AMD Newsletter 27 July 2018
In my second post I discussed the pressures facing trainees in the hope of opening a conversation about how we might address them. The response I have received has been overwhelming, with dozens of deeply thoughtful comments from trainees and Fellows, including moving accounts of personal experiences and multiple suggestions for practical action.
I would like to use the present opportunity to summarise the main ideas that have been expressed. I will also draw on discussions we have set underway within the College, both in the Adult Medicine Division and more widely.
The comments I have received can mostly be grouped under three broad headings: (1) trainee support; (2) the College’s own practices; and (3) workforce issues. I will discuss these in turn.
1. Trainee support
There seems to be general agreement with my characterisation of the high stress experienced by trainees relating to exams, work pressures and uncertainty about the future. Many trainees experience a strong sense of isolation and feel inadequately supported by their workplaces and the College. The lack of a mechanism for raising concerns in a safe and confidential manner adds to the frustration. It is recognised that not everyone is the same: for example, the conditions facing APTs and BPTs are different, as are those encountered by registrars in urban and rural placements; and some trainees have more urgent and intense mental health needs. The system must be flexible enough to respond to the specific issues that arise in all these settings.
There is widespread support for the establishment of a system of welfare officers, who could liaise with trainees, identify problems they have encountered and work with all relevant parties to find solutions. Such officers might be organised on a regional basis and would also liaise carefully with the DPEs. There is a strong feeling that a confidential complaints process should be established whereby trainees can communicate their concerns to the College without fear of victimisation or compromise of their future careers. Such complaints could encompass bullying, sexual harassment and inappropriate hospital work practices, such as the imposition of excessive working hours or failure to pay overtime.
Steps clearly need to be taken to guarantee sufficient time for educational activities. A number of members have pointed out that the relentless focus on service delivery at the expense of education and training is ultimately counter-productive and that assisting junior staff to improve their knowledge and skills contributes directly to efficient and effective patient care.
2. The College’s own procedures
Criticisms of the RACP’s practices abound. Many respondents have commented on the existence of a rigid bureaucracy, inflexible demands and deadlines, slowness to respond to queries, old-fashioned and inefficient means of communication, lack of transparency about fees, inadequate provision of training resources and a slowness to reform the examination system. It is widely perceived that the College often declines to support or advocate on behalf of its trainee members.
At the least, some of these criticisms should be seen in context. The College has many staff members who work tirelessly, with great skill and commitment, for the welfare of trainees; and a great deal of excellent, productive work has been accomplished in the ongoing process to reform the curriculum and examination system, not all of which is yet visible. It is important to acknowledge that these staff are not responsible for the deficiencies identified.
Nonetheless, it is clear that there is an underlying structural problem that needs to be addressed. This arises from the fact that the College has traditionally played two roles: on the one hand, it is a professional organisation that provides advocacy and support; and on the other, it is a regulator that is responsible for accreditation and discipline. These two roles are not always consistent: indeed, they may occasionally be in direct conflict. When a choice has to be made the latter role has traditionally been favoured over the former.
I believe that a way has to be found to allow the organisation to discharge both functions. This may require a clear definition of responsibilities and duties. It is a key function of the College to administer the exams, to accredit physicians and training and to maintain standards. However, it should also be on the side of its members and be available to support and protect them whenever necessary.
At the least, we must be able to overcome the rigid bureaucratic inflexibility that has for many become a hallmark of the organisation. We can establish a confidential complaints mechanism that would allow us to provide support for individual members, exert pressure for systemic change and collect data about the actual conditions in the workplace. We can explore ways to provide increased support for DPEs and supervisors, which might include training, a forum for the sharing of resources and experiences, and recognition of the work they put in.
We can continue to build on the progress that has already been made to reform the curriculum and provide increased on-line training resources. We can work to improve and individualise our communications with members rather than relying on mass mail-outs.
We can be more transparent about how fees are calculated and spent—although here we may need to acknowledge some sensitive issues. Until about ten years ago a system operated to subsidise trainee fees from the subscriptions of fellows which was then changed to require “cost recovery” in relation to trainee expenses. Some fellows (including myself) would, for ethical reasons, support a return to the old system. However, this will require a detailed conversation among fellows—many of whom already contribute generously in their own time to training activities—about whether this would be desirable or justified.
Finally, the ethics committee could work with all parties to develop detailed guidance regarding the multiple complex relationships and responsibilities involving trainees, and to foster continuing reflection and discussion about all of these issues.
3. The workforce and workplace
Workforce and workplace factors not only underlie many of the problems mentioned above but are undoubtedly the most difficult to address. Competition for a shrinking pool of jobs, unfair and unhealthy workplace practices and limited opportunities for job-sharing part-time work are frequently mentioned.
Here too, even though the College itself has less room for manoeuvre, there is still much that can be done. A substantial part of the postgraduate medical workforce is subject to our influence, so we have the capability to exert considerable leverage. This may relate to accreditation standards for hospitals that employ registrars undergoing training; and it may involve detailed negotiation with the various stakeholders, including Government, health services, practitioners, other professional organisations and the universities. It will require that the College accepts that it should, where necessary, take on the advocacy role discussed above to support its members, both individually and collectively.
The growing need for job sharing and part-time employment opportunities reflects changes in the nature of the workforce and will require a substantial shift in attitudes to both clinical and administrative practices. Here, the College could make a major contribution, not only by advocating for new policies and cultural attitudes but also by establishing its own database to allow interested trainees to negotiate their own suitable arrangements.
Summary and conclusion
In this post I have provided a brief account of some of the many issues that have been raised with me over the last three weeks, along with some of the ideas and suggestions for change that have been presented. The high level of interest in the welfare of our trainees and the obvious sense of urgency in many of the letters I have received emphasise the need to pursue these matters earnestly and with commitment.
There is clearly a great deal of work to be done. However, there is also a great sense of good will and optimism that change can be achieved. While some of the proposals will require detailed reflection and complex negotiation there are many others that are readily accessible and will incur little cost.
At the least, the message has been sent that the College needs to improve its performance and to accept its responsibility to care for its most vulnerable members. As an organisation we need to show courage, compassion and imagination in dealing with the challenges we presently face as well as those that will arise in the future.
I would like to thank everyone who has contacted me about this issue and encourage you to keep the conversation going. Please continue to feel free to share this article with colleagues and to contact me with any further thoughts, ideas and suggestions you might have.
Professor Paul Komesaroff FRACP AM
President Adult Medicine Division
Telephone: +61 (0)417 55 26 59
AChAM President’s Report
Well, winter has arrived (at least here in Melbourne) and the International Medicine in Addiction Conference 2019 website has been launched! The conference will be held from 1-3 March 2019 in Melbourne, once again voted as the world’s most liveable city. The conference themes for the three days include behavioural addictions, addiction in forensic/marginalised/complex populations, as well as the always popular focus on clinical updates and controversies. The Program Committee will be sending out a call out for poster abstracts next month and registrations will open in early September. Please make a note in your diaries.
May I also draw your attention to the next APSAD conference which is being held in Auckland from 4-7 November.
Chapter Committee members have been busy in the policy and advocacy space. I attended a prescription opioid misuse stakeholder discussion in Melbourne last month, and President-elect Professor Nick Lintzeris attended the National Alcohol Strategy (2018-2026) roundtable in Canberra this week on behalf of the Chapter. As the new Victorian/Tasmanian Branch Chair Dr Noel Plumley will represent the Chapter on the Victorian Government’s real-time prescription monitoring External Advisory Group which will next meet in August.
The Chapter is also providing input to the National Tobacco Strategy (2012-2018) and further work is being done in collaboration with our Public Health and Paediatric colleagues.
The next AChAM Committee meeting will be held via teleconference on Thursday, 8 August 2018.
Dr Martyn Lloyd-Jones
Australasian Chapter of Addiction Medicine
AChPM President’s Report
The Chapter Committee met on Friday, 15 June 2018 in Sydney and has released a post-meeting communique which can be viewed on the RACP website.
The Committee would like to improve Fellow and Trainee engagement over the next two years and welcomes any suggestions from Fellows and Trainees about how to achieve this goal. You can contact the Chapter Committee via our secretariat at email@example.com.
The issue of prescription opioid misuse is on the Australian Department of Health’s agenda. I attended a stakeholder discussion hosted by the Australian Government Department of Health in Melbourne on 1 June 2018. The risk of palliative care patients being caught up in a drive to reduce inappropriate opioid prescribing in the community was articulated at this meeting. In the following week, all general practitioners who were identified to be in the top 20% of opioid prescribers were sent letters to this effect. The need for appropriate opioid stewardship is vital but I am aware of real examples of palliative care patients being denied appropriate analgesia as a result of this action and would welcome any concerns that Fellows might have about this initiative of the Australian Government.
I am pleased to announce that Dr Suharsha Kanathigoda, a specialist palliative medicine physician, has been appointed to the NSW/ACT Regional RACP Committee.
The Chapter Committee will next meet via teleconference on Friday, 31 August 2018.
With kind regards,
Professor Greg Crawford
Australasian Chapter of Palliative Medicine
AChSHM President Report
I met with representatives from the Australian Government’s Enhanced Response Unit in the Office of Health Protection on 12 July to get an update on the implementation of the Action Plan: Enhanced response to addressing sexually transmissible infections (and blood borne viruses) in Indigenous populations and advocate for improved sexual health medicine services. I also met with Chief Medical Officer, Professor Brendan Murphy to advocate on this important issue. The meetings were useful and productive but much more needs to be done, including the development of increased long-term sustainable sexual health workforce.
AChSHM Trainees and Fellows are reminded that the Chapter awards a study grant of up to $4000 to support and encourage the advancement of knowledge in Sexual Health Medicine. Applications are open to Fellows and Trainees but preference will be given to Trainees. The grant can be used to participate in and present a paper at a conference or scientific meeting, support costs associated with research projects, train at an appropriate institution or gain technical expertise. Applications close Monday 6 August 2018.
The Chapter Committee will next meet via teleconference on 14 September 2018.
Associate Professor Catherine O’Connor
Australasian Chapter of Sexual Health Medicine
ANZCA’s PM10 Statement on Medicinal Cannabis
The Faculty of Pain Medicine (FPM) of the Australian and New Zealand College of Anaesthetists (ANZCA) has recently updated its statement on medicinal cannabis named PM10 Statement on “Medicinal Cannabis” with particular reference to its use in the management of patients with chronic non-cancer pain, following a consultative forum.
Compared with the its 2015 statement, there are no changes to its position fundamentally, that is – the current evidence base is insufficient to demonstrate the efficacy of cannabinoids in pain management among patients with chronic non-cancer pain and to support their clinical use in this context. This position is also bolstered by a recent landmark systematic review, on which the development of TGA’s document on Guidance for the use of medicinal cannabis in the treatment of chronic non-cancer pain in Australia is based.
Additionally, the background notes of the FPM’s 2018 statement include a brief summary of new evidence.
Are you currently planning to undertake research as part of your Advanced Training? With 20 Evolve Top 5 Lists currently available, the recommendations to drive high-value, high-quality care offer an opportunity to undertake research across specialties. Find out more about Evolve by visiting www.evolve.edu.au or contacting firstname.lastname@example.org.
Evolve Clinical Champions
Are you interested in being involved in Policy & Advocacy within RACP? The Evolve initiative offers an opportunity to advocate for high-value, high-quality care in your specialty. Find out how you can become an Evolve Clinical Champion by contacting email@example.com or visit www.evolve.edu.au for more information.
Evolve – How to have difficult conversations
Three training resources are available, which provide examples of how to include the Evolve Top 5 List recommendations in difficult conversations between:
• a patient and a physician (Associate Professor Mark Lane)
• a carer and a physician (Dr Sarah Dalton)
• an Advanced Trainee and a Fellow (Dr Brendan Ng, Dr Nick Buckmaster)
RACP Social Media Channels
The RACP has recently launched their very own Instagram page. This platform will be used to feature images and stories from around the College, with the aim of sharing our unique history, values and achievements. We would like to encourage all members of the College to follow us under the handle @theracp, and welcome you to invite colleagues, family, friends, and to anyone else with an interest in the College to do the same.
If you’re not already following us on our existing social media channels, please like/follow us via the following links:
Additionally, if you have any content you would like to put forward for consideration please email: firstname.lastname@example.org
Making a connection podcast out now
In this Pomegranate Health episode, US-based physician Associate Professor Danielle Ofri discusses where breakdowns in doctor-patient communication occur—often in the first 10 or 20 seconds of a consultation. Dr Ofri suggests ways for physicians to listen better, be understood and promote adherence.
Some media outlets also report a ‘crisis of compassion’ in healthcare. Burnout of staff is a major contributor, and palliative care physician Dr Shamsul Shah describes how to mitigate it by convening groups to reflect on the emotional challenges of the job. She recently published an evaluation of Schwartz Center Rounds® (case-based reflections) run at Auckland City Hospital in the College’s Internal Medicine Journal.
RACP Fellows can claim CPD credits via MyCPD for listening and using resources related to this episode.
Search for Pomegranate Health in Apple iTunes or any Android podcasting app.
Exciting line-up for NT event
Join colleagues from across Australia for a critical look at health care and vulnerable populations at the 2018 Northern Territory Annual Scientific Meeting (ASM).
Featuring a keynote address from Young Australian of the Year in the UK, Dr Geordan Shannon, the ASM brings together experts from Australia and abroad to share ideas, acquire new knowledge and develop unique insights that will help improve your practice.
Find out more
NHMRC Clinical Trials
Clinical trials are an important part of making sure treatments and medicines that can improve our health are safe and effective for everyone. Currently, the NHMRC are recruiting over 1000 clinical trials. Find out how your patients can get involved at AustralianClinicalTrials.gov.au
Conferences and Events
The Royal Australasian College of Physicians publishes notices of events and courses as a service to members. Such publication does not constitute endorsement or mandating of any such events or courses.
34th World Congress of Internal Medicine WCIM 2018
Young People and Substance Use - Sydney Addiction Seminar
2018 Osteoarthritis Summit
Grants on Offer
Up to $10,000 in professional development funding is offer to RACP Fellows who live and work in rural and remote Australia.
The grants are being offered as part of round three of the the Support for Rural Specialists in Australia Program.
Find out more.
To view current event opportunities please visit medical positions vacant.