victorian Institute of Forensic Medicine and is the consulting editor for the Future Leaders Communique, Clinical Communique and is the editor in chief of the Residential Aged Care Communique. </span></em></p>Junior doctors are often blamed when things go wrong in hospital. But are we placing too many demands on them?Joseph Ibrahim, Professor, Health Law and Ageing Research Unit, Department of Forensic Medicine, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/460892015-08-16T20:27:00Z2015-08-16T20:27:00ZAustralians are undergoing unnecessary surgery – here’s what we can do about it<p>For decades, clinicians and researchers have been concerned about patients getting treatments, including operations, that don’t work. As well as failing to treat the original health problem, ineffective care exposes patients to complications and side-effects and waste precious health-care resources.</p>
<p>Yet while many clinicians believe there is a problem, the policy response has been limited. It is often hard to isolate treatment choices that are inappropriate. A choice that is wrong in one case may be right in another. </p>
<p>To avoid ineffective treatments, we need a new way to identify and reduce questionable care. A new <a href="http://grattan.edu.au/home/health/">Grattan Institute report</a> shows how to do it.</p>
<h2>Warning signs</h2>
<p>The report follows up two clues that treatment choices are sometimes wrong. </p>
<p>The first is <a href="http://www.dartmouthatlas.org/downloads/atlases/Surgical_Atlas_2014.pdf">geographic variation</a>. In 2010-11, there were 1.3 tonsillectomies for every 1,000 people in Western Sydney. Along the Great South Coast in Victoria (the area around Warrnambool), the rate is 7.4 (these rates are adjusted for age and sex). It seems unlikely that <a href="http://www.oecd-ilibrary.org/social-issues-migration-health/geographic-variations-in-health-care_9789264216594-en">variation this large</a> is just a matter or people in some areas being sicker or more willing to go under the knife.</p>
<p>But while geographic variation is troubling, it is inconclusive. Some of it <a href="http://www.brookings.edu/%7E/media/projects/bpea/fall%202014/fall2014bpea_sheiner.pdf">can be explained</a> by factors such as how sick people are, but not all of it. </p>
<p>It is also hard to tell if over-servicing or under-servicing is the problem. Are people in areas with high rates of surgery getting too much, or are people elsewhere getting too little? </p>
<p>Finally, variation is typically measured among regions. That can make it hard to tell which providers are behind it. For all these reasons, years of <a href="http://www.healthpolicyjrnl.com/article/S0168-8510(13)00307-2/fulltext">debate and commentary</a> about clinical variation has resulted in little policy action.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/91713/original/image-20150813-21398-1aszhl4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/91713/original/image-20150813-21398-1aszhl4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/91713/original/image-20150813-21398-1aszhl4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/91713/original/image-20150813-21398-1aszhl4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/91713/original/image-20150813-21398-1aszhl4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/91713/original/image-20150813-21398-1aszhl4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/91713/original/image-20150813-21398-1aszhl4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Public and private hospitals should be given time to examine their own practices.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-144372445/stock-photo-ashkelon-isr-july-doctor-on-duty-in-barzilai-medical-center-emergency-department-on-july.html?src=54uMwyR6LaJMwQIy7J7p2Q-1-56">ChameleonsEye/Shutterstock</a></span>
</figcaption>
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<p>The second clue that alerts us questionable care is the use of treatments we know are ineffective for certain types of patients. Clinical research <a href="https://www.nice.org.uk/guidance/cg137/resources/search-the-nice-do-not-do-recommendations-database.">has uncovered</a> hundreds of treatments that don’t work for certain types of patients. These treatments have been targeted for reduction or removal. Australian medical colleges have <a href="http://www.choosingwisely.org.au/">recently listed treatments</a> that should be questioned in discussions between doctors and their patients.</p>
<p>Like clinical variation, ineffective care has been widely discussed but still persists. It is very hard to find treatments that are always wrong and efforts to shift treatment choices are sometimes met with indifference, <a href="https://www.health.qld.gov.au/healthpact/docs/papers/workshop/disinvestment-report.pdf">resistance</a> or <a href="http://europepmc.org/articles/pmc4010873">gaming</a>. </p>
<p>For instance, powerful <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa013259">evidence</a> shows that a certain type of arthroscopy – inserting a tube to remove tissue – <a href="http://www.prairietrailphysio.ca/_downloads/Kirkley-et-al-2008.pdf">won’t help people</a> with knee osteoarthritis. But it still happens at least 800 times a year in Australian hospitals.</p>
<h2>What should be done?</h2>
<p>The first step to address the problem is to provide better information. Clinicians cannot keep track of all the evidence published each year. Much of the <a href="https://www.nhmrc.gov.au/guidelines-publications/nh165">guidance</a> that summarise the evidence is flawed. We recommend that a body such as the <a href="http://www.safetyandquality.gov.au/">Australian Commission on Safety and Quality in Health Care</a> develop and publish clear guidance about which procedures should be avoided.</p>
<p>The second step is to monitor whether this guidance translates into practice. To show how this can be done, we measured how often hospitals provide five examples of do-not-do treatments. They are treatments that <a href="http://www.nice.org.uk/">evidence</a>, and usually <a href="http://www.msac.gov.au/">government bodies</a>, say should not be given to certain types of patient:</p>
<ul>
<li><p>Vertebroplasty for osteoporotic spinal fractures: surgery to fill a backbone (vertebrae) with cement </p></li>
<li><p>Arthroscopic debridement for osteoarthritis of the knee: inserting a tube to remove tissue </p></li>
<li><p>Laparoscopic uterine nerve ablation for chronic pelvic pain: surgery to destroy a ligament that contains nerve fibres </p></li>
<li><p>Removing healthy ovaries during a hysterectomy </p></li>
<li><p>Hyperbaric oxygen therapy (breathing pure oxygen in a pressurised room) for a range of conditions including osteomyelitis (inflammation of the bone), cancer, and non-diabetic wounds and ulcers.</p></li>
</ul>
<p>Our analysis combines the two big clues about questionable care: variation and ineffective care. It looks at treatments that we know are ineffective and identifies hospitals that are furthest from normal clinical practices. </p>
<p>This exposes outliers with troubling patterns of care. While many hospitals never provide the do-not-do treatments, some outlier hospitals provide them at more than ten times the average rate.</p>
<p><strong>Some public hospitals give do-not-do treatments far more often than average</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/91719/original/image-20150813-21409-r269xd.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/91719/original/image-20150813-21409-r269xd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/91719/original/image-20150813-21409-r269xd.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=649&fit=crop&dpr=1 600w, https://images.theconversation.com/files/91719/original/image-20150813-21409-r269xd.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=649&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/91719/original/image-20150813-21409-r269xd.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=649&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/91719/original/image-20150813-21409-r269xd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=816&fit=crop&dpr=1 754w, https://images.theconversation.com/files/91719/original/image-20150813-21409-r269xd.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=816&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/91719/original/image-20150813-21409-r269xd.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=816&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption"></span>
<span class="attribution"><span class="source">Grattan Institute</span></span>
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</figure>
<p>The Australian Commission on Safety and Quality in Health Care should report these results to hospitals, states and health insurers. Clinicians should know when they are out of step with the evidence and their peers.</p>
<p>But that won’t always be enough. When high rates of do-not-do procedures persist, states and insurers must take action. In theory, these treatments should never happen, but in practice they might sometimes be needed. For this reason, we recommend a cautious approach that uses data to drive expert clinical evaluation.</p>
<p>Public and private hospitals should be given time to examine their own practices. If after a year they still perform a do-not-do procedure at an above-average rate, the state government should initiate a clinical review of the hospital’s practices. Then doctors who perform the procedures can explain why to their peers. </p>
<p>The hospital’s practices may turn out to be justifiable. But if they aren’t, there should be consequences: states and insurers should start withholding funding for the do-not-do procedure.</p>
<p>Our report provides a proof-of-concept for this approach. Many more do-not-do treatments can be measured, including those that should be performed, but not routinely (our report looks at a further three examples in this category). </p>
<p>For years there have been concerns that patients are getting the wrong treatment. Our Questionable Care report shows how to stop it.</p><img src="https://counter.theconversation.com/content/46089/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>To avoid ineffective treatments, we need a new way to identify and reduce questionable care. A new Grattan Institute report shows how to do it.Peter Breadon, Health Fellow, Grattan InstituteStephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.