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‘ Superhero’ to broker peace among GPs
Comment
Geir O’ Rourke
THE nation’ s new Rural Health Commissioner might need to start wearing a cape— and his underpants on the outside— to please everyone, says RDAA president Dr Ewen McPhee.
Professor Paul Worley, who was named the new rural commissioner last week, is tasked with defining what it means to be a rural generalist, as well as developing a national rural generalist training pathway within two years.
In doing so, he will have to answer the vexed questions over which doctors and
GP care is best for menorrhagia
JOCELYN WRIGHT MOST women with menorrhagia can be well managed by their GPs with non-invasive treatments, according to new national guidelines.
The Heavy Menstrual Bleeding Clinical Care Standards have been developed by the Australian Commission on Safety and Quality in Health Care( ACSQHC). They call for conservative approaches to the condition, including oral contraceptives and levonorgestrel-releasing IUDs before considering
GP colleges have fought for decades. What are rural generalists? What skills do they need? And how and where should they be trained?
At stake is money, pride and longstanding inter-college rivalries.
ACRRM would like to see
endometrial ablation.
“ Around 50 % of women referred to secondary care for heavy menstrual bleeding experience severe or very severe pain, even when they do not have any uterine pathology,” the guidelines note.
The eight standards emphasis on exploring and tailoring non-invasive options, such as a suitable combined oral contraceptive, before further investigations.
Pharmaceutical options are the initial choice, with further investigation by pelvic ultrasound the Queensland model of hospital-based generalists exported around the country.
The RACGP, which privately believes the model is simply creating hospitalists, opposes any single countrywide model, arguing that
( preferably transvaginal) and consideration of a hormonereleasing IUD as secondary options.
Associate Professor Kirsten Black, a Sydney gynaecologist who chaired the commission’ s working group, said referral should only be necessary in severe cases of menorrhagia.
“ Sometimes a hysterectomy is required, but the clinical care standard is seeking to ensure that women are offered the spectrum of available treatments and options,” she told Australian Doctor. just because something works in Mt Isa, it doesn’ t mean it is appropriate for Mt Kosciuszko.
ACRRM president Associate Professor Ruth Stewart believes the two GP colleges may never agree on a definition.
In its review, the commission found that a high proportion of Australian women were referred for hysterectomy, compared with international standards.
“ Hysterectomy used to be one of the few options for women with heavy menstrual bleeding, but there are now several less invasive treatment options,” said ACSQHC medical adviser Professor Anne Duggan.
The commission also found wide and unexplained variations in endometrial ablation and hysterectomy rates between regions.
‘ No safety concerns’ as nurse endoscopy wins seal of approval to reduce waiting lists
JOCELYN WRIGHT A NURSE endoscopy scheme in Victoria has been given the seal of approval after a pilot trial in low-risk patients undergoing colonoscopy found no safety concerns.
An evaluation of Monash Health’ s first independent nurse endoscopist, who started in 2013, showed that she safely performed 255 colonoscopies after undergoing a year of training supervised by a gastroenterologist.
The nurse endoscopist was assigned procedural lists that included colonoscopies for patients with positive FOBT results in the National Bowel Cancer Screening Program, polyp recalls and surveillance colonsocopies for patients with a family history of colorectal cancer.
Professor Paul Worley with Assistant Minister for Health Dr David Gillespie.
Patients gave positive feedback for nurse endoscopy, with high ratings for technical skills and 82 % reporting no pain or discomfort during the procedure.
“ This project allowed Monash Health to successfully address the large procedural wait time,” the authors of an
The nurse endoscopy model is gaining wider acceptance. evaluation report noted.
Nerissa Duncan, Gastroenterology Clinical Services Co-ordinator at Monash Health, said the extended scope of practice model was gaining wider acceptance, with about 10 trained nurse endoscopists now operating for other services in Victoria.
However, Sydney gastroenterologist Dr Katie Ellard questioned whether funds should be directed to setting up new models of practice at the expense of existing services. Funds would be better directed at units that already had clinicians trained to scope,“ rather than training a different group of people to scope,” she said. Gastroenterology Nursing 2017; online.
“ A rural generalist is not a GP, full stop,” she told a rural conference in Melbourne last week.“ They’ re a generalist working at the broadest level of skill sets.”
Professor Stewart says the remark may have lost some of its nuance when it appeared on Twitter, sparking a debate involving the hierarchy of both colleges.
Many see the new health commissioner as the person who will have to broker some kind of amnesty on such topics.
And Professor Worley, despite hailing not from the planet Krypton, but the suburbs of Adelaide, is confident in his ability to build consensus between the various parties.
He sees an opportunity to develop“ a consensus view”.
“ It is important that we do so because medical students and junior doctors need that clarity to know what they are
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training for,” he told Australian Doctor.
Professor Worley, a former vice-president of ACRRM, said rural generalists made up the“ bedrock of doctors” in rural communities.
“ What I mean is doctors who are able to practise across the primary and secondary care continuum,” he said.
While matters related to industrial relations and employment should vary from state to state, Professor Worley said the functions of the role should be broadly similar around the country.
But he said it should not be based exclusively on the‘ Cairns consensus’: a definition of rural generalism based on the Queensland model that has been endorsed by ACRRM but, significantly, not the RACGP.
See Cartoon, page 28
Switch to HPV screening will reduce surgery risk
THE switch to HPV-based cervical screening is predicted to decrease a woman’ s lifetime risk of cervical surgery by 13 % compared with the current Pap test program, cancer researchers say. Their estimates are based on reduced rates of detected abnormalities when HPV screening starts from the age of 25. An additional benefit is a decrease in the number of pregnancy complications that arise from such surgery, said Professor Karen Canfell, Director of Research at Cancer Council NSW. International Journal of Cancer 2017; online.
Warning on shortage of combination antibiotic
CLINICIANS are being urged to conserve stocks of the broadspectrum antibiotic piperacillintazobactam because a global shortage means it is likely to be unavailable for several months in 2018. The Australasian Society for Infectious Diseases( ASID) says the antibiotic should only be prescribed when absolutely necessary and alternative options such as narrow-spectrum agents should be used where possible. It is not known when supplies of the Sandoz product would resume, ASID said.
Anticoagulants may protect against dementia ORAL anticoagulants may offer protection against dementia in patients with AF, findings from an observational study show. A retrospective review of data from 444,106 patients with AF found that patients on anticoagulant treatment had a 48 % lower risk of dementia than patients not taking the drugs. The researchers saw no difference in risk between new oral anticoagulants and warfarin.“ Early initiation of anticoagulant treatment in patients with AF could be of value in order to preserve cognitive function,” the researchers from the Karolinska Institute in Stockholm said. European Heart Journal 2017; online
8 | Australian Doctor | 3 November 2017 www. australiandoctor. com. au