[Comment] Rheumatology—a call for papers

Rheumatoid and autoimmune diseases are a heterogeneous group of disorders, many of which are of unknown aetiology and have heterogeneous clinical presentation. Often difficult to diagnose and to treat, these conditions are an under-appreciated group of non-communicable diseases that, according to latest Global Burden of Disease estimates,1 contribute as much as 20% of years lived with disability, worldwide. Research into the treatment, epidemiology, and public health and education interventions that might help to combat this diverse group of diseases is an urgent, unmet need.

[Comment] Late preterm rupture of membranes: it pays to wait

In contrast to previous assumptions, there is increasing evidence that being born in the late preterm period—between 34 and 36 weeks gestation—is associated with important long-term adverse effects. Several adverse outcomes have been reported, including cerebral palsy, more hospital admissions in early childhood, lower childhood height, asthma, limiting long-term illness, and poorer educational attainment.1–3 Findings from studies show a gradient of health outcomes with decreasing gestation.1 An estimated 4–5% of infants are born at 34–36 weeks,2,3 and 30% of preterm births follow pre-labour rupture of the membranes.

Look no further than GPs for Medical Home

GPs already perform many of the functions of a Medical Home, and should be at the centre of any move to formalise such an arrangement in Australia, the AMA has said.

As Health Minister Sussan Ley contemplates the findings and recommendations of the primary health review led by former AMA President Dr Steve Hambleton, the AMA has issued a Position Statement advising that any proposal to adopt a Medical Home approach in Australia must have GPs at its core.

Internationally, the term Medical Home is used to refer to a model of primary care that is patient-centred, comprehensive, team-based, coordinated, accessible and focused on quality and safety.

AMA Vice President Dr Stephen Parnis said in Australia these attributes were already embodied in general practice.

“The concept of the Medical Home already exists in Australia, to some extent, in the form of a patient’s usual GP,” Dr Parnis said. “If there is to be a formalised Medical Home concept in Australia, it must be general practice. GPs are the only primary health practitioners with the skills and training to provide holistic care for patients.”

Evidence suggest patients with a usual GP or Medical Home have better health outcomes, and 93 per cent of Australians have a usual general practice, and 66 per cent have a family doctor.

Dr Parnis said the Medical Home concept had the potential to deliver improved support for GPs in providing well-coordinated and integrated multi-disciplinary care for patients with chronic and complex disease, and it made sense for this to be the focus of Government thinking on adopting the Medical Home idea in Australia.

“You can’t just transplant models of health care from other countries without acknowledgement of local conditions and what is already working well,” he said.

“Australia needs to build on what works, and ensure that a local version of the Medical Home is well-designed and relevant.”

The AMA said this should involve additional funding to enable GPs to deliver comprehensive and ongoing care, including patient education, improved coordination and targeting of services, and activity that does not require face-to-face contact.

Establishing a Medical Home arrangement in Australia was likely to involve formally linking a patient with their nominated GP or medical practice through registration, and the AMA said this should be voluntary for both patients and doctors.

In addition, the peak medical group said fee-for-service must remain the predominant funding mechanism for doctors, though it acknowledged that the Medical Home could also involve a blended funding model that rewarded the delivery of services over a period of time.

The AMA Position Statement on the Medical Home can be viewed at: position-statement/ama-position-statement-medical-home

Adrian Rollins

A broad perspective on anatomy education: celebrating teaching diversity and innovations

Anatomy education is an ever-evolving field. Innovative anatomy teaching practices are actualised by dedicated, professionally qualified academic staff who often devote their entire careers to the education of future clinicians. While traditional approaches to anatomy education focused on surgical training and knowledge-based competency,1 modern anatomy literacy must be applied to a wide variety of clinical disciplines. Thus current teaching approaches need to reflect this. To this end, modern topographic anatomy is combined with other anatomical sciences (ie, embryology, histology and neuroscience), and taught within integrated medical curricula in the context of clinical medicine, clinical skills, pathology and radiology. As with other pre-clinical and para-clinical fields (including biochemistry, physiology and immunology), there are clear benefits in engaging teaching staff with a variety of qualifications and expertise to maximise the effectiveness of the vertical and horizontal knowledge integration that is essential in modern medical curricula.

The highest quality of medical anatomy education is more likely to emerge from a diverse group of motivated and dedicated academic professional anatomy educators in combination with clinically based staff than from those knowledgeable only in a single discipline as has recently been proposed.1,2 Modern professional anatomy educators may have degrees in anatomy (including clinical anatomy), anthropology and education, medicine or other clinical degrees. Staff with a variety of expertise and experiences make for a richer student learning environment. Effective anatomy learning contexts include an evolutionary focus on the developmental underpinnings of the human form, a clinical focus on anatomical relationships, and even a focus on adult learning theories to improve retention of learned material. Ultimately, each of these educator-infused contexts can foster the critical thinking skills necessary for effective clinical reasoning. Underscoring a need for diverse, multifaceted anatomy educators, the literature suggests that medical education in clinical years often lacks a clear connection to basic sciences (of which anatomy is but one).3 This work suggests that a collaborative approach between scientists and clinicians is essential for improved learning of anatomy. In addition, the role of the modern anatomy educator in the digital age is to facilitate students’ knowledge acquisition and application; this illustrates how important it is that these teachers have expertise that extends beyond anatomical facts and includes pedagogical competency.

As well as infusing anatomy teaching with clinical relevance, anatomists are pioneering innovations in medical education. Some innovations include multimedia software, peer–peer learning of surface anatomy using body painting4 and the world’s first three-dimensional printed series of anatomical dissections.5 As anatomy education continues to evolve, the roles and backgrounds of anatomy educators should and will expand. Collaboration is essential for medical education and its educators to continue to meet the changing needs of both students and the medical profession in general.

Developing competence in biostatistics and research methodology during medical specialty training

Do we equip junior specialists with the skills to conduct research throughout their careers?

The application of an evidence-based approach to patient care underpins modern clinical practice for all medical disciplines. In many specialty training programs, there has been emphasis in recent years on ensuring that trainees develop the skills needed to interpret medical literature and conduct research, as a part of overall training. In turn, it is hoped that these abilities will instil in trainees the capacity and enthusiasm to continue taking an active part in clinical research over their careers. In addition, specialist doctors are ideally placed to direct efforts towards medical education research and research on translation of evidence to practice. In this article, we focus on the need to assist trainees in attaining foundation skills required for participation in research activities, ideally as a stepping stone to leadership in research. This is distinct from looking at tools and strategies (such as journal clubs and critically appraised topic instruments) used to teach critical appraisal of published evidence, although all these concepts are closely linked.1

The case for supporting trainees in learning research skills

It may be no surprise that, when it comes to the knowledge and skills required for junior doctors to undertake clinical research, the evidence suggests that these have not been mastered at the medical student level, and are not likely to be acquired simply by osmosis as training proceeds.2 Several studies highlight the need for innovative learning tools to actively engage junior doctors in biostatistics and research skills learning, and the value of collaborative teaching efforts, combining the expertise of clinicians and biostatisticians.3

Additional learning is necessary, then, to meet the scientific rigor essential for the conduct of high-quality clinical (and other) research by vocational trainee and specialist investigators. Potential waste and challenges to high-quality research arise from weaknesses in study conduct, design and reporting.4 Furthermore, the pressure on doctors in specialty training to fulfil ever-increasing clinical service duties competes with learning in non-clinical areas. Consequently, the imperative to design more efficient and effective teaching strategies, especially for non-core medical expert skills, becomes ever stronger.

Incorporating research competencies into specialty training curricula

Contemporary competency-based curricula now reflect the multifaceted role of medical specialists. Within these, the knowledge and skills needed for basic research literacy are clearly articulated. However, the processes to achieve these and then translate them into research activity are not well defined. The Canadian Medical Education Directive for Specialists (CanMEDS) curriculum framework5 is the most common structure applied to specialty medical training programs in the global setting. Competencies relating to research and biostatistics skills are encapsulated within the Scholar Role. The CanMEDS framework has been adopted by several Australian training bodies, including the Royal Australian and New Zealand College of Ophthalmologists, the Royal Australian and New Zealand College of Radiologists6 (RANZCR, which also trains radiation oncologists) and the Australian Orthopaedic Association. For the Royal Australasian College of Physicians, the relevant learning objectives are encompassed in the Physician Readiness for Expert Practice basic trainee curriculum in Domain 3 (research) and defined within advanced learning curricula for discipline-specific programs.7 Despite these explicit curriculum statements of required knowledge and skills, the teaching of competencies within the Scholar Role or equivalent can be difficult to integrate into typical clinically orientated training programs — a concern expressed by pedagogical experts in the global arena.8 The challenge is magnified by the facts that this skill set can only be fully grasped and refined through application to real projects (ie, doing research), and many clinical supervisors do not feel adequately qualified to teach these subjects.

How might we support attainment of research skills?

Stand-alone practical courses in trial concept development, such as the Australia and Asia Pacific Clinical Oncology Research Development (ACORD) Workshops9 support selected advanced trainee participants in developing research skills. The Royal Australasian College of Surgeons runs a 2-day Critical Literature Evaluation and Research (CLEAR) course10 that is available to trainees and Fellows, and mandatory for trainees in some subspecialties. These types of courses, which typically run externally to other training program elements, may well be helpful for those who attend. However, they are not routinely integrated into training and may not be accessed by the majority, resulting in wide variation in understanding research methods and biostatistics within a specialty stream, and between disciplines. The Faculty of Radiation Oncology, RANZCR, have developed a blended learning approach, integrating activities throughout training for all trainees. Annual centralised workshops, led by biostatisticians and Fellows involved in clinical research, are run in conjunction with the main national trials group meeting. Key examples from the oncology literature (often study outcomes or protocols from that trials group) are used to illustrate specific learning points relating to biostatistics concepts, and to promote small-group discussion. In this model, one goal of alignment with the trials meeting is to increase trainees’ exposure to clinical trial development and conduct, and to provide opportunities for mentorship by senior clinician–scientists for trainees starting their own research.11 Through all stages of the training program, self-directed learning activities are selected from a suite of resources, and recorded in an electronic learning portfolio. Through attending the workshop and taking part in these other learning opportunities, trainees accumulate a mandatory number of research points by the end of their training. In addition, as for some other specialty training programs in Australia, there is a compulsory manuscript submission requirement for their research projects.

Biostatisticians’ input into doctors’ research learning is important because biostatisticians, unlike pure non-medical statisticians, have the necessary skills to bridge the gap between ensuring statistical rigor and placing this in the clinical context. However, in Australia, opportunity for professional biostatistics development is limited, hence the services of experts are in high demand and may be costly. Taking shared responsibility for assisting with junior medical researchers’ education may be constrained by this shortage but is necessary to maintain quality.

Examples of strategies used in Australian and overseas settings to promote research-related learning within medical specialty training programs, and the major benefits and limitations of these, are shown in Box. More than one of these activities may currently be available to trainees on a largely ad hoc basis, depending on the training program. To our knowledge, there are no published recommendations or guidelines on which interventions might best develop the skills that lead to the conduct of good research. The lack of educational literature evaluating the impact of these methods holds back progression in this area. Tools to equip supervisors to facilitate learning, and thus better integrate this throughout specialty training, might reduce reliance on external courses and better contextualise learning. A systematic approach to measuring the research literacy that learners derive from these activities, and determining how this translates into research conduct and leadership, will be valuable. These findings could then inform further development across specialist training programs relating to teaching in the research skills domain, and should increase the chance that high-quality clinician-led research output is maintained into the future. Efforts to develop effective and program-integrated learning opportunities that are accessible by all specialty trainees, regardless of discipline and geographic location, should, in our view, be a priority.

Box –
Examples, benefits and limitations of strategies to promote attainment of research skills and knowledge within medical specialty training programs

Type of learning tool or opportunity

Description

Benefits

Limitations

Statistics and research methods training

Courses and workshops run external to specialty training programs

May be tailored to a specific disciplineSmall-group interaction can aid learningMay reach larger numbers of participants

Potentially costly for convenors and participantsGeneral nature and/or didactic formats may not maximise learning

Protocol development workshops for a specific research project (eg, ACORD Workshops)

Trainees work up a real trial scenario with the assistance of teachers

Hands-on protocol development relating to real projects, often with input from biostatisticians and clinician–researchers

Usually small numbers of attendees acceptedOften quite lengthy and may compete with other duties

Mandatory research requirement within training

Research project for presentation and/or publication as part of training

Requires learner to put skills into practice while doing the projectConducting real projects is often a rewarding way to learn

Close supervision is required to ensure a suitable project is chosen, possible to complete and likely to be publishable

Specialty-specific research mentorship programs

Support programs that specifically help trainees find projects and link with suitable supervisors

May assist trainees in centres where research culture is weaker and local supervisors are not well equipped to provide support

Complex to set up across entire programSome trainees may have poorer access to a mentor

Clinician–scientist pathways for specialty training within a specific training program

Pre-determined pathway that promotes conduct of research (often towards a higher degree) that is integrated within other elements of a training program

May provide “discounts” of some clinical training time to facilitate more research timeTrainees often complete training while attaining a higher degree

May promote the concept of two tiers of specialists — academic versus serviceFlexibility is required to enable clinical and research components to be metCooperation between university and clinical supervisors may be challenging

Online teaching tools and programs

Self-directed learning using established modules on topics such as biostatistics, research methodology and scientific writing

Suits some trainees and allows them to tailor learning towards personal interestMore easily integrated with clinical service requirementsSome inexpensive and free products with built-in knowledge testing are available (eg, GCP training)

Tools may not be ideal for specific trainees’ needsLearning is not interactive and may not be engagingSkills are not directly applied to conducting research

GCP = Good Clinical Practice. ACORD = Australia and Asia Pacific Clinical Oncology Research Development.

From riches to riches: the effect of affluent medical students on patients

Thousands of bright-eyed and bushy-tailed students recently found out whether they had been accepted into Australian medical schools.

Selection is a highly competitive process, requiring an impressive combination of high secondary school results (ATAR/GPA), high results on various medical admissions tests (UMAT/GAMSAT), cogent personal statements and/or performance in multiple mini interviews. Only the most successful students are selected.

As selection interviewers for an Australian medical school, one of our scripted questions was “How have you helped disadvantaged people?”. A memorable candidate began, “well, our family has a maid…”.

Other applicants told stories of well-intentioned overseas trips to help “poor people” in other countries. Strikingly, of the nearly 20 aspirants we interviewed, none told stories of socioeconomic disadvantage involving themselves, family or friends.

Although we cannot say whether these students were selected, it is likely some of them were. These well-to-do students will become the future of our medical system.

About two-thirds of Australian medical students come from affluent backgrounds. Fewer than one in ten come from low socioeconomic status backgrounds. This is unsurprising as selection criteria such as ATAR and personal statements are known to be biased against low-socioeconomic-status candidates.

Universities have created special access schemes, and tests such as the Undergraduate Medical Admissions Test (UMAT), Graduate Australian Medical School Admissions Test (GAMSAT), personality tests and interviews which are supposed to reduce bias against low-socioeconomic-status candidates.

However, low-socioeconomic-status applicants are still less successful than their high-socioeconomic-status counterparts at getting into medical schools, perhaps due to the lack of access to role models, support, and opportunities necessary. Females from low socioeconomic backgrounds are the most disadvantaged.

Consequences for patients

Socioeconomic status is associated with important differences in values and beliefs.

Two families recently delivered very premature newborn babies who needed life support. If the babies survived, they were faced with a high chance of disability requiring lifetime care.

The families came from different socioeconomic backgrounds, and expressed different concerns. The parents who were struggling with money said they would not be able to afford the high costs of looking after a disabled child.

The well-off parents expressed they were worried the child’s disability was going to be so severe their child’s quality of life would not be worth putting the child through the intensive and traumatic treatments.

Although both sets of parents wished to withdraw care, they were perceived and treated differently by their health team. One set of parents was eventually referred to child protective services, and the other family had their wishes carried out.

This example highlights the difficulties in shared decision-making when values and priorities are different, and the extent of their impact. People with lower socioeconomic status consistently have poorer health and are more likely to die earlier than their more affluent counterparts, and are less involved in medical decision-making.

Conversely, patients with higher socioeconomic status tend to be more assertive, take an active role in their medical management and receive more explanations.

Selecting a medical community with such differences in socioeconomic status to the Australian population (in which only 25% of people are classified as affluent) holds the risk that the patients they serve have contrasting priorities, values and life situations to their own.

It is human nature to feel more comfortable with, and be more persuaded by patients who hold similar values and articulate them in a familiar way. Patients who have divergent preferences or goals of treatment may have their intentions misconstrued or experience conflict with their doctors.

What can be done?

Medical schools should continue refining medical selection processes to give students with lower socioeconomic status a fair opportunity to become doctors. The medical fraternity and patients would be better off with a broader representation of doctors from different backgrounds.

Doctors do not need to have the same backgrounds as their patients to deliver good care, but they should strive to understand and respect their patients’ needs, expectations and values when delivering health care. Doctors should be aware of the effects socioeconomic status has on the doctor-patient relationship and that patients’ intents and styles of communication may vary from their own.

Much emphasis has been placed on “cultural competency”, but this is often framed in racial, linguistic, ethnic and religious differences. The medical profession is more aware of the possibility of value conflicts when patients speak a different language or have a different ethnic, racial or religious background to their own.

However, when a patient shares the same language or culture, there is an unsaid assumption that there will be common understandings. Expanding these lessons to socioeconomic status is essential to creating a system that serves those who need it most.

Evelyn Chan, Medical doctor (paediatrics and public health), Royal Children’s Hospital and Paul Leong, Doctor, Monash Health

This article was originally published on The Conversation. Read the original article.

Other doctorportal blogs

Safety publications

The TGA produces a range of safety-related publications including regular safety bulletins, brochures, reports and educational materials.

[Comment] A roadmap for better mental health in New York City

New York City is frequently at the forefront of public health policy. Aggressive action to combat the dangers of tobacco use, including the 2003 Smoke-Free Air Act, tax policy, and educational campaigns, led to steep declines in smoking rates.1,2 Regulations to improve the food environment, such as labelling about calories in 20063 and sodium in 20154 and bans on trans fats in 2008,5 continue to be implemented as a way to tackle a growing obesity epidemic and rise in non-communicable diseases.

Players banned as Court rules Essendon doped

Thirty-four current and former Essendon Football Club players have been slapped with a two-year ban after being found to have taken a prohibited supplement, ending the long-running drugs saga that has blighted the Australian Football League and ended several high-profile careers.

In the final determination on the explosive issue, the Court of Arbitration for Sport has overturned the AFL Anti-Doping Tribunal’s ruling that it was “not comfortably satisfied” the players had been administered the performance enhancing drug Thymosin Beta 4 during the 2012 season.

The ruling means that 12 currently listed Essendon FC footballers will not be able to play this year, including captain Jobe Watson, midfielders Dyson Heppel and Heath Hocking, and experienced defenders Michael Hurley, Heath Hocking and Tayte Pears. Several former players who have moved on to other clubs, including Jake Carlisle and Patrick Ryder, have also been suspended, as have retired stars including record games holder Dustin Fletcher, Angus Monfries and Mark McVeigh.

The scandal has already claimed the scalp of former coach James Hird, while the sports scientist who oversaw the supplements program, Stephen Dank, was last year handed a lifetime ban from all sports.

In most cases, the ban will apply through to 13 November this year, taking into account delays caused by factors outside player control and time served by those who accepted provisional suspension in 2013.

While the CAS heard the same evidence as had been presented to the AFL tribunal, it applied a different burden of proof – comfortable satisfaction.

In appealing the AFL tribunal’s decision, the World Anti-Doping Agency (supported by the Australian Sports Anti-Doping Authority) did not have any test results to directly prove doping.

Instead, it used evidence gathered by ASADA, including text messages outlining a plan to dope the Essendon football team with Thymosin Beta 4, testimonies from players and officials, and a scientific analysis of substances sourced for the team.

ASADA said the evidence proved that the players had been injected with a prohibited substance “as part of a team program designed to give Essendon an unfair advantage in the 2012 season”.

ASADA Chief Executive Officer Ben McDevitt described the episode as “the most devastating self-inflicted injury by a sporting club in Australian history”.

Mr McDevitt hailed the Court’s decision and said there was no way the players could have escaped sanction.

“There were very little grounds for the players to claim they were at no significant fault,” Mr McDevitt said.

He said they had all received anti-doping training and “were well aware that they are personally responsible for all substances that entered their body”.

“Unfortunately, despite their education, they agreed to be injected with a number of substances they had little knowledge of, made no enquiries about the substance, and kept the injections from their team doctor and ASADA.”

The anti-doping boss said that in 30 dope tests conducted by ASADA during the period, none of the players divulged that they were receiving the injections despite being explicitly asked whether they had taken any supplements.

“At best, the players did not ask the questions, or the people, they should have,” Mr McDevitt said. “At worst, they were complicit in a culture of secrecy and concealment.”

Recently elected Essendon FC President, former Labor politician Lindsay Tanner, released a statement that the club was “currently digesting the decision”.

Adrian Rollins

Photo: Neale Cousland / Shutterstock.com

[Case Report] Vitamin A deficiency—an unexpected cause of visual loss

A 16-year-old white boy presented to the Blind Low Vision Education Network of New Zealand (BLENNZ) clinic in November, 2014, with a 2 year history of progressive vision loss in both eyes, recurrent systemic infections, and recurrent mononeuropathy.