Aboriginal and Torres Strait Islander medical students’ and doctors’ career intentions

To the Editor: In the past 30 years, the Aboriginal and Torres Strait Islander medical workforce has rapidly expanded. However, proportionally, there is still underrepresentation of Indigenous people in all areas of medicine.1 General practice has remained successful in attracting Indigenous people to undertake fellowships,1 but there are many specialties that have yet to see an Indigenous trainee or fellow.

Indigenous medical student numbers reached population parity for the first time in 2012.2 As these numbers increase, it is important to understand the demographics, career intentions and outcomes for this group, to achieve positive change for Indigenous health through improved support and reduced attrition of students.

The Medical Schools Outcomes Database and Longitudinal Tracking (MSOD) project collects data on Australian medical students and doctors.3,4 All students are invited to complete short questionnaires when commencing and finishing medical school and subsequent postgraduate years. Between 2005 and 2012, 36 244 participants completed the surveys.4

Up to 2012, 296 Aboriginal and Torres Strait Islander students had completed the commencing medical students questionnaire (CMSQ); 45 Aboriginal and Torres Strait Islander students had completed the exit questionnaire, and 26 Aboriginal and Torres Strait Islander doctors had completed the postgraduate year 1 questionnaire. Despite attrition in response rates, which may be attributable to a prolonged time to graduation, Indigenous students and doctors tend to be older, more likely to have children and more likely to identify as being from a rural background compared with non-Indigenous participants across all surveys (Box).

In all questionnaires assessed so far, general practice was the highest ranked preference for Indigenous medical students (Box). Overall, of all MSOD participants in the CMSQ, only 47 (0.2%) ranked Indigenous health as a first preference. This shows that improved pathways for Indigenous people into specialty training remain important, and that improved strategies to encourage both Indigenous and non-Indigenous people into Indigenous health should also be further developed. These results and future results of the MSOD project will provide a useful evidence base to guide policy development in Australia, particularly surrounding workforce, medical education and vocational training for Aboriginal and Torres Strait Islander medical students and doctors.

Demographic details of Indigenous and non-Indigenous survey participants in the Medical Schools Outcomes Database and Longitudinal Tracking project, 2005–2012

	Commencing medical students questionnaire		Exit questionnaire		Postgraduate year 1 questionnaire
Demographic characteristics	Indigenous (n = 296)	Non-Indigenous (n = 21 709)	Indigenous (n = 45)	Non-Indigenous (n = 8392)	Indigenous (n = 26)	Non-Indigenous (n = 4510)

Participant response rate	84.8%	91.0%	72.6%	83.0%	49.1%	67.0%
Women	55.1%	52.7%	48.9%	53.7%	61.5%	56.7%
Marital status (married)	9.1%*	3.6%	11.1%	10.4%	19.2%	20.2%
Have children (> 1 child)	16.8%*	2.8%	19.0%*	5.5%	15.4%*	8.7%
Mean age (years)	24*	21	28*	26	30*	27
Identify as being from a rural background	55.7%*	19.0%	48.6%*	17.9%	61.9%*	18.9%
First preference to pursue general practice	32.0%*	20.6%	25.0%*	19.4%	26.3%	26.4%

* P < 0.05 for comparison with non-Indigenous participants.

International medical migration: what is the future for Australia?

This is a republished version of an article previously published in MJA Open

Despite goals for self-sufficiency, migration seems certain to remain an imperative for Australia for the foreseeable future

Australia has developed extraordinary reliance
on international medical graduates (IMGs) compared with other OECD (Organization for Economic Co-operation and Development) countries. Based on analysis of an unprecedented range of secondary data, I aim to define the recent scale and sources of medical migration, IMGs’ immigration categories, their distribution, their performance in the Australian Medical Council examinations, and the impact of the Competent Authority Pathway.

From the 2005–06 financial year to 2010–11, 17 910 IMGs were sponsored to Australia on a temporary basis, with a further 2790 selected as permanent skilled migrants.1,2 Thousands of additional IMGs arrived unfiltered in advance for human capital attributes, admitted as spouses and through Australia’s family or humanitarian categories. Recent IMGs have trained in highly diverse countries, associated with very variable English language testing results and medical registration and employment outcomes.

Despite such challenges, I argue that Australia’s reliance on IMGs is likely to be maintained in the future, owing to a combination of factors. First, medical migration remains Australia’s key strategy for addressing medical workforce maldistribution, with competition to recruit and retain medical migrants recently intensifying rather than diminishing. Second, the Competent Authority Pathway for registration has improved IMGs’ outcomes, enhancing their immediate value as a source of supply. Third, Australia has become increasingly reliant on internationally trained specialists to serve in select undersupplied fields. Fourth, there is growing Australian demand for international medical students, who achieve exceptional early outcomes relative to IMGs. Despite greatly enhanced investment in domestic student training, Australia’s dependence on international migration thus appears likely to persist rather than reduce in the foreseeable future.

Australia’s level of dependence on
medical migrants

By 2006, 45% of medically qualified residents were overseas-born, including an estimated 25% who were overseas-qualified.3 In 2001–2006, 7596 doctors migrated to Australia across all immigration categories — double the number admitted from 1996 to 2000. India, the United Kingdom/Ireland, Sri Lanka/Bangladesh, China, other southern and central Asian countries, North Africa/the Middle East, South Africa, sub-Saharan Africa (excluding South Africa), and the Philippines were the primary source countries at this time (Box 1).4

Medical workforce diversification has proven challenging, however. Just 53% of IMGs who arrived in Australia during 2001–2006 secured medical employment by 2006 (across all immigration categories). Doctors from English-speaking countries made the transition seamlessly, while Asian-Commonwealth doctors from countries such as Singapore and Malaysia, India, Sri Lanka and Bangladesh fared reasonably well. Outcomes were poor for many other birthplace groups (Box 1). Just 6% from China had found medical employment within 5 years, 23% from Vietnam and 31% from Eastern Europe. Many had arrived through the family and humanitarian categories — untested in advance for employment attributes or registerability.4 Thousands were also admitted as spouses. Large numbers of recently arrived IMGs were defined as “not in the labour force” — a proxy for learning English and/or trying to pass preregistration exams. English testing for example was a powerful barrier. By 2010, a pass rate of only 43% was the Occupational English Test norm for medical applicants, rising to 52% in 2011.1

Despite highly diverse source countries, workforce integration is best for IMGs selected through Australia’s 457 visa temporary sponsored pathway (99% employed at 6 months), followed by those entering under the permanent General Skilled Migration Program. These flows now dominate (Box 2). This pathway is highly attractive to governments and employers given the potential to prescribe IMGs’ location as a condition of visa entry, allowing them to work for up to 4 years at undersupplied sites.

By 2009, 70% of labour migrants were sponsored, reflecting the recent dramatic privatisation of Australia’s skilled migration program. From 2005–06 to 2009–10, 34 870 health professionals were selected as temporary 457 visa migrants. Nurses (46%) and doctors (44%) dominated. A further 2420 visas were awarded to temporary IMGs in 2010–11: 1190 for general medical practitioners and 1230 for resident (house) medical officers (mostly new appointments). In 2010–11, most such IMGs were recruited to Victoria (600), New South Wales (540), Queensland (500) and Western Australia (280).2 From 2004–05 to 2009–10 an additional 15 940 General Skilled Migration category migrants holding health qualifications were admitted permanently, primarily qualified in nursing (52%), medicine (15%) and pharmacy (13%). In 2010–11, 460 more IMGs were approved.1,2

Additional doctors arrive from New Zealand — enjoying free entry rights under the Trans-Tasman Mutual Recognition Arrangement, in a context where 12% of the New Zealand population is currently resident in Australia. By 2006, 1163 New Zealand physicians were based in Australia, including 240 admitted from 2001 to 2006.1

Performance in the Australian Medical Council examinations

New Zealand doctors face no employment barriers in Australia. Analysis of 28 years of Australian Medical Council (AMC) data, however, reveals that other IMGs experience highly variable registration outcomes. The most detailed study to date, commissioned by the Department of Health and Ageing, showed that just a third of recently arrived IMGs had attempted to pass the AMC preaccreditation exams in the years preceding 2007. Of those IMGs attempting it, 78% were medically employed within 5 years, despite just 41% having by then secured unconditional registration.5

According to the AMC Submission to the House of Representatives Standing Committee on Health and Ageing Inquiry into Registration Processes and Support for Overseas Trained Doctors (2011) and additional data provided to me, from 2004–10, 57% of IMGs aged 21–30 years passed the multiple choice question examination on their first attempt, compared with 46% aged 41–50 years and 31% aged over 50. Similar trends were evident in the clinical examination.6 Box 3 reports outcomes by the top 10 countries of training.

In 2008, given mounting concern, the Australian Government initiated “a national assessment process for overseas qualified doctors to ensure appropriate standards in qualifications and training as well as increase the efficiency of the assessment process”.7 Multiple pathways to practice have since developed, including the fast-track “Competent Authority” option for doctors registered in New Zealand, the UK, Ireland, the United States and Canada. Eligible source countries may opt out — Singapore and South Africa have done so to minimise workforce loss.6 For IMGs requiring greater periods of adjustment, alternative pathways have been designed to provide enhanced supervision, address differential levels of training need, and increase readiness for specific locations of practice.

Factors affecting Australia’s reliance on IMGs

To redress medical workforce undersupply, Health Workforce Australia has been charged by the Australian Health Ministers’ Conference with developing a national training plan. The goal is to reach self-sufficiency by 2025.

In the foreseeable future, however, medical migration seems certain to remain an imperative for Australia, given Australia’s ageing patient and practitioner base, reduced hours worked by younger cohorts, the growing feminisation of medicine, limited access to internship places, and distribution challenges. The Department of Immigration and Citizenship has recently set “occupation ceilings” for skilled migration in 2012–13. In medicine, the ceiling is 4860 people, compared with 15 660 in nursing, 1380 in pharmacy and 720 in dentistry (numbers are reported at http://www.immi.gov.au/skills/skillselect).

Migration remains Australia’s key strategy for redressing medical workforce maldistribution, with states intensifying competition to recruit and retain IMGs

Between June 2000 and December 2002, 5304 temporary IMGs were sponsored to “areas of need”. This level of dependence has been maintained, with 3860 IMGs selected by states or territories in 2007–08 compared with 3310 a year later. In 2008–09, based on state and territory medical board or medical council data, 17 141 doctors were employed under various forms of conditional registration. Further, 2695 IMGs were employed through “area of need” registrations (primarily in Queensland [50%]), with Australia remaining highly reliant on medical migrants for primary care in remote or very remote sites.3 Definitions of eligible areas have also been extended rather than reduced. In 2007, larger regional centres characterised by significant workforce shortages were included.8 Following 5 years of service in an area of need, IMGs can apply for permanent resident status.2

By 2010, 46% of doctors in rural and remote practice in Queensland were overseas-trained. Thirty-six per cent of the 1209 GPs working in rural and remote Victoria had obtained their basic medical qualification outside Australia, primarily in south Asia (11%), the UK or Ireland (7%), Africa (5%), eastern Europe (4%) and the Middle East (3%). IMGs constituted 53% of rural and remote GPs in WA, and were derived from 33 countries of training — double the level of reliance in 2002.9–12 The majority were 457 visa (or equivalent) temporary sponsored arrivals, typically working under various forms of conditional registration. This practice has become widespread in the past decade, despite growing concerns for the risk of developing “two-tier” medical care.6 New governance systems have been introduced through the 2010 establishment of the Australian Health Practitioner Regulation Agency;13,14 however, these have coincided with concern about red tape related to changed recruitment and registration procedures.15

Australia’s Competent Authority pathway has recently transformed IMG recruitment while enhancing their value as a source of supply

From July 2007 to late 2010, 4955 Competent Authority applications were received by the AMC, and 3327 Certificates of Advanced Standing were issued. This process had been successfully completed by 1990 applicants from 56 countries of training by December 2010, a year when 1281 assessments were handled.6 In an unanticipated consequence, the Competent Authority model also enhanced Australia’s global competitiveness. From 2007–10, the Competent Authority pathway attracted relatively young applicants; 54% of those issued Advanced Standing Certificates were aged 21–30 years, compared with 38% aged 31–40 years. UK-trained applicants were the major beneficiaries (1019), followed by IMGs qualified in India (422) and Ireland (176). Massive growth in arrivals who qualified in the UK or Ireland has occurred, surging to around 3000 in 2007–10, compared with up to a hundred per year previously.16 These IMGs enjoy strong employment outcomes, despite debate over
a registration scheme that allows thousands of IMGs to practise on a supervised basis.

Australia has become increasingly reliant on internationally trained medical specialists to serve
in undersupplied fields

In recent decades, Australia’s dependence on IMGs has also become marked in select specialties. From 2004 to 2010 the AMC handled 6604 IMG specialist applications, primarily in the fields of anaesthesia (13%), psychiatry (11%), obstetrics and gynaecology (8%), diagnostic radiology (8%) and general surgery (6%).1 Most were from men (69%), with the top five countries of training being the UK, India, South Africa, the USA and Germany.

In terms of psychiatry, for example, disproportionate numbers of IMGs now work on temporary 457 visas in underserved sites.17,18 They compensate for an exodus of domestic psychiatrists from public sector and regional practice, who work in large cities in affluent suburbs, near private hospitals where they admit their patients.19 Rural psychiatrists, by contrast, typically lack access to urban amenities, quality schools and employment for their spouse. Many are on call 24 hours per day, 7 days a week, providing mental health services in regions characterised by gross undersupply.19 Comparable IMG dependence prevails in many specialties.

There is now growing Australian demand to recruit and retain international medical students

Former international students have emerged as a key medical resource for Australia. By definition they are characterised by youth, full registration, and significant acculturation. They have funded themselves to meet Australian professional standards, and face none of the IMGs’ barriers.

By December 2009, close to 3000 international students were enrolled in medical courses (and this has since accelerated). In 1999, following removal of a 3-year eligibility bar, they became immediately able to migrate.20 As demonstrated by Australia’s Graduate Destination Survey, since 2006, retention of international medical students has tripled, with large numbers wishing to migrate. They achieve nearly identical immediate employment and salary outcomes to domestic graduates. By 2010, 98.9% were employed full-time, compared with 99.7% of domestic graduates. Analysis of the Medical Schools Outcomes Database and Longitudinal Tracking Project shows 78% of final-year international students initially stay — virtually all graduates, once sponsored students are excluded.21,22 While the ethics of international student migration remain a matter of debate, parents rather than source countries have resourced their education. From an ethical perspective, their recruitment is less problematic than the normal recruitment method of OECD countries — selection of mature-age medical professionals fully trained by their countries of origin.23,24

Conclusion

Between 2004 and 2009, the number of Australian domestic medical completions rose from 1287 to 1915. Provisional registrations rose from 1699 to 2955.25 Incentive schemes were also developed (most notably the Bonded Medical Places Scheme, to which 25% of all first-year Commonwealth supported medical school places are allocated) to encourage medical graduates to serve in areas with an undersupply of doctors. Despite such measures, dependence on IMGs seems certain to remain strong, as confirmed by the recent House of Representatives inquiry into overseas-trained doctors.15 Australia is not alone in this reliance, which is intensifying across OECD nations.26–29 The challenge will be positioning to recruit and retain “the best” medical migrants, in the context of the highly variable registration and employment outcomes that many initially achieve. To facilitate this, collective action by all relevant jurisdictions will be essential.

1 Labour market outcomes for degree-qualified Australian and New Zealand-born medical graduates, compared with migrant medical graduates arriving
2001–2006 (2006 census)*

		Employed			Other
Birth country	Number	Own profession	Other profession	Sub-total	Unemployed	NLF

Australia/New Zealand	39 381	58%	29%	88%	1%	12%
United Kingdom/Ireland	1 004	71%	14%	85%	–	15%
Northern Europe	39	51%	18%	69%	–	31%
Western Europe	328	62%	20%	81%	2%	17%
South-eastern Europe	132	49%	24%	73%	2%	25%
Eastern Europe	160	31%	26%	56%	6%	38%
Vietnam	64	23%	25%	48%	5%	47%
Indonesia	73	8%	16%	25%	16%	59%
Malaysia	227	62%	5%	67%	3%	30%
Philippines	256	50%	27%	77%	5%	19%
Singapore	65	63%	14%	77%	–	23%
China (not SAR or Taiwan)	590	6%	47%	53%	11%	36%
Hong Kong/Macau	38	40%	40%	79%	–	21%
Japan/South Korea	102	14%	28%	42%	10%	48%
Other southern and central Asia	364	43%	10%	53%	7%	40%
India	1 378	61%	12%	73%	7%	20%
Sri Lanka/Bangladesh	691	56%	16%	71%	7%	21%
Canada/United States	201	48%	17%	65%	2%	33%
Central/South America	117	40%	30%	70%	13%	17%
South Africa	496	75%	18%	93%	1%	5%
Other sub-Saharan Africa	342	71%	6%	77%	7%	16%
North Africa/Middle East	564	47%	13%	60%	10%	31%
Other	365	56%	20%	75%	3%	22%
Total migrants	7 596	53%	18%	71%	6%	23%
NLF = not in the labour force. SAR = Special Administrative Region. – = insufficient cases for reliable reporting and issues of confidentiality. Many of the cells are based on very small numbers, therefore the results should be regarded as indicative only. * Source: UNESCO global comparison study, Table 23.4 Excludes those for whom birthplace or year of arrival is unknown. Due to missing data, imputation and aggregation, numbers may not add up to 100%.

2 Top 10 recent source countries for permanent and temporary migrant health professionals, 2005–06
to 2009–10*

Country	Permanent migrant health professionals†	Country	Temporary migrant health professionals‡

United Kingdom	4120	United Kingdom	9350
India	1510	India	6420
Malaysia	1300	Philippines	1850
China	970	South Africa	1770
Philippines	510	Malaysia	1570
South Africa	500	Ireland	1560
Republic of Korea	480	China	1380
Egypt	420	Zimbabwe	1180
Singapore	390	Canada	950
Ireland	350	United States	830

* Source: Scoping paper for Health Workforce Australia, Table 6, p. 51, based on Department of Immigration and Citizenship data, reported by financial year.1 † General skilled migration primary applicants; total all sources, 13 880. ‡ 457 long-stay business visa primary applicants; total all sources, 34 870.

3 Australian Medical Council clinical examination outcomes by top 10 countries of training, 2004–2010*

Top 10 countries of training	No. of candidates	Pass	Fail	Retest

India	1823	52%	29%	19%
Bangladesh	799	42%	38%	20%
Pakistan	665	48%	31%	21%
Sri Lanka	660	58%	22%	20%
China	594	58%	23%	19%
Iran	481	56%	27%	17%
Philippines	437	34%	46%	20%
Burma	374	47%	31%	22%
Iraq	333	52%	29%	19%
Egypt	277	52%	29%	19%
Other countries	2646	58%	26%	16%
Total candidates	9089	53%	29%	19%

* Source: Scoping paper for Health Workforce Australia, Table 29, p. 97, based on Australian Medical Council data, reported by calendar year.1

The future of Australian medical education: a focus on technology

This is a republished version of an article previously published in MJA Open

Technological approaches and increased use of simulation are elements of a more comprehensive solution to creating a fit-for-purpose medical workforce

Australia is undergoing considerable change in management of its health care systems. This is driven by the increase in complexity of patient illnesses and the public’s higher expectations of having access to safe, high-quality health care. Central to the success of Australia’s future health care systems will be the workforce that delivers health care services. Australia has increased the number of medical schools and accepted increased numbers of international medical graduates
to address workforce shortages in medicine that have resulted from historical decisions. However, the increasing age of graduates, their shorter working weeks and, notwithstanding the recent increase in clinical placements, the limited amount of quality clinical time available per student, raise concerns about the sustainability of a well trained medical workforce.1 Equally significant as the reduction in clinical learning opportunities are the rapid rate of change in, and complexity of, treatments that junior medical officers will need to consider offering if the best interests of their patients are to be served.

Work is underway on many fronts to ensure Australia maintains the quality of our medical graduates. At junior doctor level, development of an Australian Curriculum Framework (ACF) has provided an outline of the competencies expected of a junior medical officer,2 giving Australian universities and accredited hospital and general practice prevocational trainers a guide for their medical program development. To help sustain the medical education and training infrastructure to cope with increasing throughput, federal funding is being invested
in simulations to augment clinical placement.3 Medical schools are finding new clinical placement opportunities
in private hospitals, general practice clinics and nursing homes. However, even more training capacity will be needed to meet Australia’s future health care demands. Medical students require better scoping of what they
need to learn; greater flexibility in how they learn; more appropriate timing in when they learn; and effective methods for managing their reflective practice so that they will retain learnt skills.

The future of medical education

Above all else, medical students will need to be adaptable lifelong learners. It is likely that health care will become increasingly complex as research expands the boundaries of medicine and increasing costs burden both the public and private systems. Changes in patient complexity, medical workforce demographics and the diversity of the broader workforce, as well as innovations in technology and treatment, will all affect the role of junior medical officers. The complexity of future changes suggests there is no simple single solution that will ensure the quality of our future medical workforce. We present what we see as the more important contributing factors in the technological domains.

The ACF2 underlines the scope of practice, which is expansive, and we cannot expect all incoming graduates to be competent at everything that should be undertaken by junior medical officers. What we should be able to expect
is that they have knowledge of their own skill set and
are able to effectively communicate their strengths and limitations to patients and other health care providers. For students to have conscious recognition of competency requires more than a framework and may include national standardised assessments, a standardised curriculum or
at least competency standards for skills, behaviours and tasks against which to compare their own performance.

Getting the balance right between local innovation and national collaboration to provide our future medical workforce will require better modelling of Australia’s health care needs. Clearly, there are some components
of educational development that are better approached
by national collaborations. Compelling examples include the use of technology to support education and the development of formative assessments (using simulated
or authentic clinical environments) for procedures requiring psychomotor skills.

Technology considerations for education

E-portfolios

Society expects doctors to be lifelong learners who not only maintain a high level of competency in their scope of practice, but also continue to update their practice as better treatments arise. Internationally, there is a move to require doctors to provide evidence of maintaining their standards of practice.4 Similarly, there is a push for medical students to maintain a portfolio of experience and reflections.5 The use of e-portfolios to collect, store and share individual data will become an essential part of education throughout the continuum of medical practice. Although there are many definitions of e-portfolio6 it is likely that in the medical context e-portfolios will need to encompass:

assessment of performance standards defined by a recognised authority;
compelling and accessible evidence of learning or achievement directed at specific audiences (employers, supervisors);
ability to reflect and develop metacognition to plan learning and integrate diverse learning experiences; and
professional development planning, providing records of goals, learning, performances and achievements.

The value of e-portfolios will depend on how they are supported. Without standards for interoperability, the portability of information stored on e-portfolios will increase the owner’s workload during the transition between educational and work environments, as well
as across specialty domains.

E-health

With the development of electronic patient records there is an opportunity to provide automatic mapping between training and patient outcomes. This would require work within e-health, for example to enable access to records by health professions students while ensuring that patient information is protected. However, doctors around the world have been reviewing patient information to improve practice in many procedural areas for decades. Linking education with patient outcomes through e-records could potentially benefit both the individual doctor and the developers of educational material. Doctors would be better able to plan future learning activities to reflect areas of need, and educators could receive information about what could be used to increase the effectiveness of their training programs.

E-learning

Other emerging technologies include online learning
(e-learning, virtual worlds and portable applications). These technologies have the potential to support self-directed learning and provide greater student feedback, but will require scaled approaches to ensure feasibility.
The computer industry has demonstrated the power of engagement through well designed virtual worlds and applications on portable devices, with millions of users engaging daily. Although current e-learning in health care is often quite limited in scope and sophistication, there are examples of good interactive material and processes7 — including “serious games”, which are designed for
a primary purpose other than pure entertainment. Development of such games is currently costly because developing, validating and maintaining the quality of online learning is expensive if the target audience is small; however, when the cost of such products is spread across thousands of participants instead of hundreds, the cost is not only more affordable but the opportunity to validate training improves. One way to achieve such participant numbers is to develop these programs through large-scale collaboration where modules can be reused across disciplines and educational institutions.

Simulation

The advantage of engaging with technologies such as simulation is the guarantee that students receive exposure to particular experiences. For example, few medical or midwifery students will have the experience of observing serious complications when attending real births during their training; however, it is possible to provide a simulation program guaranteeing this exposure.8 A recent meta-analysis of technology-enhanced simulation9 demonstrated that this training was consistently superior to no intervention or traditional clinical attachment experience. It showed large effects for outcomes on knowledge (effect size, 1.20), skills (1.09–1.18), and speed (0.79), and a moderate effect for patient-related outcomes (0.50). The studies involved many professions and both undergraduate and continuing education. Interestingly, additional features and the quality of educational design
of the intervention seemed to have no consistent impact. In other words, it was the simulation alone that seemed
to provide the most consistent benefit, not how well or cleverly it was used. In simulation, students can also safely learn from their mistakes. Blended learning approaches using virtual worlds and other serious games can provide repeated exposure to meet different students’ requirements when combined with face-to-face simulation or clinical placement.

Standards and governance

There is wide concern, although scant evidence in everything but the surgical disciplines,10,11 that students’ and junior doctors’ “near patient” experience is diminishing. The risk of doing less learning by the bedside is that alternative forms of education delivery may not actually teach what we think they do. Therefore, there is
a need to validate whether simulation and e-learning approaches do produce the expected knowledge, skills and behaviours in the student population when they practise in clinical areas. The Australian Society for Simulation in Healthcare, as part of Simulations Australia, is developing standards for simulations educators;12 however, governance over compliance still rests with the many universities and hospital systems around the country. As with e-portfolios, Australia needs to develop standards and guidelines to ensure that investing in health care
e-learning includes providing effective access for learners. Where possible, health care organisations should catalogue available e-learning opportunities to avoid unnecessary duplication and increase exchange of resources.

Another necessary approach is to invest resources to demonstrate the transfer from educational programs to clinical settings. Such an approach should be effective for well defined skills (eg, procedural skills); however, it may be more difficult to validate programs for outcomes in the area of professional skills. A further approach is to expand the use of blended learning to provide educational opportunities for medical students and focus on assessing students during clinical practice. There is evidence that the transfer of intended learning objectives by senior doctors is poor during didactic teaching13 and that the reliability and quality of feedback provided to students and educational institutions during clinical placements is often questionable.14 Consequently, as the field of health
care engages more with technology to provide medical education, there is a strong need to increase the quality
of the supervision and assessment skills of our clinical educators.

Assessment, aptitude and choice

Internationally, the scope of medical skills and behaviours that are formally assessed has increased, with the majority of formal assessments being used for accreditation to practice.13 At present, we rely on clinical placement rotations to provide medical students with the experience to assess the alignment of their skills with their career choices. As clinical placements and educational opportunities contract in medicine, we must change the way we provide exposure, assessment and feedback to students so that they not only choose the right career path but are also able to pursue the appropriate education to get there. One way to do this is to increase the use of simulation.

In addition, aptitude assessments for surgical programs are already demonstrating measurable differences between individuals.15–17 Early exposure can be achieved, for example, by harnessing and sharing the experience of other students through e-portfolios and access to simulations programs designed to teach the fundamentals of specialties. By developing models of individuals’ early learning of skills relevant to particular specialties, students could receive feedback on their aptitude for each specialty. Rather than using aptitude as a barrier to program selection, this information could be used by the students
to help guide their selection. In cases where a student’s desired career and aptitude for that career conflict, the student would be better able to pursue upskilling opportunities. Effectively, using simulation, aptitude assessments, and fast-tracking for students would eventually replace the varied internship, as has been successfully achieved in the Canadian system.18 The achievement of this would require involvement of all stages of education from undergraduate to specialty,
and be guided by workforce imperatives.

Conclusions

Medical education must become more effective at using a broader range of learning opportunities to meet future training requirements. This will involve greater innovation in new types of clinical placement and better engagement with technology. Medicine must invest in the skills of educators and delivery systems to support lifelong learning. Critically, we should be investing in assessment to provide students and doctors with effective feedback on their performance.

Lessons learned in developing new postgraduate medical specialist training programs for Australia and New Zealand

What can be learned from the process of introducing major postgraduate medical education reform?

Considerable changes in the processes of medical student education have been occurring for the past 20 years. Such changes began with the recognition that the curriculum was becoming increasingly full, leading to fatigue and loss of enthusiasm for the craft of medicine in medical students just as they were entering the medical workforce.1 Changes in medical student education have included limitations on curriculum content; new ways of learning, such as inquiry-driven learning using problem-based learning principles; formative assessments; more feedback on student performance; emphases on ethics, communication and clinical reasoning; and greater integration of preclinical and clinical learning opportunities.2–4

Have these changes been mirrored in postgraduate medical training? In a general sense, changes in postgraduate training for graduates of these new medical courses have been limited.5 It could be argued that, as postgraduate trainees are already “trained” and have commenced work, such reforms are not really necessary. However, the changing health care environments in which trainees work have placed the traditional apprenticeship model under severe duress. Erosion of the apprenticeship model has weakened the previously strong links between trainee and trainer, lessening the capacity to train our medical workforce at the very time that the community is demanding greater competence and accountability.

The Royal Australasian College of Physicians (RACP) trains many of the medical specialists in Australia and New Zealand, with more than 6000 trainees currently spread across 60 different training programs. Most trainees are training in internal medicine (and its many subspecialty components) or paediatrics, but training in public health, occupational and environmental medicine, rehabilitation, sexual health and addiction medicine are also covered under the RACP’s programs.6 As such, the RACP is a highly complex medical education enterprise. In 2004, the Australian Medical Council undertook its first external review of the RACP training programs. This review recommended changes to the education programs of the RACP, hastening the process of educational reform.

Principles underlying the new RACP training programs

Design of a new postgraduate training framework for the RACP was predicated on ensuring, wherever possible, that processes and principles of training had resonance with medical school education reforms. A “handshaking” process, by which trainees feel familiar with postgraduate training as it resembles what they encountered in medical school, strengthens the vertical nature of medical training, even if that training is spread across different training bodies and locations.

Foundational to the changes introduced by the RACP in the new Physician Readiness for Expert Practice (PREP) program7 has been the principle that workplace-based education is highly effective, provided there are scaffolds for both trainees and their supervisors to articulate such learning. These supporting frameworks should:

enable trainees to know what it is they need to learn;
enable trainees to recognise that they are learning the required material;
provide educational evidence of attainment of the learning objectives, for the benefit of both trainees and their supervisors; and
ensure that reflective learning (ie, trainees thinking about their learning and the impact they are having on their patients and the health care team) is developing the trainees into mature and competent professionals.

Another key consideration in the design of the PREP program has been the development of a wide range of discipline-specific curricula, together with a Professional Qualities Curriculum that runs across all the training programs.8 The Professional Qualities Curriculum places emphasis on matters such as quality and safety, leadership, education, communication, ethics and cultural competency.

The key principles underpinning the educational developments are:

The trainee is an active participant in the learning process, as opposed to being a passive recipient of information.
The role of the teacher is no longer to only deliver factual information, but also to facilitate the trainee’s learning.
The trainees, by taking ownership of and responsibility for their own knowledge and skills acquisition, can direct, manage and organise their own learning needs within a supportive and clearly defined curriculum framework that will guide them through a defined learning pathway.
By thinking reflectively about what they need to learn and how they learn, the learning process becomes personalised and the trainees become self-motivated to achieve their own academic goals.
The programs reflect current Australian and New Zealand workplace practices and changing regulatory requirements. They emphasise the provision of exemplary patient care within the context of an increasingly complex, multidisciplinary team-based working environment.

Lessons learned

The introduction of major educational changes across the clinical and medical education sectors involves extensive planning and resourcing. Several key lessons have been learned throughout this reform process.

First, educational change requires a narrative — a description of why things need to change and the value of the new way of supporting and educating trainees in their learning and professional development.

Second, educational change requires time. Under the PREP program, clinicians need to have an understanding of the new educational tools and processes, and health services need to be aware of and support the reforms. Developing a deep understanding of educational and training processes, and their interface with clinical service delivery, takes time and persistence. Slow and progressive implementation of the PREP program was needed to enable trainees and supervisors to become familiar with the new requirements over time and to enable health services to adapt.

Third, educational change requires extensive investment. The RACP invested heavily in these training reforms, including establishing an Education Deanery to support the development of a completely new postgraduate training program. The RACP also provided support for hundreds of workshops around Australia and New Zealand and extensive communication processes with trainees, Fellows and health departments. Beyond these initial investments, supervisors and trainees must invest time and energy to understand and participate in the components of the new training program. The most common response from supervisors has been the request for their employers (mostly health departments) to provide the resources needed to allow them the time and capacity to fulfil the duties of supervision and documentation of their trainees’ performance.

Finally, educational change requires lots of communication and clinician participation. Simply providing information on the educational changes is not sufficient — active processes are needed to engage clinicians in the reform process itself, along with the narrative of the changes, using many communication channels as frequently as possible.

Conclusions

As these training program changes are still being progressively introduced, it is too early to conclude what their impact on training outcomes and clinical practice will be. Anecdotal reports of the individual experiences of many trainees suggest that documenting their learning, observation and systematic feedback on their educational journey is helpful. Moving to an electronic platform to document their training and the construction of learning plans by trainees have been less acceptable.

Australia and New Zealand have excellent medical training at all levels, and postgraduate vocational medical training is moving rapidly towards being structured along a continuum from medical school programs. Changes in the health services, changes in the profession of medicine and medical educational reforms are kept in balance through active reforms in postgraduate medical education processes. These postgraduate training reforms are extensive and expensive. Most of this “cost” is borne by the supervisory workforce — clinicians who are committed to ensuring not just their own practice of medicine, but also that of the future professional workforce, is of the highest order. What remains is the need for careful evaluation of the effectiveness of these educational changes and their impact on health service and individual clinical practice.

Equivalence of outcomes for rural and metropolitan patients with metastatic colorectal cancer in South Australia

Metastatic colorectal cancer (mCRC) is the fourth most common cause of cancer death in Australia.1 The past 15 years have seen improved outcomes in patients with mCRC, largely due to increased chemotherapeutic and biological treatment options and widespread adoption of liver resection for liver-limited mCRC.2 These improvements have led to an increase in reported median survival from 12 to 24 months since 1995. Despite these advances, patients with unresectable mCRC usually die from the disease, with 5-year overall survival of about 15%.2 Initial treatment for mCRC involves combination chemotherapy or single-agent therapy. Survival is improved in patients who ultimately receive all three active chemotherapy drugs (oxaliplatin, irinotecan and a fluoropyrimidine)3 and have access to biological agents, such as bevacizumab.2

Australia’s geographical challenges (large land area and low population density) contribute to difficulties in service provision and disparity of cancer outcomes.4 Some authors have suggested the observed higher death rate among Australia’s rural population is the result of a double disadvantage: higher exposure to health hazards and poorer access to health services.5,6 There is a complex interplay between remoteness of residence and other known causes of poor cancer outcome, including unequal exposure to environmental risk factors,5 less participation in cancer screening programs,7–9 delayed diagnosis,10 socioeconomic disadvantage,4,11 and higher proportions of disadvantaged groups such as Indigenous Australians.12 Despite these factors, an Australian study of patients with rectal cancer found that increasing distance between place of residence and a radiotherapy centre was independently associated with inferior survival.6 A recent analysis of cancer outcomes using population mortality data found that reductions in the cancer death rate between 2001 and 2010 were largely confined to the metropolitan population, with an estimated 8878 excess cancer deaths in regional and remote Australia, including 750 CRC deaths.13

Remoteness poses practical difficulties that may lead patients with cancer and their clinicians to make choices based on the need for travel, or because of perceived toxicity risks of different regimens. Population studies have shown that rural patients have reduced rates of radical surgery,9 less adjuvant radiotherapy,14 delays in commencing adjuvant chemotherapy15 and reduced clinical trial participation.16 Rural cancer patients can also face a significant financial and travel burden.17

Rural patients in South Australia have historically had limited access to regional oncology services, as population numbers outside metropolitan Adelaide are insufficient to support onsite oncologists. Until recently, this has meant that most chemotherapy is delivered in Adelaide, reflecting a more centralised service than in Australia’s eastern states. An effort is currently being made to shift to more rural chemotherapy delivery and an expanded visiting oncology service.18

In this study, we used the South Australian Clinical Registry for Metastatic Colorectal Cancer (SA mCRC registry) to investigate disparity in outcomes and treatment delivery for rural patients with mCRC compared with their metropolitan counterparts.

Methods

The SA mCRC registry is a state-wide population-based database of all patients diagnosed with synchronous or metachronous mCRC since February 2006. Previous registry-based analyses have led to the description of important associations of patient subgroups and outcomes.19–21 Core data include age, sex, demographics, tumour site, histological type, differentiation and metastatic sites. Treatment data consist of surgical procedures, chemotherapy (including targeted therapy), radiotherapy, radiofrequency ablation, and selective internal radiation therapy. The date and cause of death for each patient in the registry is obtained through medical records review and electronic linkage with state death records. Approval for this study was granted by the SA Health Human Research Ethics Committee.

For this study, we included data collected between 2 February 2006 and 28 May 2012. We compared the oncological and surgical management (primarily metastasectomy) and survival of metropolitan versus rural patients. Based on the accepted registry definitions, patients residing in metropolitan Adelaide (postcodes 5000–5174) were designated the “city” cohort, with all other patients (postcodes 5201–5799) in the “rural” cohort. Patient characteristics, use of chemotherapy across first, second and third lines of treatment, choice of first-line chemotherapy, hepatic resection rates and survival were analysed and compared between the city and rural patient cohorts.

All analyses were undertaken using Stata version 11 (StataCorp). Overall survival (OS) analysis was done using conventional Kaplan–Meier methods. Survival was calculated from the date of diagnosis of stage IV disease to the date of death, with a final censoring date of 28 May 2012. The log-rank test of equality was used for comparisons. OS was used as the end point because this outcome measure was available in the registry data and to avoid misclassification of cause of death in disease-specific survival.

Results

Patient characteristics

Data from 2289 patients, including 624 rural patients (27.3%), were available for analysis (Box 1). There was a higher proportion of male patients in the rural than the city cohort (62.7% v 53.6%; P < 0.001). The colon was the primary site of malignancy in a higher proportion of city than rural patients (75.7% v 71.5%; P = 0.04). Kirsten rat sarcoma viral oncogene homolog (KRAS) mutation testing was performed in around 14% of patients in both cohorts, and the proportion of KRAS exon 2 wild-type tumours was not significantly different between rural and city cohorts (59.8% v 59.7%; P = 0.96). Clinical trial participation did not differ significantly between the cohorts (7.1% v 9.2%; P = 0.10).

Treatment

Chemotherapy

First-line chemotherapy was administered in 58.3% of rural patients, compared with 56.0% of city patients (P = 0.32) (Box 2). As a percentage of patients who received any chemotherapy, rates of second-line (22.5% v 23.3%; P = 0.78) and third-line (9.3% v 10.1%; P = 0.69) chemotherapy administration were also similar between rural and city cohorts. There were differences between the cohorts in the type of first-line treatment: rural patients had less use of combination chemotherapy (59.9% v 67.4%; P = 0.01) and biological agents (16.8% v 23.7%; P = 0.007) than city patients, though numerically these differences were small. When an oxaliplatin combination was prescribed, the oral prodrug of 5-fluorouracil, capecitabine, was used more frequently in rural patients than city patients (22.9% v 8.4%; P < 0.001). Only 21 rural patients (5.8%), and no city patients, received their first dose of first-line chemotherapy in a rural chemotherapy centre.

Non-chemotherapy

Adoption of any of the non-chemotherapy treatment modalities did not differ significantly by place of residence (Box 3). Of note, there was no significant difference in rates of hepatic metastasectomy between city and rural cohorts (13.7% v 11.5%; P = 0.17). Pulmonary metastasectomy rates were higher in city patients (3.2% v 2.1%; P = 0.10), but total numbers were small.

Survival

Among all patients, the median OS was 14.6 months for city patients and 14.9 months for rural patients (P = 0.18) (Box 4, A). Among patients receiving chemotherapy (with or without metastasectomy), the median OS was 21.5 months for city patients and 22.0 months for rural patients (P = 0.48) (Box 4, B). For patients undergoing liver metastasectomy, the median OS was 67.3 months for city patients and was not reached in rural patients (P = 0.61) (Box 4, C).

Discussion

Our results demonstrate that rural patients with mCRC in SA receive comparable treatment and have equivalent survival to their metropolitan counterparts. In particular, patients in rural areas are treated with equivalent rates of potentially curative metastasectomy and chemotherapy, two key determinants of length of survival. These are the first Australian data specifically analysing rates of chemotherapy in rural patients with mCRC, and they suggest the excess colon cancer mortality seen in rural patients relates to factors other than access to treatment in the metastatic setting.

While there were no significant differences between the cohorts in rates of patients receiving chemotherapy across all lines of treatment, rural patients received less first-line combination chemotherapy, increased use of capecitabine and reduced use of biological agents in the first line than city patients.

First-line combination chemotherapy with intravenous infusional 5-fluorouracil, folinic acid and oxaliplatin (FOLFOX) has equivalent efficacy to oral capecitabine and oxaliplatin (XELOX).22 The choice between the two regimens is based on differing toxicities and practical considerations. FOLFOX requires a central venous catheter (CVC) and a second visit to a chemotherapy day centre every fortnight for ambulatory pump disconnection. XELOX has the advantages of single 3-weekly clinic visits and no CVC, but compliance with twice-daily chemotherapy tablets and potentially higher rates of symptomatic toxicity (hand–foot syndrome and diarrhoea) are limitations. The higher use of XELOX among rural patients reflects the relative practical benefits of this regimen where travel distances and access to nursing staff trained in CVC management are important considerations. The potential for toxicity of XELOX requires careful patient education and system approaches to enable early recognition and intervention in the event of severe toxicity among rural, often isolated, patients. Early follow-up telephone calls by a nurse practitioner or telemedicine consultations are potential strategies to provide this important aspect of care to rural patients.23,24

We observed a small but significant reduction in the rate of biological agents used in first-line therapy for rural patients, mostly due to reduced bevacizumab prescribing. It is possible clinicians were reluctant to “intensify” therapy in rural patients due to a lack of supervision or access to health care, particularly given risks of haemorrhage. It is also possible this small difference reflects a chance finding. The pattern of bevacizumab prescribing has evolved over the period captured in the registry, and an updated analysis of patients diagnosed since 2010 may provide further insights.

The equivalent rate of attempted curative metastasectomy in rural mCRC patients compared with city patients is reassuring, given this approach provides the only option for long-term survival in mCRC. The survival curves of patients undergoing liver metastasectomy showed a survival plateau at 5 years of 50% or greater for both city and rural patients (Box 4, C). This compares favourably with other modern surgical case series, with reported 5-year survival of 32%–47% after liver resection.25

Delivery of specialised health care services for rural Australians requires policymakers to carefully balance the merits of a centralised versus a decentralised system, with unique consideration for each region. For example, no regional centres in SA have a population sufficient to support a full-time resident medical oncologist and are instead serviced by a visiting (fly-in fly-out) oncologist. Limited infrastructure and staff training have also largely prevented widespread administration of chemotherapy in regional centres. Highlighting this point, we found that only 5.8% of rural patients receiving chemotherapy received their first cycle in a rural treatment centre. The SA Statewide Cancer Control Plan 2011–2015 lists the establishment of regional cancer services and chemotherapy centres as a key future direction to optimise care for rural cancer patients.18 Unfortunately, no publications have assessed outcomes of rural patients with mCRC treated in other regions of Australia, particularly in the eastern states where regional oncology services are common. While our analysis supports equivalent survival outcomes for rural patients treated within SA’s largely centralised service, the practical, social and economic advantages of regional cancer centres remain an important consideration not captured in our study. Given this, we consider that our findings highlight the positive outcomes achieved through high-quality, specialised care, rather than suggest that current regional services in Australia should also adopt a centralised approach.

As our analysis dichotomised patients into city and rural cohorts, it does not provide outcome information based on the degree of remoteness. Despite this limitation, chemotherapy and surgical treatment were almost entirely delivered in Adelaide, and thus our analysis appropriately distinguishes those patients who had to travel to access oncological care. The possibility of inadequate registry ascertainment of rural cases of mCRC also poses a possible limitation. However, we are confident this is not a source of bias, as the registry collects information from all histopathology reports in SA, which are processed centrally in Adelaide. An important limitation of our study is that we report only on mCRC, and stage I–III disease is not included. The impact of treatment differences in early-stage CRC (eg, quality and timeliness of surgery, use of adjuvant chemotherapy) on overall survival of patients with mCRC cannot be determined in this analysis. Reassuringly, however, about two-thirds of mCRC cases in both cohorts were synchronous (ie, no prior early-stage disease), suggesting this is unlikely to limit our conclusions. Further, the equivalent rates of synchronous diagnosis in rural and urban patients may suggest there was no major delay in diagnosis of rural patients.

Although higher cancer incidence and poorer outcomes have been consistently demonstrated for rural cancer patients in Australia, we found equivalent treatment patterns and survival for rural patients diagnosed with mCRC in SA since 2006 compared with their metropolitan counterparts. This confirms optimal treatment of rural patients results in equivalent outcomes to metropolitan patients, irrespective of disadvantage. Further, it suggests previously demonstrated disparate outcomes may be due to factors such as higher incidence of CRC as a result of burden of risk factors and potentially reduced screening participation, rather than treatment factors once mCRC has been diagnosed. Targeting these factors is likely to provide the greatest impact on reducing the excess cancer burden for rural Australians.

1 Patient characteristics, by city versus rural residence (n = 2289)*

Characteristic	City	Rural	P†

No. (%) of patients	1665 (72.7%)	624 (27.3%)
Median age (range), years	73 (17–105)	72 (31–100)	0.11
Sex
Male	893 (53.6%)	391 (62.7%)	< 0.001
Female	772 (46.4%)	233 (37.3%)
Primary site
Colon	1260 (75.7%)	446 (71.5%)	0.04
Rectum	405 (24.3%)	178 (28.5%)
Synchronous disease	1070 (64.3%)	407 (65.2%)	0.67
Site of metastasis
Liver only	665 (39.9%)	226 (36.2%)	0.10
Lung only	128 (7.7%)	45 (7.2%)	0.70
Liver and lung only	178 (10.7%)	65 (10.4%)	0.85
All other sites	694 (41.7%)	290 (46.5%)	0.13
> 3 metastatic sites	138 (8.2%)	54 (8.7%)	0.38
KRAS testing	243 (14.6%)	87 (13.9%)	0.77
KRAS wild-type	145 (59.7%)	52 (59.8%)	0.96
Clinical trial participation	154 (9.2%)	44 (7.1%)	0.10

KRAS = Kirsten rat sarcoma viral oncogene homolog. * Data are number (%) of patients unless otherwise indicated. † P values calculated using χ2 tests.

2 Frequency of first-line, second-line and third-line chemotherapy, and regimens, by city versus rural residence

	First-line treatment			Second-line treatment			Third-line treatment
Regimen	City	Rural	P	City	Rural	P	City	Rural	P

Total	933 (56.0%)	364 (58.3%)	0.32	217 (23.3%)*	82 (22.5%)*	0.78	94 (10.1%)*	34 (9.3%)*	0.69
Single-agent chemotherapy	271 (29.0%)	118 (32.4%)	0.23	58 (26.7%)	18 (22.0%)	0.40	21 (22.3%)	7 (20.6%)	0.83
Capecitabine	202	82	0.30	24	4		8	0
5-FU	58	31	0.29	3	3		4	1
Irinotecan	11	3		31	11		9	6
Oxaliplatin	0	2
Combination chemotherapy	629 (67.4%)	218 (59.9%)	0.01	115 (53.0%)	44 (53.7%)	0.92	49 (52.1%)	17 (50.0%)	0.83
FOLFOX	491	146	0.001	21	8		14	2
XELOX	53	50	< 0.001	15	4		8	2
FOLFIRI	76	18	0.12	62	26		15	7
XELIRI	1	0		1	2		2	2
MMC–5-FU or capecitabine	8	4		16	4		10	4
Other†	33 (3.5%)	28 (7.7%)		44 (20.3%)	20 (24.4%)		24 (25.5%)	10 (29.4%)
Biological agent	221 (23.7%)	61 (16.8%)	0.007	97 (44.7%)	30 (36.6%)	0.21	72 (76.6%)	34 (100%)	0.003
Bevacizumab	185	52		60	22		16	14
EGFR mAb	15	5		26	8		52	19
Other	21	4		11	1		4	1

5-FU = 5-fluorouracil. FOLFOX = folinic acid–5-FU–oxaliplatin. XELOX = capecitabine–oxaliplatin. FOLFIRI = folinic acid–5-FU–irinotecan. XELIRI = capecitabine–irinotecan. MMC = mitomycin C. EGFR mAB = epidermal growth factor receptor monoclonal antibody. * Total rates of second-line and third-line chemotherapy use are expressed as a percentage of patients who received any chemotherapy. † Includes use of raltitrexed and MMC (as single agent and combination).

3 Frequency of non-chemotherapy treatments, by city versus rural residence

Treatment	City (n = 1665)	Rural (n = 624)	P

Lung resection	53 (3.2%)	13 (2.1%)	0.10
Hepatic resection	228 (13.7%)	72 (11.5%)	0.17
Surgery*	858 (51.5%)	345 (55.3%)	0.11
Ablation	12 (0.7%)	3 (0.5%)	0.53
Selective internal radiation therapy	10 (0.6%)	8 (1.3%)	0.10
Radiotherapy	299 (18.0%)	132 (21.2%)	0.08

* Includes resection of colorectal primary cancer.

4 Overall survival (OS) in city versus rural patients

Splenic rupture: a rare complication of infectious mononucleosis

A 28-year-old man presented to the emergency department with acute left upper quadrant tenderness and postural hypotension. He reported having had fever and cervical tenderness for 1 week before his presentation.

Blood tests showed an elevated white cell count with reactive lymphocytosis. A test for infectious mononucleosis heterophile antibody was positive, consistent with recent infection.

A contrast scan of the abdomen showed splenomegaly with subcapsular haematoma.

Splenic rupture after infectious mononucleosis is rare (incidence, 0.1%–0.5%), but can have disastrous consequences if overlooked.1,2

New TGA warning label for use of NSAIDs in fluid-depleted children

To the Editor: Non-steroidal anti-inflammatory drugs (NSAIDs) have been very widely used for many years in Australia and elsewhere, in both prescription and non-prescription settings.

Although their potential for gastrointestinal side effects is generally well understood within the community, the capacity for NSAIDs to cause renal damage, even after short-term use in susceptible individuals, is less well appreciated.

It has been well documented that the use of NSAIDs in those who are fluid-depleted, including their short-term use in otherwise healthy individuals, can lead to renal failure, albeit reversible.1,2

On 23 May this year, the Therapeutic Goods Administration updated its Medicines Advisory Statements on labels for non-prescription medicines. Included was a warning about paediatric products containing NSAIDs.3 The wording of the advisory statement is “Ask your doctor or pharmacist before use of the medicine in children suffering from dehydration through diarrhoea and/or vomiting”.

As the person who initiated the request to have this warning label added, my intention was to have this warning added to all non-prescription NSAID-containing products for both adults and children, because we know that people who are renally compromised for any reason are at risk of kidney damage from the use of NSAIDs. This, of course, includes those taking some antihypertensive medications containing a diuretic, the well known “triple whammy” effect.4,5

Nevertheless, I hope that the warning label on paediatric products containing NSAIDs will alert parents and carers to be vigilant if giving these medicines to children in their care, and to check with their doctor or pharmacist if the child is fluid-depleted from diarrhoea or vomiting.

Multiple mini interview performance of repeat applicants to medical school admission

To the Editor: As the use of the multiple mini interview (MMI) for selecting applicants for admission to health professional programs increases, so does the number of coaching classes assumed to help improve performance on the MMI.1 Moreover, applicants applying to several professional programs have multiple opportunities to gain experience in a high-stakes environment. These realities usher concerns about the influence of “practice effect” on subsequent MMI performance.2 While short-term prior access to MMI questions did not influence applicants’ performance in a Canadian medical school,3 in Australia, MMI participation in the year after the original attempt improved scores on stations (short, structured interviews to assess personal qualities such as communication, professionalism, ethics skills) that were the same or similar to original MMI stations.2

At the University of Manitoba, Canada, about 25% of 1151 unique applicants to the Faculty of Medicine’s Undergraduate Medical Education program from 2008 to 2012 were those unsuccessful at gaining medical school admission in previous years. While 856 applicants (74.4%) appeared once for the MMI, 208 (18.1%) appeared twice, 64 (5.6%) appeared thrice, 16 (1.4%) appeared four times and seven (0.6%) appeared five times. In the faculty’s 12-station MMI,4 88 unique question stems or station scenarios were used in the 5-year period. The number of questions used once, twice, thrice, four and six times was 46, 18, 17, 5 and 2, respectively, with at least a 1-year gap between original and repeat use, as recommended.2

To assess whether the scores of those who repeated the MMI were higher, applicants’ average scores and within-year z scores were compared by calendar year, number and order of attempts and then analysed by multiple linear regression.5

There was a decreasing trend in raw MMI scores for all applicants between 2008 and 2012. The mean MMI score at first attempt of one-time applicants was 4.66 (SD, 0.65) on a scale of 1 to 7, while that at first attempt of 295 repeat applicants was 4.25 (SD, 0.60) (P < 0.001). The mean MMI score of all 707 attempts by the 295 repeat applicants improved slightly to 4.38 (SD, 0.64). After adjusting for age, sex, and calendar year, regression parameter estimates associated with 2nd, 3rd and 4th attempts, but not the 5th, gradually and significantly increased relative to the 1st attempt. Yet, only 9.1% of the variability in within-year z-transformed MMI scores was explained by the selected model.

It is unlikely that repeat attempts at MMI alone systematically and considerably benefited applicants. Other unmeasured and unexplored factors, such as individuals’ personal growth and maturity, may play a role in positively influencing MMI scores. Our study did not account for the effect of coaching that a substantial number of Australian medical school applicants reportedly attend.1,2 Despite some limitations in our study design and statistical methods, our results currently do not lend support to the concern that repeated MMI performance results in improved MMI scores.

The cost of teaching an intern in New South Wales

To the Editor: While Oates and colleagues1 provide an insightful introduction to intern teaching in New South Wales, I offer an alternative to their views; what is considered teaching is not agreed on, and does not necessarily translate to learning.

Informal teaching (and learning) occurs during work-based activities like ward rounds, departmental meetings, grand rounds and quality improvement activities. These are set out as learning opportunities for interns by the Australian Medical Council.2

What supervisors consider to be informal learning probably does not coincide with interns’ expectations of teaching.

Junior medical officers should realise that, for them, learning from informal teaching is not about acquiring knowledge of diseases or skills, as it is for medical students. Rather, it is about acquiring knowledge of work processes and resource management — expertise not well described in medical literature. Fiona Lake, a developer of Teaching on the Run,

bases her own teaching on the idea that if something can be learnt from a textbook, it is of no help for her to teach it as well. ‘It’s a complete waste of time for me to teach it!’3

Adult learning forms a significant portion of any postgraduate vocational training and can occur by both a cognitive approach, based on andragogy theory, and an apprenticeship model, in which “learning by doing” and “master as role model” are the basis.4

Perhaps the main issue is not the perception of how teaching should be done, but how learning should occur.

The cost of teaching an intern in New South Wales

In reply: We fully agree with Goh that teaching does not translate to learning. In our article,1 we were careful to concentrate on teaching, both formal and informal, received by interns, and not learning — something that is much more difficult to measure.

We defined informal teaching as being spontaneous, non-timetabled and sporadic, pointing out that it may occur during a ward round, walking along a corridor or at the end of a consultation.

Like Goh, we acknowledged that teaching also occurs as a result of observation and practical experience, which were not included in our study. We emphasised that there is much more involved in intern education than the formal and informal teaching considered here, and we mentioned: observation by interns; self-learning; practical experience; self-reflection; and the influence of role models.

It may well be that some teaching occurred that was not identified as such by the interns surveyed. What is important is that formal and informal teaching should be acknowledged as a crucial part of the intern experience and that supervisors ensure that teaching and learning, in all its forms, is emphasised.