Speciality but not specialists

[jellybean]

I can understand your frustration with this issue (evident by the number of times it has been raised on this forum ? I?m not criticising, it?s your forum and totally your perogative and I would probably also feel frustrated if placed in a similar position) but I can also see the reasoning behind the AMC?s approach, to a certain extent. (I'm not saying that it's right).

Sports med is clearly a more specialised field than general medicine (and much needed) but does cover a very broad range of issues. The much publicised issue of decreasing physical activity levels and increasing obesity and associated health issues has only served to reinforce the general relevance of sports med to the broader community (if you know what I mean).

This will not placate you (and maybe ? hopefully - I am totally wrong ? I don?t fully understand the hoops that must be jumped through in order to achieve ?specialist? status), but it would not surprise me if the AMC does not grant specialist status to sports physicians until there are formalised sub-specialities within sports med (e.g., sports physicians who specialise in knees or shoulders or tendinopathy?or exercise induced asthma ?.). From a patient's perspective, I know that I never go to a "general" sports physician. I always seek out a sports physician who I know has expertise in the problem that is concerning me and you only need to read a few posts here every day to know that others do the same thing. Perhaps the AMC thinks along the same lines.

P.S. I agree that the ability of patients to get Medicate rebates for, for example, a knee MRI ordered through a psych but not for a knee MRI ordered by a sports physician (an example that you?ve highlighted previously) - when the sports physician is the expert in the area ? is a total farce. Yes, a patient can get a rebate for their MRI if they see an orthopod (or a psych!) instead but, for me, if I?m trying to get answers about an injury I?d rather see a sports physician any day ? far more informative and often more up with the latest range of treatment options. (Not saying that to pee in your pocket, it?s just fact).

[kvantum]

"The AMC and its predecessor bodies have many times previously recognised new specialties in Australia but in all cases the recognition has immediately led to the recognised and qualified practitioners in that area becoming specialists. Even in the recent AMC decisions, the new 'specialties' recognised have generally been subspecialties of existing specialties, so that all of their practitioners were already recognised as specialists."

Mate, you are full of shit! At least have the brains to understand the process. The recogntion process is a 2 staged process - for everybody! not just the poor darling SEM folk; but for the palliative, pain and addiction medicos. All had/have to go through both stages. First a case need to be made about recognising the area of medicine; secondly - a training program needs to be accredited. Only once a training program has been accredited is Schedule 4 ammended and the speciality formally recognised. The College will then need to negotiate with Medicare Australia what the appropriate rebates are. And to compare the AMC with the NSQAC shows that you have the forensic skills of you average ameoba. Get off your self-centred arse and do a bit of background reading - although as a famous Swedish cartoon character once said - thinking before you speak is like wiping your arse before you shit!

[injuryupdate]

It's very easy to understand the process, another thing to agree that it was fair. Was it 'fair' to detain David Kicks without a charge on the basis that "....at some stage in the future we will make some charges and set a trial"? It was a process, but not a fair process.

The ACSP apparently first applied to be considered as specialists in the field of sports medicine to the government of the day in 1993, at which stage they had all of (1) first part exams (2) selection process for joining training program (3) second part exams at the end of the training program (4) 3 year full time training program. The final decision on whether sports medicine becomes a specialty and sports physicians are considered specialists rested with the Federal Health Minister, which I think is still the case. In 1993 the minister was generally going to take the advice of NSQAC whereas in 2007 the minister is generally going to take the advice of the AMC.

Since you are not full of shit, perhaps you can explain to everyone on this forum why the first application to the minister was made in 1993 and the decision on whether sports physicians are actually specialists in Australia has STILL NOT BEEN MADE in 2007? If you want to take this on, I'm sure you can put on bureaucrat-speak and explain how the NSQAC process was not fair and open and needed to be replaced and how the Howard government needed to suspend its operations and then take 5 years to set up a replacement committee. And that this replacement committee had to then go and assess all of the existing specialties first (and recently developed subspecialties since then) before they bothered to assess any completely new specialties like sports medicine.

I am a sports physician in Australia, so I do have a bias. I hope I don't give the wrong impression in that I don't think the AMC is doing anything other than its brief, which is to (slowly) go through all of the processes set out. It is the government who has been responsible for the process being so drawn out, not the AMC. I can't blame the AMC for sports medicine taking longer than 14 years to have its status assessed, but do you think this is reasonable government process?

Unlike the vast majority of other new specialties that are being assessed, sports medicine does not contain many practitioners who hold fellowships of existing colleges (e.g. most 'addiction medicine specialists' will probably already be psychiatrists, so the decisione to rubber stamp their new specialty will have few practical effects).

With respect to sports medicine there are some substantial effect of non-specialty status, the most important being:
(1) Those training in sports medicine now only hold their provider numbers by the short-term grace of the minister. There is specific legislation saying that doctors who graduated after a certain date CANNOT hold a provider number to participate in private practice in Australia. Whilst exception is being currently made for sports medicine trainees, it is unacceptable that these doctors have no actually right to practice in medicine in private practice in Australia.

(2) Sports physicians cannot order MRI scans under Medicare, even when they specialise in the area of question and the patient comes to them on referral from a GP. If you GP refers you to a sports physician to treat a knee problem, Medicare will not honour a knee MRI request from the sports physician. However, if the patient then goes to the gynaecologist, this doctor can write a knee MRI request knowing nothing about the knee joint.

(3) The practical outcome of delay in recognising sports medicine is NOT that sports physicians don't make enough money. We do, as lack of competition means that the area is quite healthy to practice in. It means that patients in the country or outer suburbs (and even small states) have virtually no access to a sports physician. It means that virtually no public hospitals put sports physicians on staff, so that if you have a sports injury you must pay out of pockets in the private system to get your injury treated. The false economy of the government 'saving' money by delaying the inevitable recognition of sports medicine means we have a population less able to exercise because many of them have poor access to getting their sports injuries treated.

Finally, it is not a law of the universe that the government must wait until the stage 2 process of the AMC is completed before sports physicians are recognised as specialists. There are sports physician item numbers (which were granted in 1998) which are a de factor recognition that the government feels that the ACSP training program is adequate. They gave these out in lieu of immediate assessment of the ACSP program and there has been no consideration to cut off these numbers in the last 9 years. If the ACSP program was not up to speed, then wouldn't this be an outrage that the government has given item numbers for such a terrible branch of practice for 9 years without assessing whether the college was doing a reasonable job?

The Faculty of Sports Medicine in the UK has just granted some foundation Fellowships to ACSP Fellows, including myself, on the basis that they consider that ACSP training is adequate to be considered of specialist level under the NHS. This is because, unlike the Australian government, the UK government is trying to encourage the development of sports medicine in their country. So many of us poor darling sports physicians are now officially specialists in the UK (and would be in NZ and many other Western countries were we to move there), but we cannot be considered specialists in our own country until a stage 2 assessment is performed as part of an ongoing bureaucratic process that has not being able to come up with anything definitive in 14 years.

Actually they have come up with something definitive. Sports medicine is officially a specialty in Australia as of now (June 2007). It is perhaps, as of now, the only specialty in the world recognised by the government of a country with no recognised specialists practising in the field. Only a government committee could come up with this.

[kvantum]

Looking at the Addiction Medicine report, it is clear that more than 50% of its practitioners come under the OMP category - ie not Fellows of an existing recognised College. So there goes that argument. From the dates, it seems that SEM was assessed before Addiction Medicine too. Looking at the assessment list, it seems that palliative, pain and rural and remote were first off cabs off the rank. SEM came before addiction and sexual health - and yet I am sure a public health person could argue that both substance abuse and STIs (including HIV) were both a greater burden of disease and more expensive than those that SEM folk do. And before you go on about obesity - how many obese patients have you recently treated and "cured" lately; how many diabetes patients do you work with as part of a broader chronic disease management plan? How many non-active arthritic (i.e non-sports related) patients do you work with? Can't see too many SEM doctors running efective public health campaigns, can you? Your work is largely confined to treating the sporting injuries of the generally fit and healthy (who are low-risk) - which is not to undervalue it, just to put it in its proper place from a public health perspective. I personally think the AMC made your argument for you, given the quality of the submission that was on their website. And yes I do have an interest in all of this as I am looking at the history of specialisation in medicine in comparable countries.

When I tried to get files from NSQAC for my reseasrch - a secretative unit, within the health department - they told me that nothing existed. When I asked the AMC ( a body with no links to the Government), all their documentation was available in the public domain, and much more provided to me on request. Anybody could make a submission, and they appeared to take the time and effort to sift through both the political landscape that is turf protection in medicine and take a balanced view that draws on the literature. I know - I interviewed them and they backed it up. So what do you prefer? an open and transparent process that dealt with the SEM application in under 12 months - and that is after the College was requested to resubmit a good portion of the application because of reasons that are best left unstated in public - or a secretive unit operating on the whim of personal opinions of committee members. What would you (personal interest and frustrations aside) prefer from a public administration perspective. Yes the Mininster retains the discretion to annoint the SEM folk, but I would regard the use of such discretionary powers as being against the spirit of public administration. From the noises being made, cosmetic surgury will be putting in an application - should the tits and dick boys get a tick from the Minister too because of perceived past injustices? Or should they have to go through due process now that a well-designed and transparent assessment system has been established? They too have a training program!

I hope this is not too bureau speak for you, as I have never worked in the public service. I am simply an academic with an interest in the history of medicine and health systems. I just took the time to understand the process. From other discussions I have had with prominent members of the medical profession - most are astounded that the AMC even gave SEM the tick. I personally take that as turf-protection; but you certainly have not endeared yourselves to your broader collegues in the profession. Maybe a little humility might get you somewhere.

Most of your other compliants seem to be directed towards the Medicare Provider Number Legislation, from which Sports Physicians seem to have received ongoing protection whilst their status is sorted out. Why should this change? When every other COllege undergoes AMC accreditation, why should the ACSP be exempted? Instead of whingeing why don't you make a considered and contribution to the medical education accreditation system.

regards
k.

[injuryupdate]

You don't have any argument whatsover from me about the AMC process being more fair than the NSQAC process. I don't have any complaint about the AMC process once it has started. The ACSP should be subjected to it, but the assessment that is currently been done SHOULD have been done in the mid-1990s rather than at the present time. I have a massive complaint about the fact that the ACSP had a the structure of a traditional specialist college in 1992 and applied to NSQAC for specialty recognition in 1993, yet it was 2006 before ANY relevant body started to process this application. That is 13 years of bureaucratic delay.

Now I appreciate that other developing specialties have also had to face delays, but just because they have also suffered less of a delay doesn't justify how the government process has panned out with respect to the ACSP.

If you would like to compare the ACSP to the addiction medicine specialists (AChAM):

The ACSP (a distinct body from all other Colleges) was formed in 1985, it had all foundation fellows invited to sit an examination in 1991 and it started first part exams, second part exams and a full-time training program in 1992. Only 3 out of 122 ACSP fellows have recognition from another specialty college (as opposed to RACGP which a further handful also have). A substantial majority of ACSP Fellows have been through the training program with a small minority having been awarded fellowship by exam only in 1991.

From the AChAM application:

It is now a sub-chapter of the RACP, although appears to have previously been a sub-specialty of psychiatry. It was formed in 2003. Its training program began in 2004. There are 196 Fellows, ALL of whom have been grandfathered. 56 also have a FRANZCP. There are 18 doctors on the training program, none of whom have reached Fellowship level.

I don't want to get into any arguments about who does more 'good' for society out of sports physicians and addiction medicine specialists. They both appear to be important areas of medical practice.

It would seem that for a training program (AChAM) which started in 2004 to have its suitability assessed in 2006 by the AMC and still not quite completed would be less than ideal, but not an outrageous situation.

For a training program (ACSP) that started in 1992 (and I can remember the date well being one of the inaugural trainees) to STILL have not been properly assessed in 2007 is a completely OUTRAGEOUS delay.

Although it is an unrelated point, FYI there are quite a lot of people/patients out there who are overweight/obese because they get injured and cannot continue with their usual exercise regime.

[kvantum]

To a certain extent, we are now talking past each other. But you are asking for the current system to be altered in compensation for ills that you believe (wrongly or rightly) to have been committed in the past - even though you would agree that the current system is more or less both fair and efficient, and the is now managed by a completely different entity/body with no connection to the past. I think the AMC would find itself in hot legal water should it proceed down that path. A matter of fact, however, the AChAM has not had its training program assessed, just Stage 1 of the recognition process - like the ACSP.

My question for you then is, quo vadis? Do you just need to vent; or do you want to join with your college to make sure that its training program meets the accreditation standards. Have you had a look at the accreditation requirements. Are you sure that the ACSP will meet them? I don't know - this is an area that I have very little knowledge about. When is the College submitting an application/have they submitted one? I do know that the AMC assessment of the College of Physicians led to wholesale educational and structural reforms, and the requirement that annual reports on progress be submitted as a condition on a 3 year accreditation period.- i.e the process ain't no rubber stamping job, even for the big boys.

[kjwilkin]

And before you go on about obesity - how many obese patients have you recently treated and "cured" lately; how many diabetes patients do you work with as part of a broader chronic disease management plan? How many non-active arthritic (i.e non-sports related) patients do you work with? Can't see too many SEM doctors running efective public health campaigns, can you? Your work is largely confined to treating the sporting injuries of the generally fit and healthy (who are low-risk) - which is not to undervalue it, just to put it in its proper place from a public health perspective.

Kvantum,

You need to be very careful about the comments you are making. Swearing will not be tolerated on this website.

For your information, sports physicians don't only just treat sports injuries. They also help people that like to maintain an active lifestyle. I have a chronic problem with loose ligaments which has affected my knees, shoulders and ankles and am seeing a good sports physician in Melbourne over a GP as they are much more in front with current treatments and know how to treat my condition properly. Also, my sports physician takes a holistic approach and considers my general health as well. Sports physicians also treat a lot of patients that suffer from arthritis. I would much rather see a sports physician over a rheumatologist as they will give you practical ideas and solutions than just prescribing you drugs to deal with your problem.

I am also a sports trainer and have seen the benefits of patients being treated properly by seeing a sports physician/doctor first.

Just be a bit more diplomatic what you are saying !

[kvantum]

Excuse me for repeating an amusing cartoon quote. If diplomacy was a factor in this debate than previous comments that were bordering on libelous would not have been published. General accusations of corruption, of the AMC being an Orwellian Ministry for Truth etc. Go back and read some of the comments that have passed as debate concerning specialty status. One swear word used as a mildly humorous remark! Diplomacy give me a break. Oh and give the AMC report a read - have a look at their considered analysis of the ACSP claim that SPorts Physicians treated those with chronic conditions...yes they idenitifed a couple out of the total Fellowship. Interesting also to have a look at the medicare breakdown.

[injuryupdate]

I think that we both agree that, according to its terms of reference, the AMC is only doing its job. Although, I don't know who was responsible for the decision/delay for the AMC to not assess sports medicine between 2002, when it was created, and 2006, given that sports medicine was obviously the longest-standing completely new specialty in the queue when the AMC was formed.

Irrespective of the outcome of the AMC process, for the last SEVEN years, Medicare Australia has had item numbers for sports physicians whilst maintaining that sports physicians are (1) not GPs and (2) not specialists. That is, Medicare has identified that sports physicians practise solely within the area of sports medicine, yet it has claimed, under its structure, that it is impossible to SPECIALISE in sports medicine, because they said so. Every other area of medicine that they recognise you can specialise in, but not sports medicine. I appreciate that there are a whole lot of areas of medicine NOT recognised by Medicare but it is a unique discrimination that only sports medicine has had to put up with that Medicare 'recognises' it as a third-tier level of medical practice that is not general practice but not a specialty. This is, please forgive me, straight out of George Orwell, and it keeps going....."......sports medicine is now a recognised specialty in Australia, we just don't recognise that the doctors practising in this field actually specialise in it".

I don't have any problems with the ACSP being told how to improve their training program given that the RACP has also had instructions on how to improve their training standards. Remember though that th RACP has MASSIVE infrastructure subsidised by the health system within public hospitals (e.g. salary for all trainees fully paid for by state government) to assist it with compliance. The ACSP gets nothing for its training program from the government, but of course that's because it hasn't been assessed as being of high enough standard, even though it is now into its 16th year.

Sports medicine has the POTENTIAL to contribute significantly to assisting patients with chronic disease become more active. I would agree that this potential hasn't been fully utilised by the Fellowship of the College, but whose fault is that? No trainees are funded, so not enough sports physicians are being trained. Medicare rebates are minimal for sports medicine (equal to GPs, lowest in the system, except that GPs can access chronic care rebates which sports physicians can't). With low Medicare rebates, are you going to tend to practice in a more straightforward area that has plenty of business (treating musculoskeletal injuries) or a more complex area that has plenty of business?

As I previously mentioned, the contrast couldn't be greater between the Australian government's attitude to sports medicine and other governments around the world. In New Zealand, sports medicine has been recognised as a specialty since 1998, and guess what - when they recognised it as a specialty they actually recognised the sports physicians practising in it as specialists! How radical! In the UK, they are actively trying to recruit sports physicians from O/S as specialists and government is putting big amounts into training positions to make up for lost opportunity.

It is quite obvious that in Australia we have a government that wants to limit physician numbers in private practice to reduce the liability of Medicare for rebates. One of the ways that they have done this is to discourage the growth of new specialties. Without completely destroying sports medicine, they have put up as many hurdles as possible to try to limit the growth of the ACSP. Low rebates, non-recognition of training for 15 years has been a fantastic way discourage doctors from joining the training program. Having the college executive focus on a core business of trying in vain to have the ACSP recognised rather than trying to expand and improve the training program has been another way.

And please don't spin any crap about the best way to achieve recognition in the past would have been to have had a better quality training program. If you haven't had your training program assessed in 16 years, it wouldn't matter if the quality was 100 out of 100, it can't pass if it isn't allowed to sit the exam.