The end of $250,000 degrees – at least for now

The Federal Government has deferred controversial plans to deregulate university fees, providing relief for aspiring medical students fearful the change would have pushed the cost a medical degree above $250,000.

Education Minister Simon Birmingham has confirmed that the higher education reform package designed by his predecessor Christopher Pyne has been taken off the table pending further consultation with the sector.

In a radical proposal unveiled in the 2014 Budget, Mr Pyne detailed plans to cut university funding and deregulate course costs, sparking fears it would push the cost of a medical degree well in excess of a quarter of a million dollars.

But legislation for the change has stalled in Parliament because of strong opposition in the Senate, and Mr Birmingham told a higher education conference on 1 October it had been shelve duntil after the next election.

“With only three months left in 2015, it is necessary to give both universities and students certainty about what the higher education funding arrangements for 2016 will be,” Senator Birmingham said. “Therefore, I am announcing that higher education funding arrangements for 2016 will not be changed from currently legislated arrangements while the Government consults further on reforms for the future. Any future reforms, should they be legislated, would not commence until 2017 at the earliest.”

The Minister’s decision was welcomed by AMA President Professor Brian Owler, who said the prospect of $250,000 degrees would have had damaging effects on the practice of medicine.

“This would have discouraged students from low socio-economic backgrounds from entering medicine, it would have pushed future graduates towards higher paying specialties, and it would have deterred graduates from working in underserviced areas, including rural Australia,” Professor Owler said.

Former Prime Minister Tony Abbott said he was disappointed by the decision to defer the legislation, and told radio 3AW he was “frankly…a little disappointed that more of the people who keep saying we need reform, we need cuts in government spending, did not get behind the 2014 budget”.

But Professor Owler urged the Government go one step further and give assurances that there will be no future blow-out in university fees.

“The Government needs to give students some certainty that education will not be priced out of their reach should the fee deregulation proposals re-emerge after the next election,” he said, adding that the AMA was keen to work with the Government to develop reforms that boost funding for undergraduate medical education without putting the cost of a medical degree beyond the means of most students.

“The new Minister for Education and Training, Simon Birmingham, has declared he wants to consult broadly about future reforms, and the AMA wants medical workforce and training issues near the top of his agenda,” the AMA President said.

The Higher Education Base Funding Review: Final Report identified medicine as a discipline that was under funded, both in terms of the resourcing required, and in comparison with the funding provided internationally for medical schools, and Professor Owler said these concerns should inform discussions about changes in the sector.

“Any future reform package must maintain our world renowned system of medical education,” he said.

Adrian Rollins

[Comment] Everyone counts—so count everyone

The year is 2015. Remarkable achievement has been made in reducing preventable childhood mortality and morbidity through collective global action by governments, civil society, and private and public sector foundations. People in high-income and middle-income countries are healthier and living longer than in the past.1 National economies in low-income and middle-income countries are projected to rise,2 with the emergence of new middle classes expectant of their rights to education, health care, and employment.

Literature review of the impact of early childhood education and care on learning and development

Early childhood education and care is a key priority for the Australian Government in recognition that ECEC programs play a vital role in the development of Australian children and their preparation for school, and enabling parents to work. This review explores the literature on the complex relationship between attendance at early childhood education and care programs and developmental outcomes for children.

The AMA Specialist Trainee Survey 2014: a survey of hospital-based specialty trainees and general practice registrars

In 2010, the Australian Medical Association (AMA) conducted its first Specialist Trainee Survey (STS)1 to provide medical colleges with feedback from trainees about key facets of their training and other aspects of their operations.

The AMA repeated the STS in May 2014,2 when it surveyed both hospital-based specialty trainees (the STS) and general practice registrars (the General Practice Registrar Survey) to monitor trends and emerging issues in vocational training.

Overall, hospital-based specialist trainees who responded to the 2014 STS reported a high level of satisfaction with their work and training, and have a more positive view about their training experience than those surveyed 4 years ago.

Trainees continue to express high levels of confidence about their career choice, level of supervision, standard of training, clinical experience and safety of the required working hours (Box 1).

It is notable that trainees’ opinions about whether they are working appropriate hours clearly improved between 2010 and 2014, with the proportion of those agreeing that college training requirements were compatible with safety rising from 69% to 79%. This is consistent with results of the AMA Safe Hours Audit,3 which found that hours of work and levels of fatigue risk have decreased over the past 10 years.

Notable improvements were also seen in areas relating to exam content, such as its relevance to practice and appropriateness for the level of training. Other areas of improvement included guidelines for the recognition of prior learning, and the time required to complete training for those with flexible training arrangements.

Disappointingly, many areas of trainee dissatisfaction had not changed since 2010. Responsiveness by the colleges to bullying and harassment, appeals and remediation processes, feedback, and the cost of training are ongoing areas where trainees are still dissatisfied. Trainees are also uncertain about how to gain access to academic streams and accredited overseas rotations as part of their training program (Box 2).

The ability to run two parallel surveys of hospital-based trainees and general practice registrars also provided valuable insight into these training environments. General practice registrars were more positive than specialist trainees about many aspects of their training program, most notably their employment prospects at the end of training, costs of training, availability of flexible training options, relevance and quality of educational activities, recognition of prior learning, and their personal health and wellbeing.

This survey continues to be one method for obtaining independent feedback from trainees about the quality of their training, in light of ongoing pressure on availability of vocational training places, changes to governance arrangements for health workforce planning and GP training, concerns about mental health of doctors, and an increasingly tight fiscal environment.

Notwithstanding its limitations, we hope that this report will prompt relevant institutions to internally review their education and training policies, focusing particularly on the areas that trainees are dissatisfied. The report also highlights areas requiring further scrutiny as part of the ongoing review by the Australian Medical Council of accreditation standards for specialist medical education programs. A single annual National Training Survey would be an excellent mechanism for efficiently monitoring and informing the quality of medical training. This approach has been successfully adopted in the United Kingdom.4

Ultimately, the AMA hopes that this survey continues to assist the improvement of trainees’ experiences and the quality of Australia’s medical education system.

1
Areas in which trainees were most satisfied in 2010 and 2014

2
Areas in which trainees were least satisfied in 2010 and 2014

The Murray to the Mountains Intern Training Program

In April 2014, we reported on the Murray to the Mountains (M2M) Intern Training Program.1 The M2M Program provides a rural alternative for interns and has the following objectives:

enhancing the level of skills and training of interns locally;
retaining new graduates in regional areas during their early postgraduate years; and
developing a cohort of rural-orientated general practitioners and medical specialists.

The program commenced in 2012 with five interns; the number has now increased to 10. Each M2M cohort over the next decade will be documented and their achievement assessed according to the above objectives. This requires the program to maintain contact with all interns. The trust engendered in the interns from the outset has facilitated contact; both informal and formal contact is maintained, the latter through multiple face-to-face assessments. Program staff make themselves readily available to both interns and their supervisors throughout the year.

Of the first M2M cohort, two doctors have successfully completed their advanced diploma in obstetrics in the local regional health services. A third doctor is undertaking an advanced diploma in obstetrics, after spending her third postgraduate year as a general practice registrar. The fourth doctor may undertake a diploma in anaesthetics in 2016, after completing 2 years as a general practice registrar in the region. The fifth has spent her third postgraduate year undergoing physician training in a regional area, and in 2015 is undertaking a second year of basic physician training in a metropolitan teaching hospital.

The 2013 and 2014 cohorts have also had a high retention rate in the region, although some from each year have successfully sought positions in metropolitan hospitals.

The assumption is that the skills and training of the M2M cohort are being enhanced by the program, but more data need to be collected to test its validity; there is an overall 50% retention rate among the interns. Of those embarking on specialist training, at least two have indicated that they wish to return. It is accepted by the program that anybody wishing to train as a specialist needs to undertake a substantial amount of training in a major teaching hospital.

News briefs

Severe head trauma mortality drops at Royal Darwin

Mortality rates for severe head trauma at the Royal Darwin Hospital are down 40% from the 79% rate reported in a study 10 years ago, according to the ANZ Journal of Surgery. The study reviewed clinical service between 2008 and 2013, highlighting the continuing challenge of remoteness to the delivery of emergency medicine and surgery in the Top End. Alcohol remains a major player in hospitalisation, with 57% of patients having evidence of alcohol involvement and 39% of patients with traumatic brain injury having alcohol as a factor in their presentations. Indigenous persons were also overrepresented, accounting for 39% of all procedures as well as being considerably younger by a median of 15 years than their non-Indigenous counterparts. Resident generalist surgeons are reliant upon interstate neurosurgeons, who provide ongoing education, training and support, both by way of outreach visits and by 24-hour telephone and teleradiology consultation over 2600 km away.

Maternal, neonatal tetanus eliminated in India

Maternal and neonatal tetanus has been reduced to less than one case per 1000 live births in India, according to a WHO report. Until a few decades ago, India reported 150 000 to 200 000 neonatal tetanus cases annually. According to Dr Poonam Khetrapal Singh, WHO Regional Director for South-East Asia, the Indian government used a mix of existing and new programs to make elimination possible. “India’s re-energized national immunization program and the special immunization weeks and the most recent ‘Mission Indradhanush’, helped ensure that children and pregnant women are reached with vaccines”, he said. “The ‘National Rural Health Mission’ promoted institutional deliveries with a focus on the poor. The ‘Janani Suraksha Yojana’ encouraged women to give birth in a health facility.” Maternal and neonatal tetanus in South-East Asia now exists in just a few districts of Indonesia.

Hazard alert for hip replacement component

The Therapeutic Goods Administration has issued a hazard alert for one model of the Profemur cobalt-chrome femoral neck (part number PHAC1254 – “long 8-degree varus”) due to the potential for the component to fracture. The manufacturer, Surgical Specialities, is also undertaking a recall of unimplanted stock. Component fractures are extremely rare; however, the manufacturer reported that there had been 27 reports of fracture of the PHAC1254 component in the approximately 9800 units sold worldwide over the previous 5 years. Only 32 units have been sold in Australia. “If you are treating patients who have had a hip replacement and are concerned about the above issue, advise them to be alert to the potential symptoms of a femoral neck component fracture (the sudden onset of symptoms such as pain, instability and difficulty walking or performing common tasks).”

Elevated lead levels in 30 NT children

The Northern Territory Health Department has confirmed that 30 children have been found with elevated blood lead levels in three separate locations across remote areas of the territory, the ABC reports. Children in Palumpa and Peppimenarti, in the West Daly region, and the Emu Point outstation, had higher than expected lead levels, probably due to contact with lead shot, used for shooting magpie geese, according to NT Health Minister John Elferink. NT Chief Health Officer Professor Dinesh Arya said that the children and their families were being interviewed to determine the cause, and all the children were receiving treatment from “specialist paediatricians”.

Ebola vaccination trial extended to Sierra Leone

The WHO reports that a new case of Ebola virus in Sierra Leone, after the country had marked almost 3 weeks of zero cases, has set in motion the first “ring vaccination” use of the experimental Ebola vaccine in the country. A swab taken from a woman who died aged around 60, in late August in the Kambia district, tested positive for Ebola virus. “The Guinea ring vaccination trial is a Phase III efficacy trial of the VSV-EBOV vaccine. Interim results published last July show that this vaccine is highly effective against Ebola. The ‘ring vaccination’ strategy involves vaccinating all contacts — the people known to have come into contact with a person confirmed to have been infected with Ebola (a ‘case’) — and contacts of contacts.”

AMA updates stance on Climate and Health

Following an extensive engagement process with members, the AMA updated its Position Statement on Climate Change and Human Health (Revised 2015), which was last revised in 2008.

The updated Position Statement takes account of the most recent scientific evidence.

AMA President Professor Brian Owler said the AMA Position Statement focuses on the health impacts of climate change, and the need for Australia to plan for the major impacts, which includes reducing greenhouse gas emissions.

“It is the AMA’s view that climate change is a significant worldwide threat to human health that requires urgent action, and that human activity has contributed to climate change,” Professor Owler said.

“The evidence is clear – we cannot sit back and do nothing.

“There are already significant health and social effects of climate change and extreme weather events, and these effects will worsen over time if we do not take action now.

“The AMA believes that the Australian government must show leadership on addressing climate change.

“We are urging the Government to go to the United Nations Climate Change Conference in December in Paris with emission reduction targets that represent Australia’s fair share of global greenhouse gas emissions.

“There is considerable evidence to convince governments around the world to start planning for the major impacts of climate change immediately.

“The world is facing a higher incidence of extreme weather events, the spread of diseases, disrupted supplies of food and water, and threats to livelihoods and security.

“The health effects of climate change include increased heat-related illness and deaths, increased food and water borne diseases, and changing patterns of diseases.

“The incidence of conditions such as malaria, diarrhea, and cardio-respiratory problems is likely to rise.

“Vulnerable people will suffer the most because climate change will have its greatest effect on those who have contributed least to its cause and who have the least resources to cope with it.

“The Lancet has warned that climate change will worsen global health inequity through negative effects on the social determinants of health, and may undermine the last half-century of gains in development and global health,” Professor Owler said.

The AMA Position Statement on Climate Change and Human Health (Revised 2015) states that:

· Australia should adopt mitigation targets within an Australian carbon budget that represents Australia’s fair share of global greenhouse gas emissions, under the principle of common but differential responsibilities.

· Renewable energy presents relative benefits compared to fossil fuels with regard to air pollution and health. Therefore, active transition from fossil fuels to renewable energy sources should be considered.

· Decarbonisation of the economy can potentially result in unemployment and subsequent adverse health impacts. The transition of workers displaced from carbon intensive industries must be effectively managed.

· Regional and national collaboration across all sectors, including a comprehensive and broad-reaching adaptation plan is necessary to reduce the health impacts of climate change. This requires a National Strategy for Health and Climate Change.

· There should be greater education and awareness of the health impacts of climate change, and the public health benefits of mitigation and adaptation.

· Climate policies can have public health benefits beyond their intended impact on the climate. These health benefits should be promoted as a public health opportunity, with significant potential to offset some costs associated with addressing climate change.

The AMA Federal Council last month passed a policy resolution acknowledging the need for the healthcare sector to reduce its carbon footprint through improved energy efficiency, green building design, alternative energy generation, alternative transport methods, sustainable food sourcing, sustainable waste management, and water conservation.

The AMA Position Statement on Climate Change and Human Health (Revised 2015) is available at position-statement/ama-position-statement-climate-change-and-human-health-2004-revised-2015

John Flannery

How new technologies are shaking up health care

New tests and drugs have impacted health care for many decades. But we’re now seeing the emergence of completely different kinds of technologies that will radically alter how health care is both accessed and delivered.

In the past, patient and doctor, or other clinician, would generally meet in person. The clinician would employ the traditional process of seeking a history, undertaking physical examination and perhaps organising tests, to obtain details of the patient’s health-care needs and preferences.

The clinician would then relate this information to current knowledge of disease, prognosis and therapeutics, hopefully involving the patient, and together they would make decisions about a management plan.

A changing world

The internet has changed all that. Health professionals or not, we already share similar access to vast amounts of information about disease processes and their management. Much of this is readily available so that patients can be, and often are, highly knowledgeable about their health and care options.

A growing number of health apps – of varying quality – are available to support patients’ decisions about those options. And social media provide an instant network of peers with whom to share health concerns and experiences.

Biosensitive wearable technologies now monitor basic physiological processes, such as pulse rate and physical activity, permitting analysis and interpretation in real time. Future wearables and home-based sensors will track a growing range of measures, providing data for increasingly sophisticated assessment of the wearer’s current health status, and decision support for their care.

Many pharmacies and other primary health-care facilities offer point-of-care testing for use on site or at home. Right now such tests are largely limited to simple biological measures, such as blood glucose or cholesterol. But the range and number of possible tests are expanding rapidly, and coming down in price.

Soon it will be possible not only to diagnose a specific infection, but to accurately predict which anti-infective (if any) would be most effective for its treatment. All this will be done within minutes, and often without the need for a doctor, nurse or other health-care professional to examine, test and prescribe.

At the same time, advances in human genomics are providing the basis for redefining and reclassifying diseases. These advances enable increasingly accurate prediction of risk; new opportunities for effective prevention; and rapid confirmation of a growing number of diagnoses, clarifying the patient’s likely prognosis as well as informing treatment selection.

This is the basis of personalised medicine, which seeks to match health-management advice to the individual and not just to their disease. Parallel developments in genetic analysis of tumours and of the pathogens that cause infections are further refining the possibilities for matching the treatment to the patient and their disease.

Mental health too

It’s not just physical health care that’s being affected; information and communication technologies are transforming psychological care. Psychologists and psychiatrists rarely examine patients physically, so video-consultations are becoming more common.

A growing number of websites provide online psychological assessment and advice for the user. These range from straightforward screening for common mental problems to sophisticated measurements of cognitive and emotional functioning, which can predict responsiveness to specific therapies.

Psychological treatments, such as cognitive behavioural and mindfulness interventions, are readily available online. There is strong evidence for their effectiveness when used appropriately.

Communications technology can also enable real-time monitoring of patients’ adherence to prescribed medical treatment: this has obvious applications in the care, for example, of people with dementia. And smart dispensers can help all of us remember to take our medicines.

These developments remove the need for patients and their clinicians to meet in person, or even to communicate synchronously, unless physical interaction such as surgery is required. The array of generic and patient-specific information, and of electronic decision support aids that both patients and clinicians can access, are redefining the role of the clinician.

Doctors will increasingly play a role as expert guides to available resources, facilitating patients’ choices and decision making. Physical infrastructure for emergency management, surgical intervention and care of the very sick will still be needed. But information technology’s ability to collapse time and space will increasingly alter how health care is accessed and delivered in the community, enabling the right care every time, and at the patient’s convenience.

The implications for health service planning and policy, and for health professional education, are profound. Key considerations will include enabling equity of access to the potential benefits of information technology and ensuring that this enhances rather than distracts from the human connection we all need when we feel ill or fearful about our health.

Tim Usherwood is Professor of General Practice at University of Sydney

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

Other doctorportal blogs

Main image: Intel Free Pass/flickr

[Editorial] India—small progress in health care, decline in rural services

As the second most populated nation in the world, with 1·2 billion people, India is a complex society, with wide ethnic, religious, and cultural variations; and deeply entrenched inequalities in wealth distribution, education, and access to health-care services. In 2011, the Lancet India Series called for the implementation of a universal Indian Health Service by 2020, accompanied by structural, educational, and political changes. The authors recommended that government overall health spend be increased from the current 1·04% to 4% of gross domestic product by 2015, and to 6% by 2020.

[Department of Error] Department of Error

Sharma DC. India’s medical education system hit by scandals. Lancet 2015; 386: 517–18—In this World Report (Aug 8), an image of identifiable medical students unconnected to the story was mistakenly used for the second image. This image was removed from the online version as of Aug 11, 2015.