tag:theconversation.com,2011:/id/topics/medical-workforce-7037/articlesMedical workforce – The Conversation2017-06-04T20:25:05Ztag:theconversation.com,2011:article/785352017-06-04T20:25:05Z2017-06-04T20:25:05ZHow can Australia have too many doctors, but still not meet patient needs?<figure><img src="https://images.theconversation.com/files/171944/original/file-20170602-25664-qdxhuc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If you live in a rural area, you would never think Australia had too many doctors.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>The statement “we have plenty of doctors in Australia” would probably not pass the pub test. Especially if the pub was in a regional city, a remote town or a less-than-leafy suburb. But it is true all the same - statistically at least. </p>
<p>With <a href="http://www.oecd.org/health/health-data.htm">3.5 practising doctors</a> for every 1,000 people in 2014 (<a href="http://www.aihw.gov.au/workforce/medical/how-many-medical-practitioners/">4.4 per 1,000 in major cities</a>) we’ve never had so many. In 2003, there were 2.6 doctors for every <a href="http://www.oecd.org/health/health-data.htm">1,000 people in Australia</a>, which is closer to the proportion in similar countries now, such as New Zealand (2.8), the UK (2.8), Canada (2.6) and the USA (2.6).</p>
<p>Yet at 2.6 per 1,000 was when <a href="https://www.mja.com.au/journal/2003/179/4/medical-workforce-issues-australia-tomorrow-s-doctors-too-few-too-far">we decided we were “short”</a> and went on to <a href="https://www.mja.com.au/">double the number</a> of medical schools and almost triple the number of medical graduates in a little over a decade. </p>
<p>And then there’s this question: if we are now so flush with medicos, why do we still need to import so many from overseas? To fill job vacancies, the Australian government <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/work-pubs-mtrp">granted 2,820 temporary work visas</a> to overseas-trained doctors in 2014-15. In the same year, Australian <a href="http://www.medicaldeans.org.au/statistics/annualtables/">medical schools graduated</a> another 3,547.</p>
<p>This heroic level of doctor production and importation is right up there internationally. Among wealthy nations, Australia is vying for the top spot, with only <a href="http://www.oecd.org/health/health-data.htm">Denmark and Ireland</a> in the same league of doctor-production for population.</p>
<p>So why do we have too many doctors, but think we have too few?</p>
<h2>Our approach to medical training</h2>
<p>In a <a href="https://www.mja.com.au/">Medical Journal of Australia</a> editorial published today, we examine the question of “work readiness” in our new medical graduates from arguably the most important perspective: what the community needs from future doctors.</p>
<p>To what extent is our medical training system producing doctors who will be providing the high quality, person centred, affordable health services we need, given we are an ageing population living with higher levels of chronic and complex health conditions?</p>
<p>There have been arguably three problems with the Australian approach to the medical workforce to date. First, we didn’t finish the job of production; second, we’ve allowed too much medical specialisation in major cities; and third, our models of health care and the ways we pay for it are out of step with where community needs are heading.</p>
<h2>1. Production</h2>
<p>Back in the early 2000s, the biggest issue relating to the <a href="http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/BN/%7E/link.aspx?_id=4FB58821DB2B49F58743E7802D1C4ED3&_z=z">training of Australia’s medical workforce</a> was a shortage of doctors in regional and remote areas. So, in addition to boosting medical student numbers overall, we set up rural clinical schools and regional medical schools, and increased admission of students who were already residents of rural areas. </p>
<p>While <a href="http://www.rrh.org.au/publishedarticles/article_print_2991.pdf">results of these policies</a> have been positive in terms of graduate rural career intentions and rural destinations, the job was really only half done. What we didn’t do is reform the training that goes on after medical school. </p>
<p>That involves internships and training for one of 64 specialty fellowships, including general practice. Because of that, too many of our medical graduates are now piling up in capital city teaching hospitals, locked in a <a href="https://ama.com.au/ausmed/trainee-doctors-face-uncertain-future">fierce competition</a> for ever-more sub-specialised training jobs. </p>
<p>Meanwhile regional Australia remains hooked on a temporary fix of importing doctors from overseas. Hence the <a href="http://www.abc.net.au/news/2017-04-13/government-bid-to-keep-medical-specialists-in-rural-areas/8440474">recently announced</a> funding for 26 new regional training hubs. The aim is to “flip” the medical training model, so the main training is offered regionally with a city rotation as required.</p>
<h2>2. Excessive specialisation</h2>
<p>There’s no question we need a reasonable number of doctors who are experts in a narrow field. However, <a href="https://www.health.gov.au/internet/main/publishing.nsf/Content/F3F2910B39DF55FDCA257D94007862F9/%24File/AFHW%20-%20Doctors%20report.pdf">there’s now an imbalance</a> between an inadequate number of medical generalists and excessive numbers of specialists in every major medical field. </p>
<p>Regional Australia in particular needs more generalists; that is rural generalist GPs, general surgeons, general physicians and the like.</p>
<h2>3. Financing and models of care</h2>
<p>Health expenditure is driven by three main factors: growth in population, providing more care for each patient and the increase in the proportion of older people with increased complex care needs. </p>
<p>Improvements in health-care technology means we can diagnose illness more accurately, less invasively and earlier, and we have more effective treatments. </p>
<p>However, in a system that pays on the basis of every service provided (regardless of need) there is also a risk of provider-induced demand. This can lead to <a href="https://www.safetyandquality.gov.au/atlas/">inappropriate medical care</a>, with examples in unwarranted eye, knee and back surgery, imaging, colonoscopy, and medication for depression and other conditions. </p>
<p>An undersupply of doctors is associated with lower rates of health-care use, whereas oversupply or mis-distribution can <a href="http://www.pc.gov.au/research/supporting/supplier-induced-medical-demand">lead to higher rates</a> of inappropriate care. Balancing the distribution of doctors according to need has important consequences for health-care costs.</p>
<h2>Time for action</h2>
<p>Make no mistake, Australia’s current health system is good by world standards. But the headwinds are building. The population is ageing, we’ve got more people with chronic and complex health-care needs, and the costs of new medicines and technologies continue to escalate. </p>
<p>Having injected a massive boost of doctors into a fee-paying healthcare system without regard to population need, workforce mix, geographic location, health-care models or financing reform, we have put the future at risk.</p>
<p>Let’s not let this bold experiment fail for want of follow-through. We need more urgency in providing the incentives and training opportunities to get our growing junior medical workforce into the specialties and areas that are underserved. </p>
<p>We have to stop allowing medical specialty training to be driven by the work rostering requirements of metropolitan hospitals. We must increase the number of specialist training positions based in regional centres. </p>
<p>And we especially need to expand the number of broadly-skilled <a href="http://www.abc.net.au/news/rural/2016-06-24/rural-health-election-promises/7540768">rural generalists</a> and get serious about efficient, team based, health-care models. This requires cooperation by all governments, medical schools, specialist colleges and the profession - and the time to act is now.</p><img src="https://counter.theconversation.com/content/78535/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Murray is Dean of a medical school and President of the peak body representing Australian and New Zealand medical schools. He is a past President of the Australian College of Rural and Remote Medicine.</span></em></p><p class="fine-print"><em><span>Andrew Wilson is a professor the University of Sydney Medical School. In 2015 he conducted a national review of medical internships for the Australian Health Ministers Advisory Committee. He is chair of the Pharmacuetical Benefits Advisory Committee. </span></em></p>Australia has more doctors per population than most comparable countries, yet many living in rural and remote areas don’t receive the care they need. Changing the way we train doctors will fix this.Richard Murray, Dean of Medicine & Dentistry, James Cook UniversityAndrew Wilson, Co-Director, Menzies Centre for Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/661412016-09-28T02:11:11Z2016-09-28T02:11:11ZBurnt-out and overworked, Australia’s nurses and midwives consider leaving profession<figure><img src="https://images.theconversation.com/files/139506/original/image-20160928-30425-12v6sw2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Almost one-third (32%) of nurses and midwives are considering moving on.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-280104965/stock-photo-nurses-pushing-a-mobile-bed-in-a-hospital-corridor.html?src=mi7nofxZzfJaIpnjYxbkqw-2-39">Anna Jurkovska/Shutterstock</a></span></figcaption></figure><p>Nurses and midwives are among society’s most highly valued professionals. But a disturbing national picture is emerging of escalating levels of over-work and burnout. Nurses say their concerns are being ignored by management, amid fear of retribution for speaking out.</p>
<p><a href="http://business.monash.edu/__data/assets/pdf_file/0004/624127/What-Nurses-And-Midwives-Want-Findings-from-the-National-Survey-on-Workplace-Climate-and-Well-being-2016.pdf">Our national survey</a> of 3,000 nurses and midwives found that 32% were actively considering leaving the profession. This comes at a time when the federal government is <a href="https://www.health.gov.au/internet/main/publishing.nsf/Content/34AA7E6FDB8C16AACA257D9500112F25/%24File/AFHW%20-%20Nurses%20overview%20report.pdf">estimating a workforce shortfall</a> of 85,000 by 2025 and 123,000 by 2030.</p>
<p>Since 2011, we have surveyed Australian nurses every three years on their working conditions, well-being, and organisational and management practices. </p>
<p>Our previous surveys in 2011 and 2013 painted a picture of increasing work demands. But this year, all indicators of work intensification have gone upwards. </p>
<p>Worryingly, 71% felt they often had more work than they could do well (up from 64% in 2013).</p>
<p>Two-thirds (67%) of respondents reported their jobs required them to work very fast, at least several times a day (up from 61% in 2013), while 67% had to work “very hard” several times a day (up from 63% in 2013). </p>
<p>Key factors in this workload included inadequate staff levels, excessive administrative tasks and inappropriate skill mix.</p>
<p>In the face of this, one of the emerging challenges for management will be staff retention. Some 32% of respondents said they were “likely” or “very likely” to leave the nursing/midwifery profession – a significant concern, given the average age of survey respondents was 47.</p>
<p>Whereas a typical organisation might expect a turnover of up to 4% (and estimates in nursing have previously suggested the turnover rate is 3-6%), our study found 25% were very likely to leave the profession in the next 12 months. </p>
<p>So, a strategy around maintaining skilled and experienced staff is essential. Our initial findings indicate that despite improved attempts by management to communicate with staff, nurses and midwives continued to feel excluded from day–to-day decision-making.</p>
<p>More than half (54%) weren’t confident to openly voice their concerns due to fear of retribution. This reflected a general feeling of disconnection between management and nurses and midwives.</p>
<p>Another aspect of organisational concern was the finding that nearly half (45%) of those surveyed believed their organisation had not invested in their further development.</p>
<p>On the positive side, graduate intake for the profession remains good; however, deterioration of working conditions may serve as a deterrent to new graduates if not addressed.</p>
<p>While few would deny nursing is a rewarding career, it can be a particularly stressful profession, and it is vital that those in the profession remain healthy and supported. It is of great concern that highly skilled nurses aged 45 years and above are in the category of lowest hours worked in the profession.</p>
<p>After this third survey, it appears the workforce is coming to a tipping point, with work intensification a key factor. These outcomes are likely to accelerate the departure of highly skilled and dedicated people, who will be expensive to replace.</p>
<p>Such high turnover will affect the quality of health care in an environment characterised by an ageing population and increasing chronic disease.</p>
<p>Issues associated with dissatisfaction at work are all in the control of those managing the system. Targeted interventions are urgently needed to tackle this issue.</p><img src="https://counter.theconversation.com/content/66141/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>Nurses and midwives are among society’s most highly valued professionals. But a disturbing national picture is emerging of escalating levels of over-work and burnout.Peter Holland, Associate Professor in Human Resource Management and Employee Relations, Monash UniversityTse Leng Tham, Higher Degree Research Student, Research Assistant and Teaching Associate, Department of Management, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/574852016-08-14T20:15:42Z2016-08-14T20:15:42ZHow your doctors’ job satisfaction affects the care you receive<figure><img src="https://images.theconversation.com/files/126082/original/image-20160610-29216-r8iex7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When doctors aren't engaged, things can go tragically wrong.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-112236113/stock-photo-thinking-surgeon-sitting-on-the-floor-in-a-hallway.html?src=HIADKOG8wwXZyrvsQGWKlw-1-10">Shutterstock.wavebreakmedia</a></span></figcaption></figure><p>When employees are engaged with their work and organisation, they’re <a href="http://www.kingsfund.org.uk/sites/files/kf/employee-engagement-nhs-performance-west-dawson-leadership-review2012-paper.pdf">more likely to perform well</a>. This is particularly important in the context of health, where engagement improves the efficiency and effectiveness of services, reduces staff absenteeism and turnover, increases patient satisfaction and improves safety. </p>
<p>Highly engaged doctors, in particular, do much better on a <a href="http://www.emeraldinsight.com/doi/abs/10.1108/LHS-03-2014-0029">wide range</a> of important measures. These include clinical performance, financial management, safety indicators, patient experience and overall quality standards. </p>
<p>When doctors aren’t engaged, things can go tragically wrong. In the United Kingdom, this was vividly illustrated at the Mid Staffordshire hospital, where a <a href="http://webarchive.nationalarchives.gov.uk/20150407084003/http://www.midstaffspublicinquiry.com/report">public inquiry</a> found a culture of fear and poor leadership had taken hold in the late 2000s. As a result, between 400 and 1,200 more people died than would have been expected between 2005 and 2008. </p>
<p>Some patients were <a href="http://www.telegraph.co.uk/news/health/news/9851763/Mid-Staffordshire-Trust-inquiry-how-the-care-scandal-unfolded.html">left hungry</a>, thirsty and in soiled bedclothes, with calls for staff often going unanswered. Other patients received wrong medications. Decisions about who to treat were left to receptionists. And junior doctors were sometimes responsible for critically ill patients they were not sufficiently able to manage. </p>
<p>Since the mid-2000s, a concerted effort has been made to enhance medical engagement <a href="http://www.institute.nhs.uk/building_capability/enhancing_engagement/enhancing_engagement_in_medical_leadership.html">in the UK</a>.</p>
<p>The issue hasn’t received the same sort of attention from Australian governments. Initiatives to improve clinician engagement have therefore been piecemeal. </p>
<p><a href="http://pwlong.com/media.html/">Our yet-to-be-published research</a> from 12 sites across Australia and New Zealand, involving more than 2,100 doctors, reveals we have lower levels of medical engagement than in the UK. Doctors in Australia feel they aren’t actively and positively contributing to the performance of their hospital.</p>
<p>This doesn’t mean doctors aren’t actively engaged in individual patient care. But they feel they’re making (or are being asked to make) fewer contributions at the organisational level, which has an indirect impact on patients. </p>
<p>We found significant variation between different specialities and types of organisation. There is no consistent national pattern, although engagement is higher in some parts of the country than others. </p>
<p>Hospitals in the UK, where doctors are highly engaged, deliver better patient experiences. This leads to an improved safety and quality culture, resulting in fewer errors, lower infection rates and stronger financial management. Staff have higher morale, less absenteeism and stress. </p>
<p>So, why are Australian doctors less engaged?</p>
<p>Australia has a fragmented health system, which spans the public and private sectors. Funding and responsibilities sit at different levels of government. This means doctors may work across both the public and private sectors and for multiple institutions, making it difficult to engage with each organisation. </p>
<p><a href="http://pwlong.com/wp-content/uploads/media/Developing_and_Embedding_the_Leadership_Framework_Progress_Report_Oct2011.pdf">Engagement of doctors</a> is also influenced by contracting regimes, education processes and the activities of regulatory regimes. Medical colleges, hospitals and other employers must therefore provide the right training opportunities, supportive and collaborative work environments and development pathways, and give staff purpose and direction. </p>
<p>A <a href="https://s3.amazonaws.com/msog-production/assets/files/000/000/351/original/MSoG_ManagementOfHealthServices2.pdf?1444616523">recent study</a> found Australia lags behind other countries in setting out pathways for doctors to become more engaged in organisations through, for example, progression to leadership and management roles. </p>
<p>Doctors who move into management often have poorly defined tasks, blurred lines of accountability, no budget and no staff. Yet they are expected to take a leadership role in managing services, quality of care and performance.</p>
<p>Health providers need to involve junior doctors in service-improvement projects, ensure they are involved in meaningful decision-making at all levels of the organisations and provide leadership development programs. They also need to ensure doctors have the time to participate.</p>
<p>The pay-off of a more engaged workforce offers a significant reward that can’t be overlooked: better patient care. </p>
<hr>
<p><em>This article has been updated to reflect the fact the comparative research on medical engagement has yet to be published.</em></p><img src="https://counter.theconversation.com/content/57485/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Helen Dickinson receives funding from Federal department of health.
Paul W. Long receives funding from health service organisations undertaking medical engagement surveys.</span></em></p><p class="fine-print"><em><span>Paul Long was was paid by NSW Health and other funders to survey medical engagement at the 121 sites where this work has been undertaken. </span></em></p>Highly engaged doctors do much better on a wide range of important measures, from clinical performance, financial management and safety indicators to patient experience and overall quality standards.Helen Dickinson, Associate Professor, Public Governance, The University of MelbournePaul Long, Visiting Fellow, Australian Institute of Health Innovation, Macquarie 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">
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<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>
</figure>
<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>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Grattan Institute</span></span>
</figcaption>
</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.tag:theconversation.com,2011:article/455922015-08-11T20:34:35Z2015-08-11T20:34:35ZActing on family violence: how the health system can step up<figure><img src="https://images.theconversation.com/files/91261/original/image-20150810-11097-txayp8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's estimated general practitioners see up to five abused women every week.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/ajay13/8788680283/in/photolist-eoChsp-j4Z16k-L7GYi-9s3iZm-atPGkx-91EVdy-ppoGu2-vP8SaY-cxm8dJ-n9Ex3z-7UHyig-kVkx24-9szkWh-6tkNag-7Q2htb-Bdzqn-r7c2Xo-cip6fS-ajqBBq-a1vpRx-5TxxkF-gyZCy1-b6ixja-uU64KP-nsJmh2-vWqf47-kx9i3B-6UMsE7-">Aikawa Ke/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>The health system has a vital role in ensuring doctors and nurses provide an appropriate, first-line response to victims of family violence. But it’s lagging behind. Today, I’ll be telling the <a href="http://www.rcfv.com.au/Public-Hearings">Victorian Government’s Royal Commission into Family Violence</a> how the health system can step up to the challenge.</p>
<p>At least <a href="http://www.rcfv.com.au/getattachment/6442E593-04E1-4C3D-839E-AEFFD15D00CC/Melbourne-Research-Alliance-to-End-Violence-Against-Women-and-Their-Children">80% of women</a> experiencing abuse seek help from health services, usually general practice. It’s <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1467-842X.2002.tb00344.x/abstract">estimated</a> a general practitioner sees up to five abused women weekly who <a href="http://apps.who.int/iris/bitstream/10665/85241/1/WHO_RHR_HRP_13.06_eng.pdf?ua=1">present with symptoms</a> of violence in the home. Some patients suffer depression, anxiety and long-term headaches. For others, the stress of abuse can lead to premature labour or even miscarriage. Doctors treat the symptoms and often don’t ask about the cause; women sometimes don’t tell.</p>
<p>There are currently <a href="http://www.racgp.org.au/your-practice/guidelines/whitebook/">excellent guidelines</a> some health professionals follow, but others don’t. This isn’t enough. Health professionals need compulsory training to ensure better health and safety outcomes for women and children experiencing domestic violence. Only an organisational shift can make this happen. Practitioners need a supportive environment and changes in health system protocols and polices. </p>
<p>It should be noted that many of the studies in this area are based on women, as they are the <a href="https://theconversation.com/to-change-attitudes-to-family-violence-we-need-a-shift-in-gender-views-44718">main victims</a> of severe physical and sexual abuse. But the same principles apply to male victims.</p>
<h2>Removing barriers</h2>
<p>Women face many <a href="http://www.ncbi.nlm.nih.gov/pubmed/21160053">barriers</a> to discussing family violence with professionals. They include shame, worries about being judged or disbelieved, and confidentiality concerns. Many doctors have had <a href="http://metatoc.com/papers/46353-are-future-doctors-taught-to-respond-to-intimate-partner-violence-a-study-of-australian-medical-schools">minimal to no training</a> in dealing with the effects of partner violence. Some don’t have the time to respond adequately if a patient discloses their experience.</p>
<p>Policymakers and researchers have suggested <a href="http://www.cochrane.org/CD007007/BEHAV_screening-women-intimate-partner-violence-healthcare-settings">screening</a> (asking all women attending a clinic or hospital a standard set of questions) to overcome these barriers and help doctors and nurses identify patients experiencing family violence. </p>
<p>Screening may sound like a good idea but many practitioners are <a href="https://theconversation.com/midwives-can-help-detect-domestic-violence-heres-how-37918">reluctant</a> to use it. They might feel overwhelmed by the emotional task of responding to disclosures. Further, health professionals sometimes have their <a href="http://www.stfm.org/FamilyMedicine/Vol44Issue6/Candib416">own experience</a> of family violence which, if recent, might hinder their willingness to bring it up with patients.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/91281/original/image-20150810-11097-1vxg8qq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/91281/original/image-20150810-11097-1vxg8qq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/91281/original/image-20150810-11097-1vxg8qq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/91281/original/image-20150810-11097-1vxg8qq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/91281/original/image-20150810-11097-1vxg8qq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/91281/original/image-20150810-11097-1vxg8qq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/91281/original/image-20150810-11097-1vxg8qq.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">
<figcaption>
<span class="caption">Women face many barriers to discussing family violence with professionals.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Although screening helps identify some women experiencing domestic violence, the numbers are still lower than expected. Screening also doesn’t increase referrals to specialist services or improve women’s health outcomes. A US <a href="http://jama.jamanetwork.com/article.aspx?articleid=2422536&linkId=15934037">study</a> released last week showed no long-term health benefits to women who were screened and provided with a partner violence resource list. </p>
<p>The <a href="http://www.who.int/reproductivehealth/publications/violence/9789241548595/en/">World Health Organisation</a> doesn’t recommend screening in health settings unless the woman is pregnant. A <a href="http://www.cochrane.org/CD007007/BEHAV_screening-women-intimate-partner-violence-healthcare-settings">global review</a> of more than a dozen studies has backed up this advice. It concludes the small amount of existing evidence shows identification increases but has little benefit to women. </p>
<h2>Training professionals</h2>
<p>The lack of evidence for screening doesn’t mean doctors and nurses shouldn’t use <a href="http://www.addictioneducation.co.uk/BMJ%20article%202008.pdf">prompting questions</a> to investigate whether family violence is present when women and children show recognised symptoms. If patients <a href="http://www.pec-journal.com/article/S0738-3991(13)00311-X/pdf">feel ready</a> to disclose abuse, health professionals should show <a href="http://www.who.int/reproductivehealth/publications/violence/9789241548595/en">empathy</a> and follow up with <a href="http://www.dhs.vic.gov.au/about-the-department/documents-and-resources/policies,-guidelines-and-legislation/family-violence-risk-assessment-risk-management-framework-manual">safety questions</a>. Women <a href="http://apps.who.int/iris/bitstream/10665/136101/1/WHO_RHR_14.26_eng.pdf?ua=1">should be</a> listened to, believed, asked about their needs, have their risk and safety assessed and be offered ongoing support.</p>
<p>Some women are ready for referrals at the point of disclosure. For the many who aren’t, studies have suggested family doctors be trained to provide supportive counselling. This <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60052-5/fulltext">has been shown</a> to reduce depressive symptoms in women experiencing abuse. </p>
<p>Advocacy is also beneficial. This is where appropriately trained <a href="http://www.researchgate.net/publication/7658230_A_randomized_controlled_trial_of_empowerment_training_for_Chinese_abused_women_in_Hong_Kong">health-care providers</a> or specialist family violence services give women information and psychological support to access community resources. Survivors can be linked with legal, police, housing and financial services. Advocacy and support intervention <a href="http://www.cochrane.org/CD005043/BEHAV_advocacy-interventions-to-help-women-who-experience-intimate-partner-abuse">trials</a> for women who have sought help from shelters report reductions in violence and improvements in mental health. </p>
<p>For training to be effective, it must be provided as part of university courses and throughout a practitioner’s career. Health professionals usually respond best when they are trained by a peer. Effective training also involves role-playing asking and responding with actors, reflections on personal attitudes towards violence against women, hearing survivor stories and reviewing patients’ files.</p>
<p>While doctors’ and nurses’ ability to respond appropriately when they suspect family violence is vital, it can only work if the broader <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61837-7/fulltext">health system</a> is supportive of women-centred care.</p>
<h2>Health system response</h2>
<p>A whole-of-system response involves an appropriate, sensitive environment for <a href="http://www.asca.org.au/Home.aspx">traumatised people</a>, <a href="https://www.thewomens.org.au/news/dr-sue-matthews-opinion-in-the-age/">strong management support</a> for the importance of the work, and practitioner support and mentoring. In the <a href="https://xnet.kp.org/domesticviolence/about/index.html">United States</a>, some of these system changes have led to a dramatic increase in numbers identified. </p>
<p>Governments should create policies to facilitate referral pathways for health professionals, both internally and externally, with community services. Policies should also ensure data collection and information-sharing between agencies. Health settings can create supportive environments with leaflets and posters promoting awareness about family violence consultations and referrals.</p>
<p>The Commonwealth government could add Medicare item numbers for general practitioners, psychiatrists, psychologists and social workers (with family violence training) – similar to the current <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-ba-fact-pat">mental health care plans</a> – to undertake safety planning. These would allow for longer, half-an-hour sessions.</p>
<p>State governments can:</p>
<ul>
<li>Allocate funding for regional health services to have family violence coordinators and for every hospital to have a clinical professional implement organisational change.</li>
<li>Allocate finances to overstretched family violence services for women, children and men.</li>
<li> Fund trauma-informed counselling for <a href="http://www.berrystreet.org.au/Assets/1252/1/Turtleprogrambrochure.pdf">mothers and children</a>, as <a href="http://www.who.int/reproductivehealth/publications/violence/9789241548595/en">recommended</a> by the World Health Organization. This would help fill Australia’s chasm of referral options, particularly for women and children who have left the relationship.</li>
</ul>
<p>Finally, we must ensure the health recommendations heard at the Royal Commission today lead to practical outcomes. If health professionals continue to only treat symptoms of family violence, the cycle of women’s physical and mental deterioration and damage to children will continue.</p><img src="https://counter.theconversation.com/content/45592/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kelsey Hegarty received funding from NHMRC for the weave trial. She has been a Temporary Clinical Advisor for the WHO and an author on the Cochrane Clinical Reviews.</span></em></p>Victoria’s Royal Commission into Family Violence will today hear how the health system can better respond to partner abuse, with the help of trained professionals and broader, government support.Kelsey Hegarty, Professor, Department of General Practice; Director of Researching Abuse and Violence in Primary Care program; Director of Post graduate Primary Care Nursing, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/452932015-08-04T04:21:42Z2015-08-04T04:21:42ZHospital patients are more likely to die at weekends but seven-day rosters are no panacea<figure><img src="https://images.theconversation.com/files/90546/original/image-20150803-6019-1yekxy5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">England's NHS is taking implementing seven-day services in an attempt to reduce excess deaths on weekends. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-191114228/stock-photo-room-with-two-beds-in-the-hospital.html?src=yxPQFULKTUvPRD9vg4pROg-1-112">www.shutterstock.com</a></span></figcaption></figure><p>If you are admitted to a hospital on the weekend, you have a higher chance of dying than if you are admitted during the week. This is known as the “weekend effect”.</p>
<p><a href="http://jrs.sagepub.com/content/105/2/74.abstract">Evidence from the United Kingdom</a> suggests an 11-16% increased risk of death for patients admitted on weekends, mostly driven by emergency admissions. This effect has also been found in <a href="http://www.sciencedirect.com/science/article/pii/S0002934304002475">the United States</a> and <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1445-5994.2009.02067.x/full">Australia</a>, among Queenslanders admitted for heart attacks.</p>
<p>But while seven-day rosters for doctors and nurses have been touted as a solution to this problem in the UK, the evidence suggests it’s a little more complicated. </p>
<h2>What causes the weekend effect?</h2>
<p>Generally, there are fewer routine elective procedures and outpatient appointments scheduled on weekends. This means there are fewer nurses and doctors available for emergency care. </p>
<p>During the week, for example, heart surgeons working on elective procedures in hospitals can easily be called away to treat patients admitted through the emergency department. These surgeons may be less readily available at weekends when there are no elective surgeries or outpatient appointments. And there may be longer delays for them to be called in to the hospital for emergency cases.</p>
<p>There is some <a href="http://www.nejm.org/doi/full/10.1056/nejmoa063355">evidence from the US</a> to support this explanation. Researchers found that a weekend effect for patients presenting with a heart attack (acute myocardial infarction) disappears when they control for the use of invasive treatments such as cardiac catheterization or coronary artery bypass graft (heart bypass). </p>
<p>This suggests that a lower “treatment intensity” for patients presenting at the weekend explains their higher chance of death.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/90540/original/image-20150803-5978-7b5vx7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/90540/original/image-20150803-5978-7b5vx7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90540/original/image-20150803-5978-7b5vx7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90540/original/image-20150803-5978-7b5vx7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90540/original/image-20150803-5978-7b5vx7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90540/original/image-20150803-5978-7b5vx7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90540/original/image-20150803-5978-7b5vx7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Surgeons may be less available for emergency procedures on weekends, and there can be longer delays for urgent operations.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/isafmedia/3424052022/in/photolist-6dzanG-6LyK5M-9866ZQ-7x8Ge-9e7G55-7x7iS-6fv9gA-dgSLw2-4jFUbM-tx6wP8-odAUX-shNHJF-dgSLKj-aw9eaM-s2qrRV-dgSLCS-dRp8pk-cDXWXC-8SNxMK-rQvc4W-8Mzmie-oYLAdr-hRLTUV-9b2ckU-fHc3B-9eC7PJ-bq7jUk-aJPKGK-eeVK74-55E23R-ni2HEj-qtWa9C-qannsh-o1vDW1-o3oLa4-Bqkyh-e5hpLQ-6dUkD9-5XGMui-giVXpA-9uuNjp-4AKLvA-48Svrw-aaEKnv-adtz2R-5Adove-65J2QU-bq8JVa-5zYqyR-dr2tf5">ResoluteSupportMedia/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>What policies could address this problem?</h2>
<p>Policies to address the imbalance of service and workforce availability between weekdays and the weekends should help to alleviate the weekend effect. </p>
<p>The most comprehensive solution would be to introduce seven-day availability of all types of hospital services, scheduling elective procedures and outpatient appointments on weekends as well as weekdays. This would essentially mean having no difference in the type of care offered on different days of the week.</p>
<p>The UK National Health Service (NHS) is <a href="http://www.nhsiq.nhs.uk/7860.aspx">taking steps towards</a> implementing seven-day services in England, which has <a href="http://www.theguardian.com/society/2015/jan/02/nhs-seven-day-service-threaten-patient-safety-doctors">generated a heated debate</a> between doctors, NHS managers and politicians on the merits of this proposal.</p>
<h2>Costs and benefits of seven-day services</h2>
<p>Health bureaucrats looking to address the imbalance between weekend and weekday service availability may try to redistribute the existing workforce supply to be evenly spread throughout the week. </p>
<p>This redistribution of services and workforce should reduce the death rate for weekend admissions. But it would come at the cost of potentially increasing the death rate (and other adverse outcomes) on weekdays where there would be a reduction in services.</p>
<p>Such a redistribution would also involve an increase in financial cost, as higher levels of pay are likely to be necessary to encourage doctors and nurses to work more of their hours at weekends. One of <a href="http://www.sciencedirect.com/science/article/pii/S0167629612000902">our recent studies</a> suggests that junior doctors in Australia would expect a 25-50% increase in salary to sacrifice control over their working hours and/or be available for more frequent on-call time. </p>
<p>A <a href="http://hsr.sagepub.com/content/20/1/31.long">similar study</a> finds a premium of 10-15% of salary is needed to encourage nurses to work at weekends as well as on weekdays.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/90547/original/image-20150803-5978-2ofi0y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/90547/original/image-20150803-5978-2ofi0y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=384&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90547/original/image-20150803-5978-2ofi0y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=384&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90547/original/image-20150803-5978-2ofi0y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=384&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90547/original/image-20150803-5978-2ofi0y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=482&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90547/original/image-20150803-5978-2ofi0y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=482&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90547/original/image-20150803-5978-2ofi0y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=482&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Seven-day services could reduce the death rate for weekend admissions, but would come at a cost.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-48064288/stock-photo-doctor-using-scrubs-walking-at-the-hospital-corridor.html?src=IFSfJX8XnIVP5YIawchb-w-3-113">Julian Rovagnati/www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>An <a href="http://onlinelibrary.wiley.com/doi/10.1002/hec.3207/abstract">important paper</a> has recently tried to quantify the costs and benefits of introducing seven-day services in the UK. It calculates the potential “lives saved” by eliminating the weekend effect and uses cost estimates produced by hospitals which have been trialling seven-day services. </p>
<p>The authors are able to quantify “cost-effectiveness” by comparing the cost per year of life saved (implied by their analysis) with the National Institute for Clinical Excellence’s “cost-effectiveness threshold” for life-years saved. This is generally thought to be around £20,000 per life year. </p>
<p>The authors find that introducing seven-day services does not come close to cost-effectiveness. The cost of avoiding excess deaths from weekend admissions is too high relative to other effective interventions the NHS could spend its money on.</p>
<p>At the heart of this debate is a trade-off between equity and efficiency. It is more “efficient” to have less service availability at weekends and more on weekdays, because of the increased costs associated with employing doctors and nurses at weekends. But we have to decide if we are willing to accept the resulting inequity: that patients admitted on weekends may have a poorer access to care and a resulting increase in mortality.</p>
<h2>Should Australia move to seven-day services?</h2>
<p>The debate over seven-day services in the UK <a href="http://www.telegraph.co.uk/news/11500692/David-Cameron-Tories-will-create-a-truly-seven-day-NHS.html">is highly politicised</a>, and influenced by the current government’s agenda to make the NHS more patient-focused. </p>
<p>We have a different health-care system and political climate in Australia and are yet to have this debate. With a much larger private sector and public hospitals run by state governments, there is not a single national focus for policy debate about public hospital services. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/90543/original/image-20150803-5983-6tdkt7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/90543/original/image-20150803-5983-6tdkt7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90543/original/image-20150803-5983-6tdkt7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90543/original/image-20150803-5983-6tdkt7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90543/original/image-20150803-5983-6tdkt7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90543/original/image-20150803-5983-6tdkt7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90543/original/image-20150803-5983-6tdkt7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&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">In Australia, we have not had the debate on seven-day hospital services.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-112477955/stock-photo-surgery.html?src=IFSfJX8XnIVP5YIawchb-w-2-145">www.shutterstock.com</a></span>
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<p>Nevertheless, the current evidence from abroad suggests that forcing hospitals to provide all services equally distributed through the week is not the answer. </p>
<p>While the weekend effect on mortality may seem large in relative terms (10-16%), it is tempered by the low mortality rate in absolute terms. The 10% relative increase of death in the UK data translates to only 0.4 percentage points (3.7% on weekdays vs 4.1% on weekends for emergency admissions).</p>
<p>Further, the <a href="http://onlinelibrary.wiley.com/doi/10.1002/hec.3207/abstract">cost-effectiveness study</a> from the UK highlights the potentially high costs of seven day services in relation to any health benefits. Further research is needed, especially on the cost side and in understanding the drivers of the weekend effect in different clinical areas of patient care.</p><img src="https://counter.theconversation.com/content/45293/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Sivey currently receives funding from the Australian Research Council and has previously been funded by the National Health and Medical Research Council, the Department of Health (Victoria) and Health Workforce Australia.</span></em></p>If you present to a hospital on the weekend, you have a higher chance of dying than if you present during the week. This is known as the “weekend effect”.Peter Sivey, Senior Lecturer, Department of Economics and Finance, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/431142015-06-23T20:08:56Z2015-06-23T20:08:56ZHappiness and the art of care and conversation on the cancer ward<figure><img src="https://images.theconversation.com/files/85499/original/image-20150618-23235-17irq1w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The gift of time makes patients happy.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-230137186/stock-photo-stethoscope-and-heart-painted-medical-concept.html?src=pp-same_artist-230137189-5T8-xbhoOgj2jRte4GZBKA-4&ws=1">Number1411/Shutterstock</a></span></figcaption></figure><p><em>This article is based on an essay from the collection <a href="http://uwap.uwa.edu.au/products/on-happiness-new-ideas-for-the-twenty-first-century">On Happiness: New Ideas for the Twenty-First Century</a> and is part The Conversation’s <a href="https://theconversation.com/au/topics/on-happiness">series</a> on what happiness means.</em></p>
<hr>
<p>When asked to contribute to On Happiness I readily agreed because I had been mulling over the meaning of happiness that whole month as I cared for a patient nearing the end of her life. She had young children, a supportive husband and, most of all, an abiding faith that allowed her to imagine heaven as a better place now that treatment was no longer possible for her advanced cancer. </p>
<p>It struck me as extraordinary that she could muster such unflappable peace in the face of something as momentous as death. But I also thought that if everyone shared a drop of her equanimity, the inevitability of dying would be so much easier on all of us, the deceased and the ones left behind.</p>
<p>The week I sat down to write the essay was the week she finally died, peacefully, surrounded by her family as she went to meet her god. All I could think about was her child about to start school whose mother would not be present to see her on her first day. With my child about to do the same, I wrote the story from a deep and affected place, not as an oncologist but as a mother who happened to be an oncologist.</p>
<p>Some days on the ward, happiness is avoiding the fate of many of my patients. Everyone who works in oncology is only too aware of the flick of the wheel of fortune that transforms happiness into its opposite.</p>
<p>But if being an oncologist is sobering stuff, it’s also a job where happiness steals into your life in unexpected ways. My working week is filled with diverse roles, including reading interesting research and fine literature, writing health columns, public speaking and mentoring, but my favourite moments in medicine are those spent in direct patient care. </p>
<p>I am at my happiest at the bedside of a patient, explaining a diagnosis and coming up with ways to navigate through a difficult time. Much of the fear of cancer arises from a total lack of control, so I am at my happiest when a patient with a new diagnosis comes in bewildered and shaken and leaves my office feeling a modicum of control. </p>
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<img alt="" src="https://images.theconversation.com/files/86028/original/image-20150623-19411-1tzisl4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/86028/original/image-20150623-19411-1tzisl4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/86028/original/image-20150623-19411-1tzisl4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/86028/original/image-20150623-19411-1tzisl4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/86028/original/image-20150623-19411-1tzisl4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/86028/original/image-20150623-19411-1tzisl4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/86028/original/image-20150623-19411-1tzisl4.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">Much of the fear of cancer arises from a total lack of control.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-236631238/stock-photo-patient-with-iv-drip-in-a-hospital.html?src=mCMExOTXOnVDqrAEYkstyA-3-84">Anan Kaewkhammul/Shutterstock</a></span>
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<p>Once or twice a week someone is vocally appreciative towards my colleagues and I. “People say the public hospital is no good, but, to me, you are all angels,” one patient recently said of her encounters with nearly half a dozen different nurses and oncologists. It’s impossible to describe how much happiness such compliments bring into our lives when we often feel we are short-changing the tide of patients that confronts us.</p>
<p>But lately, I have been hearing a lot about disillusionment in medicine. How doctors would not recommend the profession to their children. How doctors are burning out amidst skyrocketing rates of drug and alcohol abuse and mental illness. </p>
<p>Medicine is just another form of consumerism, doctors sigh, as they rush from pillar to post to satisfy the urges of a consumer society fuelled by unrealistic expectations and diminishing personal responsibility. Bureaucrats breathe down our necks, tired of our inability to distinguish cost-effective measures from plainly wasteful ones. Patients no longer regard us with the level of respect, or even affection, that they once did.</p>
<p>As an oncologist working in a public hospital system that attracts a large share of the educationally deprived and the socioeconomically disenfranchised, I find myself at the heart of these experiences. They have me wondering how to recapture the joy of medicine for myself and convey it to the next generation of doctors. </p>
<p>Here is what I have realised. More beds, shiny wards and more scanners don’t make anyone happy. More beds without more staff means more patients per overworked doctor and nurse. More scanners mean more scans but not necessarily better care.</p>
<p>I have rarely met a patient who felt better for being on a new ward that was staffed by jaded doctors and nurses. So while pouring money into medicine is usually well-intentioned, it’s a stretch to say that it makes doctors happy.</p>
<p>What does make doctors happy is happy patients. Nothing puts a spring in a doctor’s step like the sight of a satisfied patient. In a profession where established beliefs are routinely turned on their heads, this seems to be a fairly irrefutable one. In fact, the capacity to make a palpable and immediate difference to the human condition is what sets medicine apart from any number of prestigious jobs. Corporate lawyers, management consultants and investment bankers tell us this.</p>
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<img alt="" src="https://images.theconversation.com/files/86029/original/image-20150623-19397-wmopxm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/86029/original/image-20150623-19397-wmopxm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/86029/original/image-20150623-19397-wmopxm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/86029/original/image-20150623-19397-wmopxm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/86029/original/image-20150623-19397-wmopxm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/86029/original/image-20150623-19397-wmopxm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/86029/original/image-20150623-19397-wmopxm.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">
<figcaption>
<span class="caption">While pouring money into medicine is usually well-intentioned, it’s a stretch to say it makes doctors happy.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-266797934/stock-photo-blurred-patient-waiting-for-see-doctor-abstract-background.html?src=mCMExOTXOnVDqrAEYkstyA-4-121">weedezign/Shutterstock</a></span>
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<p>But how can the modern doctor make the modern patient happy? In this age of unrelenting dissatisfaction with every aspect of our life, is it even possible to aim for a happy patient, or should doctors just accept that customer service delivered with civility, efficiency and accuracy ought to be enough? </p>
<p>I think this would be a shame because the wonder of medicine really lies in its human touch. The rest Google keeps getting better at. </p>
<p>Take the example of a skin rash that a patient took to Google for a diagnosis. Google reassured her that the rash should get better by itself. It took the triage nurse’s radar to sense that although Google was right about the rash, it couldn’t possibly diagnose the patient’s distress at remembering that a similar rash had heralded the death of her mother from leukaemia when the patient was merely seven years old. </p>
<p>I often see that what makes a patient happy is the gift of time. I have met some wonderful doctors in my career, loved by patients and their colleagues. They all have something in common – they have honed the art of communication. </p>
<p>These doctors look at their computer screen less and their patients more. They smile, wince, celebrate and commiserate with their patients and they look them in the eye. They show empathy without losing their professionalism. Through their words and their gestures they show that they care. </p>
<p>I asked a very busy GP once how he managed to keep so many patients happy. “I behave as if for those ten minutes the patient before me is my only concern in the world,” he said. </p>
<p>When patients feel listened to they tend to engage in decision-making and the management of their condition. Patients come to doctors for a diagnosis and treatment but also for comfort. A kind gesture, a soothing word can be as therapeutic as a prescription. </p>
<p>“If only she’d stop trying to be extra clever and just be a little nicer,” an old lady once grumbled. For many doctors this is a difficult pill to swallow and one that is the obverse of what the profession has traditionally valued. But I am convinced that for medicine to deliver happiness we must not forget the human dimension. </p>
<p>As far back as the fourth century BC Hippocrates observed, “May you cure sometimes, relieve often and comfort always.” This may be the one prescription in medicine without an expiration date.</p>
<hr>
<p><em><a href="http://uwap.uwa.edu.au/products/on-happiness-new-ideas-for-the-twenty-first-century">On Happiness: New Ideas for the Twenty-First Century</a> is available this month from UWA Publishing.</em></p>
<p><em>Read the other articles in The Conversation’s <a href="https://theconversation.com/au/topics/on-happiness">happiness series here</a>.</em></p><img src="https://counter.theconversation.com/content/43114/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ranjana Srivastava 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>Much of the fear of cancer arises from a lack of control, so I’m at my happiest when a patient with a new diagnosis comes in bewildered and shaken and leaves my office feeling a modicum of control.Ranjana Srivastava, Oncologist, Author & Guardian Columnist , Monash HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/422432015-05-25T20:07:03Z2015-05-25T20:07:03ZLet’s stop the bullying of trainee doctors – for patients’ sake<figure><img src="https://images.theconversation.com/files/82839/original/image-20150525-32586-ef0334.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bullying is not just a problem for women, or surgeons or even just the medical profession.</span> <span class="attribution"><span class="source">'At Their Mercy' Four Corners</span></span></figcaption></figure><p>Size matters. At least, that seems to be the media’s belief when it comes to analysing social problems. The grimmer the stories, the uglier the experience, the more bodies at the bottom of the cliff, the better.</p>
<p>And last night’s episode of ABC TV’s Four Corners didn’t disappoint, with its expose on bullying among surgeons and the devastating consequences this entrenched practice has for its victims, both in the short and long term.</p>
<p>Despite casting their net wide, the show’s producers found only three medical professionals who haven’t spoken out about this issue before, and only two chose to be identified. Imogen Ibbett and Vyom Sharma have now joined the growing ranks of <a href="http://www.theage.com.au/victoria/surgeon-caroline-tan-breaks-silence-over-sexual-harassment-in-hospitals-20150312-141hfi.html">doctors, such as Dr Caroline Tan</a> and <a href="http://www.smh.com.au/national/treament-ills-as-doctors-battle-depression-20140925-10lupw.html">Dr Talia Steed</a>, in breaking the silence around the destruction of careers and health that doctors cause among their own.</p>
<p>But noticing the growing pile of bodies at the bottom of the cliff is only helpful if it triggers the essential questions – who or what is pushing them off and what can be done to stop it?</p>
<h2>Not just surgeons</h2>
<p>The program notes that this is not just a problem for women, or surgeons or even just the medical profession; it’s a public health issue that demands action. Indeed, women can also be perpetrators as Imogen Ibbett’s <a href="http://www.abc.net.au/news/2015-05-25/senior-monash-surgeon-under-investigation-over-bullying-claims/6491592">allegations against Helen Maroulis</a> clearly demonstrate. </p>
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<p>But most significantly, the show highlights the risk bullying, scalpel-throwing surgeons, misogynist physicians, and harassed and cowered trainee doctors pose to the lives of patients.</p>
<p>The problem starts early, in medical school; both local and international research persistently show most medical students experience mistreatment during clinical placements in hospitals. </p>
<p>Our recent – about to be published – research found 74% of Australian medical students experienced mistreatment during clinical placements and even more witnessed it. Similarly, a <a href="http://www.ncbi.nlm.nih.gov/pubmed/24667503">2014 US study</a> found 83% of medical students experienced some form of mistreatment during medical training in hospitals. </p>
<p>A large number of students reported <a href="http://www.ncbi.nlm.nih.gov/pubmed/23610843">use of “pimping”</a>, an aggressive form of questioning based on <a href="http://www.ncbi.nlm.nih.gov/pubmed/24667505">an abuse of the Socratic teaching method</a>, described in Four Corners, which is <a href="http://www.ncbi.nlm.nih.gov/pubmed/17971682">used to shame students</a> for their lack of knowledge. Studies have also highlighted <a href="http://www.ncbi.nlm.nih.gov/pubmed/24667505">negative environments involving belittlement</a>, disrespect and being “<a href="http://search.informit.com.au/documentSummary;dn=363091894543151;res=IELHEA">constantly ignored and told to disappear</a>.” </p>
<p>Although student reports of mistreatment may be interpreted by some senior staff <a href="http://www.ncbi.nlm.nih.gov/pubmed/24667503">as just over-sensitivity</a>, research <a href="http://www.ncbi.nlm.nih.gov/pubmed/16199465">shows students perceive negative events</a> in a similar way to physicians and nurses. Unsurprisingly, <a href="http://www.ncbi.nlm.nih.gov/pubmed/21952053">under-reporting is common</a>.</p>
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<p>Mistreatment of medical students is at odds with the <a href="http://www.ncbi.nlm.nih.gov/pubmed/18412883">explicit teaching about professionalism</a> in medical training, leaving many confused. But some others become medical teachers who “<a href="http://www.ncbi.nlm.nih.gov/pubmed/17971682">mete unto others what was perpetrated against them</a>”. The effects of all this “<a href="http://www.ncbi.nlm.nih.gov/pubmed/16707293">teaching by humiliation</a>” can be profound and enduring.</p>
<p>Medical students’ mental health has been shown to decline throughout medical training. And this can lead to poor self-confidence and burnout, binge drinking, stress and depression, and substance abuse, broken relationships, suicide and early exit from the profession.</p>
<p>Mistreatment can create cynicism and reduce empathy, which may directly affect patient care. Students are also distressed when they see doctors mistreating or being disrespectful to, or about, patients.</p>
<h2>Impact on patients</h2>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/17365392">Patients can clearly</a> be directly <a href="http://www.ncbi.nlm.nih.gov/pubmed/22905664">affected by the way the autocratic medical culture</a> affects working practices and <a href="http://www.ncbi.nlm.nih.gov/pubmed/25948788">ineffective communication causes health-care errors</a> and poor patient safety outcomes.</p>
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<p>In fact, this kind of culture poses an extreme threat to patient care, like the notorious “Butcher of Bega”, Graeme Reeves. After 35 formal complaints of bullying and harassment were made about Reeves by other doctors, nurses and patients over a 15-year period starting in 1985, he was deemed “a person unfit to remain on the register of medical practitioners” in 2004. <a href="https://www.hccc.nsw.gov.au/Publications/Media-Releases/Review-of-past-handling-of-complaints-against-Dr-Graeme-Reeves">Behind him lay</a> a trail of dead and mutilated patients and aggrieved and frustrated doctors and other staff.</p>
<p>But much bullying and harassment is subtle, insidious and harder to prove and act upon. Indeed, Four Corners shows how one doctor’s tormentor can be another’s mentor. Dr Imogen Ibbet finds Dr Tan’s tormentor, Chris Xenos to be professional and respectable, for instance, but feels very differently about Dr Helen Maroulis’ behaviour.</p>
<p>And all the bad behaviour is difficult to police because mistreatment is often so subtle and secretive it can be impossible to deal with, especially when the victim is made to feel both responsible and powerless.</p>
<p>In the program’s attempt to look for solutions, it’s confronted by the apparent buck-passing of responsibility between the Australian Medical Association (AMA), the professional colleges and the workplaces where bullied doctors work.</p>
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<p>Four Corners and BeyondBlue have nailed the problem that’s pushing people over the cliff: workplaces that have allowed a culture of humiliation, bullying and harassment to prosper with inadequate pathways for action. And the fence that’s needed at the top of the cliff to prevent the falls is now also becoming apparent. </p>
<p>If bullying is a workplace issue, and the workplace is funded on the public dollar, then the public needs more say in hiring and firing practices. Nothing can change until young doctors are safe in the knowledge that the people they need to complain about no longer have absolute control over their careers. And there’s an example that can be followed.</p>
<p>Training to become a specialist in general practice is no longer directly under the control of either of the general practice colleges. Rather it’s contracted out to 17 regional training providers. The role of the general practice colleges now is to improve practice quality as a whole, build collegial relationships, and provide continuing education and opportunities for its fellows and members. </p>
<p>This may be a model we need to emulate for all medical speciality training. While it will never be possible to completely remove the apprenticeship model from medical education, it’s possible to ensure progression decisions are made by those at arm’s length from training and that merit, not nepotism, prevails.</p><img src="https://counter.theconversation.com/content/42243/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>The widespread bullying of doctors during training is not just an issue for surgeons, or women. It’s a problem for all medical professionals – and it poses a risk to patient safety.Kimberley Ivory, Senior Lecturer, Population Medicine and Sub-dean Student Support, Sydney Medical School, University of SydneyKaren Scott, Senior Lecturer, Education, Discipline of Pediatrics and Child Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/419722015-05-20T04:35:02Z2015-05-20T04:35:02ZGetting doctors to the bush depends on more than just uni places<figure><img src="https://images.theconversation.com/files/82325/original/image-20150520-30548-4gcolz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If you need doctors to work in the country, you need a selection system that picks people with those values and commitments.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/26126239@N02/8719941425/">University of Exeter/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Prime minister Tony Abbott has justified his <a href="http://www.abc.net.au/news/2015-05-17/tony-abbott-announces-federal-support-for-third-wa-medical-scho/6475914">decision to help fund a new medical school</a> in Perth by noting that Western Australia lacks locally-trained doctors. </p>
<p>But how can we know whether the new institution will help Western Australia’s shortfall of 1,000 doctors, many of whom will be needed in rural and remote areas?</p>
<p>Three features of a medical school help predict where medical students will eventually work as doctors. They are selection, the curriculum, and the professionalism of the newly-qualified doctors. </p>
<h2>Selection procedures</h2>
<p>The aim of selection procedures is to <a href="https://www.ncbi.nlm.nih.gov/pubmed/25123968">predict and select</a> applicants who will go on and become good doctors, and reject those who are likely to perform poorly in medical school and future practice. This might be due to poor professional behaviour as well as a lack of clinical knowledge and skills.</p>
<p>If you get into medical school, there’s a 95% chance you should become a doctor. But there’s only a 10% chance of getting into many medical schools. So these schools can pick and choose from the cleverest, and still choose those who have the values and commitment to work where they’re needed. </p>
<p>Worldwide, <a href="https://www.ncbi.nlm.nih.gov/pubmed/22722353">doctors tend to like working in the city</a> rather than in country. This means there are plenty of doctors in urban areas but too few working rurally everywhere; it’s not just an Australian problem. </p>
<p>The <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/review-australian-government-health-workforce-programs">best predictor</a> of whether a doctor will work in the countryside is whether she grew up in a rural town. And also, whether she has a good rural experience during her medical training. </p>
<p>So if you need doctors to work in the countryside, you need a selection system that picks people with those values and commitments.</p>
<h2>The right curriculum</h2>
<p>The second informative feature of a medical school is the curriculum. This sets out the knowledge, skills, and behaviours that newly-qualified doctors ought to have. And the methods used to teach them. A third curriculum feature is assessment methods, which help ensure students have achieved a high standard. </p>
<p>Modern curriculum design can produce doctors who are ready for work in hospitals and in general practice. They should also have sound knowledge and skills, and be good communicators. </p>
<p>Curricula come in different flavours, depending on the kind of doctor the medical school wants to produce. Using <a href="https://www.ncbi.nlm.nih.gov/pubmed/6738402">a medical education tool called SPICES</a>, you can tell whether a medical school is based around the teacher, with all its training done in the hospital, and where all the students do the same thing. Or whether the curriculum is based around the needs of the student, teaching is done in the community, and there’s a degree of student choice around their interests. </p>
<p>An army of volunteer teachers in hospitals and general practices provides the backbone of clinical education, particularly for teaching how to manage chronic disease. But just because you are a doctor doesn’t mean you are a good teacher. So <a href="https://www.ncbi.nlm.nih.gov/pubmed/17074699">training this army to be effective clinical teachers</a> is in itself a big job.</p>
<p>Assessment always makes students anxious, but medical school examinations are about protecting the public. A good medical school will have a clear system for following student progress, and managing and supporting students who are at risk of failing. This might be because of ill health, poor behaviour, a life crisis, or simply falling behind in their studies. </p>
<h2>Training professionals</h2>
<p>Around 85% of Australians <a href="http://sydney.edu.au/medicine/fmrc/beach/">visit a general practitioner</a> at least once a year, and 7% will see a specialist. If you ask the public what they think are the <a href="https://www.ncbi.nlm.nih.gov/pubmed/18338992">characteristics of a good doctor</a>, they will mention being caring, a good communicator, understanding their culture, being a good problem-solver, and working well with other professionals in a health-care team. </p>
<p>Some of these professionalism skills, for example, <a href="https://www.ncbi.nlm.nih.gov/pubmed/21670661">around empathy</a>, are known to deteriorate during a traditional medical education. This is largely caused by the distress of the “<a href="https://www.ncbi.nlm.nih.gov/pubmed/15459051">hidden curriculum</a>”, which is the hierarchical and competitive atmosphere in medical schools. </p>
<p>It can lead to haphazard instruction and <a href="https://theconversation.com/medicine-needs-to-swallow-a-bitter-pill-for-a-healthier-future-38777">teaching by humiliation</a>, especially during the clinical training years. Senior students and newly qualified doctors can <a href="https://www.ncbi.nlm.nih.gov/pubmed/15462649">experience burnout</a> on the front line of the public hospital system, which is <a href="https://www.cis.org.au/images/stories/policy-monographs/pm-99.pdf">underfunded and short-staffed</a> when dealing every day with the increasing burden of chronic disease and emergency care. </p>
<p>But the good news is that some professionalism skills are thought to increase during the same phase in training. This happens when students are <a href="https://www.ncbi.nlm.nih.gov/pubmed/22239332">placed in rural communities</a> for up to a year, for instance. </p>
<p>Their supervisors and hosting community freely contribute towards student education because they believe such students will return to work there. Medical school rural programs find that graduates of rural programs are not only <a href="https://www.ncbi.nlm.nih.gov/pubmed/23288277">likely to enter</a> rural general practice but 70% remain in rural practice for decades. </p>
<p>There’s been much said in recent days about how this country doesn’t need another medical school. But what Australia actually doesn’t need is another traditional medical school feeding into a stressed public hospital system, and urban private practice. What this country could benefit from is an innovative medical school feeding into a reformed public health-care system. </p>
<p>But what comes first? This is where we need to challenge our politicians. We need innovative medical education and training, as much as we need health-care reform, with a focus on <a href="http://www.phcris.org.au/guides/about_phc.php">primary care</a>. </p>
<p>If this new school doesn’t innovate, based on the evidence, it will do little to get doctors into areas of need.</p><img src="https://counter.theconversation.com/content/41972/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Roberts receives funding from the Department of Health to evaluate the national selection procedures into general practice specialty training</span></em></p>Three features of a medical school help predict where medical students will eventually work as doctors: selection, the curriculum, and the professionalism of the newly-qualified doctors.Christopher Roberts, Associate professor, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/387152015-03-13T05:01:05Z2015-03-13T05:01:05ZYes, sexism is rife in surgery – and it’s time to do something about it<figure><img src="https://images.theconversation.com/files/74747/original/image-20150313-7084-1kbm59a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Fewer than one in three surgical trainees are women and the numbers fall as doctors reach advanced training.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-141477769/stock-photo-thoughtful-mid-adult-female-surgeon-with-stethoscope-in-wall.html?src=CAKIMwGyOu9rJcF431MzgA-1-95">racorn/Shutterstock</a></span></figcaption></figure><p>You would expect women to flourish in medicine. Since 1996, women have <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129546076">outnumbered men</a> in Australian medical schools. <a href="http://www.gpet.com.au/About-Us/Annual-Report">More than half</a> of general practice trainees, <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129546076">two out of three</a> paediatric trainees, and close to three in four obstetricians in training are women. </p>
<p>Look at surgical training and this pattern stops: <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129546076">fewer than one in three</a> surgical trainees are women, and the numbers fall further as doctors reach <a href="http://www.sciencedirect.com/science/article/pii/S0002961096001857">advanced training</a>. Just <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129546076">9%</a> of surgeons in Australia are women.</p>
<p>Late last week, vascular surgeon Dr Gabrielle McMullin unleashed a storm by <a href="http://www.abc.net.au/am/content/2015/s4193059.htm">suggesting</a> that sexual harassment was common in surgical training. She said gaining redress was so compromised that if a female doctor was propositioned, providing a sexual favour may be the only way to sustain her career. </p>
<p>Data from medical schools in the <a href="http://www.sciencedirect.com/science/article/pii/S0277953612000780">United States</a>, the United Kingdom and <a href="http://www.ncbi.nlm.nih.gov/pubmed/11123560">Australia</a> all confirm that sexual harassment occurs in medical school. A <a href="http://journals.lww.com/academicmedicine/Fulltext/2005/04000/Does_Students__Exposure_to_Gender_Discrimination.20.aspx">2005 US study</a> of medical students found 92.8% of female students had experienced, observed or heard about at least one incident of gender discrimination and sexual harassment during medical school. This harassment <a href="http://www.nejm.org/doi/pdf/10.1056/NEJM199302043280507">continues</a> into specialist training. </p>
<p>Systemic bullying and harassment <a href="http://hea.sagepub.com/content/8/1/101.short">ranges from</a> crass sexualised jokes, inappropriate touching and crass commentary on female doctors’ bodies, to frank requests for sexual favours. Some of these may occur in public, but much is unwitnessed. </p>
<p>Women doctors <a href="http://www.sciencedirect.com/science/article/pii/S0277953612000780">report</a> that they may be able to manage harassment by patients and by their peers, but harassment from supervisors is much more difficult to deal with. Many women doctors are reluctant to come forward and develop feelings of guilt and resignation.</p>
<p>Sexual harassment occurs within a larger culture of discrimination against women in post-graduate medical training. A <a href="http://med-ed-online.net/index.php/meo/article/view/25923">recent US study</a> of female surgeons found 87% experienced gender-based discrimination in medical school, 88% in residency and 91% in practice. </p>
<p>Anecdotal reports suggest some women trainees are asked at interview about their intentions to have children, or advised that only certain careers are suitable for women with children. When employed, some female trainees report being given job contracts that are structured so they can never meet the criteria for maternity leave. Others say their rosters make it impossible to carry on with a career while maintaining caring responsibilities. </p>
<p>The toxicity of surgical training arises because it’s highly hierarchical, male-dominated, and – like most hospital-based training in the specialties – involves an intense apprenticeship training mode. Career advancement depends on personal recommendation from supervisors, and careers can be stymied by withholding this. </p>
<p>Junior doctors face increasing pressure for specialist training places. Although positions for many specialties are gradually increasing, this is out of kilter with the large increase in medical graduates, following the establishment of new medical schools over the last ten years. </p>
<p>In a high-pressure surgical environment, where older male consultants dominate, and there is great competition for training positions and jobs, women can often find themselves in very poor bargaining positions, vulnerable to sexual harassment. </p>
<p>Although female surgeons may face the worst of sexual harassment, this culture is <a href="http://hea.sagepub.com./content/8/1/101.short">endemic to medicine</a> more generally and is so common that many doctors do not even notice it. A recurrent theme <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1540-4560.1995.tb01312.x/abstract">expressed by victims</a> is the difficulty being believed, and once believed, not seeing any consequences for the perpetrator. </p>
<p>Sexual harassment is fundamentally about power. Saying sexual harassment is about “sex” is like hitting someone over the head with a shovel and calling it gardening. Identifying sexual harassment as it occurs can prove challenging for the doctors and medical students involved, especially if senior peers, including women, laugh it off or engage in collaborative bullying. </p>
<p>Nor is it limited to women. Bullying on the basis of sexual preference, race and age have <a href="http://careers.bmj.com/careers/advice/view-article.html?id=20002644">all been reported</a> in the medical workplace. </p>
<p>To solve the problem, we first need acknowledgement that career repression via sexual harassment, bullying and humiliation occurs, and that victims are not supported when they report. </p>
<p>We also must recognise that full-time apprenticeship mode of training, particularly when there are limited training positions, places junior doctors in a structurally vulnerable position. </p>
<p>We need more and broader modes of training. Part-time training remains unusual in most training programs except general practice. There are currently <a href="http://www.surgeons.org/media/20761086/racs030_-_activities_report_2013_lr.pdf">six part-time surgical trainees</a>, accounting for 0.5% of all training positions in surgery, despite evidence that these trainees are as successful as full-time trainees. </p>
<p>The Royal Australasian College of Surgeons’ <a href="http://www.surgeons.org/media/21453090/med_2015-03-12_bullying_and_harrassment_advisory_group.pdf">announcement</a> yesterday that it will establish an expert advisory committee into bullying and harassment is very welcome. Other specialist colleges should also review harassment in their own programs. </p>
<p>Written policies on harassment in the workplace have existed for many years in health workplaces, but they have not changed the culture. It is time for a concerted approach from both colleges and hospitals to recognise and embrace the kinds of changes that will make medical training inclusive and safe for all medical graduates.</p><img src="https://counter.theconversation.com/content/38715/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>In a high-pressure surgical environment, where older male consultants dominate, and there is great competition for training positions and jobs, women are vulnerable to sexual harassment.Elizabeth Sturgiss, Lecturer in General Practice, Australian National UniversityChristine Phillips, Associate Professor, Social Foundations of Medicine, Medical School, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/353122014-12-17T03:34:38Z2014-12-17T03:34:38ZGood news for rural health: physician assistants join the workforce<figure><img src="https://images.theconversation.com/files/67214/original/image-20141215-5287-1me4bip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Physician assistants provide high-quality care and can help fill Australia's rural doctor shortage.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/36243589@N04/14471106513">Dr.Farouk/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>At a ceremony in Townsville today, four people will graduate from James Cook University’s <a href="http://www-public.jcu.edu.au/courses/course_info/?userText=102010-#.VH_jdTGUd8E">physician assistant program</a>. They will be Australia’s first bachelor’s graduates in that field. This is an important step in improving access to care, especially in rural and remote Australia.</p>
<p>Despite doubling intakes into medical schools over the last decade, there is no sign yet that this will trickle down into improved access to care in small rural and remote communities. To get good access in rural and remote Australia (and even in some parts of metropolitan areas), we have to open our minds to the possibility of doing things differently. </p>
<p>As a <a href="http://grattan.edu.au/wp-content/uploads/2014/04/196-Access-All-Areas.pdf">2013 Grattan Institute report</a> suggested, addressing general practitioner shortages in remote Australia needs to involve broader roles for existing professionals – such as allowing pharmacists to undertake immunisations – and to consider new professions. This is where physician assistants come in. </p>
<p>Physician assistants practise medicine under the direct supervision of a doctor. Their role is agreed with the supervising doctor, and can develop over time along with trust, experience and <a href="http://www.hwa.gov.au/sites/uploads/hwa-physician-assistant-report-20120816.pdf">training</a>. </p>
<p>Physician assistants have been shown to provide high quality care, and their patients report <a href="http://www.biomedcentral.com/1472-6963/13/223">high levels</a> of satisfaction. Their use has been <a href="https://www.acrrm.org.au/files/uploads/pdf/advocacy/ACRRM-PhysicianAssistant-Policy-Oct-2011.pdf">supported</a> by rural doctors and by their colleagues and patients in successful <a href="http://www.urbis.com.au/projects/health-aged-care/evaluation-of-the-physican%E2%80%99s-queensland">Australian trials</a>. <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1748-0361.2010.00325.x/abstract">Overseas experience</a> shows they can work very successfully in rural areas. </p>
<p>Physician assistants are an established part of the health care team in <a href="http://www.hwa.gov.au/sites/default/files/hwa-physician-assistant-report-volume2-literature-review-20120816.pdf">several countries</a>, but implementation in Australia is hampered by multiple veto points between the idea and its implementation. </p>
<p>To be fully effective, introduction of physician assistants to rural and remote Australia needs <a href="http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/RP0708/08rp24">coordinated action</a> by the Commonwealth and state governments. This has not happened. Prescriptions written by physician assistants are not subsidised in the same way as prescriptions written by medical or nurse practitioners, and there is no Medicare rebate for physician assistants.</p>
<p>Both levels of government have been standing at the physician assistant door saying, “you first”, “no, you first” ad nauseam. To date this has stymied implementation of this worthwhile initiative.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/67216/original/image-20141215-5281-1lhuaxi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/67216/original/image-20141215-5281-1lhuaxi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/67216/original/image-20141215-5281-1lhuaxi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/67216/original/image-20141215-5281-1lhuaxi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/67216/original/image-20141215-5281-1lhuaxi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/67216/original/image-20141215-5281-1lhuaxi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/67216/original/image-20141215-5281-1lhuaxi.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">Overseas experience shows physician assistants can work very successfully in rural areas.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-102915128/stock-photo-hospital-ward-with-beds-and-medical-equipment.html?src=4rnDlLKAsrnfHlokmNDICA-1-0">EPSTOCK/Shutterstock</a></span>
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<p>In a good move, Queensland has attempted to break this impasse. This year it has “gone it alone” and <a href="http://www.health.qld.gov.au/qhpolicy/docs/gdl/qh-gdl-397.pdf">changed its rules</a> to allow physician assistants to prescribe, refer to medical specialists or order diagnostic tests within the Queensland public health system. </p>
<p>Similarly, James Cook University has gone it alone in introducing a bachelor’s degree program for physician assistants. </p>
<p>James Cook University’s medical graduates are <a href="http://www.rrh.org.au/articles/showarticlenew.asp?ArticleID=2313">16 times</a> more likely to intend to work outside capital cities and four times more likely to intend to work in smaller cities (of less than 100,000 people) than graduates from other universities. </p>
<p>Those intentions also get converted <a href="http://onlinelibrary.wiley.com/doi/10.1111/ajr.12106/abstract">into reality</a>: JCU medical graduates are <a href="http://www.rrh.org.au/articles/showarticlenew.asp?ArticleID=2657">ten times more likely</a> to take their internship outside a metropolitan centre. And if an internship outside a metropolitan area, it is also more likely that the graduate will practise outside a metropolitan area. The same pattern will probably hold with physician assistant graduates.</p>
<p>But the full potential of these changes will only be reached if the Commonwealth recognises physician assistant prescriptions, tests and referrals under the Pharmaceutical Benefits (PBS) and Medicare Benefits Schemes (MBS). Without Commonwealth recognition under the PBS, patients outside hospitals will have to pay more for medication prescribed by a physician assistant.</p>
<p>One way to respond to problems in the health system is to keep doing more of the same despite unacceptable workforce shortages in rural areas that have persisted for decades and, with current policy settings, will be with us for decades to come. </p>
<p>A better solution is to learn from proven solutions that have worked overseas and been tested in Australia. It is about time that the Commonwealth and other states caught up with changes in practice, and changes in the health team, and removed barriers to using physician assistants to their full potential, for the benefits of patients and communities. </p>
<p>Queensland hospitals, which now have a regulatory framework to employ physician assistants, should create positions for graduates in areas of unmet need and long waiting times for services. Physician assistant intakes need to be increased and programs need to be established in other universities.</p>
<p>The graduation today means that physician assistants are no longer a “pilot”, they’re real people able to meet real needs. It’s time for policy leaders to recognise that and for policies to match this new reality.</p><img src="https://counter.theconversation.com/content/35312/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This contribution is based on an address to be given by Professor Duckett to the graduation ceremony at James Cook University today.</span></em></p>At a ceremony in Townsville today, four people will graduate from James Cook University’s physician assistant program. They will be Australia’s first bachelor’s graduates in that field. This is an important…Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/188992014-10-08T19:04:26Z2014-10-08T19:04:26ZWhy hospitals need more generalist doctors and specialist nurses<figure><img src="https://images.theconversation.com/files/58853/original/fj46mwz9-1410499511.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Elderly patients increasingly have multiple illnesses and are much more difficult to care for. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-48064288/stock-photo-doctor-using-scrubs-walking-at-the-hospital-corridor.html?src=kRm7ex3DdjWZ5ndXHnCRIA-2-64">Julian Rovagnati/Shutterstock</a></span></figcaption></figure><p>New medical technologies and treatments over the past few decades have led to remarkable improvements in treating older patients. The <a href="http://www.pc.gov.au/__data/assets/pdf_file/0005/129749/ageing-australia.pdf">annual death rate</a> for an 80-year-old male in 2011 was just 5.6%, compared with 10% thirty years earlier.</p>
<p>But health-care costs are rising inexorably due to our ageing population. The elderly use hospitals at <a href="http://www.aihw.gov.au/publication-detail/?id=6442468045">three times the rate</a> of middle-aged Australians. Costs of hospitalisation rise steeply with age as sicker patients need to stay longer in hospital. </p>
<p>Hospital resources can only be stretched so far. As more and more patients arrive in emergency departments and need admission, the capacity to perform elective surgery is reduced, and waiting times increase. </p>
<p>So, how will our hospitals cope with the inevitable influx of large numbers of elderly patients and their increasingly complex needs?</p>
<p>Hospital reforms have focused on efficiency gains and “doing more with less”. But this alone won’t enable hospitals to respond to these new challenges. We need to redesign the workforce so hospitals are staffed by general physicians and nurses who take on more complex roles.</p>
<h2>Medical generalists</h2>
<p>As we age, our risk of developing chronic diseases – such as heart disease, cancer, diabetes, osteoporosis, depression and dementia – increases. And because we’re living longer, we’re more likely to have multiple chronic diseases; in fact, this is becoming the norm, rather than the exception. </p>
<p>Hospitals traditionally treated patients with one disease who were seen by doctors who specialised in a particular part of the body or type of treatment. But patients with multiple illnesses need a generalist to manage their care. </p>
<p>This is also the case in the United Kingdom, where the Royal College of Physicians recently <a href="http://www.rcplondon.ac.uk/projects/future-hospital-commission">recommended</a> a radical overhaul of the purpose and role of hospitals. The college argues that in future, hospital will need more generalists and fewer specialists. </p>
<p>The same is true for Australia. While general physicians are assuming a more prominent role in acute inpatient care, there is a shortage of experienced generalists and training positions. </p>
<p>Luckily, with an anticipated oversupply of medical graduates in Australia over the next few years, there is <a href="https://www.mja.com.au/journal/2014/201/2/future-medical-careers">an opportunity</a> to alter the structure of medical training to promote flexibility and generalism for medical careers.</p>
<p>State governments, however, need to actively support training programs for general physicians and include rotations through specialties. This will create the cadre of outstanding clinicians who can reduce the need for over-investigation and promote timely, holistic hospital care. </p>
<h2>Specialist nurses</h2>
<p>The increasing pressure of chronic diseases on hospitals and increased demand for beds will require nurses and doctors to work <a href="http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf407990">very differently</a> to the way they have in the past. </p>
<p>Nurses will need to be better utilised, in more specialist roles. With the right support and development pathways, for instance, nurses can <a href="http://docs.health.vic.gov.au/docs/doc/A6FC107F7A0E2FA4CA257C040071C945/$FILE/Final%20FAQ.pdf">safely perform</a> medial procedures such as endoscopies and colonoscopies, which use a long tube with a video camera and light on one end to examine the inside of the body. Nurses can also oversee patients’ <a href="http://www.publish.csiro.au/paper/PY11164.htm">chronic disease management programs</a> for illnesses such as diabetes and heart disease.</p>
<p>Grattan Institute health economist Stephen Duckett has <a href="https://theconversation.com/hospital-workforce-reform-better-jobs-and-more-care-25488">previously proposed</a> up-skilling hospital-based nurses to ease the pressure on hospitals. By employing nursing assistants to undertake more administrative tasks, nurses would be free to take on more complex roles. This could help create more rewarding jobs and a more sustainable health-care system.</p>
<p>Nursing researcher Stacey Leidel agrees. She <a href="https://www.mja.com.au/journal/2014/201/2/nurse-practitioners-australia-strategic-errors-and-missed-opportunities">argues</a> that the way forward is to reinvigorate the role of the clinical nurse consultant, rather than up-skill specialist nurses (nurse practitioners, who focus on a specific area of clinical care). These clinical nurse consultants would be educated according to a generalist framework, based on national priorities. </p>
<p>However, the cultural barriers to nurses increasing their scope of practice span legislative, administrative, professional and societal domains. The argument for change will require attention to fear as much as logic and evidence. </p>
<h2>What progress is being made?</h2>
<p>Disruptive innovation will need to challenge professional silos built around specialisation, as well as stereotypes. </p>
<p>This fresh approach is starting to appear in a diverse range of settings, such as the Mayo Clinic, where the <a href="http://www.mayo.edu/center-for-innovation/">Center for Innovation’s</a> mission is to transform the experience and delivery of health care through the application of design thinking. </p>
<p>In New Zealand, the <a href="http://koawatea.co.nz/">Ko Awatea Centre at Counties Manukau DHB</a> in Auckland is changing the stance and perspective taken by health-care workers as a first step to co-design of services. </p>
<p>Locally, <a href="http://www.monashhealth.org/">Monash Health</a> in Melbourne has reorganised its general medicine model of care across three acute hospital sites. Senior nurse nurses and allied health practitioners now work in specified roles to coordinate integrated care. And general physicians focus on providing timely appropriate care across the hospital.</p>
<p>The increase in patient admissions under general medicine over the last five years has been accompanied by a reduction in length of stay which would otherwise have required an additional 120 beds to be opened. In other words, the operating efficiency gain is equivalent to 120 beds.</p>
<h2>Towards more integrated care</h2>
<p>In order to create the radically different hospital to meet the needs of the rapidly ageing population over the next 20 years, we need to create new roles for health-care workers and challenge traditional siloed professional practice. </p>
<p>Health services must bring design thinking and systems thinking together to create truly innovative health care services that make patient and front-line team experience the priority. In doing so, we must see the patient journey as an integrated whole and focus on providing effective care for our patients. </p>
<p>This, of course, will require effective care teams and <a href="http://www.nejm.org/doi/pdf/10.1056/NEJMp1301814">clinical leadership</a>. To achieve this vision, enlightened hospital decision-making boards will need to challenge service providers to take this radical design approach. And governments will need to support a more strategic approach to workforce training for doctors, nurses and other health providers.</p><img src="https://counter.theconversation.com/content/18899/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Don Campbell is a General Physician and Director of General Medicine at Monash Health. </span></em></p>New medical technologies and treatments over the past few decades have led to remarkable improvements in treating older patients. The annual death rate for an 80-year-old male in 2011 was just 5.6%, compared…Don Campbell, Professor of Medicine, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/151672013-12-12T19:43:48Z2013-12-12T19:43:48ZTrust me, I’m a doctor… of sorts<figure><img src="https://images.theconversation.com/files/37395/original/r5444fkz-1386723155.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It seems anyone can call themselves a doctor these days.</span> <span class="attribution"><span class="source">Bart/Flickr</span></span></figcaption></figure><p>Qualifications and their associated titles allow for quick identification of appropriately trained or recognised experts within a given field. They bestow legitimacy on the information provided to people looking for expert advice. </p>
<p>But how does the average person decide who to reasonably trust when it seems anyone can call themselves a doctor?</p>
<p>Traditionally, the title doctor was reserved for medical doctors, or scholars who’d completed postgraduate training to a doctoral level, and were recognised by their peers as an expert in their field. </p>
<p>Indeed, a number of dictionary definitions appear to support these two categories.</p>
<h2>Free for all</h2>
<p>But doctor creepage has been hastening with extraordinary stealth over the last few years, particularly within health care. </p>
<p>I can clearly remember assuming as an adolescent that chiropractors were doctors who specialised in a particular medical domain (back care) because the title Dr preceded their name.</p>
<p>It wasn’t until much later that I realised that Dr Chiropractor or Dr Osteopath or Dr Vet were all equally deceptive for implying that people using the title are either medical doctors, or substantially more qualified than an undergraduate degree. </p>
<p>To be fair, most medical doctors also have an undergraduate degree, but that involves six or seven years of tertiary training, similar to that undertaken in total by a doctor of philosophy degree.</p>
<p>And I’m not suggesting that members of the aforementioned professions haven’t undergone university training suited to their practice (I’ll come to that substantially more serious problem later), but there appears to be no legal impediment to a number of bachelor degree graduates using the title doctor. </p>
<p>In fact, I couldn’t easily find the answer to the question of whether there’s any legal reason why plumbers, hairdressers or retired beekeepers can’t use the title! </p>
<p>Surely this situation is confusing because most people would assume a particular type of training (medical), or level of training (recognised expert in their field) goes hand-in-hand with this title.</p>
<h2>Training and expertise</h2>
<p>But there’s an even more serious related problem here, and that involves the questionable practice of representing certain kinds of “tertiary training” as comparable to university-level qualifications. </p>
<p>This practice is also becoming increasingly rampant in the health-care field. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/37396/original/c8qwr9h7-1386723508.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/37396/original/c8qwr9h7-1386723508.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=470&fit=crop&dpr=1 600w, https://images.theconversation.com/files/37396/original/c8qwr9h7-1386723508.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=470&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/37396/original/c8qwr9h7-1386723508.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=470&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/37396/original/c8qwr9h7-1386723508.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=591&fit=crop&dpr=1 754w, https://images.theconversation.com/files/37396/original/c8qwr9h7-1386723508.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=591&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/37396/original/c8qwr9h7-1386723508.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=591&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Representing certain kinds of ‘tertiary training’ as comparable to university-level qualifications has become rampant in health care.</span>
<span class="attribution"><span class="source">Truthout.org/Flickr</span></span>
</figcaption>
</figure>
<p>I was intrigued recently by a workshop reported by the press as being run by a “world renowned expert” allegedly “recognised as one of the foremost experts in the biochemistry of ADHD and ASD” (attention deficit hyperactivity disorder and autism spectrum disorders).</p>
<p>I wanted to discover more about this presenter, whose name was followed by the letters CNC. </p>
<p>After consulting the individual’s website, I discovered that CNC stood for Certified Nutrition Consultant, a qualification I had not previously heard. </p>
<p>And here’s a tip from that experience for punters: if you type the name of a qualification into Google, and the first site in the list is <a href="http://www.quackwatch.com/">Quackwatch</a>, you’re probably justified in being suspicions about the validity of that certification. </p>
<p>In this case, I was unable to find any mention that the person in question had engaged in any university-level education whatsoever. Although, to be fair, perhaps she has but chooses not to clearly advertise her education on her website. </p>
<p>While this particular CNC-qualified expert has written a couple of books and frequently appeared in the media, I couldn’t find any trace of her authoring a published study, review, or even having presented a basic scientific overview of her “research” in any kind of peer-reviewed journal. </p>
<p>When I tried to find out how one obtains registration as a CNC, I eventually found myself at its supposed credentialing website, which appeared to have some sort of requirement for tertiary training, but not necessarily at university-level.</p>
<h2>Are you qualified?</h2>
<p>This brings me to my final point: a number of qualifications in complementary medicine cannot be obtained from a public university because, quite frankly, these institutions won’t touch them.* </p>
<p>Indeed, training in a number of alternative health domains is not even vaguely scientific or evidence-based, despite the pretence of being so. This has led to a variety of colleges popping up offering all sorts of questionable “qualifications”. </p>
<p>Now, I’m not suggesting that there’s anything wrong with people seeking alternative health options. But I dare say there’s very deliberate confusion being created by credentialing practices by these colleges, that attempt to mimic traditional markers of university-level training or expertise, presumably for personal or professional gain. </p>
<p>For those seeking a specific type or level of recognised expertise, the inflation of qualifications via the appropriation of the title Dr is at best unhelpful, and, at worst, deliberately disingenuous. </p>
<p>And those seeking a particular basis of advice (alternative versus scientific, for instance) have the unhappy task of navigating a conflation of scientific and alternative health qualifications from questionable tertiary training colleges. </p>
<p>Apart from the confusion this creates, it suggests level of insecurity among some health-care practitioners who may be attempting to establish their legitimacy through stealth and deceit. </p>
<p><em>* This article has been edited to remove an incorrect claim that Australian public universities do not offer bachelor’s degrees in naturopathy. Students can undertake a three-year <a href="http://scu.edu.au/coursesin2014/?action=matrix&command=matrix_temp_load&spk_no=301766">Bachelor in Clinical Sciences at Southern Cross University</a> with a double major in naturopathy and complementary medicine. There is also a three-year <a href="http://handbook.uws.edu.au/HBOOK/course.aspx?course=4597.2">Bachelor of Applied Science in naturopathic studies at the University of Western Sydney</a>.</em></p><img src="https://counter.theconversation.com/content/15167/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachael Sharman 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>Qualifications and their associated titles allow for quick identification of appropriately trained or recognised experts within a given field. They bestow legitimacy on the information provided to people…Rachael Sharman, Lecturer in Psychology, University of the Sunshine CoastLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/175062013-09-04T04:56:44Z2013-09-04T04:56:44ZWhy the next government must reform medical training<figure><img src="https://images.theconversation.com/files/30642/original/kwv3hsf6-1378257256.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The number of doctors in major cities is ballooning, but we need are more doctors in rural areas.</span> <span class="attribution"><span class="source">becky bokern</span></span></figcaption></figure><p>Health care is a tough nut for governments because it’s the largest source of <a href="https://theconversation.com/tough-choices-how-to-rein-in-australias-rising-health-bill-13658">growth</a> in government spending. Salary costs are the major part of this cost so workforce policy decisions have profound implications for health-care access and affordability. </p>
<p>Recent governments have made big policy decisions about medical training, but we still need to ensure we get results that resolve the problems we face. The next government needs to act on this quickly.</p>
<p>How we conduct medical training demands urgent action because, since 2000, Australia has trebled medical school intakes and boosted the importation of overseas trained doctors. </p>
<p>That’s because we were short of doctors, right? Wrong!</p>
<h2>The real issue</h2>
<p>Among high-income countries, Australia has an above-average number of doctors for its population, as you can see below; at 3.3 per 1,000, this is many more than comparable English-speaking nations.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/30443/original/j39v9zxq-1378063865.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/30443/original/j39v9zxq-1378063865.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=478&fit=crop&dpr=1 600w, https://images.theconversation.com/files/30443/original/j39v9zxq-1378063865.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=478&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/30443/original/j39v9zxq-1378063865.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=478&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/30443/original/j39v9zxq-1378063865.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=601&fit=crop&dpr=1 754w, https://images.theconversation.com/files/30443/original/j39v9zxq-1378063865.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=601&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/30443/original/j39v9zxq-1378063865.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=601&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Doctor numbers across comparable countries.</span>
</figcaption>
</figure>
<p>The real challenge is the concentration of doctors in big cities. And the imbalance between the number of doctors who provide a narrow scope of “sub-specialist” care (often jobs that are more lucrative and lifestyle-friendly) than roles providing a more comprehensive scope of clinical care. </p>
<p>As the graph below shows, maldistribution pretty much explains the real shortage of doctors in rural areas as well as in outer suburbs and generalist clinical roles. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/30309/original/dtbncyyh-1377836613.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/30309/original/dtbncyyh-1377836613.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=547&fit=crop&dpr=1 600w, https://images.theconversation.com/files/30309/original/dtbncyyh-1377836613.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=547&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/30309/original/dtbncyyh-1377836613.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=547&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/30309/original/dtbncyyh-1377836613.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=688&fit=crop&dpr=1 754w, https://images.theconversation.com/files/30309/original/dtbncyyh-1377836613.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=688&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/30309/original/dtbncyyh-1377836613.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=688&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>In spite of incentives and programs to address this maldistribution, the number of doctors in major cities is ballooning, particularly specialist consultants. A <a href="http://www.aihw.gov.au/publication-detail/?id=60129542627">net number of 11,577 clinical doctors</a> were added to major cities between 2007 and 2011 – three-quarters of the national growth for two-thirds of the population. </p>
<p>Only one in ten of these were general practitioners or GPs-in-training; the rest were consultant specialists and other hospital doctors. </p>
<p>The bush has seen growth too - but a good portion of this was due to vacancies being filled by overseas-trained doctors. Governments made this happen by providing working visas and bans on Medicare billing that restrict them to working in areas of need.</p>
<h2>Shifting the focus</h2>
<p>Clearly, we need to <a href="https://www.mja.com.au/journal/2012/197/5/do-available-predictions-future-medical-workforce-requirements-provide-sensible-0">shift the focus</a> of medical workforce planning from numbers to better use expensive medical labour.</p>
<p>After graduation from medical school, doctors pursue further training in one of the medical specialities, including general practice. In order to get doctors working in the communities and roles where they are most needed, they should be trained in those locations and specialities. </p>
<p>Efficient use of expensive medical labour is important too – this means efficient and flexible models of team-based care with nurses, allied health workers, extenders and assistants. </p>
<p>With money increasingly tight, we simply cannot afford to feed the apparently insatiable appetite for sub-speciality medicine in major cities, nor the expense of narrow disease-focused care that it leads to. </p>
<p>This arrangement of medical care is actually not good for patients either. Anyone with a loved one who lives with chronic and complex health conditions knows that health care that’s delivered organ by organ is not good for health, suffering or human dignity – let alone the bank balance.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/30647/original/d7g7hjrk-1378257591.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/30647/original/d7g7hjrk-1378257591.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/30647/original/d7g7hjrk-1378257591.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/30647/original/d7g7hjrk-1378257591.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/30647/original/d7g7hjrk-1378257591.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/30647/original/d7g7hjrk-1378257591.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/30647/original/d7g7hjrk-1378257591.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Providing training for doctors in regional areas has been identified as a key health workforce investment.</span>
<span class="attribution"><span class="source">Moyan Brenn</span></span>
</figcaption>
</figure>
<p>This is why the Commonwealth government’s <a href="http://www.health.gov.au/internet/publications/publishing.nsf/Content/work-review-australian-government-health-workforce-programs-toc%7Echapter-4-addressing-health-workforce-shortages-regional-rural-remote-australia%7Echapter-4-health-education-strategies-rural-distribution">recent review of health workforce programs</a> considered generalism in clinical care and regionally-based training as key health workforce investments.</p>
<h2>Moving in the general(ist) direction</h2>
<p>National reforms toward a regionally-managed health system, transparent funding streams, more flexibility in public-private arrangements and regionally-organised primary care are now well underway. It’s time to add medical workforce reform to the mix. </p>
<p>We have already invested in developing rural and regional health workforce training capacity through university departments of rural health, rural clinical schools and regional university medical, nursing and other health professional schools. This infrastructure can be used to support expanded regional training pipelines for medical specialities. </p>
<p>Rural generalists – country GPs who can provide primary care in the community as well as hospital, emergency, population health and extended speciality service – have always had a central role in the bush and <a href="http://www.aph.gov.au/Parliamentary_business/Committees/Senate_Committees?url=clac_ctte/completed_inquiries/2010-13/rur_hlth/report/report.pdf">their numbers should be bolstered</a>. There’s scope to expand their effective and value-for-money roles into cities. </p>
<p>In emphasising the role of the generalist, we must re-assert the effective and judicious use of the medical consultant – the specialist doctor with focused expertise for the rare or tricky problems. E-health and <a href="http://www.ehealth.acrrm.org.au/">collaborative tele-health solutions</a> provide us with great tools to do this in new, technologically-savvy ways. </p>
<p>With the surge of medical graduates on its way, it’s time for action. If these people are trained in sub-speciality medicine in big-city teaching hospitals, the unprecedented taxpayer investment in this medical workforce “solution” might yet sink the health system financially - and exacerbate the doctor drought in the bush!</p><img src="https://counter.theconversation.com/content/17506/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Murray works for James Cook University and is also President of the Australian College of Rural and Remote Medicine. He has received funding from Health Workforce Australia and other agencies for health workforce and health services research. He is a member of the Mackay Hospital and Health Service Board.</span></em></p>Health care is a tough nut for governments because it’s the largest source of growth in government spending. Salary costs are the major part of this cost so workforce policy decisions have profound implications…Richard Murray, Dean of Medicine & Dentistry, James Cook UniversityLicensed as Creative Commons – attribution, no derivatives.