Introduction: This case report aims to address the ethical issues and obligations of enforcing medical care onto psychiatric patients under the Queensland Mental Health Act 2000 Involuntary Treatment Order (ITO), and will also present Queensland’s legal standpoint and limitations on providing this care under the Act. Case Presentation: PF, a 47 year old male with a history of depression and recent diagnosis of Gleason 7 prostate cancer was admitted to the acute mental health unit following an intentional overdose of alprazolam. His risk to himself prompted the application of an ITO. Although PF was due for investigation of his recently diagnosed prostate cancer, he refused following his suicide attempt. Conclusion: Although an ITO allows for enforcement of psychiatric treatment, no legal allowances exist for enforcement of medical care. In situations where medical conditions may be indirectly detrimental to a person’s mental health, ethicallyappropriate techniques should be employed.
This case report describes a lady who presented with abdominal pain, hypotension and multiple ovarian follicles following egg collection and embryo transfer. She was provisionally diagnosed with Ovarian Hyperstimulation Syndrome (OHSS) and managed accordingly. This case study describes her clinical presentation, investigations, progress, management and outcome. No current laboratory diagnostic/prognostic markers are available for OHSS; the condition is currently diagnosed clinically. The subsequent discussion elaborates on the epidemiology, pathophysiology, clinical features, assessment, management and risk factors of OHSS, and aims to increase awareness of this important complication of infertility treatment to assist diagnosis, prevention and early institution of treatment.
Prof. Peter Doherty won the Nobel Prize in Medicine in 1996 with his colleague Rolf Zinkernagel for the discovery of the interaction between T cells and the major histocompatibility complex (MHC). He was named Australian of the Year in 1997. He continues to make major contributions to immunology research, specifically in the area of influenza. The editors of the AMSJ asked Prof. Doherty to share some of the details of his journey leading up to his renowned immunological discoveries.
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.
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…
“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…
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…
