2017 AMA media and advocacy awards

At the 2017 AMA National Conference, six media and advocacy awards were presented.

A new award category was opened for this year’s entries – the Best Public Health Initiative. State and Territory AMAs were invited to nominate an outstanding public health initiative or campaign – other than smoking and tobacco control – launched by their State or Territory Government in calendar year 2016.

Nominated by AMA NSW, The NSW Government, won this award for its campaign to combat childhood obesity. The NSW Health campaign is a comprehensive whole-of-government plan with the specific target of reducing overweight and obesity rates of children by 5 per cent over 10 years.

The judging panel, headed by Public Health Association of Australia CEO Michael Moore, noted that the campaign stood out for its clear strategic directions, and its strong focus on children and young people.

The Best Lobby Campaign 2017 was awarded to AMA Western Australia for their ‘Three-year Employment Contracts for Interns’ campaign.

The successful introduction of the three-year employment contracts for interns is a standout achievement. The reform eliminates the previous system of annual contracts, thereby eliminating both the cost and the stress of interns having to reapply for their jobs on an annual basis.

The judges commented that AMA WA’s policy success should contribute to improved health outcomes across the WA system, with the hope that this initiative may spread nationally over time. In addition, the successful recombination of the Minister of Health and Mental Health is also a noteworthy success for the WA branch.

Best Public Health Campaign from a State or Territory 2017 was awarded to AMA Western Australia for highlighting ‘Australia’s Mental Health Crisis’.

AMA WA has developed a state-of-the-art best practice mental health program that is being recognised Australia-wide as the best of its kind using a dual approach to reach youth at school and adults in the workplace – two groups under severe mental health pressure.

Judges commended the branch on the clarity and quality of the campaign. They said the effectiveness in engaging and delivering its important message pointed to a significant public health intervention that deserved to be recognised.

AMA Victoria received Best State Publication 2017 for ‘Vicdoc’, whichcovers the ethical, political, clinical, and work based issues facing the medical profession in great detail.

Judges commented that the publication was valuable and informative and a must-read for any Victorian doctor. The front covers were simple and with compelling use of images. The standard of writing in this publication was extremely high and very informative.

AMA Victoria was also awarded with the National Advocacy Award 2017 for their cooperation between federal AMA during the introduction of the Victorian Government’s ‘Assisted Dying’ legislation.

AMA Victoria’s actions and commentary on assisted dying have always referenced and reflected AMA Federal’s policy position.

AMA Victoria called for improved funding for palliative care services, and legislative changes to the Doctrine of Double Effect through the enactment of legislation to provide legal certainty to medical practitioners in connection with the accepted clinical practices of double effect and non-provision of futile care.

Judges commended AMA Victoria on its clear and concise submission to the inquiry into a very sensitive and often divisive issue.

Most Innovative Use of Website or New Media 2017 was awarded to AMA Western Australia for their creation of WAhealthfirst.com.au.

This website utilised a new media approach that generates conversation from content advocating AMA WA’s position on key political issues, most relevant to the recent State election earlier this year. An expected outcome of new media is to use technology available to provide clear and easy communication to the user. Judges commended AMA WA in the success of WAhealthfirst.com.au and said it was clear it simplified the voter education process of health policy while also providing the facts.

Meredith Horne

AMA President’s Award presented to a long-serving and dedicated GP

Professor Bernard Pearn-Rowe, who has been a constant advocate for general practice for almost three decades, has been recognised with one of the AMA’s highest awards, the President’s Award.

Professor Bernard Pearn-Rowe has juggled maintaining his solo GP practice in Perth with his active roles in AMA WA medical politics, including a term as AMA WA President, and his appointment as Foundation Professor of Clinical Studies at the University of Notre Dame.

Dr Gannon presented Professor Pearn-Rowe with his Award at the AMA National Conference 2017 Gala Dinner in Melbourne.

“During his time as Convenor of the federal AMA Council of General Practice (CGP), he has contributed to key policy areas including the role of general practice in primary care, e-health, medical education and training, GP workforce, red tape reduction, Health Care Homes, and the role of GPs in disaster situations,” Dr Gannon said.

“Professor Pearn-Rowe has been part of an AMA CGP that has emphasised the importance of quality general practice and the need for Governments to support this as part of a high quality, sustainable health care system.”

Amid his many commitments, Professor Pearn-Rowe has also found the time to pen a weekly medical column in The West Australian newspaper, making him an outstanding face of the AMA in WA.

Professor Pearn-Rowe was chair of the Royal Australian College of General Practice (RACGP) in Western Australia from 1989 to 1993, Chair of the AMA WA Council of General Practice (CGP) from 1998 to 2001, and Convenor of the Federal AMA CGP since 2004. He was appointed a Fellow of the federal AMA in 2004.

Professor Pearn-Rowe graduated in Medicine from the University of London in 1972 and joined the AMA in 1976. He has been active in AMA WA medical politics since that time, including a period as President of the AMA in Western Australia from 2002-2004. He was appointed a Fellow of the AMA in 2004.

He was appointed Foundation Professor of Clinical Studies at the University of Notre Dame in 2004 and was Foundation Professor and Head of Discipline of General Practice in the School of Medicine at the University of Notre Dame from 2006-2010. Since that time he has continued as an Adjunct Professor.

Meredith Horne

Training sessions

As part of a program of support for Small to Medium Enterprises (SMEs), we have identified education and training topics that will help SMEs, and others who may not interact with us frequently or often, to understand key issues around the regulation of…

[Series] Management of patients at risk of acute kidney injury

Acute kidney injury (AKI) is a multifaceted syndrome that occurs in different settings. The course of AKI can be variable, from single hit and complete recovery, to multiple hits resulting in end-stage renal disease. No interventions to improve outcomes of established AKI have yet been developed, so prevention and early diagnosis are key. Awareness campaigns and education for health-care professionals on diagnosis and management of AKI—with attention to avoidance of volume depletion, hypotension, and nephrotoxic interventions—coupled with electronic early warning systems where available can improve outcomes.

Disability in Australia: changes over time in inclusion and participation factsheets: community living, education and employment

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Preparedness for practice: the perceptions of graduates of a regional clinical school

The known Universities, medical authorities and employers are interested in whether medical graduates are adequately prepared for practice. Medical graduates’ self-assessment of their capabilities on entering the workforce are relevant to this question.

The new Graduates from the Launceston Clinical School generally felt well prepared for the transition to clinical practice as a junior doctor.

The implications Reforms of undergraduate medical education should focus on moving graduates from feeling merely prepared to being well or extremely well prepared by the time they commence practice. The survey could be administered more broadly to obtain a national, longitudinal perspective of perceived preparedness.

The dual responsibility of medical schools — to train doctors in the capabilities they need for practice immediately after graduating, and to prepare them for adapting to constantly changing health employment systems — is being examined in the context of an increasing focus by governments and higher education bodies on how prepared graduates are for medical practice.1–4 Most medical graduates in Australia are employed as doctors, but it is important to determine whether all are prepared to fulfil their duty of care in the face of the challenges posed by the increasing complexity of health care practice and systems.5 Higher education leaders seek to produce graduates who are “work ready plus”; that is, possessing capabilities that are relevant for future workplace requirements, not just current needs.6

Employability skills in the medical profession are high order capabilities: knowledge and skills, the capacity to continue to learn, the ability to perform in changing contexts and to be clear in professional purpose.2,7,8 In his recent report on transforming graduate capabilities, Geoffrey Scott discussed the “work ready plus” capabilities required by university graduates for future employability, including being able to implement change, to work in partnership, and to manage the unexpected, as well as being clear about their role in driving change.6

Concern has been expressed about how prepared graduating doctors are for delivering patient-centred care, about the erosion of patient-centredness during basic medical training, and about their capacity to provide this care as health care workers.9,10 The final report of the Review of Medical Intern Training commissioned by the Australian Health Ministers’ Advisory Council noted a “lack of objective, accessible and current data … on the level of graduate preparedness”.9

As the evidence for improved health outcomes and cost-effectiveness associated with patient-centred care mounts,11,12 understanding and teaching patient-centred care is becoming pivotal for cultivating graduates with a refined professional identity; that is, with patient-centredness embedded in their sense of who they are as a doctor, in their attitude and approach to medicine, so that they are more able to champion this approach in the health care system. The synergy achieved by aligning Scott’s “work ready plus” requirements6 with patient-centred medicine will enable doctors to work in partnership with patients, to cope with uncertainty, and to develop a well formed, patient-centred professional identity for managing the complex chronic health problems affecting patients and the community.

The regional Launceston Clinical School (LCS), one of three clinical schools at the University of Tasmania, has provided about 40 students from each of the final two years of a 5-year undergraduate degree with a specific patient-centred learning program,13 alongside traditional clinical hospital rotations and case-based learning, since 2005. In the executive summary of the NSW Health Education and Training Institute Medical Portfolio Programs report, emphasis was placed on the fact that the “characteristics of future doctors and the content of the curriculum and ways of teaching and learning must reflect the need for a greater focus on professionalism and the quality and safety of patient care.”8

As a pilot study in an Australian setting, we surveyed medical graduates about their perceptions of how well their undergraduate education at the LCS prepared them for a range of practice capabilities, including those central to patient-centred care.

Methods

Study design

Graduates’ perceptions of their preparedness for practice were surveyed with a self-report instrument, administered with the cloud-based SurveyMonkey software.

Participants and sample

All contactable medical graduates who attended the LCS during 2005–2014 were invited by email to participate. Alumni records and social media, among other sources, were used to identify current email addresses. Reminder emails were twice sent to non-responders.

Survey

A survey previously developed by the Peninsula Medical School (Plymouth University, United Kingdom)3 was, with permission, modified for this study. The curricular emphasis at the Peninsula School on working with patients in activity learning contexts is comparable with the LCS patient partnership learning encounters approach.

The modified survey consisted of 44 items with the stem question, “How well did your undergraduate education at Launceston Clinical School prepare you for …”. Participants were asked to respond on a 5-point Likert scale (1, unprepared; 2, not very well prepared; 3, prepared; 4, well prepared; 5, extremely well prepared). One item in the original 39-item survey (“… functioning safely in an acute ‘take’ team”) was not applicable in the Australian context and therefore omitted. The item “… overall patient-centred practice and humane care” was not regarded as sufficiently specific for exploring patient-centred care capabilities and was replaced with seven items more explicitly related to aspects of patient-centred care preparedness (Box 1). Our 10-year experience of implementing and assessing patient-centred learning, including our development of a validated assessment instrument,13 indicated that the seven items were important components of patient-centred practice capabilities. They also reflect elements of expected practice capabilities outlined in the Australian Curriculum Framework for Junior Doctors.14

Additional data (eg, sex, number of years since graduation) were also collected. Qualitative information gathered for deeper investigation of factors affecting transition to practice is not discussed in this article.

Analysis

Responses were analysed as counts and percentages; data for all items are presented in a stacked bar chart.

In order to determine the impact of time since graduation on responses, the 44 questions were grouped into six thematic clusters identified independently by each of the four investigators, with the final themes determined by discussion (Box 1). The preparedness scores were ordinal, making an ordered logistic regression analysis appropriate. Including all six themes in a repeated measures analysis allowed each graduate to act as their own control. The relative preparedness scores for each thematic cluster were compared in repeated measures, random effects, ordered logistic regression. The “core skills” theme for those who graduated 1–4 years ago was used as the comparator for generating odds ratios for the other five themes for participants who graduated 1–4 years ago, and for all six themes for those who graduated 5–10 years ago. Data for women and men were analysed separately. In addition, a time interaction analysis compared the preparedness of 1–4 year graduates and 5–10 year graduates in each theme, separately for each sex. The mean preparedness scores (with standard deviations [SDs]) for each theme–time period–sex combination are reported for illustrative purposes only. The responses of participants of each sex in each theme were also compared to assess sex differences in perceptions of preparedness. Analyses were performed in Stata/MP2 14.1 (StataCorp).

Ethics approval

Ethics approval was obtained from the Human Research Ethics Committee of Tasmania (reference, H0015128).

Results

Survey invitations were sent to the 273 of 359 graduates (76%) for whom current email addresses could be obtained; 147 responses were received (54% of invitees, 41% of the total cohort). Twelve graduates supplied demographic data only, so that 135 graduates were included in the final sample (38% of the total cohort). Of these, 51% were men and 49% women; 71% had graduated in the past 5 years, 29% 6–10 years ago.

For 17 of the 44 surveyed items, at least 80% of graduates reported being extremely well or well prepared. For six items, at least 10% of respondents reported not being well prepared or unprepared for practice: providing nutritional care (29%), using audit to improve patient care (26%), clinical governance (23%), using informatics (11%), responding to error and patient safety (11%), and cultural competency (10%) (Box 2).

More than 80% of graduates felt extremely well or well prepared for only one of the seven patient-centred care items: understanding the concept of patient-centred practice (82%). The figures for the other six items were lower: understanding the impact of patient-centred care (78%), being comfortable with the craft of consultation (76%), shared decision-making (73%), role modelling to junior colleagues (73%), self-critique (76%), and exploration of patient needs (73%).

The 44 survey items were grouped into six broad skills clusters (Box 1). Compared with the core skills theme for 1–4 year graduates, women who had graduated 1–4 years ago perceived themselves as less prepared in all other clusters, except clinical care. Among those who had graduated 5–10 years ago, preparedness for patient-centred care was not significantly different from that for core skills among those who graduated 1–4 years ago. Men who had graduated in the previous 4 years perceived themselves as less prepared than for core skills in all clusters, except for clinical care and patient-centred capabilities. After adjusting for time interaction, the perception of preparedness among men who had graduated 5–10 years ago was statistically significantly higher for core skills and lower for the system-related capabilities group. There were no statistically significant time-related differences for women (Box 3).

For recent graduates (1–4 years ago), there were no significant sex differences in the perception of preparedness in particular thematic groups. Among respondents who had graduated more than 4 years ago, the perception of preparedness was generally higher for men, but this was statistically significant only for the patient-centred care cluster (P = 0.04; online Appendix).

Discussion

A large majority of respondents reported feeling prepared for each of the 44 capabilities covered by the survey. In 17 areas of practice, at least 80% of respondents felt well or extremely well prepared; it is encouraging that these items covered a range of professional, clinical, patient engagement and reflective capabilities, indicating that graduates had a wide-ranging sense of preparedness for their role as doctors. We found some differences in perceived preparedness among male respondents according to whether they had graduated 1–4 years ago or more than 4 years ago. It is not possible to determine whether these changes resulted from changed perception of their capabilities arising from greater professional experience, pre-registration curriculum changes, or recall bias. We postulate that the difference related to changes in their understanding of their role, as there was a significantly different perception of readiness in only two domains (and for men but not for women), and there had been no significant curriculum changes.

This study was conducted at a time of increasing national9 and international1,3,15–17 focus on the preparedness of medical graduates for practice. The General Medical Council (UK) has systematically examined the question over the past decade, and recently reported that one in ten graduates felt poorly prepared for entering medical practice.1,18 Investigations by Australian medical schools have been less systematic.6,19,20 As a consequence of the Medical Intern Training Review, national surveying of Australian interns is now being considered.9,21

Measuring insights about and reflections on practice after commencing work is a worthwhile contribution to understanding the standard of undergraduate medical education and perceived gaps in their readiness to practise as a doctor.3,17,22,23 Viewing preparedness as a continuous non-linear process1 means that it should be assessed as part of an integrated, continuous assessment model encompassing both training and practice.24 Because the performance of graduates continuously improves as they become more experienced, the question of when to retrospectively measure perceptions of preparedness needs to be considered carefully. It should ideally be undertaken at a consistent point in time after commencing practice, when results from different years can be validly compared and are not subject to biases or changes in perceptions attributable to increased experience. Further research will be needed to determine the optimal methodology for such assessment.

If the objective is to prepare a “work ready plus”6 doctor, focusing on our findings relevant to the value-added or non-technical aspects of medicine3 is useful. Preparedness for “engaging in self-directed lifelong learning” and “organisational decision-making” was rated highly, skills need for building professional development, potential leadership, and adaptive capabilities.1 The levels of perceived preparedness for “understanding the concept and impact of patient-centred practice”, “educating patients”, and “shared decision making” indicate the readiness for effective partnering with patients and families for improved health outcomes. The practice areas of “coping with uncertainty” and “reporting and dealing with error and safety incidents” are capabilities that rated less well, indicating opportunities to improve building skills for competently managing unexpected and complex scenarios that arise in health care. “Coping with uncertainty” is a central outcome for Peninsula School undergraduates; they reported a particularly high level of preparedness for this capability, a finding attributed to working with patients and colleagues in activity learning contexts.3 This suggests that when students are directly exposed to key areas of and approaches to practice, their perception of being prepared is enhanced.

That “basic nutritional care” was identified as an area needing improvement is consistent with other findings3 about the capabilities and confidence required to communicate with patients about weight and obesity problems.25 This lack of confidence is important, given increasing population levels of obesity.26

While the overall perceived level of preparedness was high for these graduates, for 61% of the surveyed items fewer than 80% of respondents rated themselves as well or extremely well prepared. There are clear implications for further improving undergraduate medical education, ensuring that graduates feel well or extremely well prepared, rather than merely prepared, by the time they commence practice.

Medical schools should provide patient-centred learning that improve graduates’ capabilities and therefore readiness for the workforce, with safe, high quality care for patients as the goal.27 The LCS curriculum follows a traditional block rotation clinical learning model with a patient partnership program spread across the year and delivered alongside case-based learning.13 As yet there are no data for a direct comparison with non-explicit teaching of patient-centred care that would allow us to determine whether such a program makes a difference to preparedness for patient-centred care. Deliberate patient-centred experiential learning recognises that graduates arrive in a hospital system where “practice in partnership”27 with patients is now expected; aligning the learning continuum expectations with those of the workplace should be driven by this recognition.

Limitations to our study include the fact that respondents’ reflections on their experiences and the expectations they faced in earlier years may have caused recall bias. It is also possible that doctors further out from graduation have different perceptions of preparedness because of their greater experience working in health care. This study is also limited by its being a single site study in a regional university with small graduate numbers, meaning that its results may not be generalisable to other medical schools. Respondents’ interpretation of what constitutes preparedness for each item may also have varied, given that there were no objective criteria for graduates to benchmark their own preparedness.1,15 The judgements of graduates cannot be assumed to be equivalent, although it is likely that each graduate applied similar judgements to each of the 44 items.

Conclusion

Overall, graduates from the LCS felt well prepared for the transition to clinical practice as a junior doctor. Repeated retrospective surveying of our graduates would offer further insights that could inform redesigning areas of the curriculum. If the survey were administered more broadly and a national, longitudinal perspective of perceived preparedness obtained, the results would enhance the integration of the teaching–learning–assessment continuum with service expectations.7,24 A key consideration for such a survey would be the optimal time point after graduation for its administration.

Box 1 –
“How well did your undergraduate education at Launceston Clinical School prepare you for …”: the 44 capabilities included in the survey, grouped into six broad skills clusters

Core skills

Taking a history

Examining patients

Skills of close observation

Selecting appropriate investigations and interpreting the results

Clinical reasoning and making a diagnosis

Prescribing safely

Advanced consultation skills

Educating patients (health promotion, public health, health literacy building)

Communicating effectively and sensitively with patients and relatives

Breaking bad news to patients and relatives

Being comfortable with the craft of consultation*

Personal and professional capabilities

Managing your health including stress

Coping with uncertainty

Understanding the purpose and practice of appraisal

Engaging in self-critique of practice and clinical encounters*

Role modelling to junior colleagues*

Coping with ethical and legal issues (eg, confidentiality/consent)

Undertaking a teaching role

Engaging in self-directed lifelong learning

Being aware of your limitations

Acting in a professional manner (with honesty and probity)

Communicating effectively with colleagues

Working effectively in a team

Patient-centred capabilities

Providing appropriate care for people of different cultures

Recognising the social and emotional factors in illness and treatment

Understanding the impact of patient-centred practice*

Understanding the concept of patient-centred practice*

Exploration of patient needs*

Shared decision-making management*

Understanding the relationship between primary/social and hospital care

Clinical care

Using evidence and guidelines for patient care

Early management of emergency patients

Taking part in advanced life support

Maintaining good quality care

Planning discharge for patients

Basic nutritional care

System-related capabilities

Clinical governance

Using audit to improve patient care

Using informatics as a tool in medical practice

Reporting and dealing with error and safety incidents

Reducing the risk of cross infection

Organisational decision making

Ensuring and promoting patient safety

Keeping an accurate and relevant medical record

Time management

* Items added to the original Peninsula Medical School survey.

Box 2 –
“How well did your undergraduate education at Launceston Clinical School prepare you for …”: responses for the 44 capability items in the survey, ranked according to the proportion who responded that they were “extremely well prepared” or “well prepared”

Number of responses for each item, 135, except: * 134 responses; † 133 responses.

Box 3 –
Comparison of responses in the different thematic groups, by sex and time since graduation

	Women					Men
	Total*	Mean response (SD)^†	Odds ratio^‡ (95% CI)	P^‡	P^§	Total*	Mean response (SD)^†	Odds ratio^‡ (95% CI)	P^‡	P^§

Graduated 1–4 years ago
Core skills	234	4.2 (0.7)	Reference			161	4.1 (0.7)	1.00
Advanced consultation	272	4.0 (0.8)	0.56 (0.38–0.84)	0.005		189	3.9 (0.9)	0.43 (0.27–0.69)	< 0.001
Personal/professional	350	3.7 (0.9)	0.27 (0.18–0.39)	< 0.001		242	3.7 (0.9)	0.30 (0.17–0.50)	< 0.001
Patient-centred	468	4.0 (0.8)	0.59 (0.43–0.80)	0.001		324	4.0 (0.9)	0.66 (0.40–1.08)	0.10
Clinical care	156	4.1 (0.8)	0.80 (0.50–1.27)	0.34		108	4.2 (0.9)	1.23 (0.75–2.01)	0.42
System-related	234	3.7 (0.9)	0.25 (0.16–0.37)	< 0.001		161	3.9 (0.9)	0.49 (0.33–0.72)	< 0.001
Graduated 5–10 years ago
Core skills	215	4.2 (0.7)	1.01 (0.41–2.49)	0.98	0.98	161	4.4 (0.7)	2.67 (1.08–6.60)	0.033	0.033
Advanced consultation	252	3.8 (0.7)	0.32 (0.12–0.84)	0.021	0.15	189	3.9 (0.7)	0.84 (0.39–1.80)	0.65	0.45
Personal/professional	323	3.7 (0.9)	0.25 (0.11–0.59)	0.002	0.80	242	3.6 (1.0)	0.40 (0.19–0.85)	0.018	0.07
Patient-centred	431	3.9 (0.8)	0.48 (0.20–1.18)	0.11	0.51	324	4.1 (0.8)	1.66 (0.77–3.59)	0.20	0.88
Clinical care	143	4.0 (0.7)	0.50 (0.19–1.34)	0.17	0.26	108	4.1 (0.7)	1.82 (0.76–4.35)	0.18	0.19
System-related	216	3.7 (0.9)	0.24 (0.11–0.55)	0.001	0.93	161	3.8 (0.9)	0.67 (0.32–1.43)	0.30	0.038

* Total number of individual responses to questions in the respective category. † Calculated for illustrative purposes only. As the Likert scale responses are inherently rank-ordered (1 to 5; not interval), a rank-ordered analysis was conducted for formal comparisons. ‡ Compared with the responses to the core skills/graduated 1–4 years ago category. § Adjusted for time of graduation (by category).

Work-readiness and workforce numbers: the challenges

We need clinicians prepared for work in a system of integrated, person-centred, affordable health care

Over the past 15 years or so, Australia has embarked upon what some might describe as a “courageous” solution for guaranteeing our medical workforce. Following a perceived shortage of doctors at the beginning of the 2000s, the number of accredited medical schools has grown from 10 to 20,1 with another currently undergoing accreditation; the number of medical graduates has almost tripled from 1316 in 2001 to 3547 in 2015.2 Increasingly large numbers of doctors have also been recruited from overseas to overcome shortfalls: 2820 temporary visas were granted during 2014–15 alone.3 The per capita production of local medical graduates4 and growth in the stock of foreign-trained doctors5 are among the highest in the world.

Australia is also a leader in more sensible ways: establishing rural clinical schools and regional medical schools and increasing the numbers of rural origin and Indigenous Australian medical students. Clinical training for students has spread well beyond the traditional metropolitan teaching hospital. Rural sites are at the cutting edge of reforms, including community-engaged medical education, longer, integrated clinical placements, and inter-professional learning, resulting in some solid workforce outcomes.6–8 The high levels of graduation and importation over 15 years have markedly increased doctor numbers. With 3.5 practising doctors per 1000 population (2014), Australia has more doctors per capita than Canada (2.6), the United States (2.6), New Zealand (2.8) or the United Kingdom (2.8), and exceeds the OECD average of 3.3 doctors per 1000.4

There is accordingly no overall shortage of doctors in 2017. But a regional hospital attempting to recruit an Australian-trained surgeon or psychiatrist, or a remote community looking for a broadly skilled rural generalist practitioner might beg to differ. Regional Australia remains heavily reliant on the provisional solution of importing medical labour, while growing numbers of domestic graduates jostle for internships and specialist training positions in the cities, swelling the ranks of an increasingly subspecialised metropolitan workforce. Joining them are many international recruits who move to cities after their obligatory period of service in rural areas is completed.

Factors that promote this situation include uncapped fee-for-service insurance systems, high volume corporate practice models, and the staffing and rostering proclivities of large hospitals. Threats to the system associated with the high number of city doctors include higher levels of inappropriate care servicing, fragmentation of care, yet more constraint on the scope of generalist clinical practice, and fiscal pain for taxpayers.

Increasing the number of medical graduates as a solution for workforce shortfalls has faltered because the job was only half done. Medical school, while important in itself, is the stepping-off point for further training: the first year as an intern, and then (after a period as a junior hospital doctor) years of training towards a fellowship in general practice or one of the 63 other recognised medical specialties. Australia has the second highest number of stand-alone specialty fellowships, after the US.9

As long as the funding, physical and cultural base for internship and subsequent training remains centred on big metropolitan hospitals and city practices, there be will no home-grown solution for securing our medical workforce. Even rurally inclined graduates who have trained in rural areas may feel obliged to join the race for city training positions,6 which typically means years in a metropolitan training pathway. Meanwhile, life events intervene and become barriers to returning to rural communities.

These bottlenecks in clinical training are occurring at a time when responsibility for its support is unclear, given our regionally autonomous public hospital system, funded according to clinical activity.10 With no transparent funding model for teaching and training, historical practices more or less prevail. Opportunities for interns, junior doctors and specialist trainees to train in private or non-government organisational settings remain limited.

What does all this mean for the work-readiness of an intern, or indeed of medical graduates at any point along the medical training continuum, including career-long learning?

One view of work-readiness is that provided by surveys of graduates’ own assessment of their preparedness for work as an intern in a large hospital, as described by Barr and her colleagues in this issue of the MJA.11 Their study found that the graduates surveyed generally felt well prepared with respect to 44 specific capabilities, including patient-centred care, although there was also a small number for which they did not feel well prepared, such as providing nutritional care, using informatics, and cultural competency.

These findings raises the question of the utility of the medical internship model, a problem discussed in a 2015 Council of Australian Governments review, which concluded that the model was still of value, but could be improved to better achieve its goals.12 For instance, although outcome statements for medical graduates and interns are a helpful guide for medical graduates and their supervisors, there is room for improving dialogue between universities and employers about work-readiness.

However, we believe there is a broader perspective from which to judge work-readiness: whether the training system (including internship) is producing sufficient numbers of clinicians ready for work that is aligned with community needs for integrated, person-centred, affordable health services for an ageing population that is experiencing higher levels of chronic disease.

To achieve this goal, we must ensure more equitable geographic distribution of specialist medical training, bolster clinical generalism, emphasise teamwork, and select individuals for further training on the basis of their propensity to serve community needs. We argue that these are the greater challenges for work-readiness and reform.

The benefits of international health experiences for Australian and New Zealand medical education

Embracing structured international health experiences in mainstream medical education is critical to the development of future doctors

Globalisation has dramatically changed and continues to change the way the world works. Societies, businesses and individuals are increasingly adapting to a world with fewer borders and geographical constraints than in the past.1 Global health has been defined as:

an area for study, research and practice that places a priority on improving health and achieving health equity for all people worldwide, [which] emphasises transnational health issues, determinants and solutions; involves many disciplines between and beyond the health sciences; and synthesises population-based prevention with individual-level care.2

Despite the emergence and establishment of global health as an academic discipline, it largely resides within public health education and practice, and is typically taught and learnt within Master of Public Health programs, rather than through experiences within mainstream medical education. In Australian and New Zealand medical programs, clinical learning with a global health focus is generally achieved through the inclusion of clinical placement electives that permit student-initiated and organised international health experiences (IHEs).2 In cases where the IHEs are arranged by the university, they are generally short and optional.

Market forces and increasing demand for international health experiences

Clinical learning beyond a medical student’s home university is a relatively new phenomenon, but IHEs have expanded dramatically over the past 30 years. In the United States, the proportion of graduating medical students who completed a clinical learning experience abroad was only 6% in 1978, but has risen progressively to 22% in 2004, and 31% in 2010.3,4 Estimates for the United Kingdom indicate that 90% of medical students undertake IHEs, with 44% doing these in developing countries.5 In Australia, the Medical Schools Outcomes Database shows that half of Australian medical students undertook an IHE elective between 2006 and 2010. Of those, the majority (59%) did so in lower or middle income countries.6

When combined with the growth of medical enrolments over the past decade,7 the actual number of Australian and New Zealand medical students undertaking clinical learning in international settings is significant. Interestingly, this rapid increase in global clinical learning has been driven almost entirely by student demand and has been predominantly organised by students.2,3

The value proposition of global experiences

A recent report commissioned by Universities Australia8 highlighted the benefits of global experiences to students in a range of disciplines, and to the nation. These include promoting deep learning and cognitive development in relation to cultural differences; and encouraging civic engagement, including increased understanding of moral and ethical issues, openness to diversity, more positive perceptions of multiculturalism, and greater levels of tolerance and the reduction of ethnocentrism. These are qualities that, if held by future medical graduates, will promote the health of the multicultural Australian community and the broader global community.

In medicine specifically, there is consistent evidence for the educational and personal benefits of IHEs in both pre-certification and early post-practice settings, as well as their broader value for the health care system. A number of qualitative and quantitative evaluations, including those comparing medical students who have undertaken IHEs with those who have not, have shown the positive impact of IHEs on personal consultation, clinical and diagnostic skills;3,9,10 significantly higher average scores in the preventive medicine and public health portions of the National Board of Medical Examiners assessments;11 and a greater appreciation of the importance of public health, health service delivery and cross-cultural communication.3,9–12 Further, an increased appreciation of the role of primary care and the importance of addressing the unmet needs of under-served communities is demonstrated by the career destinations of these graduates.3,10

Many global student experiences take place between two developed countries. While these IHEs have advantages in terms of risk minimisation for students, they can limit the potential benefits that might present with experiences in developing countries. A frequent theme that emerges from evaluations is the way in which IHEs can facilitate a personal transformation in medical students’ attitudes and cultural sensitivities.3 Jacobs and colleagues emphasised the value of students experiencing cultures, health systems and learning environments different from their own when they undertake an IHE, and being able to compare different health systems and cultures in such transformative learning. They noted that the “perception of differences between the cultures resulted in a rethinking of the participants’ own views, attitudes, and actions”.12 Experiences where students undertake electives in developing countries provide this opportunity for greater comparative learning, because of the stark differences in case mix, culture and health systems between developed and developing countries. However, associated risk factors and perceived “voluntourism” raise concerns for medical schools.2 Although understandable, a focus on risk instead of opportunity has the potential to limit what could be achieved through a more open approach to medical education that embraces global health experiences. Such an approach can lead to stronger graduate outcomes, especially in the domains of citizenship and professionalism, and to positive impacts on patient outcomes and the health care systems in the host and home countries.3,8,11

Medical schools’ responsibilities in international health electives

The involvement of Australian and New Zealand medical schools in quality assuring IHEs is critical, especially in an environment where the student demand to undertake global clinical experiences is rising. Medical schools are required by the Australian Medical Council to provide “opportunities for students to pursue studies of choice that promote breadth and diversity of experience”.13 Medical schools largely address this requirement by including an elective term within the clinical placement component of their programs. In the US, the equivalent accrediting body has recently mandated pre-departure training for IHEs for accredited medical schools.14

Australia’s Tertiary Education Quality and Standards Agency (TEQSA) has a strong quality framework concerning domestic student study abroad, designed to “assure that a provider’s responsibilities under the TEQSA Act and the Higher Education Framework are upheld and maintained where the provider is involved in offshore higher education provision”.15 This responsibility includes the quality assurance of student support and course delivery, and the equivalence of student learning outcomes. By virtue of the tendency to frame IHEs within electives, the quality assurance of learning and assessment, and the assessment of the adequacy of such experiences by accrediting bodies, may not be as robust as other more formalised clinical placement experiences. Is it time for medical schools to consider the purposeful creation and inclusion of more structured, quality assured and, where possible, longitudinal global health experiences within their medical programs? This would best be achieved through the establishment of strong and mutually beneficial partnerships with international organisations, universities and health care providers.9 Further, a set of rigorous academic standards and clearly stated outcomes that respond to clinical needs and students’ desired developmental goals should be developed to ensure the implementation of evaluation, review and improvement cycles.

Conclusion

Medical education is not immune to globalisation. The strong demand from Australian students for global clinical learning, and their mobilisation to deliver opportunities that meet this demand, including the creation of student international health organisations,16 indicate the value that students place on IHEs. There is demonstrable educational value in clinical learning abroad, and it is timely for medical schools and accrediting bodies to advance the study of global health beyond Master of Public Health programs by integrating IHEs into existing medical curricula.

Art and Medicine

By Dr Jim Chambliss

It is often said that a picture speaks a thousand words.

Contemporary medical technology provides incredibly intricate pictures of external and internal human anatomy.

However, technology does not communicate holistic representations of the social, behavioural and psychosocial impacts associated with illness and the healing process.

Studies have shown that increased reliance on reports from expensive laboratory tests, radiology and specialised diagnostic technology has resulted in inadequacy of physical examination skills; decline in patient empathy, and less effective doctor/patient communication.

Having commenced in May this year and continuing until July 8, continuing professional development workshops which explore and promote the value of art expression in the development of observation skills, human sensitivity and relevant healthcare insights will be presented at the National Gallery of Victoria exhibition of the original works of Vincent van Gogh.

The program will incorporate empirical research to illustrate the way neuropsychological conditions can influence art and creativity. The objectives of the workshops are to:

• advance understanding of the impact of medical, psychological and social issues on the health and wellbeing of all people;

• promote deeper empathy and compassion among a wide variety of professionals;

• enhance visual observation and communication skills; and

• heighten creative thinking.

Over the last 15 years, the observation and discussion of visual art has emerged in medical education, as a significantly effective approach to improving visual observation skills, patient communication and empathy.

Pilot studies of implementing visual art to teach visual diagnostic skills and communication were so greatly effective that now more than 48 of the top medical schools in the USA integrate visual arts into their curriculum and professional development courses are conducted in many of the most prestigious art galleries and hospitals.

The work of Vincent van Gogh profoundly illustrates the revelations of what it means to be uniquely human in light of neurological characteristics, behavioural changes and creative expression through an educated, respectful and empathic perspective.

The exact cause of a possible brain injury, psychological illness and/or epilepsy of van Gogh is unknown.

It is speculated by numerous prominent neurologists that Vincent suffered a brain lesion at birth or in childhood while others opine that it is absinthe consumption that caused seizures.

Two doctors – Felix Rey and Théopile Peyron – diagnosed van Gogh with epilepsy during his lifetime.

Paul-Ferdinand Gachet also treated van Gogh for epilepsy, depression and mania until his death in 1890 at the age of 37.

After the epilepsy diagnosis by Dr Rey, van Gogh stated in a letter to his brother Theo, dated 28 January 1989: “I well knew that one could break one’s arms and legs before, and that then afterwards that could get better but I didn’t know that one could break one’s brain and that afterwards that got better too.”

Vincent did not, by any account, demonstrate artistic genius in his youth. He started painting at the age of 28 in 1881.

In fact, his erratic line quality, compositional skills and sloppiness with paint were judged in his February 1886 examinations at the Royale Academy of Fine Arts, Antwerp to be worthy of demotion to the beginners’ painting class. His original drawings and paintings were copies from others’ art, while his sketches in drawing class showed remarkably different characteristics.

Increased symptoms of epilepsy and exposure to seizure triggers (absinthe and sleep deprivation) ran parallel with van Gogh’s most innovative artistic techniques and inspirations following his move to Paris in 1886 to 1888.

These symptoms increased, accompanied by breathtaking innovation following his move to Arles, France in 1888 and his further decline in mental and physical health.

In Paris he was exposed to the works of many of the most famous impressionistic and post impressionistic painters, but so much of his new techniques and imagery were distinctly innovative in detail without traceable influences from others.

While in Paris his work transitioned from drab, sombre and realistic images to the vibrant colours and bold lines.

His ebb-and-flow of creative activity and episodes of seizures, depression and mania were at their most intense in the last two years of his life when he produced the greatest number of paintings.

His works are among the most emotionally and monetarily valued of all time. Vincent’s painting of Dr Gachet (1890) in a melancholy pose with digitalis flowers – used in the treatment of epilepsy at that time – sold for $US82.5 million in May, 1990, which at the time set a new record price for a painting bought at auction.

Healthcare professionals and art historians have written from many perspectives of other medical and/or psychological conditions that impacted van Gogh’s art and life with theories involving bipolar disorder, migraines, Meniere’s decease, syphilis, schizophrenia, alcoholism, emotional trauma and the layman concept of ‘madness’.

What was missing as a basis to best resolve disputes over which mental or medical condition(s) had significant impact on his life was a comprehensive foundation of how epilepsy or mental illness can influence art and possibly enhance creativity based on insights from a large group of contemporary artists.

Following a brain injury and acquired epilepsy I gained personal insight into what may have affected the brain, mind and creativity of van Gogh and others who experience neurological and/or psychological conditions.

The experience opened my eyes to the medical, cognitive, behavioural and social aspects of two of the most complex and widely misunderstood human conditions.

Despite having no prior experience or recognisable talent, I discovered that my brain injury/epilepsy had sparked a creative mindset that resulted in a passion for producing award-winning visual art.

I enrolled in art classes and began to recognise common topics, styles and characteristics in the art of contemporary and famous artists who are speculated or known to have had epilepsy, such as Vincent van Gogh, Lewis Carroll, Edward Lear and Giorgio de Chirico.

Curiosity for solving the complex puzzle of how epilepsy could influence art led me to pursue a Masters in Visual Art which included a full course exclusively about Vincent van Gogh.

I subsequently obtained the world’s first dual PhD combining Visual Arts, Medicine and Art Curation at the University of Melbourne.

The PhD Creative Sparks: Epilepsy and enhanced creativity in visual arts (2014) was based on the visual, written and verbal insights from more than 100 contemporary artists with epilepsy and provided:

• objective and subjective proof that epilepsy can sometimes enhance creativity – supported by brain imaging illustrating how that can occur;

• a comprehensive inventory of the signature traits of neurological and psychological conditions that have significant interpretive value in healthcare practice and consideration in art history;

• the largest collection of images of the visual narratives from people with epilepsy;

• comparative data to distinguish epilepsy from other medical and mental conditions; and

• the Creative Sparks Art Collection and Website – artandepilepsy.com.

Interest in these research discoveries and art exhibitions provided opportunities for me to deliver presentations at national and international universities, hospitals and conferences. Melbourne University Medical School sponsored an innovative series of workshops through which to teach neurology and empathy by an intriguing new approach.

Jim Chambliss has a dual PhD in Creative Arts and Medicine and has explored the ways epilepsy and other health conditions can influence art and enhance creativity.

Information about his Art and Medicine Workshops involving Vincent van Gogh can be obtained by visiting artforinsight.com or artandepliepsy.com

Disparities in infant hospitalizations in Indigenous and non-Indigenous populations in Quebec, Canada [Research]

BACKGROUND:

Infant mortality is higher in Indigenous than non-Indigenous populations, but comparable data on infant morbidity are lacking in Canada. We evaluated disparities in infant morbidities experienced by Indigenous populations in Canada.

METHODS:

We used linked population-based birth and health administrative data from Quebec, Canada, to compare hospitalization rates, an indicator of severe morbidity, in First Nations, Inuit and non-Indigenous singleton infants (< 1 year) born between 1996 and 2010.

RESULTS:

Our cohort included 19 770 First Nations, 3930 Inuit and 225 380 non-Indigenous infants. Compared with non-Indigenous infants, all-cause hospitalization rates were higher in First Nations infants (unadjusted risk ratio [RR] 2.05, 95% confidence interval [CI] 1.99–2.11; fully adjusted RR 1.43, 95% CI 1.37–1.50) and in Inuit infants (unadjusted RR 1.96, 95% CI 1.87–2.05; fully adjusted RR 1.37, 95% CI 1.24–1.52). Higher risks of hospitalization (accounting for multiple comparisons) were observed for First Nations infants in 12 of 16 disease categories and for Inuit infants in 7 of 16 disease categories. Maternal characteristics (age, education, marital status, parity, rural residence and Northern residence) partly explained the risk elevations, but maternal chronic illnesses and gestational complications had negligible influence overall. Acute bronchiolitis (risk difference v. non-Indigenous infants, First Nations 37.0 per 1000, Inuit 39.6 per 1000) and pneumonia (risk difference v. non-Indigenous infants, First Nations 41.2 per 1000, Inuit 61.3 per 1000) were the 2 leading causes of excess hospitalizations in Indigenous infants.

INTERPRETATION:

First Nations and Inuit infants had substantially elevated burdens of hospitalizations as a result of diseases of multiple systems. The findings identify substantial unmet needs in disease prevention and medical care for Indigenous infants.