Will the bush ever have equitable broadband access?

DR SANDRA HIROWATARI, CHAIR, AMA COUNCIL OF RURAL DOCTORS

As some readers may know, the AMA released a Position Statement in January calling for better access to high speed broadband for regional, rural and remote health care. This Position Statement was developed in response to concerns by rural doctors that were highlighted in the findings of the AMA Rural Health Issues Survey conducted in April 2016.

The survey, which sought the views of rural doctors across Australia to identify key solutions to improving regional, rural and remote health care, found that access to high speed internet services was the number one priority for rural GPs and the second highest priority among all rural doctors.

The AMA Council of Rural Doctors, at its recent videoconference meeting in February, discussed this issue with representatives of the National Broadband Network Company (nbn) directly. We were told that at the time of the survey, the widely criticised Interim Satellite Service was providing internet services to regional and remote Australia. Since then, nbn has launched the first Sky Muster satellite, and will soon bring on board a second satellite that will offer business grade services around the second quarter of this year.

Currently 68,000 Australians are connected to the Sky Muster service, which has undergone a range of fixes and improvements since it first began offering services on 28 April last year, and according to the nbn this has led to far fewer drop-outs than used to occur. This is good news for those relying on satellite internet. The speed of these services will be either 12/1mbps (upload/download) or 25/5mbps, depending upon what plan you choose.

While these speeds are nowhere near the speeds available in the big cities that use fibre technology (up to 100/40mbps), they are sufficient for a range of uses, and should allow doctors, health services and hospitals to upload health summaries to the My Health record, undertake telemedicine via videoconference and exchange high resolution images. These speeds should also enable doctors to do business with Government, comply with Government requirements, participate in online continuing professional development and education activities, and reference online help such as clinical decision-making tools and other support.

Following our strong comments about data allowances, we understand that nbn is working on making eligible health centres, practices and large medical facilities Public Interest Premises. This will potentially afford them a higher data allowance (150GB per month).

Now comes the big HOWEVER. Will the data allowance be sufficient to do all this? There is much concern in the bush about the ‘data drought’. I understand the satellite technology has inherent limitations that restrict the amount of data available. There is a real need for ‘business style’ plans to be made available, recognising the unique nature of the speeds and data allowances that businesses require.

So, while the nbn will clearly deliver improved broadband access for satellite users, it is hard to see how it can keep up with the needs of an increasingly digitally enabled health system. It’s an area that the Government will need to give much greater thought to.

What I would also like to see happen over time is an extension wherever possible of the fibre and fixed wireless services into the satellite footprint and/or the introduction of alternative technologies to lessen the reliance on satellite for those living in rural and remote Australia. Maybe then, in time, we can say there is equitable access to broadband for all Australians.

The new normal

DR JOHN ZORBAS, CHAIR, AMA COUNCIL OF DOCTORS IN TRAINING

Something strange happened to me recently that reminded me of how badly calibrated our frames of reference can be. I’m a dual trainee, and with the new training year upon us, I was migrating from the calm and collected ivory tower of the intensive care unit, back down to the chaos and madness in the pit of the emergency department. It’s clear that I like really sick people; I just can’t seem to decide on the speed of sickness that I prefer. Fast or slow? I relished the change of pace. It was frenetic. We were getting things done. I was happy.

And then we had a teaching session. One of those beautifully peaceful moments when you leave the emergency floor and you enter the tranquillity of education. We discussed stroke management. I spoke about ultrasound. So far, so good. All normal. Our director of training asked us how we were going and he made specific mention of just how busy we’d been lately. I took note and thought “OK, so we’ve had a busy few days. Nothing new here”. He kept probing and then the other trainees started talking about the pace. It then became abundantly clear to me that the last few weeks were not normal. They were chaos. The cubicle pressure, the acuity of the presentations, the backlog in the hospital… none of this was normal. Not by a long shot.

It might not sound much, but I was quite shocked by just how incorrect my frame of reference was. If you don’t have a good frame of reference, you start to misjudge things that happen. What you explained away as a quirk of the system could quite easily become a serious medical error. And so, with this new calibration I started to re-hash the events of the past few weeks. What had I missed? If this pace wasn’t normal, had I expected too much of my juniors at any point? Had I been too hasty with investigations, or documentation? What pressures had I placed on my nursing staff? Looking back with this new frame, I made my peace. Yes, things were fast. No, they hadn’t been unsafe. But I remained shocked with this error of calibration. The compass was off, and a bad compass leads you to icebergs.

I’ve been a doctor for eight years now, and in that time, I’ve had to recalibrate on several occasions. I’m no expert and I’m certainly no source of truth, but here are some common “normalities” I’ve encountered along the way:

It’s not normal to excel at every assessment along the way, and it’s normal to fail. We’ve created this system of training in which hypercompetitive medical students vie for the “best” internship (whatever that is supposed to mean) and endlessly buff their CVs to achieve immortal greatness in the specialty of their choice, to the exclusion of all others. This type of system demands that doctors perform at 100 per cent of their operating capacity, at all times, which just isn’t reasonable. I’ve spoken before about the green and red lights of assessment, and the dire lack of orange lights along the way. This isn’t normal outside of medicine and it shouldn’t be normal within it. We need systems of assessment that don’t demand shiny whitewashed walls of achievement. The odd coffee stain isn’t just acceptable, it should be encouraged. It should be a badge of honour, because stains draw attention, and they allow you to focus on how to improve yourself rather than improving at assessment. Use your frame of reference to improve, not to impress.

It’s not normal to not see your loved ones for days at a time. My partner works shift work as well, and our training has meant that while I rode the escalator down into the pit of mayhem, she’s taken the elevator to the top of the afore-mentioned tower. She relishes the opportunity to have a good laugh when I call from ED for ICU to please come and join the party. We’re less jovial about our jobs when we’re passing ships in the night, only seeing each other at the start and finish of shifts for a quick chat and a kiss goodnight. Now don’t get me wrong, we’ve chosen this life and these rosters. However, no matter how you paint it, it isn’t normal. We have had to take these runs as a sign to slow down and be sure to spend quality time with each other. If you’re going to roster work, make sure you roster life.

It’s not normal to be so close to death all the time. I’ve chosen two particularly bloody specialties, and death (often horrific death) is not uncommon. And yes, your temperament for death will be part of what guides you to your specialty. But death like this shouldn’t ever be normalised. We need to remember to debrief with those around us, especially for new staff who might not be used to the abnormality of death on invasive organ support. To extend this further, I’d like to also point out that death of our colleagues is never, ever normal. It should be treated with the utmost of seriousness and should always result in an organisational response. We should never expect doctors to just get back to business as usual when they lose a peer.

It should be normal to enjoy your job. It should be normal to be proud of your profession. It should be normal to have a healthy workplace culture. Sometimes we hit these points of normality and at other times we don’t. For my part I’m going to keep checking that compass. Pick up the deviations before we get lost, lest we run into icebergs.

Aboriginal and Torres Strait Islander People Have the Solutions to Close the Gap

AMA PRESIDENT DR MICHAEL GANNON

We continue to be handed myriad government reports on Indigenous affairs and hear well-meaning words spoken by our political leaders. But, in 2017, we still see governments fail to deliver on their commitments to improve the health and wellbeing of Aboriginal and Torres Strait Islander people.

The 9^th Closing the Gap report, handed down in Parliament House by Prime Minister Malcolm Turnbull on 14 February, reflects the inadequacy of government performance against their own commitment to close the gap in health and life expectancy between Indigenous and non-Indigenous Australians. Whilst there have been some encouraging gains in health and educational outcomes over recent years, the gap in health and life expectancy between Indigenous and non-Indigenous remains wide.

Discouragingly, only one of the Government’s seven Closing the Gap targets is on track to being met.How much longer do Aboriginal and Torres Strait Islander people in Australia have to live in disadvantage? How much longer do they need to be sicker and die younger than their non-Indigenous peers? Australia must and can do better.

Positive progress can be made if governments work directly with Aboriginal and Torres Strait Islander people, and better understand the approaches that work in their own communities. Aboriginal and Torres Strait Islander people have long called for, and continue to call for, structured engagement with governments and involvement in decision-making. The AMA recognises the importance of self-determination and fully supports Aboriginal and Torres Strait Islander people in wanting to take charge of their own lives.

Governments must recognise and value the knowledge and expertise that Aboriginal and Torres Strait Islander people have. They must understand that Indigenous people have the solutions and the expertise to deliver. This was made clear in the lead-up to the release of the Closing the Gap report, when Aboriginal and Torres Strait Islander leaders presented the Prime Minister with the Redfern Statement – a statement that calls on governments to better engage with Aboriginal and Torres Strait Islander Australians, and contains the solutions to improving health and life outcomes for Indigenous people.

The AMA considers that the current Parliament has an unprecedented opportunity to work closely with Indigenous people and meaningfully address the disadvantage that Aboriginal and Torres Strait Islander experience. The AMA urges the Government, opposition and minor parties to take note of the Redfern Statement and ramp up their efforts to achieve health equality for Aboriginal and Torres Strait Islander people and take further steps in building on existing platforms.

The AMA, along with many others working in Indigenous health, has been campaigning for long-term funding and commitments from government to improve the health and wellbeing of Aboriginal and Torres Strait Islander people. We will continue our advocacy to help achieve this goal.

We must find a way to celebrate Indigenous advancement where there is evidence of real improvement. Some gaps remain because of equivalent improvements in the health of non-Indigenous Australians. It is important to avoid a nihilism about Aboriginal and Torres Strait Islander affairs. We must never consign these issues to the ‘too hard’ basket and we risk that if we do not carefully appraise measures that are working and acknowledge them.

But having only one single Closing the Gap target on track is truly disheartening, and frustrating for Aboriginal and Torres Strait Islander people when their solutions are being ignored. It is imperative that the Prime Minister and his Government act urgently so that we can finally begin to see genuine improvements in health and life outcomes for Aboriginal and Torres Strait Islander Australians.

Nurses should have greater role in diabetes management – study

A study has found a new program where primary care nurses led insulin treatment for Type 2 diabetics can dramatically improve longer term health outcomes of patients.

Published in the BMJ, it looked into 74 primary health clinics across Australia and compared a nurse led insulin treatment initiation with a traditional approach to diabetes management.

70% of patients in the ‘Stepping Up’ program began treatment when compared to just 22% at clinics taking a traditional approach to diabetes management.

According to Associate Professor John Furler from the University of Melbourne: “By focusing on an enhanced role for the practice nurse, who is trained and mentored by a registered nurse with diabetes educator credentials, the model uses existing resources within the practice to improve outcomes.”

Early adoption of insulin can improve health outcomes and reduce the chance of damage to the eyes, kidney and nerves.

However according to the study: “Insulin initiation is often delayed, however, particularly in primary care, where implementation is not widespread despite being recommended as part of routine clinical management of type 2 diabetes.”

“After 12 months, we found that patients had significantly better HbA1c levels (an important measure of glucose in the blood), which is associated with better long term outcomes, such as reduced rates of kidney and eye disease, compared to the control group,” Associate Professor Furler said.

Thanks to these results, a further implementation study of the ‘Stepping Up’ model of care will be widened to include diabetes therapy generally and will be carried out in the North-West Melbourne Primary Health Network.

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Theory, history and contemporary topics for medical education scholars

Oxford textbook of medical education.

Kieran Walsh, editor. Oxford University Press, 2013 (784 pp, £207.50). ISBN 9780199652679

The Oxford textbook of medical education is a serious tome, appealing mainly to the professional and academic medical educator. Kieran Walsh, Clinical Director of BMJ Learning, has drawn together an impressive array of international, diverse and well credentialed contributors across the breadth of medical education.

At over 700 pages of heavy text format, it is not a light read. There are few illustrations and only occasional black and white photos. The book is strong on theoretical underpinnings and the history of medical education practice, which suits some readers more than others. For example, the chapter on curriculum offers 15 definitions of the term, dating back to 1918.

The overall structure would be familiar to readers working in medical education, with sections on curriculum, delivery, supervision, selection and assessment. There are interesting chapters on contemporary topics, such as global medical education, technology, concept maps, interprofessional education and patient involvement, which would not have been included in a similar text 20 years ago. Each chapter is well researched and covers the breadth of traditional literature in the area. For the educational scholar or the reader looking for a head start on a topic literature review, this is the text. However, the average clinician educator is likely to find the format too dense for day-to-day application.

Not including social media in medical education left the text lacking in an area rapidly growing in educational practice.1 Likewise, the references in each chapter are almost exclusively based on traditional journal sources, even in areas where there are many excellent online resources.

This is perhaps symptomatic of a larger concern of a lack of visual appeal or instructional design in the presentation of the book. When talking about medical education, surely “the medium [should be] the message,”2 and dissemination formats such as heavy textbooks may not be leading by example for educators at the coalface.

Teaching future doctors for modern health care

Medical education over time — are we keeping up?

Medical practices — including the use of plants as healing agents, surgery for wounded and injured people, and the practice of observation and reasoning regarding disease — have been in effect for many thousands of years. However, medical schools are a more recent phenomenon. Believed to have opened in the 9th century, the Schola Medica Salernitana at Salerno in southern Italy is considered to be the first medical school but officially closed in 1811.1 The University of Bologna’s school of medicine and surgery, established around 1200, is the oldest such school still in existence.2 The first medical school in the United States, the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, opened in 1765, and the Sydney Medical School at the University of Sydney, which opened in 1856, is the oldest in Australia.

In this article, we review the evolution of education in medicine and the challenges that medical schools face today.

Medieval medicine was based on Galen’s theory of humours. It was not until the 18th century that physicians became more scientific, influenced by the scientific revolution with its developments in mathematics, physics, astronomy, biology, anatomy and chemistry. Armed with knowledge, doctors in the mid-19th century, teaching at European medical schools, predominantly taught medical students by delivering didactic lectures and readings with only limited exposure to clinical experiences3 and laboratory work.

Movement towards the modern model of medical education began in the US when Johns Hopkins School of Medicine, Baltimore, opened in 1893. Influenced by German medical schools, Johns Hopkins School of Medicine implemented an educational model consisting of traditional medical knowledge combined with research and extensive laboratory learning, bedside learning at the side of experts, and postgraduate education in the hospital for interns and residents. This educational paradigm became the template for postgraduate clinical education in the 20th century4 in other American medical schools following the 1910 Flexner report.5 Flexner criticised many medical schools as a loose apprenticeship system that lacked defined standards or goals beyond the generation of financial gain. Flexner made recommendations regarding the standard of medical schools in the US and Canada and proposed that medical school training should focus on biomedical sciences together with hands-on clinical training. The report triggered reforms in the standards, organisation and curriculum of North American medical schools and gave rise to modern medical education.5

Over the past century, countless discoveries have led to an explosion of medical knowledge: the development of antibiotics and vaccines; imaging modalities such as ultrasound, computed tomography and magnetic resonance imaging; understanding of data collection for statistical and population health purposes; and new models in genetics and immunology. There is now a focus on reducing harm and improving patient health by applying research methods to help understand what facilitates quality improvement, and basing decisions on evidence-based medicine and the use of patient data. Further, rapid demographic and epidemiological transitions, complex health systems, increasing numbers of patients with chronic conditions and a longer life expectancy require medical students to integrate the rapid growth of knowledge and technologies while also learning about prevention, coordinated care across time and space, teamwork and communication.

Traditional education consisted of transmitting knowledge, skills and standards that were considered to be required in order to practise as a doctor. Students were expected to unquestioningly and obediently receive and believe the information put to them. Teachers were the instruments through which knowledge was communicated and standards of behaviour were enforced.6 This approach dominated medical education until the end of the 19th century, when the education reform movement resulted in the development of progressive educational techniques.7 Many learning theories have been proposed subsequently. What is evident is that adult learning includes transformative learning, which is based on discussing with others the “reasons presented in support of competing interpretations, by critically examining evidence, arguments, and alternative points of view”.8

Given the explosion of knowledge (estimated to be doubling every 3 years), its multiple sources including online, and the increased expectations of society for better health care, what and how do we want medical students and doctors in training to learn? Or are we now at a stage where our expectations of graduating students must change and we need to become increasingly selective as to what is critical to being a safe, competent, patient-centred doctor? With increasing participation of patients in their care, increasing use of improvement science, requirements for accountability, scrutiny, measurement, incentives and markets, medical education is becoming an ever-increasing challenge.

As a result of the rapid changes in today’s knowledge, we need to again move into a new era of education. In 2010, the global independent Commission on the Education of Health Professionals for the 21st Century acknowledged that “fresh health challenges loom”.9 The report also commented that “all health professionals in all countries should be educated to mobilise knowledge and to engage in critical reasoning and ethical conduct so that they are competent to participate in patient- and population-centred health systems as members of locally responsive and globally connected teams”.9

A General Medical Council report10 on the preparedness of United Kingdom medical graduates for practice found that graduates felt unprepared for a range of skills and experiences such as changes in responsibility; workload; multitasking; understanding where to go for help; adopting a holistic understanding of the patient; involving patients in their care; safe and legal prescribing; diagnosing and managing complex clinical conditions; and providing immediate care in medical emergencies. In addition, there were gaps in the preparedness in communication skills such as talking with angry or upset patients and relatives, breaking bad news, communicating with the wider team (including inter-professionally) and handover communication. There was also evidence to suggest that graduates were unprepared for dealing with error and safety incidents and had a lack of understanding of how the clinical environment works.10 Similar results have been reported from graduates from countries outside the UK.11,12 Such concerns about competencies of graduating medical students have been raised for at least two decades, resulting in some changes in medical school curricula and the development of guidelines for training of junior doctors.11

The ability of medical education providers to deliver medical graduates who are skilled and competent has always been challenging. Perhaps greater challenges are experienced today because professional health education has not kept pace with explosion of knowledge, learning styles of 21st century students and dramatic changes in way health care is delivered. There remains a disconnection between medical education and the health care delivery environment,13 as demonstrated by the persisting sense of unpreparedness of medical graduates. The problems in medical education are systemic and include mismatch of competencies to patient and population needs, poor teamwork, persistent gender differences in professions, narrow technical focus without broader contextual understanding, episodic encounters rather than continuous care, predominant hospital orientation when medicine is largely practised in a community setting, imbalances in the professional labour market, and poor leadership to improve health system performance.

To produce skilled and competent doctors, student-centred teaching and innovative curriculum design is needed not only in universities but also in the post-graduation teaching and learning environment. No single, uniform approach can be used to achieve this teaching and learning goal. As knowledge expands faster than our ability to assimilate, apply and teach effectively, adding more material and/or time to any curriculum is not an effective strategy. Fundamental changes are required. If the goal of education is to facilitate students’ autonomous learning and self-expression, and offer adaptable teaching, then a flexible, modern, inclusive, technologically enhanced, student-centred approach, where the student is an active participant in the learning process, is required.

To practise as a doctor today, it is not sufficient to just have knowledge. The Australian Medical Council has developed a thematic framework to ensure that medical programs provide graduates with the knowledge, skills and professional attributes required to practise medicine in the 21st century. The Council’s curriculum domains are:

science and scholarship: the medical graduate as scientist and scholar;
clinical practice: the medical graduate as practitioner;
health and society: the medical graduate as a health advocate; and
professionalism and leadership: the medical graduate as a professional and leader.14

By appreciating these domains, it becomes evident that behaviours and attitudes are as important as knowledge and skills. Because communication, handover and medication errors are the leading causes of harm,15 focus needs to increasingly turn to developing interdisciplinary, team-based curriculum units that enable students to learn from different disciplines through a unifying theme.

Today, there are many opportunities for learners to acquire knowledge outside the traditional classroom and textbooks. Sources include the internet, chat rooms and social media. The task for the teacher and learner is how to discriminate between the vast amounts of information and to extract and synthesise the knowledge necessary for clinical and population-based decision making.

With the doubling of medical students and graduates, the advent of safe working hours and the increasing expectation of delivering perfect health care, there has never been a more demanding time to train medical students and training doctors. With the added burden of the massive expansion of knowledge and information outlets, teaching and learning need to be nimble, innovative but structured in their approach to ensure that our graduating and training doctors are safe, patient-centred, effective and efficient.

Overcoming negative perceptions among Australian medical students about a career in general practice

Encouraging medical students to pursue a career in general practice is a global problem with an Australian solution

General practice is the cornerstone of the Australian health care system, and a critical component of health care systems around the world. However, recruiting a general practice workforce capable of meeting community needs remains a global challenge.

Canada is experiencing a critical shortage of general practitioners, with 14.9% of the population without a GP in 2014.1 Similarly, the United Kingdom faces a severe shortage of GPs, coupled with insufficient numbers of medical students choosing general practice as a career.2 The number of applications for GP training in the UK fell between 2013 and 2015, with 12.4% of training posts unfilled in 2015.3 In the United States, only 11.7% of 2016 residency training positions were for general practice, and 155 places were left unfilled.4 Further, an international study found that general practice is poorly perceived by medical students, with students across seven countries indicating that they were less interested in the specialty, perceiving general practice as less intellectually challenging, with lower prestige and poor remuneration.5

In 2007, Australia was facing a similar situation. Negative perceptions of general practice among medical students were a barrier to overcoming a looming GP shortage6 and graduates were increasingly choosing to not pursue the specialty as a career.7 In 2005, only 532 of 600 available GP training positions were filled.6 An ageing workforce6 and medical students’ lack of interest in general practice presented a challenge for policy makers — how could this negative perception be overcome?

Creating the General Practice Students Network

In 2005, Joe Rotella, a Melbourne medical student, recognised the negativity about general practice in Australian medical schools. With the support of General Practice Registrars Australia (GPRA) and a successful funding application to the federal government, he developed the concept of a network of student clubs to reverse this negativity.

Today, General Practice Students Network (GPSN) clubs exist in each Australian medical school. They are run by student volunteers who organise educational events to promote general practice to medical students, including educational talks from local GPs, career networking nights, clinical skills workshops and rural and Indigenous health events. Each event is planned and presented by students and supported by local organisations, including other student clubs, regional training providers and academic staff at each university. The national council of local clubs is overseen by the GPSN National Executive, a team of students who advocate on behalf of the organisation and oversee the running of the network, with support from staff at GPRA.

Between 2007 and 2016, the membership of the GPSN grew from 121 to 14 199 student members. This rapid growth led to the addition of two new programs:

the Going Places Network (GPN), which promotes general practice to prevocational doctors in training hospitals and currently has 3500 junior doctor members; and
the John Murtagh First Wave Scholarship, a program that provides placements in general practice for preclinical medical students.

Collectively, the GPSN, GPN and John Murtagh First Wave Scholarship are known as GP First, a pipeline that promotes general practice from the first day of medical school until the commencement of specialty training.

GP First

The strategy of GP First has been to target directly the factors that are known to increase interest in general practice. Enthusiasm for, and commitment to, general practice is an important determinant of whether students will pursue it as a career path.5 Since its inception, the GPSN has worked to foster this enthusiasm by using a peer-to-peer model that takes advantage of the known positive influence peers can have on student’s perceptions of the specialty.5,8 In 2014, the 21 local GPSN clubs ran 98 events which were attended by 7259 students. Research has also shown that positive role models influence student perceptions of general practice,5 and GPSN events have provided opportunities for students to network with GP registrars who are seen by students as the most current and accurate source of career information.8

Positive exposure to general practice has also been found to improve student perceptions of general practice,5,9,10 and since 2008, the John Murtagh First Wave Scholarship has provided general practice placements for over 600 medical students. Of these students, more than 92% found the program extremely useful in helping them with their future career choice and more than 77% said the program made them more likely to consider general practice as a career.11

Since the GPSN was founded, there has been a significant shift in the GP training landscape. In 2005, the Australian General Practice Training (AGPT) program was only able to fill 532 of its 600 training places. Only 366 of these applicants (69%) were Australian medical school graduates,12 representing 24.4% of the 1503 medical students who had graduated the previous year.13

In 2014, there were 2026 applications for 1500 AGPT training places; 1421 of these were graduates from Australian medical schools,14 representing 41.3% of the 3441 students who had graduated from Australian medical schools in the previous year.13 This represents not only an increase in the number of applications in absolute terms, but also substantial growth in the percentage of graduates pursuing general practice training.

Between 2011 and 2013, GPRA worked with General Practice Education and Training (GPET) to quantify the success of the GP First program by tracking the number of AGPT applicants who were either First Wave scholars or members of the GPSN and GPN. The percentage of applicants from GP First increased from 11% in 2011 to 25.6% in 2012 and in 2013, 35% of acceptances into training were from GP First.11

The more than doubling of graduating medical students over the 10 years has undoubtedly contributed to the increase in GP training applicants. However, there is little recent research quantifying the impact of other contributors to this increase. A 2011 study found that factors contributing to choice of career for GP registrars included the quality of undergraduate general practice placements, exposure to GP role models, awareness of AGPT and the GP colleges at the student level, as well as the flexibility of GP training.12

During the time that the GPSN program has operated in Australian medical schools, there has been a significant improvement in medical students’ perception of general practice since its low popularity in 2005. From 2010 to 2013 the percentage of graduates identifying general practice as their top choice for future medical specialty increased from 12.3% to 17%.15 Indeed, general practice topped the list in 2013, placing higher than internal medicine (16.6%) and surgery (16%).15

GP First is undoubtedly only one of a number of factors that may have helped to improve the perception of general practice among medical students and, unfortunately, the impacts of its three programs for students have not been quantified. With the increase in applicants for GP training, the federal government no longer sees a need for a program to promote general practice to medical students. In December 2015, the government cut all funding for the GPSN, the GPN and the John Murtagh First Wave Scholarship.

The future

The focus of GPSN clubs across Australia has shifted from promoting general practice to supporting the future leaders of the specialty. Local events and projects from the four national working groups will continue to focus on areas of need in the community, including rural health and Indigenous health, while also working on closing gaps in general practice education for medical students and junior doctors. The John Murtagh First Wave Scholarship will survive in a reduced form, supported by corporate sponsorship, to ensure that future medical students continue to have positive experiences of general practice.

In less than 10 years, the GPSN has grown from one medical student’s idea into a successful national organisation run by hundreds of volunteers who organise events attended by thousands of students each year. With the loss of government funding, GPSN clubs now face the challenge of securing their own survival while continuing to run events that inspire the next generation of GPs and ensure students are equipped to navigate the changing landscape of primary health care in Australia.

Australia has reversed the downward trend in GP training numbers seen around world, with the demand for places now exceeding supply. The GPSN is just one of several possible contributors to medical students’ increased interest in general practice. Research is needed to identify and quantify the impact of the various demographic factors and workforce programs that are contributing to this change, so that other nations can learn from Australia’s success in securing our future primary care workforce.

[Correspondence] Urgent need for reform in Nepal’s medical education

Nepal is a low-income nation with a population of nearly 26·5 million. The doctor–patient ratio is 0·17 per 1000 population—substantially less than the WHO recommendation of 2·3 doctors per 1000 population.1 Nepal has seen a burgeoning of medical institutes in the past 10 years. However, this rapid surge in the number of medical colleges—with increases in fees and corruption involved in student admissions—has not aided undergraduate and postgraduate medical training, deteriorating the quality of medical education.

[Correspondence] Transgender health in India and Pakistan

Sam Winter and colleagues (July 23, p 318 and p 390)1,2 reported a much neglected health issue of transgender people, who have been officially recognised as a third gender citizen registration category in Nepal, Pakistan, India, and Bangladesh, since 2010. Locally known as hijras (hijra), this civil recognition is profound for their social rights because it translates into confirmed allocation into government and education quotas. Despite the legal recognition, access to quality health care is alarmingly scarce compared with their cisgender counterparts.

AMA, Govt hold talks on ‘more balanced’ approach to pathology rents

AMA President Dr Michael Gannon met with Health Minister Sussan Ley in Canberra on 24 November to discuss the Government’s proposal to change the definition of market value for pathology collection centre leases.

Dr Gannon told the Minister that the AMA was prepared to work with the Government to try and come up with a more balanced policy approach that genuinely targeted inappropriate rental arrangements and did not interfere with legitimate commercial arrangements.

The AMA President also highlighted that the Government’s proposed changes had significant implications for existing leases that had been entered into freely, and on the basis of which financial commitments have been made by practices.

The discussion followed a meeting of the AMA Federal Council which reiterated its support for prohibited practices laws, but recommended significant changes to the Government’s election policy.

The Federal Council stressed the need for a more a targeted approach that focused on inducements to refer, consistent with the original intent of the prohibited practices laws, and that pathology referrals should be solely based on the quality of services, as opposed to commercial relationships.

Federal Council resolved to support the right of medical practices to negotiate collection centre leases freely with pathology providers, provided rents were not linked to a stream of referrals and that any new definition of market value must not adversely affect those medical practices that were acting ethically when entering into leasing arrangements.

The Council stated that reasonable transition arrangements would need to accompany any changes, and the Government would need to develop an appropriate educational strategy to ensure requesters and providers were aware of their obligations under existing prohibited practices laws and ensure that these and any future laws were properly administered and enforced.

Responding to allegations of sham leasing arrangements, Federal Council agreed that the Government needed to work with stakeholders to establish whether these could be sustained and, if so, develop measures to address them with urgency.

The AMA Federal Council also expressed its disappointment in successive Federal Governments for their failure to adequately fund patient access to medical care, including the prolonged freeze on Medicare rebate indexation, which increasingly threatened the viability of pathology, general practice and other specialist services.

During his meeting with the Minister, Dr Gannon welcomed her advice that the Government would not proceed with its planned 1 January 2017 commencement date, and the Minister’s commitment to allowing more time for consultation with general practice and pathology practice over the definition of market value and what transition arrangements might be needed. In this regard, the Minister stated that the Department of Health would be expected to work closely with the AMA as it developed further advice to Government.