All facets of the great profession of medicine are fascinating and that is basically the reason why I pursued a career in General Practice. It provides the opportunity to diagnose and manage diseases from A-Z (acne to zoonoses). Practising in a rural community, with the luxury of managing the local hospital, was the ideal environment for my interests and consequently I entered rural practice in partnership with my wife, Dr Jill Rosenblatt in 1969. As the only practitioners in the community of Neerim South we enjoyed considerable responsibility especially with the management of emergencies. The discipline of General Practice, however, is one of the most difficult and challenging of all the healing arts. General Practitioners are at the front line of patient care and have to manage presenting problems as they appear at any time and place.
Prostate cancer is the most common internal cancer in Australian men. Whilst recent trends demonstrate stabilising incidence and decreasing mortality rates, it remains a major health burden for Australian men and requires continued action. This report outlines the status of prostate cancer in Australia’s health care system, both past and present, and analyses the effectiveness of healthcare campaigns used to generate awareness. The aim is to assess awareness, perception and public behaviour toward this disease, as well as to impart Australia’s strategies on improving public knowledge in this area.
Methods: A comprehensive search of English language literature was conducted. Articles were limited to those relating to prostate cancer in Australia. Additionally, websites of various prostate cancer awareness campaigns or organisations were evaluated, based on a comprehensive list provided by the National Men’s Health Policy Submissions Document. [1]
Results: One hundred and ninety-five relevant journal articles were found, which were subsequently evaluated independently by three authors. Of these, 56 fit the inclusion criteria.
Conclusion: Development in knowledge, awareness and attitudes toward prostate cancer has been significant over the past few years. However, despite prostate cancer being a major health burden for Australian men, there are still misconceptions and a lack of awareness amongst the general population. The combination of prostate cancer specific organisations such as the Prostate Cancer Foundation of Australia, campaigns and events such as ‘Movember’ and ‘Be a Man,’ health promotion in schools, universities and workplaces, as well as the development of a national men’s health policy can only further serve to advance prostate cancer awareness.
Many physiological changes in pregnancy may affect the presentation of abdominal pain in the pregnant patient. Rapid diagnosis and management is required to prevent dire complications for both mother and fetus. Most radiological investigations are not harmful to the developing fetus and can avoid unnecessary and potentially detrimental explorative surgery. The role of laparoscopy in the pregnant patient is increasingly being established, particularly in centres with this surgical expertise.
Aphasia associated with brain tumours has previously been regarded as essentially equivalent to the aphasia of stroke, and as a deficit unlikely to affect a patient’s prognosis. Recent research challenges such hypotheses. Tumour-related aphasias are commonly anomic aphasias, and hence pathologically distinct from classic post-stroke aphasias. Accordingly, many rules from the world of stroke cannot be readily translated to the management of tumour-related aphasia. Furthermore, aphasia may be an important clinical prognostic parameter in neuro-oncology. Tumour-related aphasia is associated with an increased risk for developing depression, poorer coping and reduced survival time. It is important that health professionals are aware of the unique pathology and prognostic significance of neuro-oncological aphasia, and of strategies available for its relief.
The internet has woven itself into the fabric of society, by offering a plethora of services which have evolved from luxuries to necessities.
Telemedicine – the use of the internet to transmit information for diagnosis and management – has garnered recent attention because of the Federal Government’s promise to provide AU$392million for its development, and the proposed national broadband network which may increase the efficiency of telemedical services. [1,2] Telemedicine, endorsed by the Australian Medical Association, [3] has a number of applications; however, the most highly publicised of these is the concept of online interactive consultations with a specialist practitioner in real-time, potentially using a Skype™-like platform.
In the coming years, telemedicine will likely play a significant role in our careers and as such, we must have an understanding of both its benefits and limitations. Despite the obvious potential of telemedicine, several questions remain in the minds of the public, doctors and also medical students. The first is: do we really require telemedicine? The costs are significant, but so is the need for the 12% of Australia’s population inhabiting outer regional and remote locales – data travels significantly faster over hundreds of kilometres than patients and their families. For example, geriatric patients even in the relatively large Queensland town of Rockhampton may need to travel over 600 kilometres to their nearest geriatrician. [4] For frail elderly patients, this is hardly practical. To help address this, the University of Queensland’s Centre for Online Health currently provides approximately 2,200 inpatient and outpatient consultations annually, primarily for geriatric and paediatric patients. A designated outpatient clinic exists at the Royal Children’s Hospital, Brisbane, and the transmission of video, radiological images, laboratory data and medical records allow distant consultants to conduct ‘video ward rounds’ for their inpatients. [4,5]
Nonetheless, even if there is a need for telemedicine, is it effective? Can doctors really diagnose and treat patients they are not in the physical presence of? Although telemedicine has been studied in several ways, two particular studies investigated these questions. A Canadian randomised controlled trial found that telepsychiatry and face-to-face psychiatry produced equivalent clinical outcomes [n = 495]. Further, when comparing the travel and accommodation costs of patients versus the cost of videoconferencing technology, the authors found the costs of the latter to be 10% cheaper. [6] Similarly, a Scottish study which compared 44 outpatient diagnoses and management plans made by a neurologist in a face-to-face…
Since 1999, the number of Australian medical schools has doubled.
While this has brought about diversity, it has arguably also created a worrying lack of standardisation in the skills of graduates. National curricula are currently a hot topic, with the development of a standardised Australian curriculum for Kindergarten to Year 12 well underway. Is it time to rekindle a similar debate within Australia’s medical education sector?
Presently, the only force acting to maintain a degree of standardisation between Australian medical curricula is the Australian Medical Council (AMC) and its accreditation processes. The AMC accreditation standards guide, while laudable, does not direct the specific structure or content of curricula, leaving the door open for the veritable potpourri of programs that we now have across the country. For example, the guideline for curriculum content of the basic biomedical sciences, which occupies one line of the document, does not even mention the names of the various biomedical disciplines: “[t]he course provides a comprehensive coverage of … basic biomedical sciences, sufficient to underpin clinical studies.” [1] Either the AMC is not prepared to put more specific guidelines in the public domain, or little guidance exists to direct curriculum development. The open-ended regulatory framework has seemingly acted for more than a decade to feed a process of medical schools constantly reinventing the wheel with ‘revolutionary’ medical programs.
Of all the medical science disciplines, the teaching of anatomy has been the most criticised in recent times. Anatomy provides a case study in teaching disparities between universities. In a recent national survey, striking differences were demonstrated between medical schools in several areas, including the amount of hours dedicated to formalised anatomy teaching, the delivery of lessons, the use of cadavers, and the manner of assessment of anatomy knowledge. [2] For example, eleven of the nineteen medical schools surveyed have no specific requirement that student demonstrate sufficient anatomical knowledge at examination. Most medical schools pool anatomy questions with those of other disciplines, and calculate an overall passing grade. Thus, a student could be considered competent in basic clinical sciences without passing anatomy. These and other findings have prompted recent calls for a national curriculum for anatomy. [3] However, despite being extremely topical of late, anatomy is but one example of the heterogeneity in teaching across Australia. It would be difficult to make a strong case for having a standard curriculum for one subject and not others.
The Royal Australasian College of Physicians’ (RACP) Clinical Examination takes a full day and for medical registrars is the barrier between basic and advanced training, including subspecialty training. My experience was as an ‘examination assistant’ (or ‘bulldog’ in colloquial terms) for the candidates. I had been on my general medicine rotation and the consultant of my medical unit was looking for volunteers.
The clinical examination day comprises a morning and an afternoon session. Each session is comprised of two short cases and one long case. Short cases each take fifteen minutes. Candidates have three minutes before they enter the station to read one sentence which provides the name of the patient, presenting complaint and body system to examine. The candidate introduces themselves, examines the patient, presents their findings, is questioned by two examiners and walks out at the bell, remembering to wash their hands before they leave. In contrast to medical school OSCEs, candidates do not speak to the examiners while examining the patient. Instead they present afterwards, which is when they start scoring marks. My candidate asked me to signal him at six minutes (by tapping on my watch, coughing or clearing my throat) so he could spend the next nine minutes presenting and thus scoring marks. The examiners can also ask for investigations to be interpreted. For example, “What would you like to order for his murmur?” or, “You said ECG, tell us about this ECG and chest x-ray.” Fortunately, the short cases are assessed ‘blind’ by the examiners who have not examined the patients themselves. This is not so for the long cases.
For the long case, the candidate spends one hour alone with the patient. During this time, they take a thorough history, perform an examination, determine the patient’s medical and psychosocial issues and construct a management plan. After this, candidates have ten minutes before seeing the examiners. In these ten minutes, the candidate can think of potential questions and collect their thoughts. The long case assessment occurs over 25 minutes with two examiners. The candidate begins by presenting the case followed by non-stop questioning on anything from the history (“What were the circumstances of the fall you mentioned?”), physical examination (“What do you mean by nerve compression, what level?”), investigations (“How do you determine if the asthma is mild, moderate or severe?”), and management (“What if this person were to go to surgery?” or, “How might you educate this patient?”).
While the examination represents an artificial construct, particularly in respect to the short cases, the format does allow for assessment of a candidate’s ability to perform at a physician level, to analyse, interpret information and to deal with the inevitable dilemmas presented by real patients. “Under the pressure of the exam, candidates generally revert to their normal level of everyday practice,” says successful candidate Dr Luke Vos of Launceston General Hospital.
He advises budding physicians, “Preparation for clinical examinations really begins as soon as you enter physician training. The essential elements of history taking, physical examination, construction of a differential diagnosis and the establishment of a plan for the investigation and management of each clinical problem are skills you can continue to refine from day one. While somewhat daunting, a willingness to expose yourself to constructive criticism from colleagues and mentors will help improve your approach and can prove invaluable. The skills you develop in preparation for the clinical exams will continue to serve you throughout your career.”
From a bulldog’s perspective, I could see how medical school trains us for these types of exams, but also prepares us for days when we just need to remain calm and focused on the next patient. And given that the clinical examination fee was $3,780 this year, there was definitely good motivation to pass!
More information can be found at the RACP PREP Basic Training Program website: http:// www.racp.edu.au/page/basic-training / examinations/clinical-examination.
Healthcare provision and access to effective healthcare for young people (aged fifteen to 24 years) has long been a debated issue. [1,2]
The law is clear regarding the conditions under which a person under the age of eighteen (a ‘minor’) may consent to medical treatment. Yet there is a remarkable lack of clarity, and lack of legal precedent, over the right of minors to control the confidentiality of their medical information. This deficiency includes the extent to which disclosure should occur between medical professionals and the parents or guardians of the minor in question.
In Australia, adults have a right to complete confidentiality of all of their health information. The few exceptions to this occur when the doctor does not identify the person, when disclosure is in the public interest or in the case of forced disclosure. The right to confidentiality is a cornerstone of the nature of healthcare provision in Australia: if it did not exist, it is likely that the confidence of the public in seeking health care would be diminished. So why is it that minors are not afforded this right?
Ethically, the focus must be the minor’s interests, not those of the parent, and it should be remembered that the treating doctor is the final judge of a minor’s capacity to consent. In some cases, the doctor will maintain a minor’s confidentiality in accordance with their wishes, but also encourage them to involve their parents in their treatment. This approach often leads to improved outcomes for the minor, as parent involvement is on the minor’s agenda (and not that of the parent or doctor). It also establishes a more effective ‘team’ (the family-doctor unit) approach to their ongoing healthcare.
Of particular concern, parents and guardians are now able to access Medicare and pharmaceutical benefits scheme (PBS) claims for minors under the age of sixteen. [3] This allows parents to access information outlining when and from whom minors have received medical treatment, and what medications have been prescribed. If the minor is aged fourteen or fifteen, a form must be signed by the minor in order to release the information to the parent or guardian. Despite this, the ability of parents to potentially access the Medicare and PBS records of their child creates a potential deterrent for the minor to access future healthcare. Children under fourteen years, who may be deemed capable of consenting to a medical treatment, are not able to restrict parental access to their Medicare and PBS record at all. This situation also places the healthcare provider in a difficult situation.
There is little legal clarity as to the point at which a young person gains the right to confidentiality. Should a young person’s ability to gain confidential healthcare be linked to their ability to consent to their own treatment (the Gillick competence)? There is a strong argument for this case. Research into minors with chronic ongoing illnesses such as diabetes has found that they may be Gillick competent from as young as the age as six. [4] Many of these minors self-manage complex conditions with little parental involvement, and perhaps should, in some cases, also have the right to confidentiality if deemed appropriate by the doctor, the minor and the parent. However, there are situations where confidentiality is not in the best interest of the minor. This may occur, for example, when a minor refuses treatment or is unable to comply with an agreed treatment without external assistance.
Perhaps the nature of health information should be an important consideration in this discussion of confidentiality? A minor may regard some types of health information as ‘private,’ while considering other issues to be suitable to discuss with their parents. For example, vaccination records would likely fit into the latter category, whilst a prescription for the oral contraceptive pill may be a more sensitive area over which the minor may wish to retain confidentiality. The difficulty with such a requirement, whereby the law is to classify the nature of the information and whether it should be confidential, is to effectively apply criterion to different ‘types’ of healthcare information. Furthermore, different minors are likely to have different opinions about what types of information could be freely ‘shared.’
Alternatively, should privacy be linked to a specific request not to disclose that information? This may be an effective way of balancing individual opinions and relationships between minors and their guardians. Should the expectation be, however, that for every piece of information shared the doctor asks the minor whether they wish it to remain confidential, or vice versa? What about information that the doctor may assume not to be private? Of course, in many ways this is the system currently in place, with doctors respecting minors’ decisions to maintain privacy, with several notable exceptions as previously discussed.
This issue will continue to be a topic of debate and discussion within the community. Ultimately it is fundamental to put the best interest of the minor first, ensuring the best possible health outcomes. If the importance of privacy is not appreciated, we create the risk of discouraging young people from seeking healthcare – which is usually contrary to the intention of the parent or guardian in the first place. Current policy and medical practice should be evaluated to ensure that doctors have appropriate guidelines surrounding when privacy should be maintained with respect to minors. Finally, it is crucial to communicate to young people seeking care their right to privacy (and the limitations upon this right), in an upfront and honest way. This will ideally result in optimum healthcare provision for young Australians.
Acknowledgements
The author wishes to thank Sara Bird, Emily Jenkins and David Taylor for their general assistance.
I am writing in response to the review article by McMullen (AMSJ Volume 1, Issue 1). [1]
The major cause of gynaecologic-related cancer mortality in women in developed settings is ovarian cancer. [2] Recent research findings in this field provide hope in relation to both screening and early treatment – even though randomised controlled trial evidence in most screening techniques is still not available.
Serum CA125, which is the most commonly used tumour marker for ovarian cancer, is not suitable for population-based screening as it has been found to be elevated in only five to six out of ten women with stage I epithelial ovarian cancer. [3] Screening and diagnosis may therefore have to incorporate a variety of other tools. Primary prevention also needs to be considered.
Primary prevention is aimed at risk factors for ovarian cancer. A study of Australian women found an increased ovarian cancer risk related to high dietary intake of red and processed meat and fat. [4]
A meta-analysis found that smoking may increase the risk of developing mucinous ovarian cancer twofold. [5] Other studies have shown reduced serous ovarian cancer risk with hormonal contraceptive use, breastfeeding duration and increasing parity. [6] Health care workers could contribute to primary prevention by encouraging patients to quit smoking, change dietary habits and breastfeed their babies.
Screening is a type of secondary prevention. Screening will have a higher yield if it is targeted at people at increased risk. Multiple primary cancer links were found in an assessment of South Australian Cancer Registry data which suggested screening for ovarian cancers in patients with colon cancer or cancer of the uterus. [7]
Genetic counselling and testing is a good screening tool in persons at high risk of ovarian cancer and persons with familial ovarian cancer history. [8] Carriers of BRCA1 and BRCA2 mutations account for up to 15% of ovarian tumours. [9] Genetic advances have also identified GTF2A1 and GTF2A1 plus HAAO as principal markers in ovarian cancer diagnosis. [10]
As for the actual screening test to be used, urine angiostatin levels are elevated in patients with epithelial ovarian cancer and have been shown to be a superior marker in detection of epithelial ovarian cancer as compared to CA125. [11] Differentiation of cancer from healthy controls had a sensitivity of 88% and specificity of 92%; while differentiation of benign from neoplastic lesions had a sensitivity of 84% and specificity of 84%. When used in combination with CA125, 91% of ovarian cancers were identified.
Transvaginal ultrasonography has also been shown to be of use in diagnosis, especially in augmentation of CA125 screening. [12] Multimodal screening, on the other hand, involving CA125 and ultrasonography in a pilot randomised trial has a positive predictive value of 21% with prolonged survival rates. [13]
In conclusion, serum CA125 is an inadequate solitary predictor in the diagnosis of ovarian cancer. Upcoming diagnostic methods provide an unprecedented opportunity to combine methods and thus improve diagnosis in Australia.
References
[1] McMullen D. Ovarian carcinoma: Classification and screening challenges. Australian Medical Student Journal 2010;1(1):35-7.
[2] Costi M, Zeillinger R. Drug resistance in ovarian cancer: Biomarkers and treatments. Highlights from the DROC meeting held in Modena (Italy) on the 19th and 20th of February 2009. Scientific topics discussed at the meeting are reported in the present issue. Gynecol Oncol 2010;117(2):149-51.
[3] Moore R, MacLaughlan S, Bast Jr. R. Current state of biomarker development for clinical application in epithelial ovarian cancer. Gynecol Oncol 2010;116(2):240-5.
[4] Kolahdooz F, Ibiebele T, Van Der Pols J, Webb P. Dietary patterns and ovarian cancer risk. Am J Clin Nutr 2009;89(1):297-304.
[5] Jordan S, Whiteman D, Purdie D, Green A, Webb P. Does smoking increase risk of ovarian cancer? A systematic review. Gynecol Oncol 2006;103(3):1122-9.
[6] Jordan S, Green A, Whiteman D, Moore S, Bain C, Gertig D, et al. Serous ovarian, fallopian tube and primary peritoneal cancers: A comparative epidemiological analysis. Int J Cancer 2007;122(7):1598-603.
[7] Heard A, Roder D, Luke C. Multiple primary cancers of separate organ sites: Implications for research and cancer control (Australia). Cancer Causes and Control 2005;16(5):475-81.
[8] Petrucelli N, Daly M, Feldman G. Hereditary breast and ovarian cancer due to mutations in BRCA1 and BRCA2. Genet Med 2010;12(5):245-59.
[9] Despierre E, Lambrechts D, Neven P, Amant F, Lambrechts S, Vergote I. The molecular genetic basis of ovarian cancer and its roadmap towards a better treatment. Gynecol Oncol 2010;117(2):358-65.
[10] Huang Y, Jansen R, Fabbri E, Potter D, Liyanarachchi S, Chan M, et al. Identification of candidate epigenetic biomarkers for ovarian cancer detection. Oncol Rep 2009;22(4):853-61.
[11] Drenberg C, Saunders B, Wilbanks G, Chen R, Nicosia R, Kruk P, et al. Urinary angiostatin levels are elevated in patients with epithelial ovarian cancer. Gynecol Oncol 2010;117(1):117-24.
[13] Jacobs I, Skates S, MacDonald N, Menon U, Rosenthal A, Davies A, et al. Screening for ovarian cancer: A pilot randomised controlled trial. Lancet 1999;353(9160):1207- 10.
It was with some interest that I read the Review Article ‘What do medical students think about pharmaceutical promotion?’ by Carmody and Mansfield, published in AMSJ Volume 1, Issue 1. [1]
As the article reports, there is a conspicuous lack of solid data investigating the relationship between pharmaceutical companies and medical students, particularly in Australia. Clearly there are both positive and negative aspects to this relationship, and I think the main concern many students hold is, at its roots, an ethical one. Can these companies exert an influence over our opinions about drugs, and subsequently affect our future prescribing practices? More importantly, does this have any relationship at all to accepting free gifts which might benefit our education?
The ethics regarding this issue is a veritable maze of should, should-sometimes and should-nots, and as with many issues, ethics often takes a second place to convenience, and sometimes even third place behind convenience and greed. Naturally, this is not to say that medical students are either indolent or opportunistic, but the importance of this issue is undeniable, with many Australian medical students uncertain about how to deal with pharmaceutical gifts and promotions.
From ethical principles, all moral individuals are bound by the Law of Reciprocity, which unequivocally states that we are disposed, as a matter of moral obligation, “to return good in proportion to the good we receive” – but how does this fit into the situation today? [2] Can a moral person, regardless of whether they are a medical student, accept a gift, be it a pen, mug, lanyard or free sandwich, and not feel a sense of ethical obligation towards the giver?
Carmody and Mansfield report that both doctors and students believe they possess a certain ‘invulnerability’ to any such nefarious ploys of inducing a reciprocal obligation, and as such feel free to accept small gifts without fear. Yet this is acting in direct opposition to the moral law of reciprocity, and consequently, does this mean we are acting unethically?
While medical students may think that getting something for free is an obvious win-win situation, in reality nothing could be further from the truth. If anything, it’s one of those infuriating lose-lose situations. Accepting a gift means the beneficiary takes on a debt which may lead to a conflict of interest in the future, and in doing so acts unethically, something which is frowned upon quite seriously within the medical profession.
Some might argue that medical principlist ethics is not dictated by the moral law of reciprocity, but we all know that few things in this world come free, and in all seriousness, what are the odds that pharmaceutical companies are spending money on gifts for purely altruistic reasons? The Review Article mentions that each doctor in Australia is subjected to an estimated $21,000 worth of pharmaceutical company promotion each year. [1] Certainly, this is a pittance when compared to the US $11 billion that are spent on pharmaceutical marketing and promotions each year in the United States; yet the implications remain clear. [3]
With that said, there are positive sides to an early association between those studying medicine and the pharmaceutical industry. Disregarding the free pens, free food and other little (or not so little) gifts, pharmaceutical companies sponsor educational seminars, social outings and even travel costs to conferences. Surely this can only have a beneficial effect on our medical education. Or, should these too be considered ‘gifts’ of a different kind – gifts that will enrich us intellectually rather than materialistically? If nothing else, such an early relationship will help to prepare medical students for how to deal with the pharmaceutical industry after they graduate.
The path ahead is not clear, for the relationship between pharmaceutical companies and medical students has both positive and negative effects. Barack Obama is reputed to have said that “If you’re walking down the right path and you’re willing to keep walking, eventually you’ll make progress”; yet how can we know where to place our feet if the ‘right’ path is hidden from us within a murky quagmire of ethical principles? Carmody and Mansfield suggest more research studies on this issue regarding Australian medical schools, and while I am not convinced this will make a pronounced change in clearing the fog obscuring the way forward, surely it cannot be a bad place to start.
References
[1] Carmody D, Mansfield P. What do medical students think about pharmaceutical promotion? Australian Medical Student Journal 2010;1(1):54-7.
[3] Wolfe S. Why do American drug companies spend more than $12 billion a year pushing drugs? Is it education or promotion? Characteristics of materials distributed by drug companies: four points of view. JGI Med 1996;11:637-9.
