tag:theconversation.com,2011:/us/topics/surgeons-17270/articlesSurgeons – The Conversation2023-03-21T19:11:55Ztag:theconversation.com,2011:article/2021362023-03-21T19:11:55Z2023-03-21T19:11:55ZDoctors may soon get official ‘endorsements’ to practise cosmetic surgery – but will that protect patients?<figure><img src="https://images.theconversation.com/files/516551/original/file-20230321-16-ypoa6u.jpg?ixlib=rb-1.1.0&rect=15%2C117%2C3537%2C3186&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1551601651-09492b5468b6?ixlib=rb-4.0.3&ixid=MnwxMjA3fDB8MHxwaG90by1wYWdlfHx8fGVufDB8fHx8&auto=format&fit=crop&w=1213&q=80">Unsplash/Olga Guryanova</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Disturbing reports about botched cosmetic surgeries and injuries in Australia – from breast augmentations causing chronic pain to liposuction leaving patients with lifelong injuries – have <a href="https://pubmed.ncbi.nlm.nih.gov/35338692/">sparked concerns in recent years</a>. Several high-profile cosmetic surgeons alleged to have fallen short of expected professional standards have been <a href="https://www.medicalboard.gov.au/News/2022-09-01-Ahpra-MBA-CSR-reply.aspx">disciplined</a>. </p>
<p>Last year, <a href="https://www.supremecourt.vic.gov.au/sites/default/files/2022-08/Group%20Proceeding%20Summary%20Statement%20%289%20March%202022%29.pdf">a class action</a> was commenced against one clinic in the Victorian Supreme Court.</p>
<p>People who are interested in exploring whether cosmetic surgery is appropriate for them are right to feel wary and confused. Now, the introduction of a scheme to officially endorse doctors who practise in the area of cosmetic surgery promises to allay patients’ doubts. But the idea <a href="https://www.smh.com.au/politics/federal/legitimises-the-activities-of-unscrupulous-operators-cosmetic-surgery-safety-fears-20230313-p5crnq.html">remains contentious</a> for those in the field.</p>
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Read more:
<a href="https://theconversation.com/thinking-about-cosmetic-surgery-at-last-some-clarity-on-who-can-call-themselves-a-surgeon-196947">Thinking about cosmetic surgery? At last, some clarity on who can call themselves a surgeon</a>
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<h2>The story so far</h2>
<p>In the wake of cosmetic surgery controversies, two significant but separate responses have been adopted by medical regulators. First, the country’s health ministers began a <a href="https://pubmed.ncbi.nlm.nih.gov/35338692/">consultation</a> to decide whether to stop doctors promoting themselves as “surgeons”.</p>
<p>The consultation acknowledged a gap or “loophole” that allows any registered medical practitioner to call themselves a surgeon in Australia, even with <a href="https://www.sydney.edu.au/news-opinion/news/2016/05/12/call-yourself-a-cosmetic-surgeon--new-guidelines-fix-only-half-t.html">no specialist training</a> beyond their medical degree.</p>
<p>The second response was initiated in December 2021, by AHPRA, which accredits and registers doctors, and the Medical Board of Australia, which regulates the practices of registered medical practitioners. Together, they commissioned an <a href="https://www.ahpra.gov.au/Resources/Cosmetic-surgery-hub/Cosmetic-surgery-review.aspx">independent review</a> into the regulation of medical practitioners who perform cosmetic surgery in Australia. </p>
<p>Although informed by each other, these separate initiatives wrought distinct solutions. While one has been embraced, the other remains controversial.</p>
<h2>Ministerial reforms</h2>
<p>After nearly two years of consultation, the health ministers decided <a href="https://www.health.gov.au/sites/default/files/2022-12/health-ministers-meeting-communique-14-december-2022_0.pdf">last December</a> to restrict the use of the title “surgeon”. Soon, only medical practitioners holding a specialist registration, such as ophthalmology, will be permitted to use the title.</p>
<p>In a meeting late last month, health ministers approved <a href="https://www.health.gov.au/sites/default/files/2023-02/health-ministers-meeting-communique-24-february-2023.pdf">a draft bill</a> to give effect to this decision. While the draft remains unpublished, no stakeholders in the health sector appear to have criticised the change. </p>
<p>But the health ministers approved another, more controversial, reform as well. They welcomed a new model of accrediting cosmetic surgery practitioners known as an “endorsement of registration”. This proposal came from the AHPRA and Medical Board review.</p>
<h2>AHPRA and the Medical Board’s ‘endorsement model’</h2>
<p>Among its 16 recommendations (all of them accepted by AHPRA and the Medical Board), <a href="https://theabic.org.au/storage/app/media/BLOG/Ahpra---Report---Cosmetic-surgery-independent-review---Final-report---August-2022.pdf">the independent review’s</a> first and most significant reform proposal was to establish an “area of practice endorsement” for cosmetic surgery. </p>
<p>The technical language of “<a href="https://www.legislation.qld.gov.au/view/html/inforce/current/act-2009-hprnlq#sec.98">endorsement</a>” comes from <a href="https://www.ahpra.gov.au/About-Ahpra/What-We-Do/Legislation.aspx">consistent national laws</a> enacted, with minor variations, in each state and territory.</p>
<p>In a nutshell, “area of practice endorsement” would introduce new minimum standards for the education, training and qualification of Australian medical practitioners seeking to practise as cosmetic surgeons. </p>
<p>Currently, the Medical Board uses <a href="https://www.medicalboard.gov.au/codes-guidelines-policies/code-of-conduct.aspx">codes of conduct</a> and <a href="https://www.medicalboard.gov.au/Codes-Guidelines-Policies/Advertising-a-regulated-health-service/Guidelines-for-advertising-regulated-health-services.aspx">guidelines</a> to regulate most doctors’ practices. </p>
<p>But these “soft law” instruments permit doctors to decide for themselves whether they are competent enough to perform procedures like brow lifts or tummy tucks.</p>
<p>The new endorsement model would require doctors to apply to the Medical Board to qualify to practice in the area of cosmetic surgery. To be approved, the doctor-applicant would need to furnish evidence of their qualifications. Such an endorsement arrangement already exists for <a href="https://legislation.nsw.gov.au/view/whole/html/inforce/current/act-2009-86a#pt.7-div.8-sdiv.4">acupuncture</a>.</p>
<p>Together with restricting the title “surgeon” and some other reforms (such as improved information campaigns), it is now hoped the endorsement model would manage risky cosmetic surgeries by requiring practitioners to be endorsed by the Medical Board. But not everyone thinks it’s the way to go. </p>
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Read more:
<a href="https://theconversation.com/whos-the-best-doctor-for-a-tummy-tuck-or-eyelid-surgery-the-latest-review-doesnt-actually-say-189700">Who's the best doctor for a tummy tuck or eyelid surgery? The latest review doesn't actually say</a>
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<h2>What’s the problem with endorsement?</h2>
<p>Fresh forms of old tensions have arisen, based on how endorsement will be designed. At the core of these tensions is a debate about how the Australian Medical Council, which is responsible for setting the accreditation, training and education standards for the medical profession, will determine the curriculum and assessment regimes for cosmetic surgery study programs. </p>
<p>What was once a debate about an unregulated area of practice is now about what kind of training cosmetic surgeons should have before wielding their instruments.</p>
<p>Some experts suggest <a href="https://researchnow-admin.flinders.edu.au/ws/portalfiles/portal/21121551/Dean_Defining_P2018.pdf">defining cosmetic surgery</a> could help regulation and safety discussions. Meanwhile, the Royal Australasian College of Surgeons says it will <a href="https://www.surgeons.org/-/media/Project/RACS/surgeons-org/files/advocacy/20221212-Consultation-cosmetic-surgery-registration-standards.pdf?rev=a997d89161cf4abc8c7b405f1e7a5ccb&hash=F4DFEE1BC200732360B2976ACE6E1D4F">oppose</a> any study program of a lesser standard than that required of specialist surgeons. </p>
<p>Although the Australian Medical Council has not yet published its education standards for cosmetic surgery, it has proposed <a href="https://www.amc.org.au/wp-content/uploads/2023/01/Attachment-B-Draft-Accreditation-standards-for-cosmetic-surgery-programs.pdf">six draft qualification standards</a> and is consulting with the profession. </p>
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<h2>What this could mean for patient safety</h2>
<p>On the one hand, the proposed changes are a continuation of a long-running turf war. On one side are the surgeons with special accreditation, approved by the Royal Australasian College of Surgeons and typically engaged in reconstructive plastic surgeries. On the other, stand the so-called “non-surgeons” or “<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8795651/">wannabees</a>”.</p>
<p>The debate is also about protecting patients and <a href="https://www.legislation.qld.gov.au/view/html/asmade/act-2022-022#ch.3-pt.2">legislative reform</a>. </p>
<p>It is too early to determine whether the Australian Medical Council’s endorsement standards will improve patient safety. But the slow process of reforming the cosmetic surgery “industry” – in the face of explosive increases in demand, fuelled in part by <a href="https://doi.org/10.1177/07488068221105360">seductive social media claims</a> – illustrates how complex medical regulation is in Australia. With so many regulatory actors involved in our <a href="https://eprints.qut.edu.au/127800/">polycentric system</a>, feuds over governance are unsurprising. </p>
<p>Today, the cosmetic surgery industry is estimated to be worth <a href="https://www.afr.com/life-and-luxury/health-and-wellness/cosmetic-surgery-boom-is-new-face-of-covid-19-20200821-p55o0u">more than one billion dollars a year</a>. It is crucial regulators ensure the public is protected from unscrupulous – or unqualified – operators.</p><img src="https://counter.theconversation.com/content/202136/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Rudge was previously a researcher at the Medical Council of New South Wales. He is a chief invstigator on a project concerning patient decision-making about stem cell treatments funded by the Australian government's Medical Research Future Fund.</span></em></p>A new proposal is reigniting an old debate about cosmetic surgery. Now it’s focused on what kind of training cosmetic surgeons should have before wielding their instruments.Christopher Rudge, Law lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1969472023-01-15T19:00:35Z2023-01-15T19:00:35ZThinking about cosmetic surgery? At last, some clarity on who can call themselves a surgeon<figure><img src="https://images.theconversation.com/files/504385/original/file-20230113-26-qrp3n5.jpg?ixlib=rb-1.1.0&rect=2%2C0%2C1914%2C1279&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/two-person-doing-surgery-inside-room-1250655/">Vidal Balielo Jr/Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>When is a surgeon not a surgeon? It’s a riddle that’s long puzzled regulators and consumers. But it may soon be solved. </p>
<p>State and territory health ministers have <a href="https://www.health.gov.au/sites/default/files/2022-12/health-ministers-meeting-communique-14-december-2022.pdf">decided to restrict</a> the title “surgeon” to specialist doctors. The move represents a significant change in Australian medical regulation.</p>
<p>So, if you’re thinking of having cosmetic surgery in 2023 (or beyond), these reforms might help you choose the right health professional.</p>
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Read more:
<a href="https://theconversation.com/linda-evangelista-says-fat-freezing-made-her-a-recluse-cryolipolysis-can-do-the-opposite-to-whats-promised-168657">Linda Evangelista says fat freezing made her a recluse. Cryolipolysis can do the opposite to what's promised</a>
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<h2>What’s the problem?</h2>
<p>For as long as cosmetic enhancements have been offered in Australia, there have been no rules about which medical practitioners can call themselves cosmetic surgeons. </p>
<p>Consequently, any registered medical practitioner may call themselves a cosmetic surgeon in Australia, even though other specialist titles are <a href="https://legislation.nsw.gov.au/view/whole/html/inforce/current/act-2009-86a#sec.115">protected</a> <a href="https://legislation.nsw.gov.au/view/whole/html/inforce/current/act-2009-86a#pt.7-div.10">under legislation</a>. </p>
<p>A “plastic surgeon”, for instance, needs to have completed postgraduate training in surgery certified by the Australian Medical Council and Medical Board of Australia. In doing so, they attain the Australian equivalent of “board certification”, a term you might be familiar with from American TV shows, such as <a href="https://www.usanetwork.com/botched">Botched</a>. </p>
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Read more:
<a href="https://theconversation.com/whos-the-best-doctor-for-a-tummy-tuck-or-eyelid-surgery-the-latest-review-doesnt-actually-say-189700">Who's the best doctor for a tummy tuck or eyelid surgery? The latest review doesn't actually say</a>
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<h2>How did we get here?</h2>
<p>Arguments about who should be allowed call themselves a cosmetic surgeon have persisted for more than 20 years.</p>
<p>In 1999, the New South Wales Health Care Complaints Commission detailed the risks and dangers of the lack of restrictions in its <a href="https://www.hccc.nsw.gov.au/ArticleDocuments/158/Cosm%20report.pdf">Cosmetic Surgery Report</a>.</p>
<p>The report recommended all medical practitioners who performed invasive surgery as surgeons be trained to the standard required of <a href="https://www.surgeons.org/Resources/reports-guidelines-publications/useful-guides-standards/RACS-Professional-Skills-Curriculum">Fellows of the Royal Australasian College of Surgeons</a>.</p>
<p>These reforms have never been adopted, partly due to resistance from some doctors. These doctors <a href="https://engage.vic.gov.au/download/document/21586">have argued</a> they are entitled to call themselves surgeons because they hold the traditional medical degree, called the Bachelor of Medicine/Bachelor of Surgery (MBBS). Despite its name, the degree provides only rudimentary surgical training.</p>
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<a href="https://images.theconversation.com/files/502501/original/file-20221222-26-mx1fnh.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C664&q=45&auto=format&w=1000&fit=clip"><img alt="Surgeon with scalpel performing cosmetic surgery to face" src="https://images.theconversation.com/files/502501/original/file-20221222-26-mx1fnh.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C664&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/502501/original/file-20221222-26-mx1fnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/502501/original/file-20221222-26-mx1fnh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/502501/original/file-20221222-26-mx1fnh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/502501/original/file-20221222-26-mx1fnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/502501/original/file-20221222-26-mx1fnh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/502501/original/file-20221222-26-mx1fnh.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"></a>
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<span class="caption">Who can call themselves a surgeon? It’s been a long-standing debate.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/operation-on-eye-cataract-surgery-1351111802">Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/friday-essay-the-ugly-history-of-cosmetic-surgery-56500">Friday essay: the ugly history of cosmetic surgery</a>
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<h2>What’s happened since?</h2>
<p>The number of cosmetic surgery procedures has <a href="https://www.plasticsurgery.org/documents/News/Statistics/2020/cosmetic-procedure-trends-2020.pdf">increased</a> over the past 20 years. </p>
<p>Social media continues to popularise treatments, such as <a href="https://www.theguardian.com/lifeandstyle/2022/dec/30/buccal-fat-why-cosmetic-surgeons-are-removing-this-unassuming-body-part">buccal (cheek) fat removal</a> and the <a href="https://plasticsurgery.org.au/procedures/surgical-procedures/buttocks-lift/">Brazilian butt lift</a>. Many of these surgeries expose the patient to significant risks of harm.</p>
<p>Allegations of unsafe surgeons dubbed “<a href="https://pubmed.ncbi.nlm.nih.gov/35338692/">cosmetic cowboys</a>” have surfaced in the media. And the range and seriousness of complaints about unsafe cosmetic treatments (some leading to <a href="https://www.parliament.nsw.gov.au/ladocs/inquiries/2476/Final%20Report%20-%20Cosmetic%20Health%20Service%20Complaints%20in%20New%20South%20Wales.PDF">fatal outcomes</a>) have been of increasing concern to governments and regulators. </p>
<p>In 2018, these concerns triggered a <a href="https://www.parliament.nsw.gov.au/committees/inquiries/Pages/inquiry-details.aspx?pk=2476">NSW parliamentary inquiry</a> and led to a new <a href="https://www.hccc.nsw.gov.au/Health-Providers/Health-Organisations/code-of-conduct">code of conduct for health organisations</a>, which came into effect last September.</p>
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Read more:
<a href="https://theconversation.com/what-do-normal-labia-look-like-sometimes-doctors-are-the-wrong-people-to-ask-112513">What do normal labia look like? Sometimes doctors are the wrong people to ask</a>
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<p>The <a href="https://www.ahpra.gov.au">Australian Health Practitioner Regulation Agency</a> (AHPRA) has also recently taken action. Some of the doctors mentioned in media coverage have had their medical practice <a href="https://www.ahpra.gov.au/News/2022-09-01-Ahpra-MBA-CSR-reply.aspx">restricted or have been suspended</a> from practice altogether. </p>
<p>AHPRA has also formulated (but not finalised) an endorsement system to set new standards for <a href="https://www.ahpra.gov.au/Resources/Cosmetic-surgery-hub/About-endorsement.aspx">cosmetic surgeons</a>. It’s also established a cosmetic surgery enforcement unit to <a href="https://www.ahpra.gov.au/News/2022-09-02-support-for-cosmetic-reform.aspx">enhance complaints and investigations</a> through a cosmetic surgery <a href="https://www.ahpra.gov.au/News/2022-09-05-cosmetic-hotline.aspx">complaints hotline</a>.</p>
<p>However, some have <a href="https://www.smh.com.au/national/this-solution-for-cosmetic-surgery-rogues-fails-patients-20220831-p5be6g.html">criticised these changes</a> <a href="https://aestheticplasticsurgeons.org.au/asaps_media_release/ahpra-confirms-national-law-will-now-protect-the-title-surgeon/">as</a> <a href="https://www.watoday.com.au/politics/federal/regulator-announces-cosmetic-surgery-crackdown-but-won-t-hit-pause-on-1-4bn-industry-20220831-p5be4t.html?ref=rss&utm_medium=rss&utm_source=rss_feed">inadequate</a>.</p>
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Read more:
<a href="https://theconversation.com/who-is-our-health-regulator-ahpra-and-does-it-operate-effectively-101966">Who is our health regulator, AHPRA, and does it operate effectively?</a>
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<h2>What happens now?</h2>
<p>In December last year and after <a href="https://engage.vic.gov.au/medical-practitioners-use-title-surgeon-under-national-law">public consultation</a>, Australian health ministers decided to implement legislation that restricts the title of “surgeon”.</p>
<p>The <a href="https://oia.pmc.gov.au/published-impact-analyses-and-reports/medical-practitioners-use-title-surgeon-under-national-law-0">consultation report</a> warned that doctors’ continuing use of the title “cosmetic surgeon” might not just diminish public confidence, but chafe against recent <a href="https://www.parliament.qld.gov.au/Work-of-Committees/Committees/Committee-Details?cid=0&id=4162">updates to the health practitioner law</a> intended to make health regulators, such as AHPRA, put consumer protection first.</p>
<p>Soon, these legal amendments will restrict the title “surgeon” to doctors holding “specialist registrations” in surgery, obstetrics and gynaecology, or ophthalmology.</p>
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Read more:
<a href="https://theconversation.com/health-check-why-can-you-feel-groggy-days-after-an-operation-74989">Health Check: why can you feel groggy days after an operation?</a>
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<h2>What does this mean for doctors and consumers?</h2>
<p>Although the new law is yet to be drafted, the impact of the change may be significant – for doctors and consumers alike. </p>
<p>Some doctors who have long promoted themselves as surgeons will be prevented from doing so, with disciplinary action or even prosecution on the cards should they continue to call themselves surgeons.</p>
<p>For consumers, the longstanding riddle about who is a “real” surgeon may soon be a little clearer.</p>
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<a href="https://images.theconversation.com/files/504384/original/file-20230113-26-xaug0q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Patient and doctor talking across desk" src="https://images.theconversation.com/files/504384/original/file-20230113-26-xaug0q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/504384/original/file-20230113-26-xaug0q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/504384/original/file-20230113-26-xaug0q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/504384/original/file-20230113-26-xaug0q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/504384/original/file-20230113-26-xaug0q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/504384/original/file-20230113-26-xaug0q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/504384/original/file-20230113-26-xaug0q.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"></a>
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<span class="caption">Consumers may soon have more information to help them choose the right doctor for their surgery.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-patient-discussing-something-just-hands-613484831">Shutterstock</a></span>
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<h2>Will this fix things?</h2>
<p>Will this completely solve the problem of increased complaints and injuries in cosmetic surgery? That’s unlikely. </p>
<p>It still remains unclear how AHPRA’s <a href="https://www.ahpra.gov.au/News/2022-09-01-Ahpra-MBA-CSR-reply.aspx">new approach</a> will interact with the new restricted title, or how demanding the new <a href="https://www.amc.org.au/cosmetic-surgery/">accreditation standards</a> for endorsed cosmetic surgeons will be.</p>
<p>In the meantime, it’s still important for consumers to inform themselves about the skills and training of their chosen practitioner. They can check the doctor’s <a href="https://www.hccc.nsw.gov.au/Hearings-decisions/Cancelled-or-Suspended-Health-Practitioners">AHPRA registration</a> and identify whether they’re a member of any relevant society, such as the <a href="https://plasticsurgery.org.au/information-for-patients/is-your-surgeon-an-asps-member/">Australian Society of Plastic Surgeons</a>. </p>
<p>Having said that, the forthcoming changes to the meaning of the phrase “cosmetic surgeon” promises to make that homework just a little simpler.</p><img src="https://counter.theconversation.com/content/196947/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Rudge was formerly a legal research associate at the Medical Council of New South Wales.</span></em></p><p class="fine-print"><em><span>Cameron Stewart 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>State and territory health ministers have decided to restrict the title ‘surgeon’ to specially trained doctors. It’s a significant change for consumers and doctors.Christopher Rudge, Law lecturer, University of SydneyCameron Stewart, Professor at Sydney Law School, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1677842021-09-13T20:05:56Z2021-09-13T20:05:56ZWATCH: Our mobile phones are covered in bacteria and viruses… and we never wash them<figure><img src="https://images.theconversation.com/files/420662/original/file-20210913-27-tdm4lw.png?ixlib=rb-1.1.0&rect=25%2C0%2C2762%2C1573&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Wes Mountain/The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p><em>COVID-19 has seen the world embrace sanitisers and formal hand washing procedures in our private lives like never before. But even as we’ve thought more and more about surfaces and the hands that touch them as vectors for disease, mobile phones have largely escaped scrutiny.</em></p>
<p><em>We carry them everywhere (including the toilet) but they’re rarely cleaned or sanitised, and we touch them with our hands many, many times per day.</em></p>
<p><em>Lotti Tajouri explains what his research team found when they surveyed hospital staff about their phone use, the bacteria, viruses and parasites they found on swabbed phones, and the very personal reason he began this research.</em></p>
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<p><strong>Transcript:</strong></p>
<p>My name is Dr Lotti Tajouri, associate professor in molecular biology and genomics in health science medicine at Bond University. I’m also a member of the Dubai Future Council for Community Security and the Dubai Police Scientist Research Committee. </p>
<p>The first time I actually got an interest in mobile phones as contaminated platforms was associated with my wife’s pregnancy. We came up to a situation where there was an emergency: my little girl was in breech while my wife was pregnant. </p>
<p>And we had to go very quickly to the theatre. </p>
<p>And what happened is when there was this preparation for the caesarean, I actually saw that there were some health care workers walking around with their mobile phones. </p>
<p>And really with the stress of the situation and knowing that I’m actually understanding clearly what is microbiology. I was really saying, “oh, there is a red flag here with some individuals, right there in the theatre, where there was my little girl about to be born”. Something was kind of wrong. </p>
<p>And of course, it’s nothing to blame the health care workers for, or how they do their job. The issue was that they don’t really know that mobile phones are actually contaminated with microbes. </p>
<p>So that was the very first time where I said to myself, “oh, I think I really need to do something about it”. </p>
<p>We did <a href="https://www.nature.com/articles/s41598-021-92360-3">a survey within the hospital</a> and we actually surveyed 165 health care workers, including doctors and nurses. </p>
<p>And we found something very interesting. </p>
<p>First of all, 98% of all those health care workers admitted that probably, indeed, their mobile phones are contaminated. </p>
<p>They are aware of that. </p>
<p>The other thing which was very interesting is their behaviour around mobile phones. </p>
<p>52% of them, out of 165 individuals used mobile phones in the bathroom and they used that for different reasons for media, social media, etc. </p>
<p>And the other very interesting statistic is that 57% of them never, ever washed their mobile phones. </p>
<p>We have also <a href="https://www.sciencedirect.com/science/article/pii/S1477893921001368">undertaken a massive amount of swabs of mobile phones</a>. </p>
<p>And then what we wanted to do is, first of all, demonstrate that the microbes that are on the surface of mobile phones coming from health care workers, and if those microbes were viable or not. </p>
<p>After swabbing the mobile phones, we took around 30 mobile phones and we cultured them in different types of petri dishes. </p>
<p>It was very impressive. </p>
<p>If you look at the pictures that come up from those particular petri dishes, you see a huge amount of colonies coming out of it. </p>
<p>We found all sorts of types of bacteria: we found e.coli, demonstrating faecal contamination, we found <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273324/">pseudomonas aeruginosa</a> (which is extremely resistant to different types of antibiotics), we found salmonella. We found listeria. </p>
<p>Even very, very interestingly, we found parasites, protozoa. One of them was, for example, <a href="https://www2.health.vic.gov.au/public-health/infectious-diseases/disease-information-advice/amoebiasis">entamoeba histolytica</a>. </p>
<p>So those mobile phones are platforms that accommodate a huge panel, a huge spectrum of microorganisms that interact with each other and they are viable. </p>
<p>We started the video with me, for example, working in my office and holding the mobile phone and simulating a cough. </p>
<p>And with that cough, obviously, we deposited droplets on the surface of the mobile phone. </p>
<p>And then because we tend to text or touch our mobile phones, what would happen is that I would then obviously touch my keyboard, and do my whereabouts for my work, take a phone call or take a glass of water, etc. </p>
<p>And then after that, I decided, of course, to get out of my office and go, for example, to a kitchen. </p>
<p>And you will understand that because I touched my filthy mobile phone, I had actually the microbes on my hands. </p>
<p>And then when I went to the kitchen, and eat, and use whatever device I wanted to use, for example, the coffee machine. Well, the same again, you could see that spread going on again and again and disseminating itself in different areas. </p>
<p>Now, it will be natural for me once in a while to use the toilet. So then I decided to go to the bathroom. And same thing. </p>
<p>So in the bathroom, you’d touch different surfaces: the doors, the lid of the toilet. </p>
<p>So when you wash your hands, yes, your hands are clean. However, when you touch your filthy mobile phone, what happens is you contaminate yourself all over again. </p>
<p>The mobile phones are our third hand. Those ‘third hands’ needs to be ‘hand-washed or sanitised the same way as we ought to do with our two normal hands. </p>
<p>If we don’t decontaminate our mobile phones, it means that we negate the hand washing. </p>
<p>The solution is very simple. </p>
<p>At least, wipe off your mobile phone with a clean felt cloth, put a little bit of 70% isopropyl alcohol [on it]. But you have to be very careful when you wipe off your mobile phone with this type of material. </p>
<p>If you really want to clean your phone, never clean your phone when it is switched on, switch it off first. And the other advice I would tell you is probably to go back to your phone manufacturer recommendations, on how best you can clean your phone. </p>
<p>Our research, at Bond, is very clear. And this is also backed up by the literature. The best way forward [for public sector and industrial settings is] to sanitise your phone is by Ultraviolet C. </p>
<p>And there are some great technologies out there that do the job within 10 seconds, that will really be the solution for our community, for our health care workers and for any type of professional sector. </p>
<p>And my dream is to get the World Health Organisation, the CDC, etc. to embrace this technology.</p>
<p>To, first of all, understand that those mobile phones are actually probably transmitting diseases because those mobile phones are Trojan horses for the enemies that we carry with us all the time: all those germs.</p><img src="https://counter.theconversation.com/content/167784/count.gif" alt="The Conversation" width="1" height="1" />
Watch Lotti Tajouri explain how mobile phones are vectors for bacteria and viruses, why this is a problem in our hospitals, and how you can sanitise your phone to help stop the spread of disease.Wes Mountain, Social Media + Visual Storytelling EditorChynthia Wijaya-Kovac, Social Media Producer, The Conversation AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1543282021-03-02T13:22:25Z2021-03-02T13:22:25ZCOVID-19 costs could push hospitals to rethink billions of dollars in wasted supplies<figure><img src="https://images.theconversation.com/files/385934/original/file-20210223-16-14962ps.jpg?ixlib=rb-1.1.0&rect=10%2C10%2C6679%2C4456&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The pandemic's supply crunch led to more reuse and decontamination techniques that can save money and reduce waste.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/nurse-reaches-for-supplies-in-clinic-supply-room-royalty-free-image/1245241080">SDI Productions via Getty Images</a></span></figcaption></figure><p>The United States <a href="https://data.oecd.org/healthres/health-spending.htm">spends more on health care</a> than any other nation. What many people don’t realize is that a large portion of this spending goes to waste.</p>
<p>Every year, an estimated US$760 billion to $935 billion is wasted through overtreatment, poor coordination and other failures, amounting to about <a href="https://www.doi.org/10.1001/jama.2019.13978">a quarter of total U.S. health care spending</a>, research has shown. Medical supplies and equipment are part of that. One study estimated that <a href="http://doi.org/10.3171/2016.2.JNS152442">nearly $1,000 in unused supplies</a> are wasted on average during each neurosurgery procedure.</p>
<p>With hospitals <a href="https://www.aha.org/guidesreports/2020-05-05-hospitals-and-health-systems-face-unprecedented-financial-pressures-due">under financial pressure</a> from COVID-19 and medical waste <a href="https://www.waste360.com/medical-waste/hidden-risks-medical-waste-and-covid-19-pandemic">volumes even higher</a>, the pandemic could finally trigger a much-needed reset in how health care organizations and hospitals think about supply-related waste. That includes how they reuse supplies, how they plan for surgeries and what they look for in prepackaged surgical supplies.</p>
<h2>Decontaminating and reusing supplies safely</h2>
<p>It’s important to recognize that not all single-use equipment and supplies are safer. Cleaning, sterilizing and reusing equipment can be safe and cost less in the long run. For example, the U.S. Food and Drug Administration points out that surgical instruments such as clamps and forceps <a href="https://www.fda.gov/medical-devices/reprocessing-reusable-medical-devices/what-are-reusable-medical-devices">can be reprocessed and reused</a>, but they are often thrown away after a single use.</p>
<p><a href="http://doi.org/10.1001/jamainternmed.2020.4221">New sterilization methods</a> can help. For example, N-95 masks that were sterilized and sanitized with ethylene oxide and vaporized hydrogen peroxide were able to retain their more than 95% filtration efficiency. The approvals hospitals received from the Centers for Disease Control and Prevention to <a href="https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html">decontaminate</a> some disposable items could become long-term safe methods to reduce waste.</p>
<figure class="align-center ">
<img alt="Supplies on tables in an operating room during surgery" src="https://images.theconversation.com/files/385930/original/file-20210223-18-unrksz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/385930/original/file-20210223-18-unrksz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=374&fit=crop&dpr=1 600w, https://images.theconversation.com/files/385930/original/file-20210223-18-unrksz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=374&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/385930/original/file-20210223-18-unrksz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=374&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/385930/original/file-20210223-18-unrksz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=470&fit=crop&dpr=1 754w, https://images.theconversation.com/files/385930/original/file-20210223-18-unrksz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=470&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/385930/original/file-20210223-18-unrksz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=470&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Operating rooms are a large source of hospital supply waste.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/surgeons-performing-open-heart-surgery-royalty-free-image/467546155?adppopup=true">Thierry Dosogne via Getty Images</a></span>
</figcaption>
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<p>Being able to <a href="https://doi.org/10.1016/j.ajic.2020.10.013">reuse personal protective equipment</a> could not only reduce waste in landfills, lower the environmental footprint of supply production and delivery, and save money, but it could also strengthen health care organizations’ ability to be prepared for supply chain breakdowns in future pandemics.</p>
<h2>Ways to cut waste in the operating room</h2>
<p>Operating rooms are a source of large amounts of hospital supply waste. They account for over <a href="http://doi.org/10.1007/s10729-015-9318-2">50% of hospital revenues and 25% of their expenses</a>.</p>
<p>Supplies and materials in operating rooms average nearly <a href="http://doi.org/10.1097/ACO.0b013e32832798ef/">half of operating room spending</a> and account for <a href="http://doi.org/10.1016/j.jhsa.2017.11.007">70% of the 4 billion pounds of health care waste</a> produced in the United States annually. </p>
<p>A big part of that waste happens when there is a mismatch between the supplies requested and those actually needed during surgery. Surgeons submit a physician preference card that lists all the supplies they believe they will need in the operating room. In one study, my colleagues and I found that <a href="https://doi.org/10.1002/joom.1070">more frequent updates</a> to those preference cards before surgery can reduce unplanned costs.</p>
<p>We estimated that the unplanned costs in operating rooms averaged about $1,800 per surgery, adding up to tens of millions of dollars. These costs include both supplies that are opened but go unused and additional supplies brought in during surgery that make it harder to manage supply use efficiently. We found that as the frequency of updating physician preference cards increased, waste and costs initially went up but then came down as surgeons were able to narrow down the supplies actually needed. This learning can translate into an annual cost reduction of millions of dollars. </p>
<p>Just understanding how supplies are being wasted can help. When surgeons in a San Francisco hospital were given information about their supply use and an incentive to reduce it, they <a href="http://doi.org/10.1001/jamasurg.2016.4674">cut their supply waste by 6.5%</a>.</p>
<p>Rethinking packaging, including working with suppliers to reformulate surgical packs, could also reduce waste. Supplies used in the operating room often come in surgical packs, which include items typically needed during a procedure, but not all are used.</p>
<h2>Ramping up recycling</h2>
<p>Hospitals can also increase their recycling. A survey conducted across four Mayo Clinic locations across the United States in 2018 found that single-use plastics made up <a href="https://doi.org/10.1016/j.amjsurg.2018.06.020">at least 20% of medical waste</a> generated in the hospitals. Among the more than 500 hospital staff members surveyed, 57% didn’t know which items used in operating theaters could be recycled; 39% said they either sometimes or never recycled; and 48% said the greatest barrier to recycling was “lack of knowledge.”</p>
<p>In fact, <a href="http://doi.org/10.1016/B978-0-08-102528-4.00008-0">only 15%</a> of health care wastes are hazardous. The remaining 85% include packaging materials that can be recycled and gloves. Gloves worn to inspect a noninfectious patient are not hazardous and can be reused.</p>
<p>The pandemic-triggered awareness of supply waste in health care could provide an impetus for a fresh look at health care supply chain management. The result can benefit patients, hospitals and the environment, as well.</p>
<p>[<em><a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=experts">Expertise in your inbox. Sign up for The Conversation’s newsletter and get expert takes on today’s news, every day.</a></em>]</p><img src="https://counter.theconversation.com/content/154328/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anand Nair does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Hospitals have a lot of room to reduce, reuse and recycle supplies – as many were forced to discover during the pandemic.Anand Nair, Eli Broad Endowed Professor, Department of Supply Chain Management, Michigan State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1230892019-09-12T20:04:52Z2019-09-12T20:04:52ZWomen may find it tougher to get an abortion if the religious discrimination bill becomes law<figure><img src="https://images.theconversation.com/files/292115/original/file-20190912-190050-umpo22.jpg?ixlib=rb-1.1.0&rect=7%2C7%2C991%2C784&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women may need to shop around for a new doctor if the first one refuses to perform an abortion for religious reasons.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/confident-successful-young-businesswoman-short-hairstyle-712523149?src=E06daX2sOMd7UbakC2nXjA-1-49">from www.shutterstock.com</a></span></figcaption></figure><p>If the <a href="https://www.ag.gov.au/Consultations/Documents/religious-freedom-bills/exposure-draft-religious-discrimination-bill.pdf">Religious Discrimination Bill</a> passes into law, women may find it harder to get an
abortion. </p>
<p>That’s because health practitioners with an objection to performing the procedure on religious grounds may have stronger legal protection and may not be compelled to refer women to an alternative provider.</p>
<p>This may lead women to consult multiple services, if available, before finding a doctor willing to perform the procedure.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-government-has-released-its-draft-religious-discrimination-bill-how-will-it-work-122618">The government has released its draft religious discrimination bill. How will it work?</a>
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<h2>Who does the bill cover and where?</h2>
<p>In the new bill, the term “health practitioner” has a broad meaning. It includes doctors, nurses, midwives and pharmacists. If the bill passes into law, it would apply to health practitioners around Australia. This means it has the potential to override current state and territory laws protecting women seeking abortions. </p>
<p>At the moment, in states such as <a href="http://www.legislation.vic.gov.au/domino/Web_Notes/LDMS/LTObject_Store/ltobjst10.nsf/DDE300B846EED9C7CA257616000A3571/E8DB0BF2182A7CEFCA2582CC00130DDA/$FILE/08-58aa005%20authorised.pdf">Victoria</a> and <a href="https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2014_022.pdf">NSW</a>, health professionals may conscientiously object to performing abortions but must refer women to another service.</p>
<p>However, this new bill may override state laws by allowing health professionals with a conscientious objection to refuse to refer them.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/one-in-six-australian-women-in-their-30s-have-had-an-abortion-and-were-starting-to-understand-why-111246">One in six Australian women in their 30s have had an abortion – and we're starting to understand why</a>
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<p>The bill may also restrict the ability of private hospitals or private clinics to enforce a workplace policy that requires health practitioners to refer patients to other health practitioners if they object to abortion themselves.</p>
<p>If the new bill becomes law, the only situations where the health professional would be compelled to provide an abortion is if his or her employer would suffer “unjustifiable adverse impact” or if the patient would suffer “unjustifiable adverse impact”. </p>
<p>It is unclear how the courts will interpret these rules. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/factcheck-do-women-in-tasmania-have-access-to-safe-abortions-92173">FactCheck: do women in Tasmania have access to safe abortions?</a>
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<h2>The new bill may make existing matters worse</h2>
<p>The bill may also exacerbate problems some women already face in accessing an abortion.</p>
<p>For instance, in Tasmania, <a href="https://www.buzzfeed.com/ginarushton/this-woman-paid-thousands-of-dollars-to-fly-interstate-for">some</a> <a href="https://www.smh.com.au/lifestyle/life-and-relationships/faced-with-an-unplanned-pregnancy-angela-had-difficult-decisions-to-make-20190306-p51244.html">women</a> <a href="https://www.abc.net.au/news/2019-03-06/abortion-provider-still-not-operating-in-tasmania/10875438">are forced</a> to travel to Victoria due to the difficulty of accessing medical practitioners to perform the procedure in their home state.</p>
<p>In 2018, a Cricket Australia employee Angela Williamson <a href="https://www.theguardian.com/australia-news/2018/jul/30/woman-cricket-australia-sacked-abortion-rights-tweets">spoke out</a> after being forced to travel from Hobart to Melbourne for this reason. After speaking out on Twitter about the poor access to abortion services in Tasmania, she lost her job.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1024217853623320576"}"></div></p>
<h2>Conscientious objection is already a problem</h2>
<p>Not all doctors act legally under existing legislation. A <a href="https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-019-0346-1">recent study</a> focusing on Victorian providers found doctors had:</p>
<ul>
<li>broken the existing law by not referring women to another provider if they objected to perform an abortion</li>
<li>attempted to make women feel guilty about requesting an abortion</li>
<li>attempted to delay women’s access to abortion services, or</li>
<li>claimed an objection for reasons other than conscience. </li>
</ul>
<p>The study also showed how government phone staff authorising abortion pills, pharmacists, institutions like private hospitals and political groups all used or misused conscientious objection. They either delayed or blocked access to existing services or contributed to the actual lack of abortion providers and services, via lobbying the public or government. </p>
<p>The study found misuse occurred partly because people do not have to justify or register their conscientious objection. So there is no way of knowing if someone’s conscientious objection is a genuine or deeply, consistently held religious position.</p>
<p>The new bill will likely make these types of situations more common.</p>
<h2>Right to religious freedom vs right to health care</h2>
<p>The bill <a href="https://www.theguardian.com/australia-news/2019/aug/29/religious-discrimination-bill-coalition-accused-of-weakening-state-human-rights-law">is controversial</a> because it elevates the protection of religious freedom above other rights, such as the right to health care for women seeking an abortion.</p>
<p>Hugh de Kretser, executive director of the Human Right Law Centre, <a href="https://www.hrlc.org.au/news/2019/8/29/concerns-over-proposed-religious-discrimination-law">says</a>:</p>
<blockquote>
<p>Australia needs stronger protections from discrimination for people of faith, but the current bill introduces unjustified carve-outs for people to express discriminatory views and to override state and territory protections which ensure fair treatment, particularly for women accessing abortion services.</p>
</blockquote>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/religious-discrimination-bill-is-a-mess-that-risks-privileging-people-of-faith-above-all-others-122631">Religious Discrimination Bill is a mess that risks privileging people of faith above all others</a>
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<p>Adrianne Walters, senior sawyer at the Human Rights Law Centre, <a href="https://www.hrlc.org.au/news/2019/8/29/concerns-over-proposed-religious-discrimination-law">says</a>:</p>
<blockquote>
<p>The bill will undermine women’s reproductive health. In some jurisdictions, like South Australia and Western Australia, it will allow doctors to abandon their patients. The bill unjustifiably prioritises a doctor’s personal religious beliefs over the right of women to access the healthcare they need. </p>
</blockquote>
<p>In 2018, an International Women’s Health Coalition <a href="https://iwhc.org/resources/unconscionable-when-providers-deny-abortion-care/">study</a> found a failure to provide abortions to women has terrible impacts by placing “patients at risk of discrimination, physical and emotional harm, and financial stress”. Those possible harms included death.</p>
<h2>What we’d like to see</h2>
<p>The Religious Discrimination Bill should be amended to strike a better balance between religious rights and women’s right to access abortion. It is important to require conscientious objectors to refer the patients seeking abortion to other providers. </p>
<p>There should also be provisions in the bill to ensure conscientious objectors genuinely have deeply and consistently held religious positions, perhaps through a registration scheme.</p><img src="https://counter.theconversation.com/content/123089/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>Doctors who won’t perform abortions on religious grounds may have stronger legal protection and may not be compelled to refer women to an alternative provider. Here’s why that’s bad news for women.Elizabeth Shi, Lecturer, Graduate School of Business and Law, RMIT UniversityAriella Gordon, Research assistant, Graduate School of Business and Law, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1181792019-06-05T04:03:09Z2019-06-05T04:03:09ZIt’s perfectly legal for doctors to charge huge amounts for surgery, but should it be allowed?<figure><img src="https://images.theconversation.com/files/277995/original/file-20190604-69087-6q2xjq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Desperate families are increasingly turning to crowdfunding campaigns to raise tens of thousands of dollars for surgery and other medical expenses.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Australia’s Chief Medical Officer Brendan Murphy <a href="https://www.abc.net.au/radio/programs/pm/are-medical-specialists-fees-too-high/11178754">will investigate how to better protect patients</a> from doctors charging “really unjustifiable, excessive fees” of up to A$10,000 or more for medical procedures.</p>
<p>Murphy said it was potentially unethical for doctors to charge such high out-of-pocket fees that left families in severe financial pain, and that contrary to some patients’ hopes, paying more didn’t equate to better outcomes. </p>
<p>The call comes as desperate families increasingly turn to crowdfunding, remortgaging their homes and eating into their superannuation to raise tens of thousands of dollars for <a href="https://www.gofundme.com/mvc.php?route=category&term=surgery%20australia&country=AU">surgeries and other medical expenses</a>.</p>
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Read more:
<a href="https://theconversation.com/we-need-more-than-a-website-to-stop-australians-paying-exorbitant-out-of-pocket-health-costs-108740">We need more than a website to stop Australians paying exorbitant out-of-pocket health costs</a>
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<p>It is perfectly legal for a doctor working in private practice to charge what they believe is fair and reasonable. It’s a private market, so buyers beware. </p>
<p>But that doesn’t mean it’s right, or that it should be allowed to continue. </p>
<h2>Not everything is available in the public system</h2>
<p>Some patients’ out-of-pocket costs are from the gap between what their private health insurance and/or Medicare will pay for a procedure or treatment. </p>
<p>But some treatments aren’t funded by Medicare or offered in public hospitals because their safety, efficacy and value for money have not yet been demonstrated. </p>
<p>Medical technologies, devices and surgical techniques need to be rigorously tested in clinical trials to demonstrate safety and clinical effectiveness. They will only be widely adopted when they have a <a href="http://www.msac.gov.au/internet/msac/publishing.nsf/Content/about-msac">strong evidence base</a>. </p>
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<img alt="" src="https://images.theconversation.com/files/277996/original/file-20190604-69095-n4wl77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/277996/original/file-20190604-69095-n4wl77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/277996/original/file-20190604-69095-n4wl77.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/277996/original/file-20190604-69095-n4wl77.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/277996/original/file-20190604-69095-n4wl77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/277996/original/file-20190604-69095-n4wl77.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/277996/original/file-20190604-69095-n4wl77.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">Out-of-pocket costs can be particularly high for patients with cancer.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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<p>When the government pays for a health service, value for money is also considered. For really expensive services and medicines that have the potential to greatly benefit patients, the government will try to negotiate prices down, to reduce the impact on the health budget. </p>
<p>While a lack of evidence of a benefit does not necessarily mean the procedure does not benefit patients, the outcomes need to be reviewed and demonstrated to justify its ongoing use. </p>
<p>Sometimes new technologies are adopted prematurely based on weak evidence and strong marketing which can lead to poor investment decisions. This was the case with robotic surgery for prostate cancer, offered early in private practice in Australia, only to find later it was no better than <a href="https://www.ncbi.nlm.nih.gov/pubmed/28701134">traditional surgery</a>. </p>
<h2>If a patient chooses to spend money on a high-risk surgery, is it really anyone’s business?</h2>
<p>Sometimes patients will choose to undergo high-risk surgery, not covered under the public system, and are willing to pay out of their own pocket, or raise the funds through crowdsourcing or remortgaging their home. </p>
<p>Some will argue the value is whatever the patient is <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Garrison+LP%2C++2018%3B21(2)%3A124-130.">willing to pay for it</a> and it’s up to the patient’s own risk-benefit preferences. </p>
<p>There are some major problems with this. Patients often make health decisions while distressed, ill and emotional. They may not be able to determine the best course of action or have all the information at hand. They must trust the doctor and his or her superior knowledge and experience. </p>
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Read more:
<a href="https://theconversation.com/specialists-are-free-to-set-their-fees-but-there-are-ways-to-ensure-patients-dont-get-ripped-off-97372">Specialists are free to set their fees, but there are ways to ensure patients don't get ripped off</a>
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<p>Health economists call this “<a href="https://www.aushsi.org.au/market-failure-and-information-problems-in-healthcare/">asymmetric information</a>”. The doctor has extensive years of training, expertise and qualifications. The patient has Dr Google. </p>
<p>A key reason governments intervene in health care systems is to avoid market failure arising from unequal information and the profiteering of providers. </p>
<h2>Our ‘fee-for-service’ system is failing</h2>
<p>In the private system, doctors are paid a fee for each service they provide. This creates an incentive for doctors to provide more services: the more services they provide, the more they get paid. </p>
<p>But the high volumes of testing, consultations and fragmented services we’re currently seeing aren’t translating to a better quality of care. As such, economists are calling for major reforms of our fee-for-service private health system and the way that doctors are paid. </p>
<p>This could involve <a href="https://theconversation.com/more-visits-to-the-doctor-doesnt-mean-better-care-its-time-for-a-medicare-shake-up-110884">paying doctors for caring for a patient’s medical condition</a> over a set period, rather than each time they see the patient, or charging private patients a “<a href="https://www.abc.net.au/radio/programs/pm/are-medical-specialists-fees-too-high/11178754">bundled fee</a>” for all the scans, appointments and other costs associated with something like a hip replacement. </p>
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Read more:
<a href="https://theconversation.com/more-visits-to-the-doctor-doesnt-mean-better-care-its-time-for-a-medicare-shake-up-110884">More visits to the doctor doesn't mean better care – it's time for a Medicare shake-up</a>
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<p><a href="https://www.bcna.org.au/about-us/advocacy/research-reports/the-financial-impact-of-breast-cancer/">Out-of-pocket</a> costs are very high for some Australians with cancer. A quarter of Queenslanders diagnosed with cancer will pay provider fees of more than A$20,000 in the first two years after <a href="https://www.ncbi.nlm.nih.gov/pubmed/30463662">diagnosis</a>. </p>
<p>While what constitutes “value” will be in the eye of the beholder, a well-functioning and sustainable health system is one that puts patients’ interests above all others and holds health providers accountable. </p>
<p>Australia’s universal health care system is one of the best in the world and we need to work hard to preserve it. Surgeries costing tens of thousands of dollars will continue unless the government regulates private medical practice or reforms the way doctors are remunerated. </p>
<p>It’s time to cap what physicians can charge for services and provide incentives for specialists to bulk-bill their patients. </p>
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Read more:
<a href="https://theconversation.com/why-do-specialists-get-paid-so-much-and-does-something-need-to-be-done-about-it-74066">Why do specialists get paid so much and does something need to be done about it?</a>
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<img src="https://counter.theconversation.com/content/118179/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Louisa Gordon receives funding from the National Health and Medical Research Council. </span></em></p>It is perfectly legal for a doctor working in private practice to charge what they believe is fair and reasonable. But that doesn’t mean it’s OK to charge tens of thousands of dollars for a procedure.Louisa Gordon, Associate Professor - Health Economics, QIMR Berghofer Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/957192018-05-14T09:52:03Z2018-05-14T09:52:03ZThis is what really happens when you go under the knife<figure><img src="https://images.theconversation.com/files/218472/original/file-20180510-34038-y5mmtc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-team-performing-surgical-operation-bright-741433855?src=-3BA1ZyV3GGvLHsWUU-S5A-1-28">shutterstock</a></span></figcaption></figure><p>We’ve all seen the TV dramas – <a href="http://abc.go.com/shows/greys-anatomy">Grey’s Anatomy</a>, <a href="https://www.imdb.com/title/tt0108757/">ER</a>, <a href="https://www.bbc.co.uk/programmes/b006m8wd">Casualty</a>, <a href="https://www.bbc.co.uk/programmes/b006mhd6">Holby City</a> – and most of us like to think we have a pretty good idea of what happens in an operating theatre. The doctors and nurses will be clad in blue scrubs, <a href="https://www.huffingtonpost.co.uk/entry/music-surgery_n_6310842">operatic music will be playing</a>, with intermittent calls of “scalpel” or “swabs”, right?</p>
<p>For those readers, who’ve ever had an operation – whether it was <a href="https://theconversation.com/seven-body-organs-you-can-live-without-84984">planned or an emergency</a> – things in the real world probably felt very different to those familiar TV drama medical emergency scenes. In part, this is because <a href="https://theconversation.com/greys-anatomy-is-unrealistic-but-it-might-make-junior-doctors-more-compassionate-92040">TV programmes often portray the staff</a> who work on the wards also working in the operating theatre – but this isn’t the case. </p>
<p>In fact, it’s not just doctors and nurses that make up part of the team involved in an operation, there is also a group of professionals, known as <a href="https://www.healthcareers.nhs.uk/explore-roles/allied-health-professionals/roles-allied-health-professions/operating-department-practitioner">operating department practitioners</a> (ODPs), who are trained specifically to look after you when you’re under the bright lights of the operating theatre. </p>
<h2>What happens when I arrive?</h2>
<p>Having an operation can be highly stressful. You might have been told not to eat before. It all feels a bit unknown, and you aren’t exactly sure what will happen. But the staff at the hospital are on hand to try and make things easy for you. </p>
<p>As you are arrive on the ward, a whole team of staff are busy preparing for your surgery. You’ll be asked to confirm who you are and what you’re being admitted for. You will also be asked to change into a very fetching hospital gown. Someone will also sit down and talk you through what’s happening and check you have not eaten – this is so you don’t vomit <a href="https://theconversation.com/science-lesson-how-anesthetics-work-and-why-xenons-perfect-83744">during your anaesthetic</a>. </p>
<h2>Who looks after me?</h2>
<p>The team looking after you has three sub teams working as one. They are the anaesthetic team, the surgical team and the post anaesthetic team. These teams work like cogs and your care and treatment is seamless. As a minimum, this would mean you would have nine health professionals caring for you at any one time. </p>
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<img alt="" src="https://images.theconversation.com/files/218471/original/file-20180510-34021-n03u0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/218471/original/file-20180510-34021-n03u0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=316&fit=crop&dpr=1 600w, https://images.theconversation.com/files/218471/original/file-20180510-34021-n03u0l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=316&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/218471/original/file-20180510-34021-n03u0l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=316&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/218471/original/file-20180510-34021-n03u0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=398&fit=crop&dpr=1 754w, https://images.theconversation.com/files/218471/original/file-20180510-34021-n03u0l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=398&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/218471/original/file-20180510-34021-n03u0l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=398&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">Knowing you’re in safe hands is important.</span>
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<p>Your operating team on the day will have doctors – who are the anaesthetist, and the surgeon – but the rest of the team could be made up nurses, ODPs and healthcare assistants. ODPs are generally a graduate professional and they train through university in partnership with the hospital operating theatres.</p>
<h2>When do I have the anaesthetic?</h2>
<p>When the team is ready and it’s time for your surgery, you have your anaesthetic. This will be delivered by an anaesthetist, but there always has to be trained assistance – normally an ODP.</p>
<p>On arrival in the <a href="https://theconversation.com/scientists-find-way-to-predict-who-is-likely-to-wake-up-during-surgery-53217">anaesthetic room</a>, it is the ODP that greets you with a big smile and often a cheesy joke. After all, they have minutes to get to know you and for you to trust them with your life. They will attach you to the monitoring equipment and measure your baseline pulse and blood pressure readings. </p>
<p>You will need a cannula (a plastic tube) inserting into a vein, so the anaesthetist can give you the drugs. This is the point where you may be asked to start counting back slowly from ten – you won’t even get to seven.</p>
<h2>What happens during surgery?</h2>
<p>While the anaesthetic team continue to look after you, the surgical team carry out your operation. The surgeon will have at least one assistant – I have known more than ten people to be part of this team for major head and neck cancer surgery. The first assistant and other assistants scrub up with the surgeon and help with the surgery. </p>
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<span class="caption">Laser-like precision.</span>
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<p>Adding to this team there is a scrub practitioner and their role is to provide the swabs, needles and equipment to the surgeon and the assistants. They are the ones who also count everything to make sure you don’t leave the operating theatre with any unwanted extras. </p>
<h2>When can I go home?</h2>
<p>Once your <a href="https://theconversation.com/will-you-feel-better-after-surgery-now-you-can-find-out-using-this-online-tool-72758">surgery is complete</a> your wounds will be dressed by the surgical team. Your anaesthetic will be reversed and you will be taken to the post anaesthetic care unit – which used to be called recovery. Here you will be looked after until you are ready to be discharged back to the ward. Here, you wounds will be inspected, and whoever’s looking after you will make sure your <a href="https://theconversation.com/anthill-19-pain-87538">pain is under control</a> and you are not feeling sick. </p>
<p>Once you are awake and comfy, you will be taken back to the ward where your relatives may be waiting and you should be able to have something to eat and drink. Depending on your surgery and who you have at home to look after you, you may even be allowed to go home the same day.</p>
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Read more:
<a href="https://theconversation.com/health-check-why-can-you-feel-groggy-days-after-an-operation-74989">Health Check: why can you feel groggy days after an operation?</a>
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<p class="fine-print"><em><span>Deborah Robinson 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>What to expect when you’re expecting an operation.Deborah Robinson, Senior Lecturer and Head of Health and Social Work School, University of HullLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/941592018-05-02T10:41:57Z2018-05-02T10:41:57ZIn Brazil, patients risk everything for the ‘right to beauty’<figure><img src="https://images.theconversation.com/files/216868/original/file-20180430-135817-1pza6i0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A plastic surgery-themed magazine is displayed in a Brazil storefront.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/keishaf/5094464539/">hollywoodsmile310</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>In the U.S., if you want a face lift or a tummy tuck, it’s generally assumed that you’ll be paying out of pocket. Insurance will tend to cover plastic surgery <a href="https://www.zwivel.com/blog/insurance-coverage-plastic-surgery/">only when the surgery is deemed</a> “medically necessary” and not merely aesthetic. </p>
<p>In Brazil, however, patients are thought of as having the “right to beauty.” In public hospitals, plastic surgeries are free or low-cost, and <a href="http://www.osul.com.br/cirurgia-plastica-reparadora-cresce-mais-que-a-cirurgia-estetica-no-brasil/">the government subsidizes nearly half a million surgeries every year</a>.</p>
<p>As a medical anthropologist, I’ve spent years studying Brazilian plastic surgery. While many patients are incredibly thankful for the opportunity to become beautiful, the “right to beauty” has a darker side to it.</p>
<p>Everyone I interviewed in Brazil admitted that plastic surgeries were risky affairs. In the public hospitals where these plastic surgeries are free or much cheaper than in private clinics, I heard many patients declare that they were “cobaias” (guinea pigs) for the medical residents who would operate on them.</p>
<p>Yet these patients, most of whom were women, also told me that living without beauty in Brazil was to take an even bigger risk. Beauty is perceived as being so central for the job market, so crucial for finding a spouse and so essential for any chances at upward mobility that many can’t say no to these surgeries.</p>
<p>The very long queues for plastic surgery in public hospitals – with wait times of several months or even years – seem to confirm this immense longing for beauty. It’s made Brazil the second-largest consumer of plastic surgery in the world, with <a href="http://g1.globo.com/bemestar/noticia/2016/08/cai-numero-de-plasticas-no-brasil-mas-pais-ainda-e-2-no-ranking-diz-estudo.html">1.2 million surgeries carried out every year</a>. </p>
<h2>Brazil’s ‘pope of plastic surgery’</h2>
<p>Today, Brazil considers health to be a basic human right <a href="https://www.carnegiecouncil.org/publications/articles_papers_reports/0236">and provides free health care</a> to all its citizens – a hard-won victory of social activists after Brazil’s dictatorship fell and a new democratic constitution was written into law in 1988. However, public hospitals remain severely underfunded, and most middle-class and upper-class Brazilians prefer to use private medical services. </p>
<p>In effect, Brazil has a two-tiered system. There is a private health care system that is cutting-edge and luxurious and a public one that is strapped for cash but provides essential services to the working class.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/216871/original/file-20180430-135840-13ez7kh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/216871/original/file-20180430-135840-13ez7kh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/216871/original/file-20180430-135840-13ez7kh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/216871/original/file-20180430-135840-13ez7kh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/216871/original/file-20180430-135840-13ez7kh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=576&fit=crop&dpr=1 754w, https://images.theconversation.com/files/216871/original/file-20180430-135840-13ez7kh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=576&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/216871/original/file-20180430-135840-13ez7kh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=576&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A billboard advertises a private plastic surgery clinic in Barra da Tijuca, a wealthy neighborhood in Rio de Janeiro.</span>
<span class="attribution"><a class="source" href="http://pictures.reuters.com/C.aspx?VP3=SearchResult&ITEMID=PBEAHULRNBZ&RW=1317&RH=708">Gregg Newton/Reuters</a></span>
</figcaption>
</figure>
<p>Plastic surgery is considered an essential service largely due to the efforts of a surgeon named Ivo Pitanguy. In the late 1950s, Pitanguy – <a href="http://www.cmjornal.pt/mais-cm/obituario/detalhe/morreu_brasileiro_ivo_pitanguy_papa_da_cirurgia_estetica">now known as the “pope of plastic surgery”</a> – convinced President Juscelino Kubitschek that the “right to beauty” was as basic as any other health need. Pitanguy <a href="http://www.ciplastica.com/ojs/index.php/rccp/article/view/28">made the case</a> that ugliness caused so much psychological suffering in Brazil that the medical class could not turn its back on this humanitarian issue. </p>
<p>In 1960, <a href="http://www.iip.org.br/instituto.html">he opened the first institute that offered plastic surgery to the poor</a>, one that doubled as a medical school to train new surgeons. It was so successful that it became the educational model followed by most other plastic surgery residencies around the country. In return for free or low-cost surgeries, working-class patients would help surgeons learn and practice their trade.</p>
<p>Brazil was the perfect testing ground for this idea. In the early 1920s, Brazilian eugenic scientists suggested that <a href="https://www.tandfonline.com/doi/pdf/10.1080/13569325.2015.1091296">beauty was a measure of the nation’s racial progress</a>. Beauty started to assume more cultural clout, and plastic surgeons inherited these ideals, seeing their trade as “fixing” the errors of too much racial mixture in Brazil, particularly among the lower classes.</p>
<h2>Beauty’s hidden costs</h2>
<p>In my recently published book, “<a href="https://www.ucpress.edu/book.php?isbn=9780520293885">The Biopolitics of Beauty</a>,” I question the idea that humanitarianism is the driving force of plastic surgery in Brazilian public hospitals. </p>
<p>Burn victims and individuals with congenital deformities were once the main beneficiaries of plastic surgery in these hospitals. But at many of the clinics where I carried out my research, nearly 95 percent of all those surgeries have become purely aesthetic. I documented hundreds of instances where surgeons and residents purposely blurred the boundaries between reconstructive and aesthetic procedures to get them approved by the government. </p>
<p>Since most of the surgeries in public hospitals are carried out by medical residents who are still training to be plastic surgeons, they have a vested interest in learning aesthetic procedures – skills that they’ll be able to later market as they open private practices. But they have very little interest in learning the reconstructive procedures that actually improve a bodily function or reduce physical pain.</p>
<p>Additionally, most of Brazil’s surgical innovations are first tested by plastic surgeons in public hospitals, exposing those patients to more risks than wealthier patients. Working-class patients are understood as subjects for inquiry, and I spoke to the small but significant number who were very unhappy with the results of their surgery. </p>
<p>Take one woman I interviewed named Renata. The medical resident who operated on her left her with deformed breasts and uneven nipples. She also developed severe infections that took months to heal and left significant scars. She considered suing the doctor, but discovered she would need a costly expert medical evaluation. She also knew that the Brazilian legal system would likely grant her very little in terms of damages. In the end, she settled for another free surgery, one that she hoped would provide a better result and leave her less unhappy.</p>
<p>This was a typical story among low-income patients that were harmed by plastic surgeons. Their lack of financial resources made it nearly impossible for them to find any justice if anything went wrong, so they assumed all of the risk.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/217100/original/file-20180501-135810-xm2zk5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/217100/original/file-20180501-135810-xm2zk5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=801&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217100/original/file-20180501-135810-xm2zk5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=801&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217100/original/file-20180501-135810-xm2zk5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=801&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217100/original/file-20180501-135810-xm2zk5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1007&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217100/original/file-20180501-135810-xm2zk5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1007&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217100/original/file-20180501-135810-xm2zk5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1007&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Extensive necrosis in a patient after an application of PMMA.</span>
<span class="attribution"><span class="source">Anderson Castelo Branco de Castro</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Plastic surgeons, on the other hand, are eager to try new techniques if they seem promising, no matter how risky they might be. A technique known as “bioplastia,” for example, consists of injecting a liquid compound called <a href="https://en.wikipedia.org/wiki/Poly(methyl_methacrylate)">PMMA</a> into the body in order to permanently reshape a patient’s features. The compound, which is similar to acrylic glass, doesn’t cause problems in most patients. But in a small minority <a href="http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-72992007000600019&lng=en&nrm=iso&tlng=en">it causes very severe complications</a>, including necrosis of facial tissue. Yet many doctors I interviewed strongly defended the technique, claiming it was a phenomenal tool that allowed them to transform the human body. Risk, they argued, was inherent in any surgical procedure.</p>
<p>Around the world, Brazilian plastic surgeons are known as the best in their field, and they gain global recognition for their daring new techniques. During an international plastic surgery conference in Brazil, an American surgeon I interviewed told me, “Brazilian surgeons are pioneers… You know why? Because [in Brazil] they don’t have the institutional or legal barriers to generate new techniques. They can be creative as they want to be.”</p>
<p>In other words, there are few regulations in place that could protect low-income patients from malpractice.</p>
<p>In a country where appearance is seen as central to one’s very citizenship, patients agree to becoming experimental subjects in exchange for beauty. But it’s often a choice made under duress, and the consequences can be dire.</p><img src="https://counter.theconversation.com/content/94159/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alvaro Jarrin received funding from the Wenner-Gren Foundation and the American Council of Learned Societies to carry out his research on beauty in Brazil.</span></em></p>Who’s really benefiting from a health care system that provides free or low-cost plastic surgeries for the poor?Carmen Alvaro Jarrin, Assistant Professor of Anthropology, College of the Holy CrossLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/796592017-06-21T20:04:07Z2017-06-21T20:04:07ZSurgeons admit to mistakes in surgery and would use robots if they reduced the risks<figure><img src="https://images.theconversation.com/files/174829/original/file-20170621-26746-1ciui33.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Surgeons admit to unintentional mistakes when performing delicate surgery.</span> <span class="attribution"><span class="license">Author provided</span></span></figcaption></figure><p>How good are humans at performing manual surgery? </p>
<p>Major surgical errors must be reported and there has been research into the <a href="http://www.cbsnews.com/news/would-a-surgeon-tell-you-if-something-went-wrong-during-an-operation/">attitudes of surgeons</a> in how they report such errors.</p>
<p>But there is no requirement or legislation in place to report minor unintentional damage, and how that is even defined is a grey area. Very little research exists into the frequency of unintentional surgical damage, the challenges that cause this damage, or understanding of the long-term effects.</p>
<p>We are developing semi-autonomous robotic tools to help surgeons, especially for knee surgery. It’s estimated that around <a href="http://orthoinfo.aaos.org/PDFs/A00299.pdf">4 million</a> knee arthroscopies are performed each year worldwide. </p>
<p>In <a href="http://journals.sagepub.com/doi/10.1177/2309499016684993">our recent study</a>, some surgeons said they found that such knee procedures could be physically challenging and could cause unintentional damage to their patients. </p>
<p>But a majority said they would be prepared to use robotic tools if they could be shown to help in the surgery and reduce the risks of injury to patients.</p>
<h2>Unintentional damage in surgery</h2>
<p><a href="https://www.healthdirect.gov.au/osteoarthritis">Osteoarthritis</a> is by far the leading cause of pain in joints, especially knees.</p>
<p>Following X-ray and MRI scans, the first line of minimally invasive diagnostic and treatment procedures is known as <a href="http://orthoinfo.aaos.org/topic.cfm?topic=a00299">knee arthroscopy</a>. It is a procedure in which a surgeon slides a camera and a range of instruments into the joint through small incisions.</p>
<p>This procedure is somewhat controversial as the evidence of its effectiveness for some patients <a href="http://www.abc.net.au/health/features/stories/2015/03/25/4203985.htm">has been questioned</a>. But it is still one of the most common surgical procedures carried out in the world.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/174347/original/file-20170619-28759-icnp47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/174347/original/file-20170619-28759-icnp47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/174347/original/file-20170619-28759-icnp47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=449&fit=crop&dpr=1 600w, https://images.theconversation.com/files/174347/original/file-20170619-28759-icnp47.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=449&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/174347/original/file-20170619-28759-icnp47.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=449&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/174347/original/file-20170619-28759-icnp47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=564&fit=crop&dpr=1 754w, https://images.theconversation.com/files/174347/original/file-20170619-28759-icnp47.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=564&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/174347/original/file-20170619-28759-icnp47.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=564&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Knee arthroscopy surgery showing a surgeon holding a patient’s leg.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>With our colleagues, we asked 93 surgeons in Australia with a range of experience how often they observed unintentional damage occurring during a knee arthroscopy. The survey was anonymous and the results were <a href="http://journals.sagepub.com/doi/10.1177/2309499016684993">published earlier this year in the Journal of Orthopaedic Surgery</a>.</p>
<p>Half the surgeons (49.5%) said unintentional damage to articular cartilage, which is the tissue that covers the end of your bones that make up your joints, occurred in at least one in ten procedures.</p>
<p>A third (34.4%) of them said the damage rate was at least one in five procedures. Incredibly, seven of the surgeons (7.5%) said such damage occurred in every procedure carried out.</p>
<p>Damage to cartilage is probably <a href="http://www.arthritis.org/about-arthritis/types/osteoarthritis/causes.php">one of the causes of osteoarthritis</a> and your body does not repair cartilage if damaged, which can then result in knee pain.</p>
<p>So patients who suffer unintentional cartilage damage during an arthroscopy have an additional risk of developing osteoarthritis. This is somewhat ironic, given that the motivation for many arthroscopic procedures is to try to treat osteoarthritis.</p>
<h2>A pain for the surgeon</h2>
<p>Knee arthroscopy is considered straightforward, and a skilled surgeon will make it look easy. But it is actually very difficult and requires considerable <a href="http://bjj.boneandjoint.org.uk/content/97-B/10/1309.short">skill and experience</a>.</p>
<p>During the procedure, the leg must be manipulated to create the space for the camera and the tools. This means that the surgeon has to continually lift and hold the leg, while at the same time hold the camera and the tools and operate by looking at the video on a screen. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/174675/original/file-20170620-8734-cbq214.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/174675/original/file-20170620-8734-cbq214.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/174675/original/file-20170620-8734-cbq214.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/174675/original/file-20170620-8734-cbq214.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/174675/original/file-20170620-8734-cbq214.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/174675/original/file-20170620-8734-cbq214.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/174675/original/file-20170620-8734-cbq214.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/174675/original/file-20170620-8734-cbq214.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The view from an arthroscope. Note the metal tool on the left of the image.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>We asked the surgeons whether they found knee arthroscopy to be physically challenging, and whether they had experienced pain themselves after performing this surgery.</p>
<p>Nearly 59% reported they found the procedure to be physically challenging, and more than a fifth (22.6%) said they had experienced physical pain afterwards. It is in the interests of patients that their <a href="https://theconversation.com/you-should-care-about-your-doctors-health-because-it-matters-to-yours-78039">surgeons remain in good health</a>.</p>
<h2>Robots to the rescue</h2>
<p>So how can we reduce the risk of any unintentional damage during knee arthroscopy surgery and make the procedure less challenging for the surgeon?</p>
<p>At the moment there are no robotically assisted technologies used in knee arthroscopy. All the surgery is performed manually. </p>
<p>Our current research focuses on how robots can be used by surgeons to improve patient and surgeon safety, to reduce the need for future medical treatment, and to lower the costs of healthcare.</p>
<p>We are exploring how robots can be used to hold and move the leg during a knee arthroscopy, freeing the surgeon to focus on observing the interior of the knee. </p>
<p>We are also developing new types of flexible robots and tiny stereo cameras to replace the existing arthroscopes and which will feed into <a href="https://theconversation.com/how-do-robots-see-the-world-51205">robotic vision systems</a> to map the 3D structure of the knee. These 3D knee maps will be used by other tool holding robots to avoid colliding with the cartilage. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/5HBORi_LyYQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A prototype flexible ‘snake’ robot, designed to move around curved spaces like joints.</span></figcaption>
</figure>
<p>Our aim is to give surgeons semi-autonomous robotic tools so they can concentrate on what they are best at: deciding what is wrong with the patient and how to treat it.</p>
<p>About a third (32.3%) of surgeons<a href="http://journals.sagepub.com/doi/10.1177/2309499016684993"> we surveyed</a> said they were nervous about the introduction of any semi-autonomous arthroscopic systems.</p>
<p>But about three-quarters (76.3%) said they would use a robotic assist system if it improved the efficiency of the procedure, and 86% said they would use a robot if it decreased the rate of unintentional damage to cartilage.</p>
<p>Overall, 47.3% of the surgeons said they saw a future role for semi-autonomous arthroscopic systems.</p>
<p>All surgeons will tell you that surgery carries a risk. As a patient, you must balance the benefits of a given surgery against those risks.</p>
<p>Future upgrades to their toolkit in the form of robotic manipulators, scopes and tools, will hopefully allow surgeons to reduce the risks for both the patients and themselves.</p><img src="https://counter.theconversation.com/content/79659/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anjali Jaiprakash is an Advance Queensland Fellow and receives funding from Australia-India Strategic Research Fund.
</span></em></p><p class="fine-print"><em><span>Jonathan Roberts receives funding from the Australia-India Strategic Research Fund and the Australian Research Council.</span></em></p><p class="fine-print"><em><span>Ross Crawford consults for Stryker Corp. He receives funding from ARC, NHMRC and Australia India Strategic Research fund</span></em></p>Surgeons say minor unintentional damage can happen during surgery, and much of that goes unreported. They say they would be prepared to use robotic tools if they could be shown to help.Anjali Jaiprakash, Advance Queensland Fellow, Medical Robotics, Queensland University of TechnologyJonathan Roberts, Professor in Robotics, Queensland University of TechnologyRoss Crawford, Professor of Orthopaedic Research, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/642282016-10-30T19:06:52Z2016-10-30T19:06:52ZSurgery isn’t always the best option, and the decision shouldn’t just lie with the doctor<figure><img src="https://images.theconversation.com/files/142121/original/image-20161018-12454-11m0fyv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Weighing up the evidence for surgery is just one thing to consider before going under the knife.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=G5r9D6sZtKvWkj3xzKlPTw-1-19&id=210890980&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Surgeons often decide to perform procedures because that’s what’s usually done, it’s what they’re taught, it sounds logical or it fits with observations from their own practice.</p>
<p>If the surgeon’s decision is in line with evidence from scientific studies, there’s little problem. But if the two conflict, either the surgeon’s opinion or the evidence is wrong.</p>
<p>The best way to test whether surgery works (particularly when the outcome is subjective, such as with pain) is to compare it with a sham or placebo procedure. The idea is to keep the patients and those who measure the effectiveness “blinded” to which treatment is given.</p>
<p>A <a href="http://www.bmj.com/content/348/bmj.g3253">review of studies</a> comparing surgery to sham or placebo surgery showed surgery was no better than placebo in just over half of the studies. And in studies where surgery was better than placebo, the difference was generally small.</p>
<p>As an example, two studies compared placebo surgery to keyhole surgery (arthroscopy) of the knee in patients with degenerative conditions (arthritis, meniscus tears and catching and clicking). Both studies showed no important difference in surgery outcomes between the two groups.</p>
<h2>What about other options?</h2>
<p>We don’t always need to compare surgery with a sham. Sometimes comparing surgery with non-surgical treatment (like physiotherapy or medications) is more appropriate.</p>
<p>One <a href="http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0096745">study</a> looked at all orthopaedic surgical procedures performed on more than 9,000 patients in three hospitals over three years. Only half the procedures were compared with non-operative treatment. And of that half, about half were no better than not operating.</p>
<p>So there are two problems in surgery: an evidence gap (in which there’s a lack of high quality evidence) and an evidence-practice gap (where there’s high quality evidence that a procedure doesn’t work, yet is still performed).</p>
<p>Part of the problem is that operations are often introduced before there’s good quality evidence of their effectiveness in the real world. The studies comparing them to non-operative treatment or placebo often come much later – if at all.</p>
<h2>When should surgery be funded?</h2>
<p>Doctors should not perform surgical procedures and taxpayers should not have to cover their cost until there’s high quality evidence they work. It should be unethical for surgeons to introduce a new technique without studying whether or not <a href="http://www.ncbi.nlm.nih.gov/pubmed/24484092">it works</a>.</p>
<p>Unfortunately, the opposite is true: ethical approval is not required before surgeons can start performing new procedures, but it is required to study the effectiveness of that procedure.</p>
<p>Often, procedures surgeons consider effective are later shown not to be.</p>
<p>In the US in the 1980s, a new procedure for the lung disease emphysema touted removing some lung tissue. Animal studies and (non-comparative) human studies were encouraging. So the procedure became common. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/142124/original/image-20161018-12459-vq1dx6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/142124/original/image-20161018-12459-vq1dx6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/142124/original/image-20161018-12459-vq1dx6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/142124/original/image-20161018-12459-vq1dx6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/142124/original/image-20161018-12459-vq1dx6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/142124/original/image-20161018-12459-vq1dx6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/142124/original/image-20161018-12459-vq1dx6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/142124/original/image-20161018-12459-vq1dx6.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"></a>
<figcaption>
<span class="caption">Weighing up the evidence for surgery could shed light on whether it should be funded.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=lfFyW8Ym2fcj54AIiy-Tfw-1-0&id=89667058&size=medium_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Some surgeons called for a trial comparing the procedure to non-operative treatment. But proponents of the procedure said this would deprive many people of the procedure’s benefits, the effectiveness of which was obvious.</p>
<p>Medicare in the US decided only to fund the surgery if patients took part in a trial comparing it to non-surgical treatment. The <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa030287#t=article">trial</a> was done and the surgery was found wanting, with no overall benefit over non-operative treatment. The trial cost the government some money, but much less than paying for the procedure for decades until someone else studied it.</p>
<p>This type of solution should be considered in Australia: new procedures should only be funded by the public if they are performed as part of a trial to adequately test their effectiveness.</p>
<p>Once evidence is available, the key is using it to make good decisions about the effectiveness of a particular procedure for an individual patient. So how should surgeons do that? The answer lies in measuring the right outcomes to begin with and then making shared decisions.</p>
<h2>How do we know if surgery works?</h2>
<p><a href="http://www.theaustralian.com.au/national-affairs/health/budget-2016-healthcare-waste-costs-20bn-a-year/news-story/37475d4c7c3a7adfcd65b8216b8ed015">Billions</a> are spent worldwide on surgical procedures that may not be <a href="https://www.mja.com.au/journal/2012/197/10/over-150-potentially-low-value-health-care-practices-australian-study">effective</a>. But how should we define effectiveness?</p>
<p>There is a growing acceptance that doctors should partner with patients to identify outcomes important to them. These might include avoiding complications and an unexpectedly long stay in hospital. But they should also consider longer-term quality of life, disability and <a href="https://www.ncbi.nlm.nih.gov/pubmed/25689756">survival</a>.</p>
<p>This is important when a good operation might be a bad choice. Some medical conditions herald a terminal decline in health, for which living longer is not as good as living well. A good operation may also be a bad choice in cases where attempts at prolonging life are futile.</p>
<h2>Sharing decisions</h2>
<p>Shared decision-making takes into account beliefs, preferences and views of the patient as an expert in what is right for them, supported by clinicians who are the experts in effective therapeutic options.</p>
<p>Patients should have the opportunity to ask further questions when deciding whether to go ahead with surgery to see if surgery is consistent with their values and lifestyle goals. For the critically ill, frail or confused, this discussion should often include the person’s spouse, family or next of kin.</p>
<p>The right decisions in surgery are patient-centred, based on good evidence, clearly communicated and made in a supportive environment. Everyone – doctors, other health professionals, the patient, sometimes their family, and the public – have a right and a responsibility to be included.</p><img src="https://counter.theconversation.com/content/64228/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Harris receives no direct payment or funding for research projects. He is an investigator on research projects funded by NHMRC, HCF Research Foundation, AO Trauma Asia Pacific, Lincoln Centre, UNSW, Arthritis Australia, AOA Research Foundation, MAA and SIRA</span></em></p><p class="fine-print"><em><span>Professor Paul Myles receives research funding from the NHMRC and the Australian and New Zealand College of Anaesthetists. </span></em></p>There’s often limited evidence for many common types of surgery. Understanding what makes good evidence is the key to deciding what’s best for you.Ian Harris, Professor of Orthopaedic Surgery, UNSW SydneyProfessor Paul Myles, Chair of the Department of Anaesthesia and Perioperative Medicine, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/578092016-04-18T20:09:14Z2016-04-18T20:09:14ZAustralia’s first robotic help in a hip replacement operation<figure><img src="https://images.theconversation.com/files/119046/original/image-20160418-23646-1hclau5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The surgeon and the robotic arm will work together on a hip replacement.</span> <span class="attribution"><span class="source">Stryker</span>, <span class="license">Author provided</span></span></figcaption></figure><p>The first robotically assisted hip replacement operation in Australia is due to be performed today on a patient in Brisbane.</p>
<p>A total hip replacement (THR) is one of the <a href="http://bonesmart.org/hip/how-successful-is-hip-replacement-surgery/">most successful</a> operations that surgeons perform, with more than 43,000 carried out last year in Australia alone.</p>
<p>The <a href="https://www.stryker.com/en-us/products/Orthopaedics/MakoRobotic-ArmAssistedSurgery/index.htm">robot technology</a> to help in such operations has been used for some years in the US but has only recently reached Australia.</p>
<p>But if the operations are so popular and successful, why let a robot in on the surgery?</p>
<h2>The hip opp</h2>
<p>A hip replacement involves an incision to expose the hip joint and the placement of an acetabular component (the cup) and a femoral component (the stem). A head is then placed on the stem and a ball and socket joint is created that is the patient’s new hip.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/119049/original/image-20160418-23649-ww24al.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/119049/original/image-20160418-23649-ww24al.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/119049/original/image-20160418-23649-ww24al.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=576&fit=crop&dpr=1 600w, https://images.theconversation.com/files/119049/original/image-20160418-23649-ww24al.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=576&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/119049/original/image-20160418-23649-ww24al.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=576&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/119049/original/image-20160418-23649-ww24al.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=724&fit=crop&dpr=1 754w, https://images.theconversation.com/files/119049/original/image-20160418-23649-ww24al.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=724&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/119049/original/image-20160418-23649-ww24al.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=724&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A typical ball and socket artificial hip replacement.</span>
<span class="attribution"><span class="source">Ross Crawford</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Though very successful, the operation can be quite challenging to perform in <a href="http://www.sciencedirect.com/science/article/pii/S1877056812002952">certain patients</a> such as the very overweight and those with complex deformities due to childhood diseases or trauma. There is also a learning process for the surgeon in performing a hip replacement and it is hoped this can be shortened by using robotic technology.</p>
<p>Accurate positioning of the components of a hip replacement is important. Having the cup and stem in the correct position can decrease the chance of <a href="http://bonesmart.org/hip/hip-replacement-surgery-complications/">complications</a> such as dislocation, where the head comes out of the cup. Making sure the joint stem is located in a way to ensure optimal leg length may also lead to improved function of the new hip.</p>
<p>Currently, surgeons rely on their experience and judgement to correctly place the components of a hip replacement. Many studies have shown that even experienced surgeons can have difficulty in reliably and accurately placing the cup in the correct orientation. They sometimes find placement of the stem challenging too. </p>
<p>This is where a <a href="http://www.lafayettegeneral.com/services/orthopedics/makoplasty.aspx">robot can help</a>.</p>
<h2>The robot surgeon</h2>
<p>Up until now, the Australian experience of robotic orthopaedic surgery has been limited to <a href="https://patients.stryker.com/knee-replacement/procedures/partial-knee-replacement">partial knee replacements</a>. The first was <a href="http://www.sjog.org.au/hospitals/subiaco_hospital/about_us/media/latest_news/orthopaedic_robot.aspx">carried out in April last year</a>, and since then more than 280 of these procedures have been performed.</p>
<p>The first robotically assisted total hip replacement operation will take place today at Brisbane’s Holy Spirit Northside Hospital, and it’s likely such procedures will quickly become just as popular as the knee operations.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/119045/original/image-20160418-23622-12bgw8b.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/119045/original/image-20160418-23622-12bgw8b.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/119045/original/image-20160418-23622-12bgw8b.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1101&fit=crop&dpr=1 600w, https://images.theconversation.com/files/119045/original/image-20160418-23622-12bgw8b.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1101&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/119045/original/image-20160418-23622-12bgw8b.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1101&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/119045/original/image-20160418-23622-12bgw8b.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1383&fit=crop&dpr=1 754w, https://images.theconversation.com/files/119045/original/image-20160418-23622-12bgw8b.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1383&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/119045/original/image-20160418-23622-12bgw8b.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1383&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Stryker Mako advanced robotic arm that helps with the surgery.</span>
<span class="attribution"><span class="source">Stryker</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>So what is different with a robotic total hip replacement and where does the robot help?</p>
<p>The <a href="http://www.stryker.com/en-us/products/Orthopaedics/MakoRobotic-ArmAssistedSurgery/index.htm#">MAKO robotic system</a> is a carefully controlled robotic arm that aids surgeons in placement of the components of a total hip replacement. It makes the operation more accurate and safer for surgeons, regardless of their experience.</p>
<p>The main difference from a patient’s point of view is that a pre-operative <a href="https://en.wikipedia.org/wiki/CT_scan">CT scan</a> is needed to plan the procedure. Traditionally, surgeon relied purely on an X-ray to plan a total hip replacement. </p>
<p>When performed by a robot, planning for the procedure is done by specialist engineers in collaboration with the surgeon. The engineer and surgeon work together to determine the optimal position for the components and they create a plan. </p>
<p>The plan places the cup in the correct orientation to match the patient’s anatomy and the stem is also sized to fit the patient’s femur. The aim is to accurately restore the patient’s hip anatomy, particularly leg length.</p>
<p>Once the surgery begins, the surgeon exposes the hip joint in the usual way. Trackers are placed on the pelvis and on the femur allowing the robot to register these bones.</p>
<p>The trackers are attached to the bones using small posts with a screw thread on the tip. A series of points on the patient’s pelvis and femur are then registered and the robot creates a 3D representation that matches the CT scan.</p>
<p>Once the robot understands the geometry, it is able to follow any movement of the patient by the signal transmitted by the trackers fixed to the bones.</p>
<p>A cutting tool called reamer – somewhat like a powered round cheese grater – is attached to the robot and is used to prepare the bone to accept the cup. The surgeon holds the reamer but the robot constrains it and will not let the surgeon remove bone beyond the planned amount.</p>
<p>This will prevent any accidental damage to the bone and make sure the reaming can only occur as planned. Human error is removed from the preparation.</p>
<p>After reaming is finished, the cup is grasped by the robot and the robot sets the correct positioning. The surgeon then hammers the cup into the correct position in the pelvis. </p>
<p>They are able to monitor the position of the implant on the computer screen as it is “seated”. The cup cannot be driven in too far, as the robot constrains where the cup can be placed, as with the reamer.</p>
<p>Next the surgeon places a broach in the femur to prepare a cavity for the femoral component (stem). The broach can be tracked by the robot to make sure it is placed in the correct orientation and the patient’s legs are at the planned length.</p>
<p>Once happy, the surgeon cements the stem into where the broach was positioned, places a head on the femur and puts the head into the cup.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/fSU_R9mgeSg?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<h2>Who’s in charge?</h2>
<p>Though the robot is constraining the surgeon to execute the plan, the surgeon remains in charge at all times. The surgeon continues to carry all responsibility for the success of the operation and any complications.</p>
<p>This first step of robotically assisted total hip replacement is relatively easy. The robotic technology (robotics, navigation and haptics) being used is very mature. </p>
<p>But as we are seeing in many industries, the capability of robotics is expanding rapidly. It will not be long before the technology is advanced enough to <a href="https://www.theguardian.com/technology/2014/oct/10/medical-robots-surgery-trust-future">take over far more of the operation from the human surgeon</a>.</p>
<p>Then the big ethical questions will arise. Even now orthopaedic robots are being limited in what they can do because the step to autonomous surgery is currently a step too far.</p>
<p>Like <a href="https://theconversation.com/au/topics/driverless-cars">driverless cars</a>, the questions of liability and trust continue to be aired when discussing <a href="http://www.medscape.com/viewarticle/466691_4">robotic-surgery</a> or <a href="https://theconversation.com/robots-in-health-care-could-lead-to-a-doctorless-hospital-54316">health care</a>.</p>
<p>But also like driverless cars, robotic surgeons do not have to be perfect. They just have to be better than humans.</p><img src="https://counter.theconversation.com/content/57809/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ross Crawford receives funding from Stryker corp. the owner of the MAKO robotic hip system. </span></em></p><p class="fine-print"><em><span>Jonathan Roberts is an Associate Investigator with the Australian Centre for Robotic Vision.</span></em></p><p class="fine-print"><em><span>Anjali Jaiprakash 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>Thousands of hip replacement operations are performed each year, but today is the first time in Australia that a robot will help with the surgery.Ross Crawford, Professor of Orthopaedic Research, Queensland University of TechnologyAnjali Jaiprakash, Post-Doctoral Research Fellow, Medical Robotics, Queensland University of TechnologyJonathan Roberts, Professor in Robotics, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/473502015-09-10T20:10:27Z2015-09-10T20:10:27ZSurgeons take a scalpel to their own toxic culture<figure><img src="https://images.theconversation.com/files/94381/original/image-20150910-27328-anyrzq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Committing to genuine action to address the 'toxic culture' is a positive step, but the actual detox will require more radical surgery to some deeply held beliefs.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/s3a/462149592/in/photolist-GQCYq-39gBGe-7gd3qU-zVfQK-znHqu-8DSQXU-7FSvX-6mVBUi-9uQrNa-4gfVvC-7yvWLQ-7BUcXf-9Hxbo-7uVFhD-8EFqYG-9oSxFU-8ga91-6jGm54-6NgBjo-7vHe5k-99thqR-7BQrMX-r9VUqh-z92h8-abZPj-awTutL-xWHwb-aifhEs-awzjex-62q6No-8N96U9-4fbj4j-86toxV-CNzwU-cbYtrC-awTuH1-e1fxCt-5rS94Z-4gc1Cv-4gg1BC-4gfRK3-6DAv5D-3MH2t7-4YNXr6-mtjTUB-dgXDud-jHVaGJ-4g4ME7-hzwZYU-4LFjre">Jonathan/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>An independent <a href="https://www.surgeons.org/about/expert-advisory-group/reporting/">report</a> commissioned by the Royal Australasian College of Surgeons (RACS) released yesterday has found bullying, sexual harassment and discrimination are commonplace in the culture of surgeons. <a href="https://www.surgeons.org/news/racs-apologises/">Apologising</a> and committing to genuine action to address the “toxic culture” is a positive step, but the actual detox will require more radical surgery to some deeply held beliefs and a transplant of new attitudes about who is, and what it is to be, a doctor. </p>
<p>After reading news of the report in the morning, I found myself later in the day listening to a second-year medical student – let’s call her Jessica - describe the humiliating bedside teaching methods of a female clinician she’s nicknamed “The Trunchbull”*. She said:</p>
<blockquote>
<p>The most offensive part was that this all occurred in front of patients. You could even see the looks on the patients’ faces, willing us to get the questions right, as they knew the humiliation that was to ensue.</p>
</blockquote>
<p>We already know that <a href="https://www.mja.com.au/journal/2015/203/4/teaching-humiliation-and-mistreatment-medical-students-clinical-rotations-pilot">74% of Jessica’s peers</a> have had similar experiences. And we now know that if her training leads her down the surgical path, there’s a 58% chance Jessica will continue to be bullied and a 30% chance <a href="http://www.surgeons.org/media/22045685/EAG-Report-to-RACS-Draft-08-Sept-2015.pdf">she will be sexually abused</a> or assaulted. This figure is tragically in line with the 33% chance of such abuse <a href="http://www.ncbi.nlm.nih.gov/pubmed/24667512">described in earlier studies</a>. </p>
<p>And we know that if Jessica chooses to take action against her tormentors, she faces a <a href="http://www.smh.com.au/national/health/royal-australasian-college-of-surgeons-revelations-patients-complicit-in-promoting-surgeons-god-complex-20150909-gjitc6.html">30% chance it will continue unabated</a>.</p>
<h2>‘Toxic culture’</h2>
<p>The events of this year have left no doubt the culture of medical training in Australia is toxic. That <a href="https://www.beyondblue.org.au/docs/default-source/research-project-files/bl1132-report---nmhdmss-full-report_web">toxicity is killing doctors</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/23194748">it’s killing patients</a>. </p>
<p>The release of the RACS report was accompanied by contrition and <a href="https://www.youtube.com/watch?v=lm_YLicg9Sw">an apology from the college</a> about its own part in enabling this “toxic culture” to flourish. But demanding cultural change is one thing. Achieving it is quite another.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/lm_YLicg9Sw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The RACS apologises for discrimination, bullying and sexual harassment.</span></figcaption>
</figure>
<p>The college should be congratulated for taking the essential first step towards cultural change: acknowledging the existence and scope of the problem. They’ve also identified that there are still some surgeons who don’t believe these problems exist. </p>
<p>This mirrors much of the commentary of denial and victim-blaming around this issue in recent months. The deniers say, “It didn’t happen to me, therefore it doesn’t happen.” The victim-blamers suggest trainees are “whingers” and need to toughen up, or that they’re using their “<a href="http://www.australiandoctor.com.au/news/latest-news/women-doctors-accused-of-using-feminine-wiles-to">feminine wiles</a>” to get ahead. </p>
<p>Despite accepting all the report’s recommendations unequivocally, the next step for the RACS is much harder. It requires not just a new willingness to hold surgeons to account against revised policies and procedures, but also a frank scrutiny of the culture itself, especially its institutionalised norms and privileges.</p>
<h2>Social exclusion</h2>
<p>There’s a disturbing similarity between the statistics about negative health outcomes and experiences of abuse in medicine to those seen in other populations that experience high levels of social exclusion. Two notable examples are <a href="http://www.abs.gov.au/AUSSTATS/abs@.nsf/lookup/4704.0Explanatory+Notes1Oct+2010">Indigenous Australians</a> and <a href="http://www.glhv.org.au/files/PrivateLives2Report.pdf">people from sexual and gender minorities</a>. Social exclusion – the negative consequence of stigma and discrimination – causes mental distress, substance abuse, reduced access to health care and poorer health outcomes.</p>
<p>Surely doctors, especially surgeons, are not a marginalised or stigmatised group? They’re revered, trusted and highly valued by society. </p>
<p>Actually, what matters most within a culture is not how doctors are perceived by society, but how they perceive each other. And within the society of doctors, not all doctors are equal.</p>
<p>Medicine today is a complex, increasingly diverse, but still very hierarchical culture. But as recently as the mid-20th century, it was much more mono-cultural: predominantly white, Caucasian, affluent, heterosexual and male. That is no longer the case. </p>
<p>In 2012, three out of five employed doctors were men, but the number of women graduating is increasing at a greater rate than men. By 2025, 42% of the medical workforce will be female. About one-third of doctors received their original qualification in a country other than Australia and the average age of Australian doctors was 46. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/94354/original/image-20150910-4741-1q2elak.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/94354/original/image-20150910-4741-1q2elak.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=499&fit=crop&dpr=1 600w, https://images.theconversation.com/files/94354/original/image-20150910-4741-1q2elak.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=499&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/94354/original/image-20150910-4741-1q2elak.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=499&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/94354/original/image-20150910-4741-1q2elak.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=627&fit=crop&dpr=1 754w, https://images.theconversation.com/files/94354/original/image-20150910-4741-1q2elak.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=627&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/94354/original/image-20150910-4741-1q2elak.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=627&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Surgeons have traditionally been a male-dominated ‘in group’ with privilege and power – and a vested interest in keeping it that way.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/35168673@N03/3726556961/in/photolist-6Fizy6-dRuL4G-8smSSV-8WmTzE-8snYbH-8sr2gw-gojAYo-8sprAJ-bqTiHw-997ZeR-bpSduZ-8sprFW-8smTLD-8spW85-bVPN6N-8snrsx-dnh1LW-8spwpf-dngY3B-iUTx9E-8snr2i-8snYhc-8squRo-8snr7V-8sqst9-8sr2jE-8snrwD-8squFS-8squCS-8spZpA-8spZhf-8smVw2-8spYfs-8spYjh-8smtjZ-8spY73-8smUsv-8spXth-8spXgd-8smSFz-8smt8k-8smopi-8snrFg-8smVRB-8squKE-8spZ1h-h9md1-8spZcq-p6QEPc-8smowB">tiffany terry/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>But despite their significant numbers at graduation, women still make up only about 25% of the specialist workforce and only 24% of those are in surgical specialities. Even <a href="https://www.hwa.gov.au/sites/uploads/australias_health_workforce_series_doctors_in_focus_20120322.pdf">with increasing diversity</a>, the dominant medical culture in Australia remains skewed against the young, the female and the foreign. </p>
<h2>The nature of privilege</h2>
<p>To understand how a privileged group can be marginalised, we first have to understand privilege: the advantages available to members of the dominant group, such as resources and power, that are not available to others. To an outsider, that would look like all doctors. But insiders know “some doctors are more equal than others”. </p>
<p>Doctors are an “in group”. Within “in groups”, we recognise other members as being diverse individuals, but we also measure them against their conformity with the dominant cultural norms of the group. Younger women and people with diverse identities, in particular, risk falling short of the prevailing standard despite their medical competency.</p>
<p>Privilege is often invisible to those who have it and they have a vested interest in keeping it that way. It’s invisible because it constitutes what the group deems as “normal” or “ordinary” – and so it remains unexamined. Those who have it are often unable to see that others do not, or <a href="http://dro.deakin.edu.au/view/DU:30029495">blame those who do not</a> as somehow deficient or to blame for their situation rather than critically examining their own.</p>
<p>Once privilege is established, it’s not even necessary for individuals to actively oppress others. The institutionalisation of cultural norms effectively reinforces the exclusion of non-conformers and also makes it difficult for them to challenge their oppressors. </p>
<p>Medicine is not alone among Australian workplaces in its experience of bullying and harassment, but the stakes are higher there. Students like Jessica fail to learn, individual competency and work performance are affected, team morale declines and ultimately <a href="https://www.mja.com.au/journal/2015/203/4/not-so-innocent-bystanders">patient safety is threatened</a>. </p>
<p>The time for talking is over. The results are in. Yes, the problem is real. The authors of the RACS report note:</p>
<blockquote>
<p>Long-established traditions that have been inherited and have normalised unprofessional, and sometimes illegal, behaviours must be relinquished … Everyone involved in the practice of surgery … has a role in leading the way.</p>
</blockquote>
<p>The process of change will be similarly slow and as painful as breaking down the institutionalised discrimination against Indigenous and sexual and gender minority people. But it will happen. In the meantime, none of us – neither doctors, other health workers, nor patients – can remain silent or pretend to be innocent bystanders.</p>
<hr>
<p><em>* Miss Agatha Trunchbull, also known simply as “the Trunchbull”, is the fictional bullying headmistress of Crunchem Hall Primary School and main antagonist in Roald Dahl’s book, Matilda.</em></p><img src="https://counter.theconversation.com/content/47350/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kimberley Ivory receives funding from the Harold and Gwynneth Harris Endowment for the Medical Humanities.</span></em></p>An independent report commissioned by the Royal Australasian College of Surgeons (RACS) released yesterday has found bullying, sexual harassment and discrimination are commonplace in the culture of surgeons…Kimberley Ivory, Senior Lecturer, Population Medicine and Sub-dean Student Support, Sydney Medical School, University of SydneyLicensed 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.