Series: Volume 2, Issue 1 2011

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Book Reviews

Good Medical Practice: Professionalism, Ethics and Law

Breen KJ, Cordner SM, Thomson CJH, Plueckhahn VD. Good Medical Practice: Professionalism, Ethics and Law. Port Melbourne: Cambridge University Press; 2010.

RRP: $75.00

Anyone brave enough to write a textbook about Australian law quickly runs into an almost insurmountable obstacle: federalism. In effect, Australia has nine jurisdictions. The number of activities that are illegal in one jurisdiction (usually Queensland) whilst positively encouraged in another (usually the ACT) is myriad. Producing a textbook for a national audience that covers these jurisdictional variations comprehensively without boring the reader senseless is a challenge.

Not satisfied with simply exploring the complexities of the Australian legal system as it affects medical practice, however, the authors of Good Medical Practice: Professionalism, Ethics and Law decided to examine ethics and professionalism as well. Drawing together these three systems that govern appropriate conduct was surely a Herculean task, but it has resulted in a thoroughly readable and useful book.

The authors’ decision to combine ethical, legal and professional principles has allowed them to distil key concepts and provide comprehensive, practical guidance without overwhelming the reader. For example, a chapter on the complex legislative regimes surrounding the issue of privacy could usually be expected to leave the reader confused, or possibly even sobbing. Here, the heavy legal content of the chapter is rendered almost redundant by the authors’ perceptive preface that doctors who adhere to ethical principles of preserving patient confidentiality are unlikely to fall foul of privacy law. If you choose to stop reading after that point is made, you probably already know enough to avoid a major problem.

This “all-in-one” approach acknowledges the interaction between law, ethics and being a good doctor. It is the key to the success of this book. Complex legal and ethical ideas are conveyed succinctly, within the framework of practical advice on how to conduct oneself professionally. The authors’ tips on preventing unfortunate outcomes – such as formal complaints, lawsuits or drug-fuelled meltdowns – are sensible and worth reading even if you skip just about everything else.

First-year medical students and international graduates will find the chapter explaining the ins and outs of Australia’s health system valuable; a chapter on the professional responsibilities and regulation of other health care workers is also useful for those experiencing their first exposure to multi-disciplinary teams. Chapters covering issues relevant to clinical research, prescribing, entering practice, and the ethical allocation of health care resources are likely to be useful to later-year students and junior doctors.

There are a few problems with the text, however. For example the chapter on the Australian legal system appears towards the end of the book. I’d suggest reading it first, to avoid confusion when legal terms are encountered. In addition, unfortunate timing has meant that the chapter on the regulation of the profession does not address the new regime of national registration, but the general principles it outlines are still relevant.

Overall, the book is well-structured, easy to use, and succinct without sacrificing clarity. For those who would like more information, there are some good resources suggested at the end of each chapter. For the most part, however, it will be unnecessary to consult an additional text if one requires simply a good working knowledge of relevant ethical and legal principles.

It is perhaps disappointing that a book exploring ethical concepts is not more thought-provoking (in this line, I’d recommend Annas’ excellent, if somewhat dated, book [1]), but it seems that the authors have elected to guide rather than challenge their readers. In this they have been successful.

In short, Good Medical Practice delivers exactly what its title promises: succinct information about the ethical and legal responsibilities of medical practitioners (and students) within a broader professional context. The intended audience of medical students and junior doctors is likely to benefit from some time spent reading this book.

Conflicts of Interest

None declared.

Reference

[1] Annas GJ. Standard of Care: The Law of American Bioethics. New York: Oxford University Press; 1997.

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Book Reviews

Apley’s Concise System of Orthopaedics and Fractures

Solomon L, Warwick D, Nayagam S. Apley’s Concise System of Orthopaedics and Fractures. 3rd ed. London (UK): Hodder Arnold; 2005.

RRP AU$52.65

The 2006-2007 Australian Hospital Statistics demonstrated that fractures alone accounted for 173,410 separations from Australian Hospitals. [1] As such, all interns will see a potential orthopaedic patient at least once in their Emergency rotation and will require a sound knowledge of orthopaedics. Like all medical fields, knowledge is gathered from clinical rotations, doctors and peers. However, this learning will need to be supplemented with textbook study. One of the most popular medical student level textbooks for orthopaedics is Apley’s Concise System of Orthopaedics and Fractures. Currently in its third edition, Apley’s provides 390 pages of musculoskeletal medicine ranging from the classification and management of basic fractures to more obscure genetic conditions such as brittle bone disease.

Apley’s is separated into three general categories: General orthopaedics, Regional orthopaedics and Fractures and joint injuries. Each Orthopaedic condition is explained in the time-honoured method of history, examination findings, imaging and investigation findings, and management. This provides medical students with a well-structured and concise guide to the signs and symptoms of each specific condition. Furthermore, for some of the more common musculoskeletal conditions, such as osteoarthritis, considerable time has been donated to the pathophysiology and both the operative and non-operative treatment options.

One of the criticisms of this text is that there is information on some of the more obscure genetic orthopaedic conditions, unlikely to be useful in the acute setting. The section on fractures is detailed and provides information on the different types of fractures possible for every bone. For the average medical student on a standard orthopaedic rotation, it is unlikely that they will remember all of the specifics of each fracture type and eponyms, let alone their management. Further, Apley’s provides minimal therapeutic drug classification and doses for the management of some of the medically treated orthopaedic conditions.

A sufficient grounding in orthopaedics is essential for any intern. A significant proportion of this textbook is dedicated to fracture diagnosis and management, invaluable for the Emergency Department setting where acute traumatic injuries are more commonly treated, rather than progressive chronic conditions. Apley’s Concise System of Orthopaedics and Fractures provides an easy-to-read textbook for students wishing to learn the basics of the diagnosis and management of common orthopaedic conditions.

Conflicts of Interest

None declared.

References

[1] Australian Institute of Health and Welfare. Australian Hospital Statistics 2006-2007 [Internet]. Canberra: Australian Government; 2008 [updated 2008 May; cited 2010 July 10]. Available from:URL: http://www.aihw.gov.au/publications/hse/ahs06-07/ahs06-07.pdf

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Feature Articles

Delays in adoption of statins on the Pharmaceutical Benefits Scheme: Reflections of a John Snow Scholar

This article is sponsored by the Royal Australasian College of Physicians

The evidence for using statins in diabetic patients with normal cholesterol levels to prevent myocardial infarction or stroke was firmly established in 2002 with the publication of the Heart Protection Study. This large, prospective controlled trial found a relative risk reduction attributable to statins of around 25% in this and other population groups. [1] Statins were not subsidised for this indication in Australia until 2006. [2] I conducted a research project that sought to quantify the effect of this delay in terms of the number of cardiovascular events that might otherwise have been prevented if the subsidy for statins had occurred in 2002, when the evidence for this indication became available.

Completion of the project provided me with a more complete understanding of the use of the breadth of data sources available to synthesise an answer to the research question: what was the impact of the delay in subsidising statin drugs for diabetics with normal cholesterol from 2002 to 2006, in terms of cardiovascular outcomes? It also gave me valuable insights into the public health implications of the decisions of Medicare Australia relating to the funding of drugs, such as those for lowering cholesterol for the primary or secondary prevention of cardiovascular disease.

As an unusual research question, for which I could find little precedent in the published literature, it posed a challenge in terms of designing some means of answering it and required a creative approach. I used baseline cardiovascular risk data from the United Kingdom Prospective Diabetes Study, [3] statin-related risk reduction data from the Heart Protection Study, [1] and epidemiological data from the Australian Bureau of Statistics’ National Health Survey. [4] For one part of the study I also referred to unpublished data from the Perth Risk Factor Survey.

In order to integrate these data to provide an answer to my research question, I had to learn statistical methods and familiarise myself with software that I had never previously used, which was also very challenging and at times frustrating, although good supervision helped to somewhat offset this! I have no doubt that the skills learned will be of use in the future. I then had to present my research methodology and findings in the format of a journal article.

The project allowed me to learn about access to pharmaceuticals in Australia and how the decision-making process is conducted for subsidising medicines for particular patient groups. I gained…

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Feature Articles

Contemporary rural health workforce policy in Australia: Evidence-based or ease-based?

Introduction

Australia has a history of a rural health workforce shortage. This shortage was originally perceived to be within the context of an overall oversupply of health practitioners throughout Australia, an assumption that is now believed to be erroneous. Likewise, interest group support for Government policy responses to the maldistribution has waned over time. Regardless, Australia has consistently experienced a shortage of health workers in rural areas.

This article critiques the development of contemporary rural health workforce policy in Australia against theories of policy development, highlighting the introduction of section 19AB (the “ten year moratorium”) in 1996 to the Health Insurance Act 1973 as a turningpoint for the selection of policy instruments.

The Australian Healthcare System

Medicare is Australia’s universal healthcare system. The provision of medical care by medical practitioners in Australia is regulated through Medicare Provider Numbers (MPNs). A doctor must obtain a MPN in order to charge fees for professional services rendered outside of salaried hospital positions. [1]

In 1996, the Australian Federal Government introduced an amendment to the Health Insurance Act 1973 (the Act), restricting access to MPNs by foreign graduates of an accredited medical school (FGAMS; a term which includes international students studying at Australian medical schools) and overseas trained doctors (OTDs). For simplicity, this article will hereafter use the term OTD to refer to both OTDs and FGAMS. Under the amendment, OTDs must wait a minimum period of ten years from the date of their first Australian medical registration before being eligible for a MPN. This requirement, introduced under section 19AB of the Act, has subsequently been referred to as the “ten year moratorium.”

By 1999, Government policy began to utilise section 19AB exemptions as a means to address rural health workforce shortage. OTDs willing to work in Districts of Workforce Shortage (DWS) were given access to MPNs. [2] These DWS are determined by the Federal Government’s Department of Health and Ageing (DoHA), and consistently have primarily been rural and remote areas.

Policy introduction: The Ten Year Moratorium

Issue identification

The introduction of section 19AB was undertaken within the context of a perceived oversupply of urban doctors and ballooning costs to the Government through Medicare’s fee-for-service system. [4-6] These costs were a result of the introduction of Medicare in 1984, which caused private health insurance rates to plummet, shifting responsibility for healthcare costs from individuals to the…

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Feature Articles

Better preparing Australian medical graduates: Learning from the New Zealand model of trainee interns

The New Zealand experience of preparation

In New Zealand, the trainee intern (TI) year is a clinical apprenticeship year undertaken in a hospital under the aegis of a medical school. It is undertaken in the final year of medical school and comprises eight clinical attachments (Table 1). The year aims to provide learning in the work environment with limited clinical responsibility. Trainee interns are paid an annual stipend (60% of a house officer’s salary) from the New Zealand government via the education budget; however, the year remains under the jurisdiction of the medical school and thus retains an education focus. Although required to be supervised, TIs contribute to service (taking on approximately one-third of the patient load) and often stay on after graduation in their respective hospitals for postgraduate year one (PGY1). [1,2] Formal education and rotation assessment occur continuously throughout the year.

In Australia, there is no equivalent transition from medical school to internship and this transition may be overlooked. Medical graduates switch from enjoying little or no clinical responsibility to suddenly being accountable for the safety and management of a large number of inpatients. This precipitous change of role affords minimal time for satisfactory adaptation and preparation for the stress associated with internship. Some medical schools have attempted to soften this transition by introducing pre-internship terms into the curricula. [3]

Transitional stress from medical student to intern

The transition from university to workplace, with accompanying increase in professional responsibilities, is inherently challenging for most graduates. The reality of being personally responsible for patients can induce stress, psychiatric morbidity (including depression and anxiety) and burnout. [4] In a prospective longitudinal study of 110 interns who had graduated from the University of Sydney, 70% of interns met criteria for a psychiatric disturbance on at least one occasion during PGY1. This level of stress leads to decreased effectiveness at work and a reduced level of patient care. [4,5]

Some identified stressors include newly gained responsibility, managing uncertainty, working in multi-professional teams, experiencing the sudden death of patients and feeling unsupported. The stress of transition can be reduced with early clinical exposure, including opportunities to act in the role of a junior doctor. [6]

Lack of preparedness for internship

Despite extensive research and frequent appraisal of medical curricula, junior doctors still perceive gaps in their preparation for internship. In one survey of interns, medico-legal aspects and resuscitation skills were identified as areas where…

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Feature Articles

Up the creek without a paddle: An Australian take on disaster medicine

Figure 1. Participants are assessed in water rescue from a previous module during a water rafting exercise. Here, participants begin to resuscitate an unconscious patient during a disaster simulation.

Disaster medicine is a subject category that invokes thoughts of emergency medicine on a much grander scale; one that involves all levels of healthcare governance. But in reality, it is an area of medicine that is often neglected in Australia, despite its pertinence in this land of extremes. This has been shown to be currently so with the education of Australian medical students, where it is perceived as being too “young a branch on the old tree of medicine.” [1] But what exactly is disaster medicine, and why is there a lack of discussion of this field in a country so often threatened by disasters, natural and man-made? This was recently investigated by a delegation of medical students across Australia during a summer course in disaster medicine and management. They were amongst the 41 students, across five continents, that converged upon Gadjah Mada University in Yogyakarta, Indonesia under the auspices of the World Health Organisation and the Indonesian Ministry of Health. The following article explores the nature of disaster medicine. It then outlines the experiences of students undertaking the summer course run in Indonesia in this area. Finally, it provides an insight into the potential value of incorporating disaster medicine training into the Australian medical education curriculum.

Introduction

Imagine you are on placement in a rural location in the middle of summer enjoying your free time when wildfires rapidly surround and engulf the town you are based in. Local gas explosions rock the area, as you see dozens of patients with severe burns or in critical conditions lying on the ground. Some are conscious, screaming or clutching their abdomens, while others are unconscious and there is word of hundreds more streaming into the local hospital to escape the fires. All desperately need your help. Hysteria erupts and communication lines are down due to the catastrophe that has suddenly occurred. With nothing in hand, what do you do with no one else on the scene? Who do you save and how do you deal with streams of panicking individuals?

The term ‘disaster medicine’ is difficult to define, and over the years numerous definitions have been proposed as the discipline began to flourish. The World Health Organisation (WHO) defines ‘disaster’ as an occurrence where normal conditions of existence are disrupted and the level of suffering exceeds the capacity of the hazard-affected community to respond to it. [2] The distinct difference between disaster and emergency…

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Feature Articles

The good, the bad and the ugly of mobile phone use in clinical practice

Act 1

Scene: at the bedside

Enter stage: registrar, intern, medical student, Mrs. Thompson

Registrar: “Hi Mrs. Thompson, how are you travelling?”

Mrs. Thompson: “Not too well dear, I’ve had a pounding headache since last night.”

Registrar: “Really? Well you are recovering from a stroke, but I wonder if we have overlooked something. Maybe we should scan your head again?”

Medical student (to the rescue!): “We changed Mrs. Thompson’s aspirin to Asasantin yesterday and it says here on my mobile phone application that Asasantin can cause headache. Should we try stopping it to see if her headache resolves before we zap her brain again?”

Act 2

Scene: outpatient clinics

Enter stage: consultant, medical student, Mr. McLeod

Consultant: “We seem to have your COPD under control with your current medications. It has been a while now since you’ve been hospitalised with an exacerbation.”

Mr. McLeod: “Yeah I feel…”

Ring, ring (interruption by consultant’s mobile phone)

Consultant: “Yes, it’s me speaking. Go ahead…”

Conversation between consultant and his registrar regarding Mrs. Vince, a current inpatient; during conversation it is revealed to all present in the room that Mrs. Vince’s bowel habits have been erratic and now she has PR bleeding; consultant recommends a gastro consult

Consultant: “Now, what were we saying?”

Act 3

Scene: at the bedside

Enter stage: consultant, registrar, intern, medical student

Mr. Walker’s biopsy report has confirmed squamous cell carcinoma of the lung; it is now time to break the news to him

Consultant: “Hi Mr. Walker, how did you sleep?”

Mr. Walker: “Didn’t get much sleep last night. I’m very anxious about the result.”

Consultant: “Well, the result has come back and I’m afraid the news is not as good as we would have hoped for. Is your wife here with you today?”

Mr. Walker: “No she’s just stepped out to run some errands. That’s ok though, just give it to me straight. I want to know exactly what’s going on.”

Consultant: “Ok Mr. Walker. Well the biopsy reveals that you do have cancer. It is a type of lung cancer called squamous…”

Ring, ring (interruption by consultant’s mobile phone)

Consultant: “Hold on Mr. Walker, I need to take this call. I will be back in a moment.”

Registrar, intern and medical student standing around the patient’s bed looking at each other and feeling rather awkward about the…

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Feature Articles

A trauma elective in Sydney: How does it compare to London?

“Will you see shark bites?” was a question I was asked a few times by other medical students when I told them I was doing an elective in trauma at Liverpool Hospital, Sydney. While I promptly replied this was unlikely (especially as Liverpool is a lot further from the coast than I initially realised), I was secretly hoping I would see something exciting. Although there were no shark bites or kangaroo assaults, I did see some very interesting cases while over on your side of the world, such as a patient who managed to sever his radial artery with an angle grinder and a traumatic amputation of a patient’s arm by an industrial machine.

Trauma as a speciality

One of the first things I noticed was that the set-up of the trauma department was different from in the United Kingdom (UK). At home, trauma as a speciality is generally combined with orthopaedics, and there are few surgeons specialising in trauma as a whole. This helped to explain the initial email I received back from my elective supervisor, who said that this was an elective in trauma, not emergency medicine, which made me worry I would be doing orthopaedics for six weeks! The orthopaedic and trauma surgeons in the UK manage the musculoskeletal aspect of the poly-trauma patient’s care, and other surgeons are called upon as necessary, for example vascular surgeons. Here there are specific ‘trauma’ surgeons who specialise after completing general surgical training, and are responsible for the overall surgical management of the trauma patient. This includes following them up on the wards, in the intensive care unit (ICU) and clinic as necessary. This was something I had not come across before. Indeed, trauma surgery as a single speciality does not currently exist in the UK, nor is there a training program. There are, however, some centres that provide more specialist trauma care, such as the Royal London Hospital.

Mechanism of injury

In many ways, the type of trauma I saw in Sydney was very similar to that of London. The majority of the trauma I have seen in both cities is as a result of motor vehicle collisions, which was not surprising. [1] Another common mechanism was falls, with increasingly elderly populations with many co-morbidities contributing to this problem in developed countries. [2] This is now being complicated when the fall results in a head injury, with many of these…

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Feature Articles

Why medical school is depressing and what we should be doing about it

Introduction

In recent years, there has been quite some attention given to supporting the health and well-being of doctors but less to that of medical students, particularly their mental health and well-being. [1-3] Up to 90% of medical students will need medical care whilst in medical school, and while many of these health needs may be routine, medical students are more susceptible than age-matched peers for serious mental illnesses such as depression, anxiety, substance misuse and burnout. [4,5] Preliminary data from a study last year showed that Australian medical students reported higher rates of depression, while another study estimated that one quarter of students suffered from symptoms of mental illness. [6] There is also some evidence that difficulties during medical school may manifest later in one’s medical career. [7] With up to a third of hospital physicians at one point experiencing psychiatric morbidity, identifying and supporting these individuals is essential as these doctors are more likely to deliver sub-optimal patient care, misuse substances and leave the profession early. [8] This article will discuss how medical school can and does have a profound effect on our mental well-being, putting us at risk of depression, burnout and other mental illnesses…

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Medical Careers

Martin Van Der Weyden: A Career Sustained by Scholarships

Dr. Martin Van Der Weyden

Martin Van Der Weyden has been the editor of the Medical Journal of Australia (MJA) for the past fifteen years. Over this time, he has earned a reputation as a passionate, quirky, and often controversial figure. His influence has most definitely been a transformational one, taking the MJA from near irrelevance (once irreverently nicknamed the ‘Blue Comic’) to being one of the top 20 general medical journals in the world and a key driver of change here in Australia.

As we go to print, Dr Van Der Weyden is preparing to retire from his position as Editor, which will mark the end of an era in Australian medical publishing. The editors of the AMSJ invited him to share some of his life story and reflections at this fitting juncture. What follows is a short account of the making of one of Australia’s most interesting medical personalities.