Series: Volume 1, Issue 1 2010

This is the inaugural issue of the Australian Medical Student Journal.

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Editorials

International medical students: Interned by degrees

The progression from university to the workforce in medicine is not comparable to any other discipline or profession.

An internship is essentially an extension of a medical degree, and the degree is redundant without one. The issue of the burgeoning numbers of Australian medical graduates, and the associated ‘crisis’ in intern placement availability, is currently the preeminent political issue for medical students. Increasingly, international students have been caught in the middle of the storm.

To put this situation in the proper context, one needs to look back to the late-1980s and 1990s. At this time, Australia was seen as being oversupplied with doctors in general. There was a strong policy reaction to this sentiment, which capped student numbers, and levied heavy restrictions on overseas-trained doctors. The turn of the century saw an abrupt turnaround in this attitude, as a different picture was painted about the country’s long-term health workforce requirements. Temporary resident visas for overseas doctors grew from 664 in 1993-1994 to 1923 in 2001-2002. [1] On the graduate front, from around 2003, government policy has allowed international medical graduates to remain in Australia. [2] Given worsening projections for future workforce shortages, one could be forgiven for thinking that this was seen as the start of a norm that would continue indefinitely. While incoming international students were never given a guarantee of placement after graduation, until recently, it was often implied that this would never be an issue.

Australia only had ten medical schools in 1999, whereas today we have twice this number. [3] International places have increased as a proportion over this time. In 2002, 161 international students graduated from Australian medical schools, representing 11% of total graduates. This year, the number is predicted to be 423 students, or 16% of the total. This is as high as 34% at one institution. [4] Unfortunately, while governments eagerly and justifiably expanded the numbers of medical places at universities, this was not matched by sufficient planning for long-term doctor training. Consequently, last year, many graduates had genuine cause for concern about receiving an intern placement. However, just because we have a bottleneck of medical graduates does not mean that we have an oversupply. Make no mistake; the future of our health system needs every single graduate we are producing. Although we are dealing with unprecedented numbers, the training system needs to come to terms with this reality as soon as possible.

Even domestic Commonwealth-supported students have had reason to worry until the Australian Health Ministers’ Conference this February, when they were given a guarantee of training places for the foreseeable future. This is to be achieved by doubling the undergraduate clinical training subsidy across all states for 2010-2011, with the annual commitment totalling $140m nationally. [5] While this is a very positive and encouraging step forward, it excludes many potential future doctors.

For international students, there are no guarantees. Worse still, some international graduates from certain Australian medical schools would not even be able to gain an internship-equivalent in their home country. One cannot underestimate the perspective of our international colleagues – after spending a fortune on living expenses and university fees, being told that they will not be able to continue their training in the country where they graduate. For some, continuing their training anywhere may be extremely difficult. This is the frightening scenario that many are now facing.

It is not a well-kept secret that many medical faculties around the country are heavily reliant on international students and their fees to fund medical programs. Can we justify milking international students for their dollars, followed by abandonment at graduation in favour of the colleagues whose degrees they subsidised? Furthermore, there is the possibility that the international student funding source could deplete if recent developments discourage new students from coming here.

Currently, governments spend enormous sums of money attracting and retraining foreign health workers. Admittedly, overseas-trained doctors are filling a more immediate gap in the system that is considerably further down the line of training than internships. This is no doubt necessary for the time being. Nonetheless, it seems senseless that we are prepared to spend such amounts bringing overseas-trained doctors into the country, but cannot bring ourselves to adequately train and retain doctors reared in our own top-class medical schools.

The ramifications extend beyond just international students. Local full-fee-paying students, who make up further 6% of medical graduates, are also excluded from the recent guarantee of training places. [6]

The challenge, of course, is not just to make places for more students, but to ensure that this does not affect the quality of teaching that all trainees receive. It is also critical that we do not simply replicate the mistakes of the past: we need to ensure that there is adequate downstream planning, not just more intern places. Recent government announcements about General Practice and specialist training places are encouraging in this regard. [7]

If governments consider international and domestic full-fee-paying students not worth retaining, then they should perhaps reconsider the approval of such medical places in the first instance. But for those already in our programs, this line of reasoning simply is not good enough. There is no adequate justification for any Australian-trained medical student being denied an intern placement. It is nonsensical to on one hand have a workforce shortage, and on the other hand be turning away the best long-term solution to that shortage. If someone is good enough to be trained in an Australian medical school, then they should be good enough to practice here.

References

[1] Hawthorne L, Birrell B. Doctor shortages and their impact on the quality of medical care in Australia. People Place 2002;10(3):55-67.

[2] Joyce CM, Stoelwinder JU, McNeil JJ, Piterman L. Riding the wave: current and emerging trends in graduates from Australian university medical schools. Med J Aust 2007; 186(6):309-12.

[3] Prideaux D. Medical education in Australia: Much has changed by what remains? Med Teach 2009;31:96-100.

[4] Medical Deans Australia and New Zealand. National Clinical Training Review: Report to the Medical Training Review Panel Clinical Training Sub-committee [Online]. 2008 Mar 26 [cited 2010 Mar 12]. Available from: URL: http://www.medicaldeans.org.au/pdf/Medical%20Deans%20National%20Clinical%20Training%20Review%20March.pdf

[5] Department of Health and Ageing. Australian Health Ministers’ Conference Communiqué [Online]. 2010 Feb 12 [cited 2010 Mar 12]. Available from: URL:http://www.health.gov.au/internet/main/publishing.nsf/Content/mr-yr10-dept-dept120210.htm

[6] Medical Deans Australia and New Zealand. Medical students may never qualify, warn Deans. [Online]. 2010 Mar 9 [cited 2010 Mar 12]. Available from: URL:http://www.medicaldeans.org.au/media_090310.html

[7] Department of Health and Ageing. Building a National Health and Hospitals Network: Training a record number of doctors [Online]. 2010 Mar 15 [cited 2010 Mar 20]. Available from: URL:http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr10-nr-nr046.htm

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Letters

Getting excited about Evidence-Based Medicine

Significant emphasis is placed upon Evidence-Based Medicine (EBM) during medical school, resulting in student responses ranging from apathy to consternation.

Students take home the importance of systematic reviews and highly populated, well-powered trials, to the apparent exclusion of all else. That these trials often have landmark effects is not disputed, but there remains a paucity of data for many aspects of clinical practice. EBM is well equipped to handle this and hence it is worth re-emphasising the principles at the core of EBM.

In a well known BMJ Editorial, Sackett et. al. defined EBM as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients”. [1] A core principle that is seemingly becoming confused in medical education is that EBM involves utilising the best available, not necessarily the best possible, evidence.

It is essential medical students understand that EBM consists of three strands: several levels of published research, core scientific knowledge, and individual clinical experience. Whilst landmark trials, such as the S4 trial, [2] are easy for students to appreciate as quintessential EBM, smaller general publications, such as John Murtagh’s Practice Tips, [3] equate to a distilled clinical experience that cover many areas of practice and should certainly be considered part of the EBM framework, particularly for students who have limited personal clinical experience.

The challenge is to successfully integrate EBM’s three strands into clinical practice, particularly in scenarios where there is insufficient evidence in one area or even disagreements between data. In these situations, it is imperative to understand EBM’s hierarchy of evidence and to critically appraise evidence; both of which require a sound understanding of the scientific method.

To achieve an optimal outcome in scenarios with conflicting or limited evidence is the hallmark of good EBM practice. As more data is gathered, disagreements are resolved and gaps filled. However, today’s patients cannot wait for this to occur and medical students must develop thorough knowledge of EBM, including statistical analysis and philosophy of science, to allow them to confidently deal with such occurrences.

EBM lies at the core of modern medical practice; we who become doctors also become scientists. Our clinical decisions, based on experience and core knowledge, are moulded by the guiding hand of research. Indeed, it is our duty to integrate the strands of EBM to ensure the best possible outcomes for patients. We applaud the AMSJ on its inauguration as a vehicle to encourage medical students into well-rounded, evidence based clinical practice.

References

[1] Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2.

[2] Pedersen TR, Kjekshus J, Berk K, Haghfelt T, Færgeman O, Thorgeirsson G, et. al. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian simvastatin survival study (4S). Lancet 1994;344(8934):1383-9.

[3] Murtagh JE. John Murtagh’s Practice Tips. 5th ed. Sydney: McGraw-Hill; 2008.

Categories
Letters

An evidence-based approach to representation

Ross Roberts-Thomson

Research is an important part of a medical education and to be able to accurately interpret, contribute to and even publish research is something all medical students should be able to do.

Thus, it is a pleasure to be able to welcome you to the first edition of the Australian Medical Student Journal.

Medical students have made some significant discoveries over time, including heparin, insulin, Ether anesthesia and even the sinoatrial node. Furthermore, a significant proportion of medical students would like to have research as part of their future career. Thus it makes sense for medical students to have and run a journal to showcase their work.

Over the past number of years, AMSA has conducted the AMSA Medical Education Survey. This survey looks at what medical students think about medical education in Australia and what their future intentions are. Governments, non-government organisations, lobby groups, universities and researchers around the world have used these data for various purposes and they are, of course, infinitely useful for AMSA itself.

In the current paradigms of science, politics, and education, being merely a representative body is no longer sufficient. Representation must be backed by robust evidence and thus AMSA must be the true authority on medical students if it is to be successful into the future. It is in this light that AMSA is pursuing a more evidence-based approach to medical student advocacy, something we like to call Evidence-Based AMSA.

As part of this initiative we are looking to collect qualitative as well as quantitative and anecdotal evidence to help further our advocacy and shed light on issues affecting medical students. Evidence-Based AMSA will be conducted in consultation with epidemiologists and education experts. It will allow us to better direct our arguments on issues affecting medical students, and subsequently enhance AMSA’s influence over Governments, university institutions and non-government organisations.

AMSA will also be forming ties with one of the world’s biggest pools of data on medical students – the Medical Deans of Australia and New Zealand Medical Student Outcomes Database (MSOD). The MSOD collects a variety of data including where medical students come from, what rotations they do and their respective career intentions. The Medical Deans Longitudinal Tracking Project even follows these students beyond university to see where they actually end up practicing.

Linking the AMSA Medical Education Surveys with the MSOD and Longitudinal Tracking Project provides a more solid foundation upon which to base our conclusions and recommendations, and this partnership is one AMSA is extremely excited about.

Finally, to give students the opportunity to publish and be involved in the running of a journal such as this is a great initiative and I very much look forward to future editions of the Australian Medical Student Journal.

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Letters

Medical training: A key part of health reform

Dr Andrew Pesce

The AMA is very honoured to be part of the inaugural edition of the Australian Medical Students Journal, and to be involved in the work and thinking of the next generation of medical professionals.

Medical education and training is a key part of any health reform agenda. Without a quality future medical workforce, no health reform will be a success. The AMA keeps reminding Governments of this important fact.

The Commonwealth’s recent health reform announcements are an opportunity to improve and to define more clearly the funding arrangements (and therefore responsibility) across the stages of medical education and training. Like all parts of the health system, clinical training in particular has been caught up in blame shifting. The Commonwealth decides on intakes to medical schools, but the States and Territories provide the lion’s share of clinical training in the public system. This means that while the Commonwealth has embarked on a massive increase in medical student numbers since 2004, there is no guarantee that the States and Territories will supply all the pre-vocational and vocational training positions in public hospitals that are needed for the increased graduate numbers.

The Commonwealth’s plan to identify and fund 60 percent of the costs of training in public hospitals may give the Commonwealth more say in making this happen. The Commonwealth has also recently announced a significant investment in training places. This funding provides for more pre-vocational General Practice placements, more GP vocational training places and more specialist training places in private, community and rural settings. This is great news and is in line with the proposals put forward by the AMA.

States and Territories must now play their part and fund more prevocational and specialist training positions in their public hospitals to make sure that we can give all future graduates a training position. We need to make sure there is the right level of investment in the infrastructure and resources to support these places; quality supervision is key to the successful roll out of these places.

The AMA met with the Minister for Health and Ageing in March to discuss clinical training issues – specifically infrastructure and resources for clinical training, including the AMA proposal for the Government’s new body, Health Workforce Australia, to take a strong role in providing for pre-vocational and vocational training. Currently it only provides for undergraduate clinical training.

Health Workforce Australia funding should supplement the efforts of the States and Territories by funding discrete projects that will boost training capacity across the system. This includes funding for dedicated teaching and training time for senior clinicians, the development of innovative training programs for interns, professional development programs to enhance the teaching capacity of junior doctors, and extra prevocational training positions in community settings.

Importantly, the Government has recently agreed to a continued and expanded role for the Medical Training Review Panel (MTRP). The MTRP has a key role to play in monitoring and reporting on the availability of clinical training places, particularly for pre-vocational doctors such as interns, given the significant increases in medical school places in Australia. The AMA has strong representation on the MTRP.

While there is positive movement by the Government with regards to numbers, we need to make sure that the quality of medical education is not compromised. There is a very real threat to this as Governments attempt to do more with less.

While the AMA appreciates the need to find innovative ways of teaching, methods must respect that quality clinical placements and mentoring by senior doctors must remain the cornerstone of medical education.

We need to constantly remind politicians that it is bad policy to reduce the quality of medical education and training or seek to replace the central role of the doctor with lesser-qualified health workers.

The AMA will be running with many messages this election year – just as we have been doing already on the health reform agenda. Boosting quality medical education and training will be one of those messages.

Categories
Letters

From the Minister for Health and Ageing

The Honourable Nicola Roxon MP, Minister for Health and Ageing

The Rudd Government knows that Australia needs an effective, streamlined and integrated health workforce if it is to meet the challenges our health system faces in coming years – including the ageing of our population and an uneven distribution of health services.

We recognise that increasing numbers of medical students and junior doctors are coming through the system and we need to ensure that students are provided with quality clinical education and training. Since our election two years ago, the Rudd Government has made significant progress to achieve these goals.

Accordingly, we led the major health workforce reforms agreed to by the Council of Australian Governments in November 2008 and formalised in the National Partnership Agreement on Hospital and Health Workforce Reform. This $1.6 billion package, of which the Australian Government will contribute $1.1 billion, is the largest investment in the health workforce ever made in Australia. This landmark investment includes $1 billion for the clinical training of undergraduate students. Importantly, an agreement was also struck with the states and territories agreeing to provide intern places for students with Commonwealth-supported places.

Another key measure in the package is the establishment of Health Workforce Australia (HWA), an independent, truly national body that will work across the health and education sectors to deliver the right number of high quality health graduates. HWA will support workforce reform initiatives: of particular interest to medical students will be its role in funding, planning and coordinating undergraduate clinical training across all health disciplines and in a variety of settings and locations. It will also provide support for an international recruitment program and capital infrastructure, including for simulated learning environments, innovative clinical teaching and training initiatives and rural clinical school programs.

We are facing a time of great change for our health system. I recently joined the Prime Minister to announce a vision for the future that will be the most significant health reform since the introduction of Medicare. Simply put, this will mean a national hospital network, funded nationally and run locally. The second plank in this reform is that we intend to produce a health workforce that complements and supports this vision – and you, as medical students, are a vital part of that endeavour.

On March 15, the Prime Minister and I announced that the Rudd Government will invest another $632 million to train a record number of doctors – to tackle doctor shortages, expand capacity and deliver better health and better hospitals. This investment will deliver an additional 5,500 new or training General Practitioners, 680 medical specialists, and 5,400 pre-vocational general practice program training places over the next ten years. These major investments will meet projected shortfalls, and help reduce pressure on hospitals by improving access and availability of GP and specialist services.

When you have completed your training, we want you to be proud to be joining the Australian health workforce. So we intend to build for you, and all Australians, a health system that is not only able to cope with the challenges ahead, but do so while offering even better quality, even better access, and even greater choice.

Congratulations on the first edition of the Australian Medical Student Journal and best of luck to all readers with their studies.

Categories
Letters

From the Prime Minister

The Honourable Kevin Rudd MP, Prime Minister of Australia

Congratulations on the inaugural issue of the Australian Medical Student Journal.

As Australian medical students, you are the future medical workforce studying to shape the health and well-being of the next generation of Australians.

This is an exciting time to join the medical profession, in the midst of the biggest reform to the health and hospital system since the introduction of Medicare. Recently, I announced the Government’s National Health Reform Plan. The Plan is based on a vision that future generations will enjoy world class, universally accessible health care — the quality of care that has helped deliver Australians the third longest life expectancy in the world.

The Reform Plan will build on the strengths of our current health system, such as access to primary health care through Medicare, and free public hospital treatment for public patients. We want to improve public hospital and primary health care services, since these services underpin Australia’s entire health system.

Most importantly, the Reform Plan will harness and build on the skills, experience and ingenuity of those, such as yourselves, who work on the front line of our health and hospital system.

Yours is the work of saving lives – restoring, curing and protecting the young; the old; rich and poor alike – through life-changing treatments, discoveries and breakthroughs. It is work that I appreciate. Work that all Australians appreciate.

Australia needs students such as yourselves to achieve the breakthroughs in medical science that prevent disease, cure illnesses and deliver a better quality of life. I wish each of you all the very best for your future endeavours, and I commend you for choosing a profession which is so important to the future of our nation.

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Letters

A promising future for youth mental health

Prof. Patrick McGorry

We have good reason to be concerned about the mental health of our young people.

In Australia, mental health issues account for 55% of the total burden of disease in those aged between 15-24 years, with depression, anxiety and substance misuse being the most prevalent problems in this age group. [1,2] Furthermore, epidemiological evidence tells us that over 75% of people who suffer from a mental illness experienced their first episode by the age of 25 years. [3] Given the exquisite developmental sensitivity of this period of life, when psychological, social and vocational pathways are being established as part of the transition to independent adulthood, it is not surprising that mental disorders, even relatively brief and mild ones, can disrupt and disable, seriously limiting or even blocking a young person’s potential. Ample evidence shows that mental ill-health in young people is associated with high rates of enduring disability, including school failure, unstable employment, poor social and family functioning, which all too often lead to a spiral of disability and disadvantage that becomes difficult to reverse.

As a society, we cannot afford to ignore the human, social and economic consequences of this situation. A recent report by Access Economics has estimated that in 2009, the financial cost of mental illness in Australians aged between 12 and 25 years was $10.6 billion, with 70.5% of this due to the costs of lost productivity due to lower employment, absenteeism and premature death. Furthermore, the value of the loss in well-being (disability and premature death) was estimated at a further $25 billion. [4] We need to invest in our future, and clearly, investing in youth mental health makes good sense: a strong focus on young people’s mental health has the capacity to generate greater personal, social and economic benefits than intervention at any other time in a person’s lifespan. Put simply, mental health equates with national wealth, in the broadest possible sense.

Fortunately, there is a growing movement that aims not only to raise awareness of this crying area of unmet need, but also to redress it. In the early 1990s we began to promote the idea that intervention in the very early stages of the development of a mental illness was the most effective strategy to reduce the burden of disease created by these disorders. Intervening early to stop the progression of a mental illness should also prevent the accumulation of collateral damage to educational, social and vocational functioning associated with the evolution of the illness. Evidence supporting this proposition has been building steadily over the last decade, and with this progress, it is now accepted at both the State and Federal Government levels, as well as within the wider community, that major reform and significant investment is required in mental health care in Australia, and indeed world-wide.

As Australian doctors, present and future, we live in exciting times. We have reached the tipping point; reform is inevitable, and indeed, the first steps have been taken. A career in psychiatry has always offered benefits such as real contact with patients, rewarding work, intellectual stimulation, interesting research questions and the possibility of maintaining a good work/life balance, but now Australia’s psychiatrists have the potential to be part of a social climate change not only here in Australia, but also world-wide. The need is only too real, and the potential to address it has never been better. As Australia’s doctors of the future, an exciting career option beckons you: consider psychiatry, and make a real difference to our future.

References

[1] Public Health Group. Victorian Burden of Disease Study: mortality and morbidity in 2001. Melbourne: Victorian Government Department of Human Services; 2005.

[2] Australian Bureau of Statistics. National Survey of Mental Health and Well-being. Summary of Results. Canberra: Australian Bureau of Statistics; 2008.

[3] Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:593-602.

[4] Access Economics. The economic impact of youth mental illness and the cost-effectiveness of early intervention. Canberra: Access Economics; 2009.

Categories
Letters

The Australian Medical Student Journal is born

A group of AMSJ staff members at a meeting in Febuary, 2010

It is a delight to welcome you to the inaugural issue of Australia’s new national medical student journal.

As you will no doubt discover, this first issue of the AMSJ really is a showcase of the talent, passion and achievement of medical students from across the country.

In recent times, medical education in Australia has seen a paradigm shift to self-directed learning and evidence-based medicine, and medical students themselves have become an increasingly diverse cohort with a wide range of backgrounds and interests. The AMSJ is in many ways a response to the corresponding need for avenues of expression.

In less than a year, the AMSJ has developed from an idea to a reality of previously unimaginable quality and scale. Every stage in the journal’s development has been somewhat of a leap into the unknown. One of the critical hurdles for the concept was always going to be the response in terms of submissions. We were overwhelmed with both the quality and quantity of what was received, with the vast majority of Australia’s twenty medical schools being represented among the submissions. The only regret is that only a small proportion were able to be published in the inaugural issue. Ultimately, it is the authors who have made the AMSJ a success, and will continue to do so.

The AMSJ has been a challenging balancing act in many respects. While we wanted to steer well away from being another student magazine, we did not want to be constrained by all of the typical expectations of a biomedical journal. We are not the first such journal in the world, however we found that the whole concept of a ‘student medical journal’ still needed to be defined; such a journal needs to be student-friendly for both authors at one end, and readers at the other.

From the perspective of student authors, we aimed to provide an unintimidating forum that could be a stepping-stone into the world of academia. While all academic articles underwent rigorous internal and external review processes, being anonymously peer-reviewed by at least two experts in their particular field, a central concern was to be as constructive as possible with any author feedback. A student journal needs to avoid the type of harsh uninformative rejections that are sometimes met with in existing journals. The AMSJ offers opportunities for a wide variety of styles, and for more general-interest articles that may not find a place elsewhere. As such, in this issue, you will find what you are familiar with in existing journals, such as review articles, original research, and case reports. However, you will also find many pieces that traverse the traditional boundaries, such as reviews of student resources, career pieces, and a host of feature articles.

From the perspective of you, our readership, the central concern was to be relevant and interesting. There is little use in publishing articles, regardless of the excellence of the research behind them, if they are of an extremely specialised nature and of no appeal to the vast majority of medical students. By the same token, we needed to publish articles that could extend students beyond the limits of standard medical curricula.

None of this would have been possible without our extremely dedicated volunteer staff of twenty-two students, to whom I offer heartfelt thanks and congratulations. As we all quickly learned, being involved in a totally new professional organisation is no easy task – every single process has to be designed from the ground up, without the luxury of a predecessor to lean on for advice. But at the same time, this has imparted an amazing degree of creative freedom that everyone found most rewarding.

There are a host of other people who have made this venture possible, including the generous and dedicated academics and clinicians who became peer-reviewers, our sponsors, medical societies from around the country, and the UNSW Faculty of Medicine, particularly Dr. John Hunt.

If what follows in the next seventy or so pages represent what is possible for an inaugural issue, then the future for the AMSJ certainly seems bright. I would encourage any student who reads this issue to take inspiration from their colleagues’ work published in these pages and think of how they could contribute to future issues, and indeed to the field of medicine in general.