Internal Medicine: Global Perspectives
Prof. Geoffrey L. Metz, MBBS, MD, FACP
President, Royal Australasian College of Physicians
The Land Down Under captures the interest of many for obvious reasons, but beyond the kangaroos and interesting accent is a country more interesting for its unique solutions to its unique dilemmas. Dr. Geoffrey Metz, President of the Royal Australasian College of Physicians, discusses how collaboration between the government and the medical profession has headed off disaster, why internal medicine in Australia is alive and well, and who gets to fly aboard the “Royal Flying Doctor Service.”
- 89 percent of Australia’s population lives in urban areas
- The number of people over 65 is expected to triple by 2051
- Over two-thirds of total health expenditure is funded by the public sector
Over the last 20 years, life expectancy at birth has increased by 5.9 years for boys and 4.2 years for girls.
What inspired you to become a physician?
Although no one in my family had been involved in medicine, I found that when I reached the end of my school years, I was reasonably adept at science subjects and liked communicating with people…in fact I probably talk too much! So the life of a physician felt like the appropriate path for me.
What is the role of "internist" in Australia and New Zealand?
We have a system in which patients are required to visit with their family practitioner before a specialist, which creates a filtering system that funnels only the most complex and difficult problems to the internist. We think it is a good system that serves internists well, as internists are both compensated well and given the most complex and difficult medical problems. Patients understand that we undergo more rigorous training and a more detailed continuing medical education so that we are able to deal with these complex problems.
What are your responsibilities as President of the Royal Australasian College of Physicians?
The president of the RACP is a very hands-on role and I think it is fair to say that the president and the chief executive officer run the college collaboratively, communicating with each other on a daily basis. As the president, I write multiple letters and emails every day in response to communications from Fellows, the public or politicians, while the CEO manages the administration functions of the college.
What motivated you to take the role?
It is a very interesting position with interaction at all levels of the community, media and bureaucracy.
How long have you been serving as President and what have you accomplished?
At the RACP, we tend to have a long apprenticeship. For example, in my case, I have served as chairman of the workforce committee, chairman of the continuing professional continuing development board, honorary secretary and president-elect over the previous twelve years before becoming president for two years. In my time as president-elect and president, we have completely revised our governance structure and education model. Before, we were more of a passive educational body that would examine people who wanted to become an internist; now we are a body that actively trains physicians who wish to become internists through a very vigorous program of formative and summative assessments, guided by curriculum developed over the past five years by a large team working in each subspecialty, as well as a team of contributing educators. I believe that we can now be seen externally as a very transparent organization which takes pride in guiding prospective internists through a thorough and complex training program and then assisting Fellows post-Fellowship in their continuing professional development activities.
What have you found to be the most challenging part of leadership?
The role is very enjoyable but extremely demanding in time and pressure. There are multiple challenges each day (including Sundays!) with complex questions arising both internally, from our Fellows, subspecialty societies and trainees, and externally from the public, government bureaucrats and the media.
In Australia, it is estimated that the number of people over 65 is expected to double by 2051. How will this affect your health care system and what are your thoughts on how to best address it?
Australia already has a life expectancy which is equal to the longest in the world, and the life expectancy continues to expand. This clearly puts pressure on the medical workforce and the government because of the increasing complexity and chronic nature of diseases of the ageing and the increased need for hospitalization and medical and pharmacological assistance. The Australian Government in collaboration with the medical profession has kept spending on health care at reasonable levels by trying to ensure that potentially excessive spending on hospitalization, investigation or pharmacological expenditures is kept to a minimum. At the same time, they have tried to ensure that essential care is provided for all Australians through the universal health insurance, which is paid for through our taxes. We are very proud of the fact that access to hospitals and to medical care is available to all Australians through the universal insurance paid for by all of us.
Does the concentration of population on the seaboard affect people living in the interior?
Accessing doctors and hospitals is easier for people living in a large city compared to those who may live over 200 miles from the nearest doctor. However, the government in conjunction with the medical profession supports the Royal Flying Doctor Service, which gives access to medical care for all people, no matter how remote patients are from major centers. There is also support for doctors and specialists to travel to clinics in remote areas to service those who live in the most isolated parts of the continent. Of course, these people don't see a doctor or hospital as easily as those who live in the center of major cities, but there is a lot of money spent on trying to give equitable access to all, no matter where they live.
Are avian influenza and severe acute respiratory syndrome problematic in Australia?
Avian flu and more recently, swine flu, has had an effect in Australia and New Zealand, but the profession and the government have worked closely together on both epidemics to minimize the impact of what could have been a major epidemic. Many people suffered swine flu and there were a small number of deaths, but considering the numbers that came into the country from Mexico in the early weeks after the epidemic began, we believe that the response was adequate and that harm was minimized by the actions taken by the profession and the government.
Are there enough young physicians choosing to be internists?
We could always do with more internists, but in fact the major shortage here is in family practice rather than specialist practice, as I understand is the case in the USA also. It is very popular to be an internist both in hospital practice and in private practice and while we are surveying the population and the workforce to try to match the needs of the community with those coming into training, there is no major shortage in any subspecialty currently. The most urgent problems we face are supplying subspecialty care in rural and remote areas of the country which has always been a problem of a small population in a very large continent.
What is the public debate on your healthcare systems?
While there certainly are improvements that we can make to our health care systems, I believe most people in Australia and New Zealand regard our health care systems as being accessible, equitable and affordable. In the context of affordability, we have a mixed private and public health system in which the care in the public system is as good as that in the private system and people can choose either. The public system offers access to any and all forms of care, and the private system provides access to the doctor of their choice. However, the RACP has a health policy unit which advises the government on improvements that we believe can and should be made.
Do you admire the health care systems of other countries?
I believe the debate of the best health care system revolves around the issues of access, equity and affordability. In that context, I think the system of a mixture of private and public health care is very good. I don't believe I am an authority to say whether other systems are better or worse than those of other countries.
Is access to electronic information products influencing what patients want from their doctors?
We are now very familiar with patients arriving for a consultation clutching a bundle of papers that they have downloaded from the Internet. The public is obviously better informed than ever before, but I believe they also have confidence that their doctors are well trained and well informed through continuing medical education.
Does your society have collaborative relationships with other societies?
Certainly, our college interacts on a daily basis with subspecialty societies, such as the Cardiac Society and the Gastroenterology Society. And indeed we have a collaborative and good working relationship such that the education of prospective internists in the first three years of internist training are provided by the college and the second three years (of a six year training program) are provided by the subspecialty societies in conjunction with us. Specialists from the subspecialty society do the teaching and we provide a lot of the educational support.
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