Palliative care provides assistance for people living with a terminal medical condition, for which the primary goal of treatment is improving quality of life. There are numerous barriers to the provision of palliative care. There is little research into barriers to the provision of palliative care and little with an Australian context. This research explores barriers to palliative care in Australia through questionnaires and interviews with stakeholders. One hundred and one questionnaires were given to South East Palliative Care (SEPC) community nursing and allied health staff, general practitioners and aged care facility staff. Five interviews were conducted with representatives from SEPC, Palliative Care Australia and two aged care facilities. Most agreed that palliative care was essential in the community, hospital and aged care setting. Four major themes were identified from interviews: 1.) Education & stigma barriers; 2.) Communication barriers; 3.) Aged care barriers; and 4.) General practice barriers. Inadequate prescriptions of pain medication were a significant issue. These themes were supported by questionnaire data, with 25.6% identifying education and 28.2% identifying resources as major barriers. Knowledge of palliative care was poor in both aged care staff and GPs, only 8.3% and 38.5% respectively answering all palliative care questions correctly, compared to 64.2% amongst SEPC staff. The study addresses a deficit in previous research, identifying barriers to palliation in aged care. The data collected has potential for further research or interventional approaches to improve the provision of palliative care for Australians.
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.
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…
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 had always considered myself an exceptional dancer. In my mind, my dance moves were unparalleled. However, in reflection, I must admit that the majority of my moves were employed to impress the scrub-nurses by turning my gown in tune to the bopping background beat of the theatre iPod. However, my delusions of dancing grandeur were shattered after watching a number of the popular dance-based shows on television. I realised it took far more than genetic talent, which I still choose to believe I have in abundance, to make a dancer. It requires hours of practice combined with fitness, good music, choreography and originality to succeed. Research, it appears, is not too dissimilar.
I had never been the most proactive student and my CV was barer than a middle-aged German tourist holidaying in Thailand. I had reached a stage in my career where it was time to contribute to medical research. Those who partake in evidence-based medicine know how important research is to the field of medicine.
If you have ever considered undertaking some formal research yourself, here are a few lessons I learnt the hard way:
What do you need?
So, you want to research? Not sure where to begin?
In dance, you need to start with either good music or a good choreographer. In research, your music is your idea, question or inspiration, and your choreographer is your supervisor.
The music (idea)
The chances are that someone, somewhere, has already attempted to adapt “the sprinkler” to your chosen music. As in research, if you think you have a good idea, someone else may have had it before you. To find out, the next step is to conduct a literature review. Medline is a good place to start.
Don’t be disheartened if someone has already researched your hypothesis. In medicine, most people can only answer very specific questions. So, if your good idea has already been partially covered, then read a few articles and find a more specific, unanswered question similar to your original one.
For example, if your question was “How effective is heparin in preventing DVT?” then refine your question to “How effective is low molecular weigh heparin in preventing DVT in male patients aged between 80 and 81 with a past history of smoking 22 cigarettes a day who have just undergone a knee replacement and whose favourite colour is light blue, when compared to Aspirin?” and believe you me, it is unlikely anyone else has researched that topic! Also, if someone has attempted to answer your question, it is worthwhile reading their article. If you find that their methodology is lacking, then you may decide to investigate that topic regardless, albeit with more watertight…
Timorese girls from the Gleno Orphanage, located about 40km or a two hour drive from Dili in the Emera Mountains. The mobile clinic from Bairo Pite Medical Clinic visited the orphanage monthly.
The medical elective is notorious for being an excuse for taking a holiday in an exotic corner of the world. Like many of my colleagues, I also travelled to one such corner, Bairo Pite Clinic in Timor-Leste (the official name of East Timor), in search of an adventure with some medical experience thrown in. In retrospect, those six weeks were without doubt the steepest learning curve of my medical training. However, there are a number of things I wish I had known and a great number I would have done differently. Therefore please let me share some insights I have gained with use of the retrospectoscope – the device in medicine which enables the viewer to judge past events or actions with the aid of knowledge obtained since they occurred. This is in the hope of equipping you with some knowledge to make your elective experience the time of your life.
Language
I arrived in Dili, the hot, dusty capital of Timor-Leste after an almost sleepless night in Darwin airport and with a four-word vocabulary of Tetun, the local language. Nevertheless, I was almost immediately loaded onto the clinic’s four-wheel drive ambulance to embark on my first of many mobile clinics into the mountains. For such clinics the four-wheel drive is loaded up with a box of very basic medications, and a driver, a doctor or medical student and a medications dispenser drive up to six hours on a road resembling a goat track to a remote village. There, they see a queue of patients – some waiting, some materialising from the surrounding forest- and drive back, often with acutely ill patients. And thus was the experience from which stems my first insight – learn some of the language.
Despite having an ‘interpreter’ – she spoke as much English as I spoke Tetun – I was luckily armed with the Lonely Planet Tetun phrasebook, which I think saved more lives than I did that morning. Daily Tetun lessons, jotting phrases on the back of my hand and the phrasebook ensured I quickly picked up enough language to hold a reasonable medical consultation. Despite this, I wished countless times I knew some Tetun before I arrived in-country. If you are planning on travelling to a non-English speaking country, do try and learn some local language before you depart. Being able to communicate with your patients makes a world of difference.
Pre-Read
After my mobile clinic baptism of fire, I returned to the Bairo Pite clinic in Dili to be confronted with the afternoon ward round, and a lady in the final stages of labour. Prior to my elective I had seen one patient with tuberculosis (TB) and delivered five babies. Score at the end of the first ward round: 67 TB patients and eight babies delivered. I vividly recall returning to my room that night acutely aware of how much I did not know. I sincerely wished then that I had taken the time to read up on the common problems experienced in Timor: tuberculosis, malaria, labour and its common complications and gastroenteritis. A basic understanding of how to identify and manage these conditions in resource poor countries is essential to getting the most out of your elective. The World Health Organisation (WHO) has some great articles on managing these and other health issues specific to the developing world. [1-4] I thoroughly recommend utilising these prior to and during your elective. Along with the Lonely Planet phrasebook these articles saved a number of lives.
Change the World
Before travelling to Timor-Leste, a number of people warned me against thinking I could change the world in six short weeks. And, yes, I completely agree with them, it is not possible. However, do not allow anyone to convince you of the disillusion that you cannot make a difference, but, like chocolate cake, there is a delicate balance between too much and too little. During my time in Timor-Leste, I fluctuated between strategising how to revolutionise their health system and becoming exasperated with the staff, the patients and the system itself.
I only found this happy medium after many discussions with long-serving expatriates, my supervisor, the famous Dr Dan Murphy and a 24 hour flight using the almighty retrospectoscope. Be aware that revolutionising the local health care system includes ensuring nurses actually take observations rather than just filling in normal results; it is amazing how your patient can be saturating at 99% when the clinic does not have a working saturation probe! The work ethic in Timor is much more relaxed than the Australian system, and it is worth remembering that the way you are used to is not necessarily superior and you are the visitor, so embrace and work along with their system. And remember, change on a big scale, if you want it to last, takes time, dedication and education. So if you are planning a revolution, be prepared for your elective to go for six years rather than six weeks.
However, it is also worth noting that you can make a difference for…
Addendum
The arrow head was lodged in the young man’s right atrium. In order to remove it we did a transverse thoracotomy and made a pericardial window. After placing a purse-string around the arrow shaft we removed it, although we had to extend the entry site a small amount in order to remove the barb. Then, we pulled the purse sting taught and oversowed the pericardium (i.e. when repairing the pericardial window you overlap the edges to prevent tamponade in the event of leakage). He made a remarkable post-operative recovery. He was demanding food in an hour and asking when he could go home in two hours! Thankfully he didn’t develop any infections, and because we didn’t open the pleura at all, he didn’t require a post-operative chest-tube. All of this meant he was discharged home after three days. I saw him again about four weeks later and you never would have guessed he had been in hospital, let alone had an arrow pierce his chest!
As the prevalence of those seeking health information online rises, the potential for information overload and misinformation increases. This study aims to evaluate and explore the Internet’s role as a health information source, specifically for university students. In total, 120 university students were surveyed for their behaviours and attitudes when accessing online health information. Of the respondents, 61% had used the Internet as a personal health information source at least once in the past and 34% do so at least once a month. In comparison with other common information sources, the Internet was the third most commonly used (41%) behind General Practitioners (73%) and family and friends (60%). Despite this frequency of use, only 5% of participants regarded the Internet to be very accurate, while 27.5% had found health information on the Internet to be misleading. Online health advice had delayed appropriate medical treatment at least once for 28% of participants. Both information inaccuracy and treatment delay pose risks to health outcomes. The findings from this research provide a useful starting point for future research into Australian Internet health information seeking behaviour.
