“‘Change’ is scientific, ‘progress’ is ethical; change is indubitable, whereas progress is a matter of controversy.” – Bertrand Russell
Forty years ago it was generally accepted that a baby born more than two months premature could not survive. Now neonates as young as 22 weeks can be kept alive with medical intervention. This essay will explore the medical, social and legal aspects of artificial resuscitation of extremely premature neonates and argue for a change to a palliative approach towards infants born at the threshold of viability.
Background
Extremely premature newborns face a number of medical problems, affecting almost all systems of the body. These problems include extreme skin immaturity and fluid balance instability, lung immaturity and breathing problems, malnutrition and gut damage, retinopathy of prematurity, early and late onset infections and brain damage which can lead to a spectrum of long-term neurological sequelae. [1,2]…
This photograph was taken during a four week elective placement at Ilula Lutheran Hospital, located in the southern highlands of rural Tanzania, East Africa. It emphasises the innocence and resilience of this country’s generous, kind people.
Ilula Lutheran Hospital is a 70-bed facility with a geographically broad service area. Patients often travel long distances to seek attention at the facility, and present most commonly with conditions such as malaria, complications of HIV, malnutrition, trauma, burns, respiratory and diarrhoeal illnesses, often in their advanced stages.
This photo was taken while visiting a village on an HIV outreach clinic. Nurses and doctors attend villages monthly to diagnose new patients, dispense anti-retroviral therapy and perform general check-ups. The rate of HIV infection in the Ilula area has not been accurately measured; however, the infection rate has been estimated at approximately 20% in the general community and 50% amongst hospital inpatients. The day this photo was taken, the nurses and doctors were helping villagers form a support group to facilitate communication between them and the hospital, to encourage new patients to seek help and to give existing patients a support network to aid with compliance. This little boy was shy as he hid behind the skirt of his HIV-positive mother. The support group was named Tumaini – hope.
This photo was the winner of the 2011 Medical Students’ Aid Project photo competition. MSAP is a not-for-profit organisation run by medical students from the University of New South Wales. MSAP’s goal is to send targeted aid to developing world hospitals visited by UNSW medical students on their elective terms. This is done through collecting donations of equipment from hospitals and doctors around the state, as well as fundraising to purchase additional equipment and arrange for delivery of these supplies. To ensure that the equipment sent is appropriate and useful, the hospitals are asked to compile a “wishlist” of required supplies. In addition, MSAP also educates medical students on issues associated with global health throughout the year. To find out more, and how you can help, visit www.msap.unsw.edu.au today!
In early 2010 the Commission on the Education of Health Professionals for the 21st Century (the Commission) convened to outline a strategy for advancing healthcare towards a system that provides “universal coverage of the high quality comprehensive services that are essential to advance opportunity for health equity within and between countries.” [1] The strategy focuses on the education of health professionals to empower their capacity as agents of social transformation. [1] This paper endeavours to encourage medical students to think critically and ethically about the consequences of different modes of health finance on the equity of the Australian healthcare system. In doing so, it contributes to this project of health professionalism in the 21st century.
Health finance may seem of little relevance to aspiring or practicing health professionals. However, it is an important determinant of how and to whom medical services are delivered and a critical aspect of Australia’s response to the increasing resource demands of the healthcare system. Rising costs are attributable to a variety of trends including innovative but expensive technology, an ageing population, and increasing prevalence of lifestyle associated disease. Policy makers continue to debate the most effective funding methods to achieve effective use of resources, quality services and equity within the healthcare system…
Sally is a pregnant nineteen year old woman at eight weeks gestation. Sally is currently serving time in gaol and has arrived at the hospital gynaecology clinic with several members of Justice Health.
Sally is informed that the hospital can offer surgical termination of pregnancy and she is advised about the possible complications and risks of the procedure. Upon hearing these, Sally becomes tearful. The doctor advises Sally that she should not terminate the pregnancy if she has any uncertainties. Sally explains that she is concerned about the risks of the procedure, but still wants to go ahead with the termination.
As part of her initial assessment, the doctor performs an ultrasound. The consultant points out the fetal poles and heartbeat stating, “Here is the baby’s heart beating.” Upon hearing this, Sally begins crying and becomes withdrawn, not responding to any questions. The doctor concludes that Sally should be given more time to contemplate whether she wants to terminate this pregnancy and does not book her in for the procedure.
The above clinical example raises a number of ethical issues in regards to abortion. Can the woman make an informed choice without coercion when she is shown the ultrasound in this manner? Is the autonomy of the patient compromised when she is forced to listen or view information that is not necessary to her medical care? Is it in the patient’s best interest to show her the ultrasound without first asking her preference? In this article I will focus on the medical ethical values of autonomy, informed consent and beneficence in regards to the use of pre-procedure ultrasound for abortion…
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…
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…
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…
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…
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…
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…
