A guide to OSCEs: my findings on examination

With over 25 years of development and review contributing to Talley and O’Connor’s Clinical examination, it is no wonder that the educational guide, now in its 7th edition, has become an essential reference for medical students.

While maintaining its dependable content, the new edition has added depth, particularly regarding investigations useful for the diagnosis and ongoing evaluation of common differential diagnoses. Examples include indications for and interpretation of echocardiograms, abdominal computed tomography scans and lumbar punctures. This is consistent with a clear shift towards supporting students in their preparation for assessment, which involves more than physical examination.

The exam focus is substantiated by the addition of “OSCE (objective structured clinical examination) revision topics”, “T&O’C essentials” and a far more reader-friendly format. While the book preserves its system-based structure, the clear division of content ensures information is significantly more accessible.

The guide takes a further step towards preparing students for their future medical practice, with additional chapters on the assessment of the geriatric patient, of the acutely ill patient and of death. While the latter begins to extend beyond the immediate scope of a student, the topics are only covered superficially and, at most, would serve as a starting point for supplemental reading in emergency and end-of-life care. It is important to bear in mind that these topics are not a pressing concern to students in their current clinical roles and, as such, would not justify significantly greater coverage.

There is no doubt that Clinical examination is the cornerstone reference for medical students studying the skill of physical diagnosis. The systematic guide also provides experienced physicians with a reliable and thorough resource on examination findings and patient interactions. It is highly recommended to all those seeking to improve their understanding of, or requiring succinct templates for, structured physical examinations.

What influences doctors to work in rural locations?

Student background and clinical education act synergistically

We are fortunate that there is increasing evidence available on which to base policy decisions for building the rural medical workforce. The concept of the rural pipeline1 provides a framework in which to consider who we admit to medical programs, where we can best deliver medical education that is motivating towards rural practice and why graduates then choose to work in rural locations.

Two new sources of evidence are helping to address the “who” and “where” considerations. The Medical Schools Outcomes Database and Longitudinal Tracking (MSOD) Project has provided evidence of medical student career intentions on commencement and completion of undergraduate education, and data on location of practice in the early postgraduate years. In this issue of the Journal, Hays and colleagues describe their analysis of national MSOD data to determine where full-fee paying (FFP) students intend to practise.2 They conclude that FFP students are significantly more likely to practise in an urban area.

Their findings should cause us to pause and reflect on the question of who to admit. If we no longer have a shortage of medical practitioners in Australia (compared with other OECD [Organisation for Economic Co-operation and Development] countries3) but the challenge of distributing practitioners to rural areas is ongoing, FFP students with urban practice intentions are not likely to help address the maldistribution challenge.

Also in this issue, Kondalsamy-Chennakesavan and colleagues, who studied determinants of rural practice in University of Queensland medical graduates,4 affirmed that rural background is one of the greatest predictors of rural practice.5 Owing to the maturity of the University of Queensland Rural Clinical School (UQRCS) program, the authors could show a direct relationship between length of rural background (before medical school entry) and likelihood of rural practice. Those who had attended UQRCS as undergraduates for 1–2 years had increased odds of rural practice, and more time spent at UQRCS increased the odds. The effect of rural background plus rural undergraduate clinical education was also affirmed as very influential for recruiting future rural practitioners.4,6

We now need to build on these promising findings from over a decade of federal government support for the Rural Clinical Training and Support program and explore why graduates go on to practise in rural locations. The next stage in the vertical continuum of the medical education pipeline, including the social issues that affect practice location, surely deserves attention.

Postgraduate education occurs at a crucial time in a trainee’s personal and professional life. For most specialties, this training is currently based in large urban centres, and trainees spend very little time in rural settings. Thus mentor–trainee relationships, life partnerships, work opportunities for partners, purchases of homes, and stable child care or schooling arrangements become established in urban centres.

Reversing this trend offers promise of influencing trainees to train in rural locations and then remain there. This may be attractive to older or married students, who are more likely to choose a rural location.4 The considerable investment in infrastructure and human resources for undergraduate education in rural Australia can then be leveraged to build regional local postgraduate training networks. Start-up funding will help establish the necessary partnerships with postgraduate training providers and colleges for regionally based postgraduate education.

Medical school debt and financial incentives potentially also influence decisions regarding rural practice. Hays et al highlight the large debts that many FFP students incur by graduation, and suggest that these might motivate choice of urban practice in lucrative subspecialties.2 In the future, increasing debts incurred by Commonwealth-supported place (CSP) students, owing to proposed changes to the HECS-HELP scheme (Higher Education Contribution Scheme, Higher Education Loan Program), might dissuade doctors from working in rural locations and in the needed vocation of general practice, despite the HECS Reimbursement Scheme for rural service.7 Evidence for the influence of medical school selection on rural medical workforce is growing. Recruiting CSP students from rural and lower socioeconomic backgrounds may prove to be an influential strategy.8

Proposed changes to the District of Workforce Shortage, Australian Standard Geographical Classification – Remoteness Area (ASGC-RA) system and Bonded Medical Places Scheme should encourage more doctors to work in rural locations. The Modified Monash Model (MMM) — the updated geographical classification system) — will focus support and resources on small rural and remote communities (where the need is greatest), and any bonded student will be able to complete their return of service obligation in any small town (< 15 000 population). Application of MMM classifications to the General Practice Rural Incentives Programme is planned to ensure that incentive payments are targeted to relocating doctors to the areas of most need and retaining them there. Better targeting of incentives should provide a synergistic strategy9 and, when used in conjunction with key strategies associated with rural background, rural education and rural service obligations, should increase the number of doctors working in rural locations.

Determinants of rural practice: positive interaction between rural background and rural undergraduate training

In developed countries, including the United States, Canada and Australia, a fifth to a third of the population live in rural areas yet the number of medical practitioners employed per 100 000 population in those areas is about half that of major cities.1–4 It has long been recognised that rural doctors are more likely to have a rural background and to have had some medical training (undergraduate or postgraduate) in rural areas,5–16 although the effect of undergraduate rural exposure has been questioned.17 Other factors associated with rural practice include being single, having children, having a partner with a rural background, rural primary and secondary education, intention or desire to practise rurally, sex, age, having a bonded scholarship, and medical school attended.18–20

From the early 1990s, the Australian Government introduced national initiatives aimed at encouraging rural practice. This included funding medical schools to increase enrolment of students with a rural background and provide short-term undergraduate rural exposure.21,22 In 2001, to increase the duration of rural exposure, universities began to establish rural clinical schools (RCSs); by 2008, 17 were operating. Participating universities are funded to train 25% of domestic students who are publicly funded (those have a Commonwealth-supported place) in a rural area, defined by Australian Standard Geographical Classification – Remoteness Area (ASGC-RA) categories ASGC-RA2 to ASGC-RA5.23

To track students through medical school and training, the Australian Government has supported a large prospective cohort study involving all Australian medical students — the Medical Schools Outcomes Database and Longitudinal Tracking Project.24 In the future, this study will generate robust data (currently, most participants are undergraduates or are in early postgraduate training).

The University of Queensland Rural Clinical School (UQRCS) was established in 2002. It is one of the largest RCSs in Australia and has teaching sites in four regional cities situated 130–650 km from Brisbane. The University of Queensland (UQ) School of Medicine also has eight metropolitan clinical schools (MCSs).

We aimed to quantify determinants of rural practice and interactions between them, particularly the role of rural background and years of RCS training, for UQ medical graduates. We hypothesised that attendance at UQRCS is an independent predictor of rural practice, after adjusting for confounders, and that a positive interaction between UQRCS attendance and rural background enhances the effect.

Methods

This study was part of the UQ Medical Graduates Cohort Study — a retrospective cohort study of UQ medical graduates who graduated during the period 2002–2011. Lists of eligible participants (those who had been domestic students [ie, Australian citizens and permanent residents]) and their current contact details, if available, were obtained from UQ. If not available, current suburb and postcode were sought by searching the Australian Health Practitioner Regulation Agency (AHPRA) register of practitioners. This information was used to narrow telephone directory and internet searches. Potential participants were invited by email, post or telephone and sent a link to an online questionnaire, or a hard copy if requested. Since UQRCS attendance was a critical exposure variable but only 20% of potential participants would have attended UQRCS, we targeted this group to improve the power and efficiency of the study.

The questionnaire comprised questions on demographics, family information (parents’ rural background, partnership status and partner’s rural background), residential history (birth place and location during preschool, primary school, high school and post-school years), boarding school attendance, gap year after high school, scholarships (including bonded scholarships), rural health club membership, tertiary education and postgraduate training, year of medical school graduation, and location of current clinical practice (primary location for those with more than one). The outcome of interest was location of current clinical practice categorised as rural. The primary predictor variables of interest were attendance at UQRCS and rural background; the latter was defined as having resided in a rural area in Australia for at least 5 years since commencing primary school and before commencing UQ medical degree, as per funding parameters.

Statistical analyses

Descriptive statistics were used to report location of current clinical practice by ASGC-RA categories and UQRCS status. The category ASGC-RA1 was considered metropolitan, and categories ASGC-RA2 to ASGC-RA5 were considered rural (RA2, inner regional; RA3, outer regional; RA4, remote; RA5, very remote). If location of current clinical practice was overseas, it was categorised as metropolitan.

Univariate and multivariate logistic regression analyses were used to identify factors predictive of rural clinical practice. Multivariate models were adjusted for potential confounding factors: parent’s rural background, partnership status, partner’s rural background, bonded scholarship, boarding school attendance and gap year after high school. Interactions between these determinants were evaluated and included in the final model if statistically significant.

Stata for Mac (version 12.1, SE [StataCorp]) was used for statistical analyses and P < 0.05 was considered statistically significant.

The UQ Behavioural and Social Sciences Ethical Review Committee approved the study.

Results

Of 2833 medical graduates who graduated during the period 2002–2011, 2478 were domestic students. Of these, contact information (email address, postal address or telephone number) was available for 1714. Of these potentially contactable graduates, 142 were initially excluded — emails bounced for 127 (no other contact details were available) and 15 declined to participate. The questionnaire was sent to the remaining 1572, of whom 754 completed it during the period December 2012 to October 2013 (response rate, 48.0% [likely to be an underestimate as the status of sent emails could not be verified]). Characteristics of the participants are shown in Appendix 1.

Of the 754 respondents, 31.3% (236) had a rural background, 36.6% (276) attended UQRCS for 1 or 2 years and 27.2% (205) were currently practising in a rural area — 18.8% (90/478) of those who attended an MCS and 41.7% (115/276) of those who attended UQRCS (P < 0.001). Of those categorised as currently practising in a metropolitan area, 20 were practising overseas.

The proportion of participants currently practising in a rural area was lowest for those with a metropolitan background who attended a metropolitan clinical school (reference group; 16.9% [61/361]), intermediate for those with a rural background who attended a metropolitan school (24.8% [29/117]) and for those with metropolitan background who attended UQRCS (26.8% [42/157]), and highest for those with a rural background who attended UQRCS (61.3% [73/119]). For all rural ASGC-RA categories, the proportion of practitioners who had attended UQRCS was about twice that of those who attended an MCS (RA2, 9.2% [44/478] v 22.5% [62/276]; RA3, 7.5% [36/478] v 14.5% [40/276]; RA4, 1.0% [5/478] v 2.5% [7/276]; RA5, 1.0% [5/478] v 2.2% [6/276]). Also, the geographic distribution of UQRCS graduates matched the distribution of Queensland’s general population more closely than that of MCS graduates (Box 1).

Associations between rural practice and potential predictors of rural practice are shown in Appendix 2. On univariate analyses, the following variables showed an odds ratio (OR) of at least 2.0: UQRCS attendance; rural background; father’s, mother’s and partner’s rural background; any scholarship; bonded scholarship; and rural health club membership. There was no association between sex and rural practice.

Two multivariate models predicting rural practice are shown in Box 2. In the model with main effects (without interaction terms), the following variables were independent predictors: UQRCS attendance (1 or 2 years); rural background; partner with rural background; being single; and bonded scholarship. With the exception of the interaction between UQRCS attendance and rural background, all other two-way and three-way interactions between UQRCS exposure, rural background and partner’s rural background were not statistically significant and were not included in the final multivariate model. The variables relating to rural background exhibited multicollinearity, so parents’ backgrounds were not included in the final multivariate model.

To simplify the interpretation of interaction between UQRCS attendance and rural background, the participants were grouped into six categories. The model that included interaction between UQRCS attendance and rural background shows that a substantial positive interaction exists (Box 2). Compared with the reference group, participants with a rural background who attended UQRCS for 1 and 2 years were 4.44 and 7.09 times as likely, respectively, to practise in a rural area after adjusting for partner with a rural background, being single and bonded scholarship.

To explore the effect of the duration of rural background on the adjusted predictive probability of current rural practice, we developed a logistic regression model with explanatory variables: UQRCS attendance v MCS attendance, years spent in a rural area (since primary school and before commencing UQ medical degree) as a continuous variable, and an interaction term between these two variables (Box 3). The predicted probabilities are divergent across the range of years spent in a rural area. In UQRCS attendees with 10 and 20 years of rural exposure, the predicted probabilities of rural practice are 54% (95% CI, 46%–62%) and 79% (95% CI, 69%–89%), respectively.

To determine the representativeness of our sample, we linked 2360 of the 2478 domestic medical graduates (95.2%) to the AHPRA database to determine current practice location. Characteristics of these two groups and crude ORs of rural practice for them are shown in Appendix 3. All characteristics for these two groups are similar except there was a higher proportion who attended UQRCS in the group of 2478 students from which we recruited participants than the group of 2360 for whom data linkage was done (36.6% v 19.8% [476]), which is consistent with our recruitment strategy.

Discussion

Our study shows that rural background and 1 or 2 years of UQRCS training are independent predictors of subsequent rural practice after adjusting for confounders including partnership status, partner’s rural background and bonded scholarship. For UQRCS attendees, a positive, nearly linear, correlation exists between the probability of rural practice and duration of rural background over a range of 0–20 years. In addition, there was a similar beneficial effect across inner regional, outer regional, remote and very remote areas on rural practice.

It also shows that there is a strong positive interaction between rural background and UQRCS attendance in enhancing the probability of rural practice. In contrast, training students with a rural background at an MCS or training students with a metropolitan background at UQRCS does not have a statistically significant effect on probability of rural practice (although trends exist [ORs, 1.46–1.83]). Our finding that having a bonded scholarship is associated with rural practice is not unexpected given that these graduates are financially committed to working in a rural area or an underserviced area, many of which are rural.

Few studies have used multivariate analysis to identify independent determinants of rural practice. A retrospective survey of 264 rural and 179 urban practitioners in Ontario, Canada, found that rural background and any rural undergraduate training were independent predictors of rural practice (ORs, 3.31 and 2.46, respectively), as were rural postgraduate training, medical school location and being male.19 In this survey, the main effects were reported but the interactions were not.

An Australian survey of 268 rural and 236 metropolitan general practitioners found statistically significant associations between current rural practice and rural background, rural school education and partner with a rural background.20 In the multivariate analysis, only rural primary school and partner with a rural background were independently associated with rural practice (ORs, 2.43 and 3.14, respectively).

A multivariate logistic regression analysis with seven variables using a sample of 359 medical graduates in the US found that the only independent predictors of rural practice were rural background and intention at medical school entry to become a family physician.18 Interaction between the variables was not reported.

At the University of Minnesota (UMN) Medical School, 27% of students had one or two different rural exposures — first 2 years of undergraduate training in a regional city (UMN-Duluth) and/or 9 months with a primary care preceptor in a rural community in their third year (Rural Physician Associate Program [RPAP]).25 In multivariate analysis for the outcome of current rural practice, RPAP, UMN-Duluth and rural background were independent predictors of rural practice (ORs, 4.6, 4.1 and 2.8, respectively). Other confounders were not assessed. When two- and three-way interactions were assessed, only UMN-Duluth training plus rural background was statistically significant and the interaction was negative (OR, 0.56 [95% CI, 0.33–0.96]), in contrast to our finding.

In a recent data-linkage study conducted by the Rural Clinical School of Western Australia (RCSWA), rural practice of 1017 medical graduates who graduated during the period 2002–2009 was determined from the AHPRA register and rural background was defined by medical school entry through a quarantined rural pathway.26 In a multivariate model with interactions, the OR for rural practice for students with rural background who attended RCSWA compared with those with metropolitan background who did not attend RCSWA was 7.5 (95% CI, 3.5–15.8) — a very similar result to ours.

Although the study did adjust for age and sex, no adjustments were made for other confounders. Further, the proportion of graduates practising rurally in the Western Australian and Queensland cohorts is markedly different (7.7% and 27.2%, respectively), which may be partly due to the lower proportion of the population living, over the study period, in areas categorised as RA2 to RA5 in Western Australia compared with Queensland (27% v 42%).

Our study has strengths and limitations. The main strength is that extensive data were available on sufficient numbers of graduates with different exposures to provide power for multivariate analyses with interactions on the outcome of rural practice. The study was conducted in a single large medical school with a uniform curriculum across 4 years, except that in year 3 and/or year 4 clinical training was delivered at UQRCS or an MCS. The findings may be generalisable to other Australian medical schools that offer MCS and RCS placements but perhaps not to regional medical schools that have much higher proportions of rural background students and routinely deliver rural exposure across multiple years of their courses.27

Our sample represents only 30.4% of domestic 2002–2011 medical graduates from UQ, so there could have been participation bias. However, a previous study with a response rate of 64% found that 40% of UQRCS attendees were in rural practice28 — a very similar result to ours (42%). In addition, the consistency of the result for rural practice between 2007–2011 graduates and 2002–2006 graduates (Appendix 2) suggests no participation bias relating to time since graduation. Further, our analysis of representativeness suggests that sampling would not have caused significant bias in the results.

Our results may be affected by self-selection bias regarding clinical school attended — that is, students who attend UQRCS may do so because they intend to enter rural practice. In the first few years of teaching at UQRCS, most students were conscripted, but in recent years 70%–90% have had UQRCS placement as their first preference. However, other factors influence students’ first preferences, such as free or highly subsidised accommodation, academic reputation, patient and teacher access, lifestyle and work opportunities.24,29 Rural intention has been shown to be associated with other rural exposures (rural background or rural upbringing, having a spouse who had lived in a rural area),30,31 which we adjusted for. Also, other unknown confounders may have influenced our results.

Between 2002 and 2012, the number of full-time equivalent doctors practising in Australia per 100 000 population (FTE rate) increased by 33% in metropolitan areas but increased by 50%–75% in rural areas,32,33 indicating reversal of the previous downward trend seen for GPs.1 Nevertheless, the FTE rate remains 33%–39% lower in rural areas for all doctors and 48%–78% lower for specialists, so more needs to be done.

Rural clinical placements are limited and more expensive than metropolitan clinical placements, so policy measures that maximise the cost-effectiveness of RCS programs are warranted. Our results suggest that the probability of rural practice could be increased by policies that increase the proportion of RCS attendees who have a rural background and who attend for more than one year. In addition, preferential recruitment of students with a background of longer-term rural residence should be considered.

1 Location of current clinical practice for study participants (n = 754) by clinical school attended, and distribution of Queensland’s general population*

MCS = metropolitan clinical school. UQRCS = University of Queensland Rural Clinical School. * Distribution of Queensland population according to Australian Bureau of Statistics data for 2010.

2 Multivariate models predicting rural practice

Odds ratio (95% CI)

Model with main effects

UQRCS attendance

MCS attendee

Reference group

UQRCS attendee (1 year)

1.84 (1.21–2.82)

0.005

UQRCS attendee (2 years)

2.71 (1.65–4.45)

< 0.001

Background of participant

Metropolitan background

Reference group

Rural background*

2.30 (1.57–3.36)

< 0.001

Background of partner

Metropolitan background

Reference group

Rural background

3.08 (1.96–4.84)

< 0.001

Not applicable (single)

1.98 (1.28–3.06)

0.002

Bonded scholarship

No bonded scholarship

Reference group

Bonded scholarship

2.34 (1.37–3.98)

0.002

Model with interaction between UQRCS attendance and rural background†

UQRCS attendance and background of participant

MCS attendee, metropolitan background

Reference group

MCS attendee, rural background

1.61 (0.94–2.75)

0.08

UQRCS attendee (1 year), metropolitan background

1.46 (0.85–2.51)

0.17

UQRCS attendee (1 year), rural background

4.44 (2.38–8.29)

< 0.001

UQRCS attendee (2 years), metropolitan background

1.83 (0.91–3.67)

0.09

UQRCS attendee (2 years), rural background

7.09 (3.57–14.10)

< 0.001

Background of partner

Metropolitan background

Reference group

Rural background

3.14 (1.99–4.96)

< 0.001

Not applicable (single)

2.02 (1.30–3.12)

0.002

Bonded scholarship

No bonded scholarship

Reference group

Bonded scholarship

2.27 (1.32–3.90)

0.003

UQRCS = University of Queensland Rural Clinical School. MCS = metropolitan clinical school. * Rural background was defined as at least 5 years since primary school and before commencing University of Queensland medical degree spent a rural area (areas in Australian Standard Geographical Classification – Remoteness Area [ASGC-RA] categories ASGC-RA2 to ASGC-RA5). † Other two-way and three-way interactions (among UQRCS status, rural background status and partnership status) were not statistically significant and were not included in the model.

3 Predicted probabilities of current rural practice, according to duration of rural background, by clinical school attended*

MCS = metropolitan clinical school. UQRCS = University of Queensland Rural Clinical School. * Based on a logistic regression model with the following as explanatory variables: UQRCS attendance v MCS attendance, years spent in a rural area (since primary school and before commencing University of Queensland medical degree) as a continuous variable, and an interaction term between these two variables. Shaded bands represent 95% CIs.

The Australian medical response to Typhoon Haiyan

Our well equipped civilian professionals made a rapid and valuable contribution to internationally coordinated aid

On the morning of 8 November 2013, category 5 Typhoon Haiyan (known locally as Typhoon Yolanda) made first landfall over Eastern Samar province in the Philippines. Sustained, damaging winds of 235 km/h gusting to 275 km/h were accompanied by a tidal storm surge and subsequent inundation. The official number of fatalities stands at 6190, with 28 626 injuries attributed to the event, and over 16 million people affected.1

On 9 November, as reports indicated the scale of the disaster, the government of the Philippines officially requested international humanitarian assistance. Eastern Samar and Leyte provinces, including the major population centre of Tacloban (population 220 000) sustained catastrophic damage.

As part of a $40 million assistance package, the Australian Government deployed a field hospital and a fully self-sustaining civilian medical team with a mandate to assist the Philippines Department of Health in immediate postdisaster medical care. The first Australian medical assistance team (AUSMAT) of 37 medical, nursing, paramedical and logistics professionals deployed on 13 November with over 28 tonnes of equipment. They were relieved on 27 November by a second team of 37.

At the direction of the Philippines Department of Health, a field hospital with 35 inpatient beds, two operating tables, an outpatient clinic and a resuscitation room was deployed to Tacloban, the most critically affected population centre. Clinical activity commenced 7 days after Typhoon Haiyan made landfall — one of the fastest deployments of a foreign field hospital to a sudden-onset disaster.2 The field hospital was registered as a Type 2 facility under the new World Health Organization guidelines for foreign medical teams in sudden-onset disasters.3 This was the first occasion on which a host government was able to use the WHO guidelines to assess the contribution of foreign medical teams.

The AUSMAT field hospital rapidly became a critical adjunct to the overall medical response in Tacloban, providing surgical and trauma care while the major local referral centre gradually restored its own surgical services. The surgical casemix, reflecting the nature of the disaster, comprised a high proportion of traumatic injuries from high-velocity debris. As the deployment continued, individuals with minor to moderate injuries, but who had not yet sought medical care, presented with wound infections that were frequently exacerbated by intercurrent type 2 diabetes. Many of these patients had either been searching for lost family or attempting to rebuild their homes and livelihoods, but not attending to their own need for health care.

During a 23-day operational period, 238 surgical procedures were performed, of which 90 were considered major. A total of 2734 patients were seen. Based on average numbers of outpatients, this meant that, for the time it was operational, the AUSMAT field hospital was as busy as the Royal Darwin Hospital emergency department. In addition to surgical patients, our clinicians treated patients with a variety of acute and chronic medical conditions, ranging from respiratory tract infections and diarrhoeal illness through to uncontrolled hypertension.

Operation Philippines Assist marked two critical points in the evolution of Australia’s capacity to provide professional, emergent medical relief after sudden-onset disasters. It was the first occasion on which a clinical team comprising members from each state and territory was deployed (it also included an orthopaedic surgeon and logistician from the New Zealand Medical Assistance Team). This was also the AUSMAT field hospital’s first deployment overseas as part of an Australian response.

Historical perspective on AUSMAT

Previous responses funded by the Australian Government to regional natural disasters such as those in Aceh, Yogyakarta, Samoa and Christchurch were managed through the state-based disaster medical assistance teams model, with involvement of some multijurisdictional teams. Since 2010, the AUSMAT concept, derived from the global movement towards professional, trained medical disaster-relief teams, has become the national model for medical disaster response. AUSMAT training and deployment is primarily coordinated via the Darwin-based National Critical Care and Trauma Response Centre under the auspices of the Australian Government Department of Health. Each state and territory has a coordination focal point linking local health departments to the national team.

Since 2010, over 400 health professionals and medical logisticians have undergone specific and tailored training to deliver care in typical austere, resource-poor environments. The team member training course focuses on safety and security, cultural awareness, team dynamics in the field and familiarisation with equipment. Its centrepiece is a high-fidelity 36-hour simulated deployment to a fictitious nation where each key competency is tested in field conditions. Specific courses for surgeons and anaesthetists, team leaders and medical logisticians have also been developed.

AUSMAT also has a nationally agreed set of standards governing all aspects of deployment including vaccination and predeparture health checks, in-country codes of conduct and postdeployment psychological debriefing. These standards, documented in the national AUSMAT manual,4 have been endorsed by the Australian Health Protection Principal Committee and ensure that the Australian Government maintains a consistent and predictable medical response to regional disasters.

The need for standards in disaster response

Sudden-onset disasters attract a wide variety of responders, from clinicians trained specifically in humanitarian and disaster response to well meaning but untrained individuals or teams. As seen over a number of natural disasters in the 20th and 21st centuries, significant harm to a disaster-affected population can be caused by foreign medical teams who are either untrained in disaster medicine or poorly resourced and not self-sufficient.5

Analysis of responses to the 2010 Haiti earthquake provided clear evidence of the effects of underprepared and underresourced teams. A review of the surgical response in Haiti found that amputation rates varied considerably between foreign surgical teams, from 1% of surgical procedures to over 45%. The lowest rates occurred among specialised orthoplastic teams experienced in limb salvage.6

One account of a trauma team’s experience in Haiti documents the rapid overwhelming of the team by the scale of the disaster, forcing them to self-evacuate. The authors suggest that individual and institutional medical responders partner with experienced disaster-relief organisations to “facilitate the personnel from the more developed countries to learn how to live and work under unfamiliar austere circumstances”.7

Typhoon Haiyan was a typical natural disaster in that it attracted responders with varied training and differing levels of self-sufficiency, ranging from skilled government teams from Australia, Japan, Korea and Belgium, and well known non-government organisations (NGOs) such as the International Committee of the Red Cross and Médecins Sans Frontières, through to individuals who were essentially “disaster tourists”. In between were many small NGOs and philanthropic organisations. Frequently, the AUSMAT team was asked to supply medications or other supplies to teams that had arrived in the country inadequately equipped to provide effective care. Typically, these teams were not participants in the WHO and Philippines Department of Health global health cluster coordination process.

An extensive body of literature points to the key competencies required by medical disaster responders. Clinical medicine, public health and disaster incident management are the core disciplines practised by disaster health professionals.8

Similarly, the AUSMAT concept is firmly rooted in the philosophy that disaster health professionals must have key clinical and humanitarian competencies. First, they must be registered to practise in their stated profession. Too often, clinicians, under the pretext of saving lives at all costs, extend themselves far beyond their scope of practice without following the fundamental principle of medical practice — first do no harm.

Second, health professionals must be able to perform their clinical specialty in a disaster context. It is outdated practice to pluck individuals from their clinical practice in developed-world tertiary hospitals and deposit them in a disaster zone, expecting them to be able to function in austere circumstances with limited resources. Not only does poor patient care result, but it may cause psychological and professional distress for the clinician. Fortunately, in Australia, the clinical experience of many doctors and nurses in rural and remote settings means they are ideally suited to the demands of practice in an austere environment.

Finally, to appreciate the context in which they work, health professionals must have a set of core humanitarian competencies. These range from an understanding of international humanitarian norms through to self-management skills in the field and an ability to operate safely and securely in difficult circumstances.

AUSMAT’s efficient and timely deployment to Tacloban demonstrated the importance of preparedness and consistency. A repository of well trained and prepared clinicians and support staff with a suite of appropriate skills meant an effective response could be mounted. While training is obviously required for preparedness, the importance of an agreed consistency in disaster training is less obvious. The AUSMAT response to Typhoon Haiyan showed well the advantages of both.

The need for qualified and capable medical professionals to be deployed to assist disaster-affected populations will continue into the future. It is the responsibility of organisations rendering assistance to ensure that personnel are trained in the nuances of humanitarian and disaster medicine and to adhere to the new international standards for deployment of foreign medical teams.

The devastation of Tacloban in the wake of Typhoon Haiyan was mirrored across the Philippine provinces of Leyte and Eastern Samar

Surgeons Vaughan Poutawera (New Zealand) and Cea-Cea Moller (South Australia) complete a skin graft for a diabetic patient with typhoon-related injuries

The Australian field hospital in Tacloban, with outpatient tents in the foreground and wards and operating theatre behind (blue-and-white tents)

Enabling the success of academic health science centres in Australia: where is the leadership?

Lack of policy development hinders the effective integration of research, education and health care delivery

The expanding health care demands of our community require that our health system have an expanding knowledge base, enhanced capability, greater process efficiency and more targeted application of clinical interventions. The search for new groundbreaking discoveries should continue unabated (for example, in replicating the success of statins in ameliorating coronary heart disease or antiretroviral therapy in controlling HIV infection). However, there is an equally important, immediate and ongoing daily need for all patients to receive better, safer and more efficient care from highly competent health professionals using existing knowledge and resources. This responsibility must be shared between health administrators, front-line health professionals, and academic teachers and researchers.

In recognition of this shared responsibility, at least four academic health science centres (AHSCs) have been established in Australia in the past 5 years. They comprise partnerships or collaborations between universities and their affiliated research institutes and health service organisations.

There is no universally agreed definition of an AHSC, but most are alliances of geographically co-located entities, with varying descriptions of what they actually do or hope to achieve. However, all AHSCs are committed to a tripartite mission of advancing research, education, and patient care. This mission presents challenges for AHSCs worldwide in responding to demands for high-value, patient-centred care and improved population health. Historically, the research stakeholders within AHSCs have attracted funding primarily to conduct basic research and biomedical studies aimed at new diagnostic and therapeutic discoveries, with less emphasis on education, patient care (especially primary care and preventive medicine), and health services research.1 However, this is likely to change as AHSCs realise they must match their pre-eminence in the science of discoveries with equal commitment to translational and implementation science focused on health system improvement.2 Can AHSCs truly claim to excel in scientific discovery if they are not researching ways of making clinical services more reliably excellent? Can they truly claim to teach high-quality medicine without consistently providing high-quality care? The AHSC needs to be defined as a centre of learning committed to improving health and health care by advancing, applying and disseminating knowledge through a learning health system.

Defining stakeholder roles and functions

Putting this ubiquitous aim of high-quality care for all into operation is the prime responsibility of health departments and health services, and is exacted by multiple key performance indicators (KPIs) and contractual obligations applied to their staff. Universities and research institutes are also subject to a regulatory system, but one that involves different performance measures centred on research output and academic excellence. These different objectives constrain the development of integrated health, education and research partnerships, which need to share a set of common objectives, incentivised by funding arrangements that all parties in the alliance can sign up to.

Such convergence is possible and necessary. In exploring new and better models of care, managers are seeking front-line clinician–researchers with leadership skills who can assist in the process. Engaging practising health professionals in the science of health service innovation presents a challenge. Specialty colleges and other professional bodies need to view and endorse AHSCs as one means of engaging their clinician constituency in health system improvement and the acquisition of requisite skills.3 Front-line consumers of health care must also be involved in determining priorities for research and service delivery.

In turn, senior government representatives and policymakers must show leadership in endorsing and resourcing ASHCs as vehicles for drawing together, with appropriate balance, all of the endeavours directed towards improving health care for, and the health of, the community. Health service managers need to make their services more research-friendly by actively facilitating research governance, ethics approvals, participant access and recruitment, and data collection systems.

The success of AHSCs as vehicles underpinning learning health systems requires structural alignment and functional integration of research, education and clinical service delivery. Accountability for each of these three elements, which are currently held by different agencies (traditionally universities and research institutes for research, teaching hospitals for education, and hospitals and health services, including primary care, for clinical services), must be brought together under one integrated learning health framework. This will not be easy. It requires both bottom-up leadership by local academic and clinical leaders and top-down leadership from government departments, statutory bodies and health service administrations. The boards of AHSCs must overcome the current physical, financial, administrative, professional, legal and historical factors that currently constrain research, education and service excellence within the individual partnering organisations. The operations of these new partnerships must be aligned so that new and better ideas and technologies that solve priority population health problems can be introduced more quickly, efficiently and effectively.

Encouragingly, there is evidence that the need for such alignment is recognised and is beginning to happen within AHSCs in the United States,4 United Kingdom5 and Canada,6 driven in no small measure by government policies, such as the Affordable Care Act 2010 in the US, and the Health and Social Act 2012 in the UK. In particular, AHSCs in the UK are now being surrounded by academic health science networks to ensure broader implementation of knowledge into patient care.5 In Australia, calls for recognition of the value of university teaching hospitals7 have drawn attention to our nation lagging behind international developments in integrating science and clinical service delivery,8 and have advocated for government action in developing AHSCs.

The research community perspective

In late 2010, the National Health and Medical Research Council (NHMRC) released a discussion paper that proposed to “invite consortia of universities, hospitals and medical research institutes to apply for recognition for excellence in research and research translation”.9 The NHMRC proposed that such centres be designated “Advanced Health Research Centres”. This descriptor was criticised by deans from the Group of Eight Universities8 for its eschewing of academia. The apparent tight alignment of “excellence” with basic science research, disproportionately rewarded by the NHMRC project grants system,1 also constrained any significant shift of academic mindsets towards applied clinical research and implementation of knowledge. This shortcoming was further profiled in the McKeon Review of health and medical research (HMR) in Australia,10 commissioned by the federal government. That review involved a wide diversity of stakeholders, and it proposed “an overarching message . . . [about the] lack of a sufficiently strong connection between HMR and the delivery of healthcare services”.10 It highlighted the need for an academic leadership body, as well as financial commitment and closer integration of research centres, if research was to be better embedded in the health care system. It also recognised the need for more commercialisation of research in parallel with translating evidence into practice. The review was released in February 2013, but the federal government is yet to formulate a policy and a structure for meeting these identified needs.

This shift towards closer integration between those who generate and those who use research has continued with the establishment of an NHMRC research translation faculty and, more recently, calls for submissions from academic and health care precincts to be recognised as Advanced Health Research and Translation Centres (AHRTCs).11 This new concept places yet more emphasis on how the scientific output of AHRTCs directly influences clinical practice and teaching, health care policies, and population health outcomes, both locally and more broadly.

Uniting for a common cause

We acknowledge that the prevailing uncertainties in the absence of a national plan for AHSCs may make whole-hearted commitment to comprehensive integration of academic and service organisations more difficult. Universities and biomedical research institutes are concerned that some of their research funding may be diverted to health service delivery, while health services have concerns that the reverse could occur, especially given the potentially large scope of clinical and health services research that will be required to drive evidence implementation and innovation across the entire health care system.

This uncertainty impedes a concerted effort to bring applied clinical and health services research into both mainstream academia and service delivery, as evidenced by the relatively few centres of clinical effectiveness or health service evaluation in this country. Although the science of implementation is receiving increasing attention internationally,12 maximal benefit from clinical research, knowledge translation and service innovation will only be realised by collaborative academic–service partnerships that cover the whole spectrum, from basic science to front-line patient care. Within such partnerships, the mindsets of all agencies and individuals involved, including those of practising clinicians, must converge on creating learning health care systems that aspire to deliver the best possible health care within declared financial constraints. Strategies for facilitating such convergence in our AHSC13 are provided in the Appendix.

The mission for AHSCs and AHRTCs is to serve as vehicles for integrating academia and service delivery for the benefits of the community. Whether they succeed will depend on whether the partnering organisations within them, government departments, the NHMRC and the health professions believe in their worth and are prepared to openly support them with the required resources and governance frameworks. We challenge government and all key stakeholders to step forward and develop policies for ensuring their creativity, relevance, and sustainability.

The G20, human health and sustainability: an interview with Jeffrey D Sachs

To the Editor: I am both amazed and disappointed that the Journal would assault the goodwill and common sense of its readership by publishing uncritical barracking for the unproven thesis of human-induced climate change,1,2 at a time when we expect evidence-based medical practice as a maxim.

To suggest that there is any consensus on climate science is an untruth that disenfranchises the many genuine physicists, geophysical scientists, climate engineers and astrophysicists who refute the anthropogenic proposition (consensus is not a scientific discipline). Neither Jeffrey D Sachs1 nor the eminent signatories petitioning the Prime Minister2 are entitled to any more scientific credibility than Joe Blow in urging massive changes to our economy and society on the basis of an unproven precautionary principle. One would hope that their climate prognostications are more accurate than those of Tim Flannery, who stated that we would never see worthwhile rain again (http://www.abc.net.au/landline/content/2006/s1844398.htm), before Australia-wide flooding left a several billion dollar legacy of rusting desalination plants. We need not mention pink batts and their resultant death and destruction.

For someone who expresses concern for the impoverished, Sachs makes no mention of the opportunity cost of misguided low-CO2 emission (not carbon) policies that have wasted billions of dollars which could have been used more productively in health, infrastructure, education and aid. Direct investment in dams, levees, vaccine development, improved agriculture and technology to reduce genuine pollution (not CO2 levels) are more effective than chasing the CO2 phantom. Alarmists do not acknowledge the enormous contribution that cheap energy has made to lifting billions of people throughout the world out of poverty and pestilence. The resultant development of a middle class in China, India and elsewhere will lead to a better environment both socially and physically. Interestingly, the alarmists are the same people who vehemently reject large-scale replacement of fossil fuel sources with advanced nuclear power plants or dam building for hydroelectric power. A combination of green evangelism and condescending paternalism seeks to rob the poor of developing countries of equal opportunity in power generation. While Sachs despairs of continuing poverty in Africa because of climate change, many would argue that endemic corruption is a greater threat to African nations.

Sachs’s trajectory for global warming of 4–6ºC by the end of the century flies in the face of the absence of global warming over the past 17 years, acknowledged by the Intergovernmental Panel on Climate Change, and the recent controversy over the homogenising of the Australian temperature record by the Bureau of Meteorology to convert a slight cooling trend to a warming trend (http://jennifermarohasy.com).

Sachs has spent too long at the United Nations. His reference to the immorality of greed and power is misguided, and code for the massive economic redistribution that socialism failed to achieve but seeks to realise through the deep-green (and red) politics embedded in the UN. Sachs’s gratuitous demonising of a major public figure such as Rupert Murdoch is unworthy of a true professional.

A social conscience is no excuse for outsourcing opinion to the socialist left and green movements. Most readers of the Journal would prefer to see debate rather than pronouncements. I hope that the Journal wakes up to itself before it is too late.

Leading the rebirth of the rural obstetrician

In 2002, 30% of all Australian births occurred in non-metropolitan hospitals, and 57% of these hospitals did not provide specialist obstetric cover.1 Antenatal care led by general practitioner obstetricians is offered in 50% of South Australian and Victorian public hospitals and is the only public sector model in most non-metropolitan hospitals.2 GP obstetric care has been shown to provide safe care for pregnant women at low risk of complications, and access to such services in rural Australia is essential.3–8

A looming crisis in the provision of rural obstetric services in Australia was identified in 2007.9 An important study of survey data from 2003 reported that Victorian GPs were becoming less likely to provide obstetric management and that half of the existing GP obstetricians intended to cease practising in the next 5–7 years. In addition, they found that 71% of GPs who completed a Diploma of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (DRANZCOG) did not then go on to practise independent procedural general practice obstetrics.9

Factors contributing to the forecast deficit in GP obstetric services included a rise in specialisation, centralisation of services, concerns regarding indemnity and litigation, rural workload and difficulty maintaining competence.9,10–13 The problem of maintaining competence in rural environments has been compounded by reported difficulties in accessing appropriate locum coverage to allow attendance at upskilling courses, in addition to the time and travel required to participate.10

The impending shortage of GP obstetricians and the need for strategies to train, retrain and retain GP obstetricians in rural practice have been the integral considerations in developing a comprehensive training and support program offered in the Gippsland region of rural Victoria. The Gippsland region lies east of Melbourne, covering a land mass of 41 524 square kilometres, and has a population of around 240 000.14 The program by Southern GP Training (SGPT) combines training for registrars and upskilling of GP obstetricians with strategies aimed at overcoming the professional isolation confronting rural GP obstetricians. The program (outlined in the Appendix) expanded registrar training at the larger regional (specialist-led) units to include a 3-month rotation on secondment to a metropolitan hospital. Further training was extended to include a state government-funded 6- or 12-month placement in a GP-led obstetric practice (bridging post) with secondments to larger centres; provision of a clear, individualised postdiploma pathway with supported placement in a GP-led, community-based obstetric practice; continued professional development; upskilling of existing GP obstetricians through the DRANZCOG Advanced qualification, which includes competence in performing caesarean sections; regular GP obstetrician meeting days attended by both registrars and practising GP obstetricians; specialist-led support and mentoring through a regular email forum; and specialist involvement in subregional GP perinatal education and morbidity meetings. In this way, the model provides a supported transition from specialist-led hospital obstetric units to GP-led, community-based obstetric services and integrates this with support for practising GP obstetricians.

The program is continuing to evolve, with new developments such as rotations to the Northern Territory and Pacific islands,15 to enrich the experience of the trainees. The implementation of this program has been matched by a period of recovery for Gippsland maternity services with an increase from 31 GP obstetricians in 2007 to 39 in 2013, including an increase from 10 to 23 conducting caesarean sections. This represents a reversal of the pre-existing trend in service closures.9,16 Of the 39 currently practising GP obstetricians, 18 received their training in the SGPT Gippsland obstetric training program.17 Another three trainees went on to practise GP obstetrics elsewhere, meaning that 21/33 program graduands were active in procedural practice.17

Recent government initiatives have supported GP obstetricians through funding professional development, incentive payments for upskilling, annual incentives for continuing GP obstetric practice and indemnity insurance support. These developments have removed some of the structural disincentives identified as barriers to procedural obstetric practice.

The aims of our study were to understand the factors influencing the decisions of rural GPs and GP registrars to practise obstetrics, and to understand the impact of this innovative GP obstetric training and support program on these decisions.

Methods

Our research was conducted in Gippsland in July and August 2013. Within the region, there are three specialist regional centres that offer a GP-led model of obstetrics, and five hospitals with GP-led services only, all with the facilities for caesarean sections.

Participants were identified from training records and the GP database of the past 5 years for the SGPT GP obstetrician and registrar training and support program. Letters of invitation, explanatory statements and consent forms were sent to potential participants.

We adopted a qualitative approach using semistructured face-to-face interviews.18–20 The research questions examined were:

What challenges face rural GPs in practising obstetrics?
What impact has the Gippsland GP obstetric program had on GP obstetric career decisions?

A three-stage framework method of data analysis (data display, data reduction and data interpretation) was applied,21 and measures were employed to augment the validity and reliability of this research. To ensure correct and detailed collection of participants’ experience and views, all interviews were audiotaped, and copies of the transcripts were provided to participants to check for accuracy. Recorded interviews were analysed by two researchers for credibility and validation of the analysis. Analysis of the transcripts, once uploaded into NVivo 10 (QSR International), was conducted independently by two researchers to check interrater reliability of the emerging themes.

Ethics approval was obtained from the Monash University Human Research Ethics Committee for this research.

Results

Of the 60 potential participants contacted, 22 agreed to take part. The sample included registrars, GPs who were upskilling and established GP obstetricians who supported registrars in training. Interviews ranged from 40 to 90 minutes in duration.

Six major themes emerged: isolation, work–life balance, safety, professional support, structured training pathway and effective leadership.

The first three themes relate particularly to the first research question.

The theme of isolation included the subthemes of distance from specialist services, access to assistance, and access to professional development. The challenge of isolation came with the awareness that it was critical to have the confidence and competence to handle difficult situations and that access to assistance and advice was important. When experienced GPs talked about the impact of isolation, their comments were focused on managing a situation, often in the context of access to assistance from a local team.

Neonatal Emergency Transfer Service (NETS) can come down, [but due to] the weather, it may be several hours before they can … the GPs rally around and can keep working on the babies, intubate them, and keep breathing for them. It is not ideal, but it works well most times. (Participant t)

Comments about isolation from registrars and GPs who were at an earlier career stage focused on how access to assistance with the guidance and information available through the SGPT program ameliorated this isolation.

I’ve got someone to call on at the drop of a hat if I am out of my depth at any point, even if it’s just for advice over the phone. (Participant e)

The theme of work–life balance included the subthemes of impact of after-hours call out, the demands of emergency situations, dealing with scheduled patients at the clinic after being at deliveries during the night, and family commitments.

Obstetrics interrupts the rest of life, both clinical, family life, and sleep. You know to be woken up in the middle of the night … isn’t a particularly pleasant thing, and try getting back to sleep after all the excitement. (Participant g)

Being part of a team of GP obstetricians assisted in achieving an acceptable work–life balance.

The theme of safety was mentioned more often by doctors who were at an early point on their career trajectory. This theme included the subthemes of patient safety and practitioner safety. Patient safety was related to backup and competence, while practitioner safety was about feeling supported and having confidence in dealing with the unknown. The SGPT Gippsland program was seen to contribute to improving safety.

Because (obstetrics) is a high-risk area and people burn out. They [SGPT] don’t want us having disastrous situations when we are junior. (Participant a)

The second three themes —professional support, structured training pathway and effective leadership — relate particularly to the second research question. Professional support was mentioned by all 22 participants. Participants from all groups within the cohort commented on the quality and availability of professional support within the Gippsland program. This theme included the subthemes of professional backup, professional networks and a respectful learning culture. With regard to professional backup, the availability of backup from specialists was described as timely and appropriate, as nominated mentors assisted with advice on practice in the clinic, and teams were built to support the training experience. Doctors in training and doctors in independent practice perceived they were well supported professionally.

When you are training you are always first on call, which is fantastic because you have to deal with everything that walks in the door. But you are paired with a consultant on the day. You basically run your assessment with them and see if they are happy with your plan, and for any instrumental deliveries or complicated issues you contact them to come in. So, it is very well supported. (Participant d)

Involvement in the Gippsland program made available both formal and informal professional networks to participants. The professional networks provided an environment where people at all stages of their career received support and timely, up-to-date information. Regular professional development opportunities were a valuable component, strengthening these networks and providing opportunities to reflect on best practice.

Ongoing professional development offered is fantastic, as it keeps you abreast of new developments as well as provides an opportunity for professional networking. (Participant v)

A respectful learning culture with an emphasis on empowering and enabling participants was an important component of professional support.

Respect is a huge factor; the leaders in the program lead by example and are very inclusive and respectful of individuals’ experience and needs. (Participant u)

The structured training pathway theme emerged as an important component of the Gippsland GP obstetric program. This included the subthemes of community-based bridging posts for registrars; secondment for additional experience; and continuous professional development. Registrars rated the bridging posts as critical to offering a safe transition.

I think it is about fostering supported practice and this is a particular time of vulnerability in terms of support … the movement from hospital-based practice to being a new person in community-based practice. (Participant g)

The theme of effective leadership was apparent across all interviews. There was clearly the perception of supportive, knowledgeable and respectful leadership within the program, and this was highly valued.

They are definitely good mentors and good role models and that is part of the reason … to want to keep going with this pathway. (Participant f)

Discussion

The themes of isolation, work–life balance and safety for the practitioners and patients emerged in our study as substantial challenges for rural GPs in practising obstetrics. These findings are consistent with the findings of other researchers who have studied the challenges of rural and remote medical practice more broadly.22,23 Work–life balance is particularly important for sustainable practice24 and is vulnerable to the demands of isolated obstetric practice. Our study indicates that the Gippsland GP obstetric program has contributed to a recovery and retention of maternity units in Gippsland founded on its success in helping doctors deal with these challenges.

Participants found the obstetric program to be professionally supportive, with meaningful backup, advice and support of professional development. The program has also been instrumental in building and supporting professional networks. Reliable, relevant backup and advice ameliorates isolation and enhances patient and practitioner safety. Professional networks remove isolation and enable cooperative rostering, which is a means to improving work–life balance. In this way, the SGPT Gippsland GP obstetric program would seem to have become fundamental for sustaining GP obstetric practice in Gippsland.

Our study suggests that the structure of the Gippsland GP obstetric training enables its trainees to continue into active, independent procedural obstetric practice. The bridging post after the primary training was highly valued. A large decrease in use of procedural skills 1 year after their primary procedural training has been reported previously.9,25 Supported transition after completion of hospital-based training has been found to be an important factor influencing recently qualified GPs to continue into independent procedural practice.25 Structured, respectful clinical supervision by senior role models is vital to effective postgraduate medical education,26 with the supervision relationship being shown to be more important than the supervision method.27

Leadership was clearly a major factor in the impact and success of the SGPT Gippsland GP obstetric program. This leadership was provided by committed specialist obstetricians and active GP obstetricians.

There was a notable absence in the data of mention of financial disincentives to practising GP obstetrics. This suggests that disincentives identified previously1 have been largely removed by recent government initiatives in this area.

This study was conducted in a particular geographic area, so transferability of the results cannot be assumed. In particular, this program was introduced where a shortage of GP obstetricians was forecast but not yet apparent. The participation of GP obstetricians was key to the success of the program. Therefore, this program design may not be as effective where GP obstetrician shortages already exist. However, themes such as isolation, safety and leadership are likely to be relevant in most rural settings, and the strength of these themes across the different practitioner groupings and towns suggests that the findings are generalisable. The stratified sampling method used was a strength of the study.

Our study also suggests that the Gippsland GP obstetric program has had a substantial impact on trainees continuing into active obstetric practice and on GP obstetricians continuing in their obstetric practice. This innovative program was made possible by state and federal government funding, the support of local and metropolitan hospitals, and ownership by both specialist and GP obstetricians. Leadership, organisational support and administrative support by SGPT have provided the scaffolding for the program. Key features of this training include a supported transition into community-based GP obstetrics; adequate clinical exposure through secondments; a culture supportive of GP obstetrics; building and sustaining professional support networks; and inspirational leadership. The increase in numbers of practising GP obstetricians has enabled more acceptable rosters and greater flexibility in accommodating personal commitments. These key features should be foundational considerations in replicating this successful model elsewhere.

Anomalous warning labels on alcoholic energy drink cans

To the Editor: Despite longstanding calls for mandatory evidence-based warning labels on alcoholic beverages or at point of sale,1 they remain elusive and are actively resisted by industry groups.2

There is widespread ignorance of the current Australian guidelines to reduce health risks from drinking alcohol3 as well as the recommended daily limits for consuming highly caffeinated energy drinks. In high enough quantities, caffeine is toxic; consequently, some advisory labelling is already mandated for these controversial “soft” drinks.4 These labels are often difficult to find, and if the caffeine is from guarana only, a statement that the drink contains caffeine is the only warning required. This has resulted in anomalous and confusing labelling on cans of the even more contentious alcoholic energy drinks5 — such that consumers could be forgiven for thinking the alcohol component is not as potentially injurious to their health as the caffeine.

Based on caffeine content, labelling on cans that also contain between 1.3 and 1.9 standard drinks of alcohol advises a limit of two cans per day, which equates to a daily intake of between 2.6 and 3.8 standard drinks of alcohol. This exceeds the limit recommended in the Australian guidelines — two standard drinks per day — for reducing the risk of long-term damage to the body from alcohol.3 The advice on brands at the higher end of this range barely complies with the recommended limit of four standard drinks per day for preventing acute harm.

With such confusing advice, the general public cannot be expected to understand or follow recommended limits for either alcohol or caffeine consumption. Packaging should display unambiguous and prominent warnings, including whichever is the lower of the two daily use limits calculated according to guidelines on alcohol and caffeine intake. A second maximum might be given for usage in a single session. Public health messaging needs to be clear and consistent, and an overhaul of both alcohol and caffeine advisory labelling is long overdue.

Rural clinical school outcomes: what is success and how long do we wait for it?

To the Editor: Do we sense a touch of frustration in the letter from Adam and colleagues1 in describing the outcomes of their rural clinical school (RCS) program? Career choices within medicine are influenced by many factors, and we agree with their comment that it is impossible to compel and unreasonable to expect all RCS graduates to enter rural practice. However, a factor that they have not taken into account is that of rural student recruitment, which has been shown by numerous studies, together with a positive rural exposure during training, to be a major factor in rural career decision making.2–5 If, as they suggest, currently only half of RCS graduates can be expected to choose a rural career, with the present requirement for medical schools to admit 25% of their intake from a rural background, is it time for this requirement to be reviewed upward?

In our experience, it is not all doom and gloom. At the University of Wollongong, we have far exceeded our 25% rural background admission requirement. Over the past 4 years, our intake of domestic students with a rural background (Australian Standard Geographical Classification – Remoteness Areas 2–5) has averaged 67%. Although we are too young to have longer-term data, our experience of selecting students with a rural background — together with a significant rural exposure during the program with an emphasis on generalism — is translating to an average of 43% of our graduates choosing internships in rural settings, and 61% choosing internships outside of metropolitan areas.

We will be following the longer-term career choices of our graduates with interest, but feel that to date we are on track to achieve our mission of producing young doctors for regional, remote and rural Australia.

Rural clinical school outcomes: what is success and how long do we wait for it?

In reply: Garne and colleagues raise the important matter of whether the current quota of rural students in medical schools (25%) should be increased, given the positive impact of rural background on future rural practice. We agree that this warrants serious consideration, but suggest that there should not only be an increased national quota for rural students but also consideration of the distribution of these students between different medical schools.

Medical schools are not all the same. They have differing staff expertise and facilities, and also recruit students in a number of different environments and populations. These factors facilitate student recruitment and training, and hopefully influence students’ future career choices to serve in disadvantaged communities (such as underserved urban or ethnic communities), and also in underserviced subspecialties (such as dermatology and otorhinolaryngology) and other health priorities (such as public health and research leadership). Perhaps individual medical school quotas for rural students should vary depending on their staff expertise, facilities and environments.

We are not frustrated. We are proud of our achievement in training rural practitioners and congratulate the University of Wollongong on theirs.