I have, over the last couple of weeks been giving a little advice to others about Locum work and some of the problems experienced. Learning, generally, is the gaining of knowledge from someone of experience willing to share that experience, whether it be "scientific truths", anecdote, or the admission of mistake in the hope the learner will not be required to make the same mistakes.
Check list :
1) register yourself for an ABN and register for GST. You can register as a sole trader, you do not need an additional company entity, however you must seek financial advice on your options and what best suits your personal situation.
https://abr.gov.au/abrweb/default.aspx?pid=71
2) register for Medicare HPOS and obtain a PKI security dongle. This will allow you to apply for a provider number online and receive it within minutes, as long as you have no provider number restrictions. This is a personal identifier, do not let anyone else use it or access HPOS with your log on.
http://www.medicareaustralia.gov.au/provider/business/online/register/apply.jsp
Update June 2016 : PRODA is now the best way to access HPOS
https://proda.humanservices.gov.au/pia/pages/public/registration/account/createAccount.jsf
3) choose a Locum agency, one with a good reputation and preferably one that comes highly recommended by a colleague you trust. Talk to someone at the agency, don't apply yet, just talk, get information and get a sense whether or not you are happy to work with the agency. Remember you are a valuable commodity to the agency, their survival depends on the commissions generated by the work you do via their referrals. Get on their email list and then sit back and observe two things. The frequency of communications and the quality of placements being offered. Don't be in a rush, sit back and wait ... you will have other things to be doing while you wait. Get yourself on the email list of two other agencies and do the same, wait and observe. Do not be in a rush to commit.
4) While you are waiting, create a Resume/CV ... it needs to be the perfect generic CV that clearly summarizes your training and experience from the moment you entered medical school. It must be clear, succinct and easy to read. First impressions count. Get some professional advice on how to write your CV, the money paid for this will be returned tenfold and more.
http://careers.bmj.com/careers/advice/view-article.html?id=3043
5) Get two references from contemporary professional peers, written by your referees and with those referees willing to be spoken to by both the agency and prospective "employers". Your referees need to be able to confirm intimate knowledge of your professional skills in the area of work you are seeking. Whenever your reference is 12 months old, get new ones, and if possible renew them every 6 months.
6) Gather 100 points of identification documents.
http://www.transport.nsw.gov.au/content/100-point-check-proving-your-identity
7) Gather your original qualification documents - ie. your graduation certificate and your FRACGP or equivalent.
8) find a JP near where you are. Don't stuff around with other people for document certification, some places will only accept a JP certified copy.
http://australia.gov.au/topics/law-and-justice/justices-of-the-peace
... or "google" find a JP and choose the finder site for your state.
9) Make six copies of your 100 points of ID documents and six copies of your qualification documents. Call a JP nearby and ask for an appointment to have documents certified. JPs don't get paid to do this job so be polite and accept the possible inconvenience of the timing of that appointment. Don't take shortcuts and get a non-JP to certify the documents.
10) Get a Federal Police check done .. Yes, at your expense. This will consume your first set of ID documents.
http://www.afp.gov.au/what-we-do/police-checks/national-police-checks.aspx
11) Book yourself in for an advanced life support course.
12) By now you will have received a number of emails from your chosen agencies. Remember you have not committed yet, just receiving email lists of Locums available. Is there a state you would prefer to travel to? Pick one .. best to start with just one. Do you choose based on where you would like to travel? Do you choose based on the type of work available? Do you choose based on the amount paid?
13) Now you have chosen which state you want to do your first Locum, get a state Working With Children Clearance. Go on, "google" it. Yes, this too is at your expense. Each state has their own and will be valid only in that state. The following link is only as an example - it is for the Northern Territory and will only be valid for NT.
http://www.workingwithchildren.nt.gov.au/
14) no, you are not ready yet ... if you has reached frustration point already, leave now ... you are not suited to Locum work.
15) find yourself a simple invoice generator (eg software for PC, app for mobile device) ... ask around to find out what is out there and make sure you know how to use it.
16) Now is the time to choose your Locum agency. Choose one and stick with them. Make it clear to them you are committing to just them and you expect a high level of service for that commitment, but don't hesitate to move on if you are not happy. The agent will send you the registration package that will have at least a dozen pages of application paperwork, including declarations and providing proof of immunization status. This is likely to be needed if you are working with or in association with any hospital service, even small regional hospitals that the GP clinic provides medical services to.
17) By this time you will realise you will need access to a fax machine and or scanner. Get one for your home if you don't already have access to one elsewhere. Also find a means of storing copies of all your documents in the "cloud" so you can access them whilst traveling.
18) Once your Locum agent has indicated that all the paperwork is complete including consuming a full set of your certified documents, you are almost ready to choose your first Locum placement.
19) Almost, because you need financial savings to cover at least the period of time you are doing the Locum and then some more. Choose a short Locum for your first one, in your travel comfort zone. Expect to travel initially without your family ... not all places provide suitable family accommodation, and very rarely do they cover family member expenses of any sort. If your first placement is for two weeks, double that for a savings."cushion" to live off. Make sure you have enough to live on for at least the period you are away. Do not expect prompt payment. Many will pay promptly but don't allow yourself to be dependent on prompt payment for your family's financial survival in case a delay in payment does happen.
20) Now wait for that Locum placement that ticks all your boxes in terms of where and when. When it comes, express an interest with your agent but ask details of where, who for and if another Locum has been there and given feedback. Then if it suits, double check the arrangements for travel, accommodation, vehicle if provided, and timing of payment of invoices. Then, if still happy, ask the agent to put forward your details for consideration and patiently wait.
Give very serious consideration to getting legal advice on all the contracts you sign, before you sign and make sure your level of medico legal insurance will cover the type of work expected of you.
Enjoy your foray into Locum work. It provides variety, experience and opportunity to travel like no other. And remember to be joyful for the opportunity you have been given. And please, give consideration to prioritizing your work in rural areas ... rural doctors always need assistants. You never know, you may find a place of heaven you may wish to move to longer term.
Friday, February 22, 2013
Thursday, February 21, 2013
2012
Twelve months go by and it is time to review the year that was. 2012 began with 2011 Christmas and New Year in Julia Creek and then almost three weeks in Normanton, both under the auspices of the Mt Isa health district of Queensland Health.It was also the year I started a little photographic project, taking a photo every day for the year of 2012 and unimaginatively called it "Project 366".
You can find the link to the final product here ... on my Facebook page.
It was a full year. I entered into a challenging financial arrangement by purchasing a high end property in a fast falling market (ie. bought at about about 70% of the building cost) which has now stabilised but has a high mortgage to service for the next 5 years before settling to a basic interest/principle repayment system. I deliberately loaded repayments at the front end to minimise risk if the valuation goes pear shaped. As a result any non-full-time working life has been pushed to about 15 years into the future, which suits a "standard" retirement age rather than "early" retirement and gives me a more focussed approach to work planning.
So yes, 2012 was a full year. Julia Creek, Normanton/Karumba, Gin Gin, Gladstone (Indigenous health), Clifton, Cooktown (incl Wudjal and Hopevale), Orbost, Gladstone (hospital ED), Innisfail (2.5 months), Brisbane Northgate, Yulara (2.5 months) and for the first time in a few years, spent Christmas at home.
The year was professionally and emotionally challenging. Firstly my Queensland Health state-wide credentialling was up for renewal and there was talk about an "unfavourable reference" that, of course, all refused to give me details of what and who for "privacy reasons" and for a period of about ten days I discovered what sleepless nights was all about.
At the same time a locum that was pre-booked and already contracted to the Mt Isa hospital ED was cancelled without explanation other than talk about my credentialling being renewed and the "unfavourable reference".
As it eventuated, my credentialling was renewed and shortly afterwards I was given a Queensland Health job for two weeks in Cooktown.
As the year progressed it became more obvious that I had been "banned" from working in the Mt Isa district, without explanation, without formal notification and without recourse. In a petty sort of way, I got enjoyment from the fact that the $1300 airfare that Mt Isa paid in advance for my locum that was cancelled was actually not recovered by the Mt Isa district but lost because no one cared to follow up the cancelled locum's expenses. We hear about financial mismanagement within Queensland Health, this was just a small example of financial carelessness.
The medical director of Mt Isa hospital rang and welcomed me to the district during my Julia Creek placement but did not show any sort of professional courtesy in letting me know why he refused to allow me back into the district after my Normanton placement.
To the best of my knowledge there has been no formal complaint to the Medical Board about my professional competence, there has been no formal complaint to the Health Services commissioner, there has been no formal complaint to the Queensland Health Director General. Simply a "you cannot work in the Mt Isa district".
I have pondered for almost the whole year how to address this issue. I have come to the conclusion it was a reaction to my harsh and quite verbal criticism of the standard of care being provided to the community of Normanton and Karumba. A standard of care that was in my less than humble opinion, substandard, unsupervised and delivered by someone who showed disrespect for other people around them. The staff of the clinic and local hospital feared to speak up, and the community (85% indigenous) did not like him and dreaded his return each time a locum who covered his leave left.
I drafted on more than one occasion a letter of concern to be addressed to the area Medical Director (Mt Isa), to the Queensland Health Director General and to the Australian "medical board" AHPRA.
I ended up leaving it as a detailed and harsh appraisal through the locum agency.
I feel sad for the community of Normanton, but the standard of health care in the world is not my personal responsibility - I simply provide the best I can where-ever I am at the time.
During the year of 2012 I had the good fortune to meet someone who knew the circumstances in Normanton personally and her experience was not too dissimilar to mine and from that time I felt a little more comfortable that my assessment of the standard of service provided in Normanton was pretty close to the mark, not purely personal bias.
About mid-year, I went back to Gladstone Hospital ED to revisit a place I had become fond of years earlier. It was an experience that left a bitter taste in my mouth.
Most of the good nursing staff had left (and continued to leave later in the year), all the good doctors had left, as had the personal assistant to the Medical Superintendent and the hospital was still managed by a "locum" Medical Superintendent who I found hard to be convinced was actually serving the hospital's best interests. The welcome to me from the Med. Super. was to pass on a petty, unfinished business from two years earlier where I was accused (inappropriately) of leaving my accommodation in a mess and he instructed me that this must not happen this placement. He in fact interrupted my attempt at explanation and with that I knew this whole experience was not going to go well.
A "primary care clinic" was set up as a trial alternative for lower acuity emergency department patients in preparation to create a Medicare scam to have patients who otherwise should have had their care funded by the hospital (state funded) to be funded at least in part by Medicare billing (federal funds). The state vs federal war has been going on for decades, but I was not happy being placed in an, in my view, immoral setup that was incompetently managed with dysfunctional workflow. I made my views clear, including to a unit manager who had the audacity to complain to me that the wait time was too long when 8 patients who all turned up to ED at about 8:30am were all triaged to my "primary clinic" queue (single doctor) whilst the ED was empty of patients and two doctors were sitting on their arse doing nothing.
I was also, under duress, required to complete a purely theoretical training package to "accredit" me to perform procedural sedation. I pointed out that a theoretical training package without any practical component was in fact potentially dangerous ... and not surprising, something that again they did not want to hear. I answered the "test essays" truthfully and listed the minimalist approach I would take based on my lack of anaesthetic training and skills and received absolutely no feedback despite assurances by the "medical trainer" that I would.
My second week was, without prior notification, a week of night shift, solo senior doctor not only in the emergency department, but for the whole hospital. Could I keep my mouth shut ? No, of course, and it came to a crisis point that despite the hospital knowing well in advance I was flying out on the Friday morning they had rostered me on the overnight Thursday night shift. I refused to work the shift.
The reference I received, not surprisingly suggested that I was "unsuitable for emergency department work". Yes, I am old and grumpy enough to not tolerate substandard and under-resourced health care systems. Once again, not a formal complaint to the Medical Board or the Health Services Commissioner about my competence as a doctor, just simply a closure of another door because I was outspoken enough about perceived competency and service level deficiencies at such a level to be potentially dangerous for patient care.
In the context of consistently positive references for the previous four years, and the rest of my 2012 references of a similar high standard, I was confident that it was my lack of "keeping my mouth shut" that resulted in a process where the assailed became turtles and sought to deny me further access to the ability to observe system and possible personal failings.
Yes I am arrogant ... my role as patient advocate drives me to speak out against injustice.
So, with needing two emergency department references to work in emergency departments and without two references I could not work in emergency departments to actually obtain the necessary two references, it was clearly time to move on.
2012 and the early part of 2013 has reinforced my desire to continue to work supporting communities in rural and remote Australia that lack good quality health care services and confirmed that doing locum work is still a privileged way to see Australia, especially when I am paid to do it and when Lesley, my wife, has the opportunity to travel with me any time she chooses.
I make a final note of my 2012 experiences that I am greatly honoured to have spent 10 weeks in the country around Uluru and Kata Tjuta, central Australia. I acknowledge with heart felt thanks the traditional owners of the land and the elders of the Anangu people.
You can find the link to the final product here ... on my Facebook page.
It was a full year. I entered into a challenging financial arrangement by purchasing a high end property in a fast falling market (ie. bought at about about 70% of the building cost) which has now stabilised but has a high mortgage to service for the next 5 years before settling to a basic interest/principle repayment system. I deliberately loaded repayments at the front end to minimise risk if the valuation goes pear shaped. As a result any non-full-time working life has been pushed to about 15 years into the future, which suits a "standard" retirement age rather than "early" retirement and gives me a more focussed approach to work planning.
So yes, 2012 was a full year. Julia Creek, Normanton/Karumba, Gin Gin, Gladstone (Indigenous health), Clifton, Cooktown (incl Wudjal and Hopevale), Orbost, Gladstone (hospital ED), Innisfail (2.5 months), Brisbane Northgate, Yulara (2.5 months) and for the first time in a few years, spent Christmas at home.
The year was professionally and emotionally challenging. Firstly my Queensland Health state-wide credentialling was up for renewal and there was talk about an "unfavourable reference" that, of course, all refused to give me details of what and who for "privacy reasons" and for a period of about ten days I discovered what sleepless nights was all about.
At the same time a locum that was pre-booked and already contracted to the Mt Isa hospital ED was cancelled without explanation other than talk about my credentialling being renewed and the "unfavourable reference".
As it eventuated, my credentialling was renewed and shortly afterwards I was given a Queensland Health job for two weeks in Cooktown.
As the year progressed it became more obvious that I had been "banned" from working in the Mt Isa district, without explanation, without formal notification and without recourse. In a petty sort of way, I got enjoyment from the fact that the $1300 airfare that Mt Isa paid in advance for my locum that was cancelled was actually not recovered by the Mt Isa district but lost because no one cared to follow up the cancelled locum's expenses. We hear about financial mismanagement within Queensland Health, this was just a small example of financial carelessness.
The medical director of Mt Isa hospital rang and welcomed me to the district during my Julia Creek placement but did not show any sort of professional courtesy in letting me know why he refused to allow me back into the district after my Normanton placement.
To the best of my knowledge there has been no formal complaint to the Medical Board about my professional competence, there has been no formal complaint to the Health Services commissioner, there has been no formal complaint to the Queensland Health Director General. Simply a "you cannot work in the Mt Isa district".
I have pondered for almost the whole year how to address this issue. I have come to the conclusion it was a reaction to my harsh and quite verbal criticism of the standard of care being provided to the community of Normanton and Karumba. A standard of care that was in my less than humble opinion, substandard, unsupervised and delivered by someone who showed disrespect for other people around them. The staff of the clinic and local hospital feared to speak up, and the community (85% indigenous) did not like him and dreaded his return each time a locum who covered his leave left.
I drafted on more than one occasion a letter of concern to be addressed to the area Medical Director (Mt Isa), to the Queensland Health Director General and to the Australian "medical board" AHPRA.
I ended up leaving it as a detailed and harsh appraisal through the locum agency.
I feel sad for the community of Normanton, but the standard of health care in the world is not my personal responsibility - I simply provide the best I can where-ever I am at the time.
During the year of 2012 I had the good fortune to meet someone who knew the circumstances in Normanton personally and her experience was not too dissimilar to mine and from that time I felt a little more comfortable that my assessment of the standard of service provided in Normanton was pretty close to the mark, not purely personal bias.
About mid-year, I went back to Gladstone Hospital ED to revisit a place I had become fond of years earlier. It was an experience that left a bitter taste in my mouth.
Most of the good nursing staff had left (and continued to leave later in the year), all the good doctors had left, as had the personal assistant to the Medical Superintendent and the hospital was still managed by a "locum" Medical Superintendent who I found hard to be convinced was actually serving the hospital's best interests. The welcome to me from the Med. Super. was to pass on a petty, unfinished business from two years earlier where I was accused (inappropriately) of leaving my accommodation in a mess and he instructed me that this must not happen this placement. He in fact interrupted my attempt at explanation and with that I knew this whole experience was not going to go well.
A "primary care clinic" was set up as a trial alternative for lower acuity emergency department patients in preparation to create a Medicare scam to have patients who otherwise should have had their care funded by the hospital (state funded) to be funded at least in part by Medicare billing (federal funds). The state vs federal war has been going on for decades, but I was not happy being placed in an, in my view, immoral setup that was incompetently managed with dysfunctional workflow. I made my views clear, including to a unit manager who had the audacity to complain to me that the wait time was too long when 8 patients who all turned up to ED at about 8:30am were all triaged to my "primary clinic" queue (single doctor) whilst the ED was empty of patients and two doctors were sitting on their arse doing nothing.
I was also, under duress, required to complete a purely theoretical training package to "accredit" me to perform procedural sedation. I pointed out that a theoretical training package without any practical component was in fact potentially dangerous ... and not surprising, something that again they did not want to hear. I answered the "test essays" truthfully and listed the minimalist approach I would take based on my lack of anaesthetic training and skills and received absolutely no feedback despite assurances by the "medical trainer" that I would.
My second week was, without prior notification, a week of night shift, solo senior doctor not only in the emergency department, but for the whole hospital. Could I keep my mouth shut ? No, of course, and it came to a crisis point that despite the hospital knowing well in advance I was flying out on the Friday morning they had rostered me on the overnight Thursday night shift. I refused to work the shift.
The reference I received, not surprisingly suggested that I was "unsuitable for emergency department work". Yes, I am old and grumpy enough to not tolerate substandard and under-resourced health care systems. Once again, not a formal complaint to the Medical Board or the Health Services Commissioner about my competence as a doctor, just simply a closure of another door because I was outspoken enough about perceived competency and service level deficiencies at such a level to be potentially dangerous for patient care.
In the context of consistently positive references for the previous four years, and the rest of my 2012 references of a similar high standard, I was confident that it was my lack of "keeping my mouth shut" that resulted in a process where the assailed became turtles and sought to deny me further access to the ability to observe system and possible personal failings.
Yes I am arrogant ... my role as patient advocate drives me to speak out against injustice.
So, with needing two emergency department references to work in emergency departments and without two references I could not work in emergency departments to actually obtain the necessary two references, it was clearly time to move on.
2012 and the early part of 2013 has reinforced my desire to continue to work supporting communities in rural and remote Australia that lack good quality health care services and confirmed that doing locum work is still a privileged way to see Australia, especially when I am paid to do it and when Lesley, my wife, has the opportunity to travel with me any time she chooses.
I make a final note of my 2012 experiences that I am greatly honoured to have spent 10 weeks in the country around Uluru and Kata Tjuta, central Australia. I acknowledge with heart felt thanks the traditional owners of the land and the elders of the Anangu people.
PS ... as a gentle reminder to younger doctors who's career is dependent on whose arse you lick and turn a blind eye to, seek legal advice if you are ever to "open your mouth" against injustices and medical incompetence. You have a difficult choice to make.
Thursday, September 20, 2012
More from The Conversation
Man v mountain: how to overcome the evidence overload
By Joseph Ting, University of Queensland
Most doctors shudder at the sight of the growing mountain of unread medical journals gathering dust on their desks over months, if not years. They need not despair though, as there are less time-consuming ways to keep up-to-date than meticulously working your way through the journal pile.
Of course, one could simply walk away from the threat posed by the information overload avalanche, cancel journal subscriptions, not buy the latest medical textbooks or ship the lot to a needy medical library. But the out-of-sight out-of-mind approach risks the doctor being left behind.
Doctors are expected to be attuned to the latest developments in health care, keeping pace with extremely well-informed patients. The rhetoric of medical research underpinning optimal health care is incompatible with the grinding reality of busy work life.
So our lassitude with keeping up to date with the latest research is, we believe, excused by busy clinical practice and the accelerating pace of modern life. And the flood of new evidence gives clinicians only a remote chance of breaking the surface and catching breath, let alone reaching the summit of the journal mountain.
What’s more, doctors may not be able to confidently recognise and understand important and reliable developments, let alone decide on their relevance to patient care. Most remain unenamoured of the bruising and seemingly irrelevant encounters with statistics and research methods from their undergraduate years.
And after a long work day, a demanding journal article can’t compete with relaxation and family time. Serious engagement with an article is, for most of us, not conducive to rest and recreation.
Two decades after leaving medical school, my enthusiasm about the latest issue of the New England Journal of Medicine often extinguishes the fire of work tearoom conversations. Like-minded colleagues (those unshackled from the entrenched cultural disdain for research) are a rare species found only at journal clubs, teaching hospitals, medical schools and conferences.
Time constraints and apathy aside, there’s the other not inconsequential problem of discerning crop from chaff in the research. How to keep up with the latest research relevant to one’s clinical practice and verify what’s claimed by new drugs, tests and technology?
But keeping abreast of the latest research is important because doctors can’t deliver the latest evidence-based health care if they’re not aware of it. Patients benefit from doctors keeping up to date and being knowledgeable about recent studies that are reliable as well as being relevant to clinical practice.
Treatments evolve rapidly and established drugs and procedures may turn out no better than placebo. Doctors also need to be vigilant about newly discovered side-effects or harm resulting from reputable treatments.
Careful scrutiny of drug-company sponsored clinical trials could lead doctors to the conclusion that exciting but expensive new treatments are not superior to reliable old work horses. Sponsored studies may ignore comparisons with long-established effective drugs (there’s little income in established patent-expired drugs).
If only doctors had the time at work (preferably paid and without clinical obligation) and the necessary skills to assess the methodological robustness of a study, decipher its findings and apply its conclusions to patients. Such favourable conditions are rarely available outside the journal club, postgraduate training, teaching hospital and medical school.
If health executives really care about research bearing relevance to patient care in ambulatory and community practice, they need to fund doctors to train in appraising the quality of what they read and pay them for the time spent keeping up to date. Better informed doctors are likely to deliver better care and dividends in improved care will likely outgrow remuneration to doctors.
Ultimately, there’s nothing better than scrupulous journal reading or attending conferences to stay in touch with the latest research evidence. But alternative strategies for the time-poor include:
- Participation in specialist college on-line continuing medical education activities or moderated clinical topic websites;
Attending non-sponsored local hospital medical education sessions is difficult as they are scheduled within office hours so webcasts can offer flexibility;
Registering for e-list-servers of research relevant to their work (including abstracts and selected editorials) and e-alerts of the contents for major general medical and sub-speciality journals;
Reliably moderated medical guidelines and texts (many available online) such as Up-to-Date, e-Therapeutic Guidelines. These circumvent the need to assess the primary studies individually; and
Adhering to the latest treatment guidelines from learned entities such as the Acute Coronary Syndrome recommendations of the National Heart Foundation and acute asthma strategies from the National Asthma Foundation.
Burgeoning health-care evidence needs to be efficiently delivered to doctors caring for patients in digestible allotments that will not prove overwhelming. This involves communicating information relevant to their clinical practice or specialty, in a format and schedule compatible with achieving balance in a doctor’s work and personal life.
Paying doctors for non-clinical time to learn about the latest evidence is a good start. Even if one has not assessed the original studies, investigation and treatment summaries updated with newly emerging clinical research provides a short-hand way for ensuring patients receive the best of care.
Joseph Ting received funding from ARC Linkage Grant for Emregency Health Services Qld Study 2007-2011.
This article was originally published at The Conversation. Read the original article.
Friday, March 9, 2012
Reproduced from "The Conversation"
What Australia should do about prescription opioid misuse
Knowing the dose of the tablet means overdoses are less common than with heroin.
d ab d z/Flickr
The Electronic Recording and Reporting of Controlled Drugs system will be made available to doctors, pharmacists and state and territory health authorities across Australia to monitor the prescribing and dispensing of addictive drugs in real time.
Before the government moved toward national implementation, this system was tried out in Tasmania and evaluated favourably.
Consumption trends
Consumption of these drugs began earlier and increased faster in the United States. Overdose deaths from prescription opioids there first outnumbered such deaths from heroin and cocaine in 2000. That gap has steadily widened in the past ten years. And more and more people in the United States struggling with dependence on prescription opioids have been coming forward to seek help.So we know the pattern of what would happen in Australia if we allowed consumption of prescription opioids to keep increasing. Canada and the United Kingdom have also reported similar developments to Australia.
Road to problems
Doctors prescribe opioids to treat pain from cancer, acute pain (such as after an operation or heart attack) and chronic pain not due to cancer. They’re usually very effective for the first two sorts of conditions but nowhere near as effective for the latter.In Australia, prescriptions for opioids are obtained by a relatively small number of people who visit a large number of doctors to obtain huge quantities of these drugs. Profits from selling the drugs on the black market are very high because people who enjoy taking opioids for recreational purposes have found heroin a little harder to purchase since a heroin shortage started in Australia in 2000.
Another contributing factor to the increasing use is the growing difficulty in recent years of getting on to methadone and buprenorphine programs. There are no votes in funding these forms of treatment, even though 70% of the community now support them.
So, many heroin users have started buying prescription opioids from the black market, crushing these tablets and injecting them. Overdoses are less common than with heroin because, unlike street heroin, the dose of the drug in tablets is known.
Effective interventions
Australian health authorities have known all this for a while. But it’s a complex problem that crosses commonwealth, state and territory governments. And within each department of health, several sections have to be involved.There’s no silver bullet but a number of strategies will help, especially if some leadership is applied to the problem. Unfortunately, leadership is a scarce commodity in Australia’s current volatile political climate, with attempts at major health-care reform taking up a lot of time.
And we are now moving to a national real-time, web-based data system for prescriptions. That will help, but efforts to stem the supply of drugs in the face of strong demand, while politically irresistible, often promise more than they end up delivering.
Important steps
Improving the treatment of chronic non-cancer pain will have to be part of the solution.Most of this treatment is provided by general practitioners. While Australia has a surfeit of excellent guidelines for treating chronic non-cancer pain, none are written by general practitioners for general practitioners.
We also need a whole system for training allied health professionals to help manage chronic non-cancer pain with non-pharmacological treatments. But there’s no training course, no qualification and no way of funding this at present. So general practitioners will continue to prescribe large quantities of prescription opioids while treating chronic non-cancer pain.
Other options
Expanding methadone and buprenorphine treatment and making these more affordable to drug users, who generally have low-incomes, would also make the black market for prescription opioids less lucrative.We need to develop a new treatment system for people struggling with dependence from prescription opioids. While there’s some overlap with the population using heroin, some of the people who develop problems with prescription drugs are quite different from heroin users.
A national policy for prescription opioids and benzodiazepines is now being prepared and this is a positive step since Australia has never had a policy covering these drugs. It seems ironic that these legal drugs have been ignored for so long. Many of the people who enjoy taking prescription opioids and heroin recreationally also take benzodiazepines.
Path least travel
In the alcohol and drug field, the politics of implementing effective responses are generally much more complex than working out the right public health interventions. And the cost of politically attractive policies that don’t work is getting harder to bear in an era when government budgets are stretched to breaking point.The lesson of Australia’s heroin epidemic of the 1990s was that politicians must start getting serious when increasing numbers of deaths begin occurring among middle-class kids.
This effort by the Federal government to create a national electronic record system for prescription opioids is a step in the right direction. But unless it is supported by a range of other measures, there is a risk that it will send us backwards. Supply measures are easy to sell to the public but are often disappointing and sometimes seriously counter productive.
This article was originally published at The Conversation. Read the original article.
Thursday, February 23, 2012
Lying to patients
This is a transcript of a video presentation on Medscape. Medscape is a site that requires registration and logging in, so I reproduce the transcript here to permit wider observation and discussion.
Lying to Patients: No Huge Ethical Failure, Says Bioethicist Arthur L. Caplan, PhD
I am Art Caplan, and I am at the University of Pennsylvania in the Department of Medical Ethics and Health Policy. Today I would like to talk to you about a pretty thorny subject and one that is fascinating because it is so ethically rich: Should doctors ever lie to their patients?
Lying to Patients: No Huge Ethical Failure, Says Bioethicist Arthur L. Caplan, PhD
I am Art Caplan, and I am at the University of Pennsylvania in the Department of Medical Ethics and Health Policy. Today I would like to talk to you about a pretty thorny subject and one that is fascinating because it is so ethically rich: Should doctors ever lie to their patients?
The trigger for this discussion is a study that just came out that found that doctors do lie. In fact, the study found that 20% of more than 2000 doctors surveyed admitted that they had not told patients the truth when an error had taken place. They found out that more than 10% hadn't discussed financial conflicts of interest, and 15% said they gave a rosier picture about prognosis and risk and benefit with respect to a disease.
There has been a good deal of interest in this survey, and the public and some media reports are saying that this is shocking. We expect our physicians to always be truthful; this survey apparently shows that there is a considerable amount of lying going on, withholding of the truth, and not being forthright. What's wrong? Is there a huge ethical failure going on out there among doctors and medical practitioners?
The answer is no. It is inexcusable and not advisable to lie about an error. You may dodge a bullet on that one by having the patient not find out, but if it really affects their care, if they wind up harmed, if they wind up having to pay more and it comes out later that you didn't tell the truth or that there was an omission of the fact that an error occurred, you are going to get clobbered. I have seen it again and again in courtrooms. It may seem the easiest way out, to avoid telling the truth when an error takes place, but getting it out there and getting it over with early is the best protection in terms of malpractice associated with error. It isn't lying.
With respect to financial conflict of interest, patients have a right to know about it, and it should be brought up. But a lot of patients don't care, so you can get around that very quickly. You don't have to lie or withhold information. You can simply offer the patient the opportunity to know that you see a lot of drug representatives or that you went out to dinner and learned about this drug, and they probably will say, "Doctor, I don't care. What do you think is the right thing for me to do?" Making the offer is a better way to deal with something that a lot of patients don't think is all that important.
What about that circumstance in which a better prognosis is offered than is really the case for the patient? That circumstance, and a couple of other topics, are real ethical gray zones. It is not as clear that lying is always bad. Think about the use of a placebo. If you think that you can save a patient money and save them a lot of risk and side effects by giving them a placebo to see if it will calm their anxiety or help restore their sexual function, I am not sure that it is always wrong to prescribe a placebo. It is controversial, but I am not sure one is always wrong in trying to deal with a difficult or noncompliant patient, or one who has a bad, unhealthy lifestyle.
Is it wrong to "up the ante" a little bit and scare the patient more than you might otherwise about the consequences that might follow from their bad behavior? I am not sure that that is wrong either. The goal is good, and by being a little bit on the far end of the truth about what could happen to them, I am not sure that it isn't worth it. With respect to the "rosy prognosis," if someone has cancer or Parkinson disease or Alzheimer disease, I'm not sure that they want to hear in the first visit exactly what is going to happen to them or the grim nature of the statistics.
You might say that telling the truth is a noble thing to do, an important thing to do, and it is the way that we are going to keep patients trusting the doctor. At the same time, however, truth is not an event; it is a process. The survey may have failed to capture that insight. Telling the truth is important, but letting it come across in a humane way, letting it come across sometimes in "dribs and drabs" so that the patient can absorb it and not be psychologically devastated or emotionally harmed, is the right thing to do.
So, don't lie about mistakes, don't lie about conflict of interest, and be forthright when things go wrong. When there is a reason not to be trusted, let the patient decide how they want to manage that. Truth is a better policy. In some other areas, the truth, although it ought to come out eventually, is probably something that is more of a tool to be worked with in trying to help patients than it is an absolute necessity all of the time.
I am Art Caplan at the University of Pennsylvania. Thanks for watching.
Friday, February 17, 2012
Visit the outback's mechanical victims
Visit the outback's mechanical victims - ABC Southern Queensland - Australian Broadcasting Corporation
Just a little light diversion from medical, but a look at the outback that many of us "out here" are familiar with.
Tuesday, February 14, 2012
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