Managing information overload

To the Editor: Gee’s introduction to a recent issue of the Journal discussed the impact that the overwhelming growth of health information has on doctors.1 While it is true that doctors are an important mainstay of advice to patients, health librarians are an important resource to doctors. Health librarians are trained to acquire, organise and disseminate credible information resources which enable doctors to find the best evidence to support clinical decision making.2

Perhaps the largest exercise to date on the impact of health libraries has been the 2013 Value of library and information services in patient care study in the United States.3 The study encompassed 56 libraries serving 118 hospitals with a survey of physicians, residents and nurses involved in either patient care or clinical research. There were 16 122 respondents including 5379 physicians, 2123 residents and 6788 nurses. About three-quarters of these respondents reported that they had definitely or probably handled some aspect of patient care differently because of information obtained from libraries. The study found that using health libraries resulted in clinical staff changing the advice given to patients (48%), changing diagnosis (25%) and changing choice of drugs (33%), as well as avoiding or reducing the risk of patients misunderstanding their disease (23%).3

Therefore, as Revere and colleagues highlight, it is important to remember that health librarians can “serve a significant role in helping public health professionals meet their information needs through the development of evidence-based decision support systems, human-mediated expert searching and training in the use [of] information retrieval systems”.4

Problem-based learning in medical education: one of many learning paradigms

The role of problem-based learning should be weighed carefully against that of other models

In 1978, when problem-based learning (PBL) was introduced in the University of Newcastle medical faculty,1 the prevailing educational style in 6-year undergraduate medical programs in Australia was teacher-led learning (TLL), wherein students first acquired core knowledge in basic sciences, which were taught in large class lectures, tutorials and laboratory sessions during the 3 preclinical years of the course. They then progressed to a multilayered, sequential, integrated approach incorporating fundamental clinical skills in history-taking and eliciting and interpreting physical signs, leading to differential diagnoses and patient management. These skills were taught in small tutorial groups at the bedside, in the operating room, in outpatient clinics and in consulting rooms. During the clinical years students were assigned to separate blocks (medicine, surgery, obstetrics and gynaecology, paediatrics and psychiatry) where they were embedded in the daily activities of individual departments. These departments were responsible for designing and delivering separate lecture-based programs which, together with recommended textbooks and printed handouts, provided core information. The students were taught, assessed and examined by each department separately. The integration of basic sciences, pathology and clinical practice was reinforced during the clinical years, but there was little or no cross-disciplinary integration. Thus the learning experience was acquired from vertically structured academic departments and hospital clinical services. Although some attention was given to personal development, communication, medical ethics and the law, it was assumed that these would be largely absorbed from mentors. Anecdotally, the competence of Australian medical graduates from this system was well regarded throughout the English-speaking world.

In the late 1970s, the medicopolitical environment began to reassess hospital practice and patient care. In particular, questions were raised about whether patients should be treated solely by individual clinicians and their departments rather than in a multidisciplinary manner, and the limited evidence base for many treatments meant that claims of their efficacy were increasingly challenged. There was a push for a holistic approach to patient care and a perception that communication and empathy were lacking. Consequently, hospital organisation was changed from vertical structures to horizontal streaming across disciplines and even across geographical districts. It was assumed that horizontal streaming (for example, neurology linked to neurosurgery; urology and renal medicine) would lead to better patient outcomes. At the same time, three fundamental changes occurred. Funding for universities contracted, models of patient care changed and there was a rapid growth of information technology. These changes, among others, led to medical schools seeking alternative models for teaching and learning in this new environment. It was argued that detailed knowledge of the basic sciences was not essential; instead, there should be greater emphasis on communication, medical ethics, professional development, self-motivated lifelong learning, problem solving and a multidisciplinary approach to illness, wellbeing and patient care. This philosophy led to several changes including a shift from the traditional 6-year course to 5 years or 4 years, the introduction of graduate medical programs, and the use of PBL as the main vehicle for teaching in some Australian medical schools subsequent to it having been developed and adopted at McMaster University School of Medicine in 1965.

There is no single, accepted definition of PBL, but its central concept is that students learn best by working collaboratively on real-world problems.2 It seemed to offer several advantages. It encouraged horizontal multidisciplinary integration; it emphasised a discovery mode of self-learning in contrast to rote learning; and it promised the acquisition of knowledge that was titrated against the problem to be solved rather than to the disciplines which had hitherto been thought necessary for students to master. Furthermore, the role of the facilitator in PBL sessions was to direct group learning without having detailed knowledge or vocabulary of the problem to be solved, which led to the introduction of a new breed of non-specialist facilitator supported by medical education centres rather than by traditional departments and disciplines. Consequently, many clinicians who had hitherto been willing to devote their time to clinical teaching and mentoring now found themselves disconnected and disenfranchised. Expert bedside clinical teaching suffered, and student contact with practising physicians was diluted. Enquiry-based learning3 and case-based learning,2,4 in which knowledgeable instructors promote active engagement in the process of enquiry, and where clinical problems are raised and students attempt to solve them during the session, are put forward as alternatives to PBL, but these have not been adopted widely.

The impact of PBL was particularly detrimental to dissection-based courses in anatomy, which rapidly fell into decline despite opposition,5 both in Australia and worldwide.6–8 For example, at the University of Sydney, anatomy teaching fell from 253 hours in the first 2 years of the old undergraduate course in 1996 to 50.5 hours in the new graduate teaching program in 1997.9 As a result, students now question whether their knowledge of gross anatomy is adequate for safe medical practice and argue for a return to cadaver dissection.10This has led not only to a proliferation of student requests for optional extracurricular courses in anatomy to provide clinician-supervised dissection,11,12 but also to acknowledgement that there is a need for an overall improvement in anatomy teaching for the betterment of future surgical training.13 Arguably this deficiency would be best served by establishing a national core curriculum.14 The appropriateness of PBL in anatomy teaching continues to be examined in Australia15 and in other countries.16–18 PBL has also had a detrimental impact on the delivery of meaningful programs in surgery. The surgical themes of PBL cases were minimised, and student exposure to surgical teaching suffered. Increasingly, students have found it necessary to establish their own societies in order to promote surgical teaching, course content and career pathways.19

PBL has spread worldwide over the past four decades, and we are now in a position to consider its effectiveness in comparison with TLL. Two early major reviews of the effectiveness of PBL were cautious but indicated a tendency for PBL to achieve more positive outcomes than TLL on a variety of dimensions of learning.20,21 However, it was also noted that it is very difficult to conduct high-quality generalisable, comparative research on PBL because of variations in definitions and implementations of PBL, conceptual problems in choosing and defining outcome variables, and the difficulty of designing studies that circumvent a wide range of methodological problems such as confounding, sampling bias and lack of blinding.21 From 1994 to 2008, several evaluative studies were published.22 Two very recent reviews, spanning more than two decades of research, reach very similar conclusions: “Twenty-two years of research shows that PBL does not impact knowledge acquisition; evidence for other outcomes does not provide unequivocal support for enhanced learning”22 and “. . . PBL has a number of positive effects in key areas of student education but there is limited high quality evidence to prove its superiority over the teacher led education”.23 Indeed, it is striking that, although PBL was introduced contemporaneously with the emergence of evidence-based medicine, to date, there is very little high-quality evidence for its effectiveness compared with TLL. Whether or not PBL can develop students’ insight into the sciences that underlie medical practice has not been demonstrated, but this could be an interesting focus of future research.16,17

Historically, undergraduate medical education has employed a variety of learning paradigms and teaching methods including TLL, PBL, case-based learning, large group lectures, small group tutorials, bedside teaching, dissection- and prosection-based learning, computer-assisted interactive learning and human patient simulations among others. None of these is universally accepted as optimal in all circumstances, and all can contribute to effective and efficient education of future health care professionals.

Removing the interview for medical school selection is associated with gender bias among enrolled students

To the Editor: Wilkinson and colleagues recently presented data showing a reduction in female graduate-entry enrolments in the University of Queensland’s medical program,1 and suggested that this was due to the removal of interviews from the selection process and gender bias in GAMSAT scores.

This explanation is a poor fit for the observed data (r2 = 0.586; see Box 1). The GAMSAT gender bias explains why male students were favoured (and not female), but Wilkinson et al did not explain why removing the interview would directly impact enrolments. Since the magnitude of the GAMSAT bias has remained stable over time, the yearly increase in the magnitude of bias towards male enrolments from 2009 until 2012 remains unexplained.

We present an alternate hypothesis: that the gender bias occurred due to the increase in school leaver pathway enrolments, and the corresponding decrease in direct graduate-entry places offered (r2 = 0.956, Box 2).

Before 2009, about 130% of the expected intake was shortlisted for interview using GAMSAT score as the ranking criterion. From 2009 onwards, 100% of the intake was selected using GAMSAT ranking only — thereby raising the cut-off score. Given the male GAMSAT bias, this resulted in the small increase in male enrolments between 2008 and 2009.

Data from Wilkinson et al show that since 2010, the school leaver pathway intake has increased substantially but the total domestic enrolment has remained constant. This reduced the number of places offered to graduate-entry applicants, which resulted in higher GAMSAT cut-offs2 that favoured male applicants due to the underlying GAMSAT gender bias.

We believe that the dramatic bias towards male graduate-entry enrolments in 2011 and 2012 is a direct consequence of the reduction in the number of places offered. To restore gender equity in a GAMSAT-based ranking system, we recommend that the School of Medicine restore the graduate-entry intake in future cohorts to prior levels.

1 Gender ratio in graduate-entry enrolments with (2004–2008) and without (2009–2012) interviews in the selection process

2 Gender ratio in graduate-entry enrolments, and the proportion of domestic medical program places available to graduate-entry applicants

Removing the interview for medical school selection is associated with gender bias among enrolled students

In reply: We thank Behrendorff and Liu for their interest in our paper and their insightful comments. We acknowledge the validity of their argument that gender bias may be associated with a decrease in the number of direct-entry, or domestic, graduate places offered at the University of Queensland (UQ) School of Medicine. However, we would counter that the change in numbers across the two domestic entry pathways is another contributing factor, rather than an alternative hypothesis. In our article we point out that the change in gender ratio was associated with the removal of the interview, not that it was caused by the removal of the interview. As with graduate medical student performance in general,1 there are likely to be a number of interacting factors underlying the change in gender proportions at UQ. For example, the possibility of changing characteristics within the GAMSAT candidate pool is worthy of exploration. Further research is underway to help identify the factors related to the gender differences in GAMSAT performance as well as the underlying causes.

The Australian’s dissembling campaign on tobacco plain packaging

As plain packaging bites into smoking, The Australian newspaper relentlessly attacks the legislation

This year marks two 50th anniversaries — the first United States Surgeon General’s report on smoking and health1 and the establishment of The Australian newspaper.

Fifty years on, there is literally universal acceptance of the massive harms caused by smoking — 178 governments have signed the World Health Organization’s Framework Convention on Tobacco Control — but smoking still causes 6 million deaths each year. Given the preventability of the problem, action has been distressingly slow, largely because of the power and ruthless opposition of the global tobacco industry.

Expert reports have noted over the years that there is no magic bullet: a comprehensive approach including legislation and education is needed. In December 2012, legislation came into force in Australia mandating plain packaging of tobacco products, despite ferocious opposition from tobacco interests. This was recommended by the National Preventative Health Taskforce as part of a comprehensive approach, and Health Minister Nicola Roxon was explicit about the main aim: “we’re targeting people who have not yet started, and that’s the key to this plain packaging announcement — to make sure we make it less attractive for people to experiment with tobacco in the first place”.2

Eighteen months later, The Australian ran a front-page story headed “Evidence ‘world’s toughest anti-smoking laws’ not working: Labor’s plain packaging fails as cigarette sales rise”. This was based on a tobacco industry report, still unpublished, claiming a 0.3% increase in tobacco sales volume during 2013. The Australian‘s campaign against plain packaging continued with (thus far) 14 articles, including three front pages and three editorials attacking plain packaging and its advocates, and even defending the tobacco industry’s right to advertise.

The Australian failed to declare a lengthy past association between News Limited and the Philip Morris tobacco company (Rupert Murdoch was on Philip Morris’s board from 1989 to 1998), or that some of its journalists and commentators on the issue have associations with the tobacco industry-funded Institute of Public Affairs,3–5 including the author of the original article, who also has a history of attacking the “nanny state”6 and “health fascists”.7

The industry’s report remains secret, but Treasury has since published authoritative data showing that “tobacco clearances (including excise and customs duty) fell by 3.4% in 2013 relative to 2012”;8 according to the Australian Bureau of Statistics “total consumption of tobacco and cigarettes in the March quarter 2014 is the lowest ever recorded”;8 and newly released National Drug Strategy Household Survey results show that between 2010 and 2013, daily smoking rates among people aged 14 years and over “declined significantly” from 15.1% to 12.8% (Box); the average number of cigarettes smoked weekly by smokers fell from 111 to 96; and the average age of starting to smoke has increased to 15.9 years.9

Australia is a small market, but plain packaging has massive global implications for an industry desperate to maintain its capacity to promote and glamorise its products. The history of tobacco control shows that when one country implements a measure previously thought difficult, others speedily follow. Governments committed to introducing plain packaging already include New Zealand, the United Kingdom, Ireland and possibly France. The British debate is currently at a crucial phase. Legislation there would be a massive blow for Big Tobacco, not only because it is a much larger market than Australia, but because many countries still look to the UK as an exemplar in areas such as this.

The Australian‘s misleading reports are unlikely to achieve much in Australia, where there is long standing bipartisan support for plain packaging and comprehensive approaches to tobacco control. Other media have provided accurate and unbiased coverage on this issue, as well as the reality that all the tobacco industry’s predictions about disastrous consequences from plain packaging have failed to eventuate.

But The Australian‘s reports have — as their authors must have expected — attracted attention overseas. UK headlines include “Plain packaging has backfired in Australia — don’t bring it to the UK”, “Australia tobacco sales increase despite plain packaging”, “Plain packaging can increase smoking. That’s the power of branding”, “Plain cigarette packaging hasn’t worked in Australia and it won’t work in Britain”. Tobacco companies and their allies have assiduously promoted a similar line — for example, the Institute of Economic Affairs (a tobacco industry-funded group, like Australia’s Institute of Public Affairs10) asserts that “with tobacco sales rising after plain packaging was introduced in Australia, the public health case for this policy looks increasingly weak”.11

What can we conclude from this? Plain packaging passes the tobacco “scream test” — the more the industry screams, the more impact we know a measure will have. There is nothing new about deception and distortion from tobacco companies: this has been their practice for six decades. Fifty years on from the landmark Surgeon General’s report, it is disappointing that a newspaper such as The Australian provides support for such approaches. Health campaigners should continue to promote measures that will benefit the community, especially children, even if opposed by powerful commercial interests, and to take pride in Australia’s capacity to lead the world.

Proportion of Australians aged 14 years and over smoking daily, from the National Drug Strategy Household Survey 1991 to 20139

The future of medical careers

How can we ensure that medical workforce supply matches population health need?

The medical workforce in Australia is undergoing substantial changes. Oversupply of domestic medical graduates, coupled with growth in international entrants, has led to increased competition for internships and prevocational training positions.1,2 In coming years, more applicants will vie for vocational training positions in their preferred fields and many doctors may be disappointed in their eventual career pathways.3 Such challenges should have been foreseen when the new medical schools were established; however, the health system has reacted slowly.

The relative freedom historically enjoyed by doctors in choosing their vocational pathways has resulted in imbalances across geographic regions and between specialties. There is strong competition for those regarded as desirable (eg, high-status and highly paid specialties such as surgery4), while others continue to experience relatively low interest. Recent modelling suggests that the generalist specialties, including general medicine and psychiatry, as well as general practice, will continue to experience shortages.5

Should we and can we manage medical careers in a more proactive fashion, so that young doctors are ushered into geographic areas of need and are encouraged to specialise in clinical areas that will effectively meet population health needs? Should the regulation of practice location be changed, and what is the feasibility of changing the allocation of vocational training places across specialties? Can medical careers be made more flexible and generalist in their nature?

Governments and employers wish to shape medical careers in some of these ways.6 However, a recent review found little evidence that this can be done.7 Medical career choices are a complex mix of individual aptitudes, preferences and characteristics; the structure of, and experiences during, undergraduate and postgraduate education; and the expected characteristics of different medical careers and jobs. The literature is not clear as to which of these factors policymakers should focus on. Studies have considered the potential role of clinical supervision and mentoring8,9 and career advice.10 Providing information on the availability of specialty jobs may also be important.11 Interventions may be most effective in early postgraduate years, when doctors generally make their career decisions.12 Doctors from a rural background are more likely to choose rural practice, but there is much less evidence on the role of incentives to encourage practice and retention in rural areas or areas of socioeconomic disadvantage.13 There is evidence that the characteristics of specialties play a role, including flexibility of working hours and earnings; however, these may be more difficult to change.14 To improve the evidence base, we need better study designs and more capacity to undertake health workforce research. Although the Productivity Commission recommended more research almost a decade ago, little has changed.15

Longer term solutions require us to consider the economics of the medical labour market. The 20-year boom–bust cycles of the health workforce involve relatively rapid expansions and contractions of supply and demand that affect the health care system and patients.16,17 However, governments have ignored the basic economics of demand and supply and have failed to manage these fluctuations strategically. Decisions to increase medical school places to meet increases in demand did not taken into account expected costs or benefits to the health system of employing more doctors, and failed to consider more potentially cost-effective ways of improving population health, such as changes in skill mix.

Although competition may help to keep wages down and quality high, oversupply can also lead to unemployment. Market imperfections and failures in health care mean that costs will not necessarily fall and that quality will not necessarily increase when supply increases. For example, bargaining agreements in public hospitals and fixed Medicare fees mean that doctors’ earnings lack flexibility. Increasing the number of doctors does not necessarily improve population health, as issues of overdiagnosis and overtreatment are becoming more prominent18 and suggest that we are already at or beyond the flat of the curve of effective medical care.

An evidence-based approach to managing medical careers to improve population health is a laudable goal, but there is insufficient evidence on how best to do this. Government interventions to manage the medical workforce have been largely ineffective, but this does not mean that market forces should rule without government intervention. As purchasers of medical labour, governments should focus more on strengthening relative price signals and improving flexibility and information in health care labour markets to nudge the market in the desired direction.

A number of new interventions may be appropriate. First, more national information about career options, vacancies and employment rates in specific specialties and specialty training programs could be provided, so that choices can be more informed, realistic and unbiased. In such a competitive labour market, doctors will also want to be treated fairly and based on merit.3 A second option is to begin to think seriously about altering the structure of medical training to promote flexibility and generalism.19,20 Long periods of training and increasing subspecialism foster inflexibility such that, in times of shortage or surplus, doctors are unable to change specialties or unwilling to move to geographic areas in need. Is the nature and structure of medical training inhibiting the pursuit of improved population health? Health Workforce Australia has been abolished at a crucial time when new policies need to be developed. Maintaining the momentum is essential to produce a medical workforce that can continue to improve the population’s health.

A short-term rural placement can change metropolitan medical students’ knowledge of, and attitudes to, rural practice

Initiatives to address rural and remote health workforce shortages in Australia1 have resulted in a large number of international medical graduates working in rural Australia, often with low job satisfaction.2 Students from a rural background are more likely to choose a rural career than their colleagues from urban backgrounds.3–6 Efforts to reduce the rural workforce deficit in Australia include the Rural Clinical School (RCS) program. Similar initiatives are in place in Canada and the United States.7

Early indications are that the RCS program has a positive influence on rural career choice.8,9 The Mason Review of Australian Government health workforce programs recommended that the requirement for all Commonwealth-supported Australian medical students to undergo a minimum of 4 weeks of rural training be abolished in favour of longer placements10 which, together with a rural background, would lead to improved medical workforce outcomes.11

Medical students require an understanding of rural practice, which presents different challenges to urban medicine.1 2 An experience of rural medicine is a factor in choosing careers in rural health, and improves access to medical care for rural communities.1 3 Since 2004, all University of Melbourne medical students have undertaken a compulsory Rural Health Module (RHM) run by the Rural Health Academic Centre. The RHM includes a 2-day orientation (Appendix 1), an 11-day rural clinical or community placement and a concluding placement presentation day. In this study, we sought to establish if the short-term RHM changes medical students’ knowledge of and attitudes to rural issues.

Methods

Ethics approval for this evaluation was obtained from the University of Melbourne Human Research Ethics Committee. Students taking part in the March and May 2013 3-week RHMs were asked to participate in a focus group and complete a short questionnaire at the beginning and conclusion of the orientation, and on the final day of the RHM. Focus group facilitators used the same set of questions (Appendix 2) but adapted and probed for more detail, where appropriate, as consistent with semi-structured interviewing approaches.1 4

Focus groups were recorded and transcribed for analysis. Two of us independently read the transcripts and agreed on themes that reflected the common ideas of participants and/or a change in knowledge of, or attitudes to, rural health issues during the RHM experience. The same two researchers then re-read transcripts independently to thematically code all the data.1 5

Questionnaires focused on topics covered in the orientation and investigated attitudes to rural practice. Responses were scored using a seven-point Likert scale with “1” denoting a response of strong disagreement and “7” denoting strong agreement. Questionnaire data were described in terms of mean question scores. Data were analysed using paired sample t tests.

Results

A total of 101 medical students, who were all based in metropolitan clinical schools, completed the RHM. Of these 101 students, data on place of origin were collected for 91 (90.1%). Five students were of rural origin. Most (68%) of the RHM students took part in the research: 69 medical students took part in the first focus group and questionnaire, 50 took part in the second and 54 took part in the third.

Focus group analysis

Findings from the focus groups fell under five themes identified by the students.

Access. Access to health care was identified as a major issue. Distance to larger centres posed a challenge to both practitioners and patients: “. . . a lot of [rural] people require transport into metropolitan areas and it might be a bit difficult sometimes”. As students progressed through the RHM, their “. . . understanding of access . . . expanded a little bit, it includes things like affordability which I didn’t really think about. In the country, things are a lot more expensive for people”.

Many students initially noted that small towns lacked amenities and felt this was a disincentive to working in rural health: “It is not just the hospital, but petrol. You can’t get petrol on Saturday or Sunday . . . they close down at 5 pm on Friday and you can’t get petrol till Monday. I would always be running out of petrol”. Another stated, “There is seriously nothing to do in town, like everything was closing by 5 [pm]”.

Teamwork, models of care and generalist practice. Initially, students perceived rural doctors as providing generalist care with little collegial support. Students thought rural doctors were isolated from specialists, working alone with little social support. In the final focus groups, students commented on how much teamwork they had seen during their placements. Some were surprised at how much a general practitioner has to do but also at the support of other staff and how models of care supported teamwork and quality of care. Talking about their placements, students indicated important learnings about interprofessional teamwork, models of care and generalism. “I think it really had better patient outcomes because it was so unified.”

Overlapping relationships. Initially, students spoke tentatively about the practical implications of “everybody knowing everybody else” in small communities: “You would be friends with your patients and that would be a conflict of interest”. Over the RHM, students achieved more understanding of the challenges and opportunities overlapping relationships pose. On the one hand, students suggested that awkward social situations could occur, “. . . [the doctors] would go home for lunch and people would come in the back door and be like, ‘Hey I am feeling sick’. Because they were like ‘I know you so well, we are friends’, and the doctor is like, ‘We are not really friends, I just know you really well’ ”. On the other hand, students also recognised that the detailed knowledge doctors had about their patients enabled them to provide more holistic health care. Students felt this was a contrast with metropolitan clinics where emphasis was more on patient throughput: “I was just staggered at how much information he had in terms of their personal history. You got a completely different perspective on this patient”.

Indigenous health. Few RHM placements were based in Aboriginal health; a Cultural Safety day was held as part of the orientation by an Indigenous team. One student summed up this day saying, “I didn’t feel so conscious of my own skin until I went to yesterday’s Aboriginal talk”. Another stated, “I was just wondering why it is that we are never exposed to [this] . . . I am just wondering why you are making all these points now when it was pretty much abandoned for the first 5 years of our [course] . . . It is so important”. Students who undertook a placement in Aboriginal health were more likely to understand Aboriginal health and the concepts of cultural safety and cultural security, “. . . because you can hear about it theoretically . . . but when you sort of see the doctors having to deal with it, and you see the patients that are walking in and walking out . . . it really brings it home”.

Working in a rural career. Initially, many students assumed that rural careers would be an unpopular choice. “I don’t think anyone, unless they came from a rural setting, is interested in working in a rural [area] . . .” A few students were more open to a rural career: “I feel like as a doctor it would be quite professionally rewarding to work rurally”. Thoughts about a rural career were mainly about lifestyle and lack of medical specialist opportunities.

By the end of the RHM, students were more positive about a rural career. “. . . I think a GP in a small rural town could be fun.” “I am more positive now, it seems nice working in the country, you know people . . . you have autonomy in your practice.” To others, some aspects of rural health care did not appeal: “I am not a big fan of seeing your patients outside of clinics”. Many considered spending some career time in a rural environment. “I think most of us see it as a temporary thing . . .” Almost all students agreed that they had to experience a rural placement to understand the issues of rural practice.

Questionnaire data

Students’ responses (Box) suggested a positive attitudinal change during the RHM to working in rural areas, with questions about rural health knowledge, working in a rural health service and wanting to work in a rural environment all showing significant changes. Significant changes also occurred in more clearly identifying the enhanced level of professional autonomy, the close community role and the difficulty of overlapping relationships that rural doctors may experience. The positive changes in attitude to rural practice were reported in the context of recognising more strongly the complexities of the rural health care environment. While all students received information about Aboriginal health care, most did not experience an Aboriginal health care placement. Students reported a significant change in their confidence to work in such a setting.

There were differing opinions among the students as to the reasons they would or would not wish to work in a rural setting (Appendix 3 and Appendix 4). A similar percentage of students noted lifestyle advantages and disadvantages in their top four reasons at the beginning of the RHM. It was noticeable that at the end of the RHM a higher percentage of students noted lifestyle advantages and community engagement in their perceived reasons for why they would like to work in a rural environment. Separation from metropolitan friends and family was a consistent reason against working in a rural environment. The other consistent reason students gave for not wishing to work in a rural environment was the lack of training opportunities and career development.

There was a significant difference between student responses in the first and final questionnaires to the statement, “I would like to work in a rural environment” (posed in an alternative format to the item listed in the Box). All six students who indicated “yes” initially confirmed their desire to work in a rural environment by answering “yes” on the final questionnaire. Of the 36 students who indicated “maybe” initially, 26 answered “maybe” again on the final questionnaire, and eight responded “yes”, while two indicated “no”. Twelve students answered “no” initially; however, after returning from their placements, nine indicated “maybe”, one “yes”, and two answered “no” again. Therefore, those indicating a desire to work in a rural environment remained positive throughout the RHM. Additionally, most students indicating “no” or “maybe” at the outset were more open to working rurally after participating in the RHM.

Discussion

Evidence to date suggests that the longer the rural placement, the more likely that the graduating student will choose a rural career pathway.11 However, this evaluation of the RHM suggests that there are benefits to be gained from short-term rural placements incorporating formal rural health teaching in terms of knowledge of and attitudes to rural health issues.

There was an improvement in students’ knowledge of the rural issues of access, overlapping relationships, and teamwork, models of care and generalist practice, as a result of completing the RHM. Students appreciated the gaps in their previous knowledge of Aboriginal health issues and also changed their attitude to the possibility of a rural career in the future. These results, seen after the 3-week RHM, show that there remains a place for short-term rural placements. Whether positive change in attitudes to rural health issues continues, resulting in students being more likely to pursue a career in rural health, remains untested.

A limitation of this evaluation is that it only examines one short-term RHM in one geographical location. A second limitation of this study is that only a small sample of 50 students completed all of the focus groups and questionnaires; over 9 years about 2850 students have completed the RHM. Finally, although students’ participation in this study was voluntary, completing the RHM was a compulsory part of their curriculum. Different results may have emerged from students motivated to complete the RHM by a personal desire to learn more about rural health. It has been suggested that longer placement times are required to influence student career choices,11 but the optimal time of exposure to a rural environment to influence students’ career choices remains unknown.

Students’ responses to questionnaire items before and after completing the Rural Health Module (RHM)

Mean response score*

Questionnaire item

Before RHM (±SD)

After RHM (±SD)

I am confident in my knowledge of rural health

3.4 (±1.4)

5.3 (±0.9)

< 0.001

It is easy to learn about rural health

4.0 (±1.2)

4.4 (±1.3)

0.010

The advantages of working in rural areas outweigh the disadvantages

3.5 (±1.2)

4.2 (±1.1)

< 0.001

There are career advantages to working in rural areas

4.6 (±1.3)

4.7 (±1.3)

0.51

I am confident I could work in a rural health service

3.7 (±1.5)

5.3 (±0.9)

< 0.001

I am confident I could work in an Aboriginal health service

2.9 (±1.6)

3.6 (±1.5)

< 0.001

I am not confident in my knowledge of Aboriginal health

5.3 (±1.4)

4.3 (±1.6)

0.013

Personal and professional boundaries are more difficult for rural doctors to maintain than for regional doctors

5.2 (±0.9)

5.9 (±0.9)

< 0.001

I would like to work in a rural environment

3.8 (±1.4)

4.4 (±1.4)

< 0.001

There are lifestyle advantages to working in rural areas

4.7 (±1.3)

4.9 (±1.1)

0.10

Working as a rural doctor is more complex than working as a regional doctor

4.9 (±1.1)

5.1 (±1.0)

0.36

Rural doctors have more professional autonomy than regional doctors

4.7 (±0.9)

5.2 (±1.0)

0.001

Working in a rural health setting is different to working in a regional setting

2.4 (±1.1)

2.4 (±1.0)

0.62

I am familiar with the complexities of working in a rural environment

3.8 (±1.5)

5.3 (±0.9)

< 0.001

A rural doctor works more closely with the local community than a regional one

5.4 (±1.1)

5.9 (±1.0)

0.004

Most rural practice is primary health care

5.1 (±0.9)

5.7 (±1.1)

0.003

Most of what I know about rural practice I learned in my medical course on my RHM placement

5.7 (±1.5)

4.8 (±1.5)

0.68

* Responses are scored on a seven-point Likert scale of 1 to 7 (1 = strongly disagree, 4 = neither agree nor disagree, 7 = strongly agree).

The Australian’s dissembling campaign on tobacco plain packaging

As plain packaging bites into smoking, The Australian newspaper relentlessly attacks the legislation

This year marks two 50th anniversaries — the first United States Surgeon General’s report on smoking and health1 and the establishment of The Australian newspaper.

Proportion of Australians aged 14 years and over smoking daily, from the National Drug Strategy Household Survey 1991 to 20139

After the Quality in Australian Health Care Study, what happened?

Milestones in Australia’s journey to high-quality care

The 1995 Quality in Australian Health Care Study (QAHCS) demonstrated the potential to improve the quality and safety of health care.1–3 Using a modified version of the earlier Harvard Medical Practice Study on medical negligence, the QAHCS focused on the more useful measure of preventability of medical error. The incidence of adverse events was higher than in the Harvard study, and at first the Australian rates were queried by government: 16.6% of hospital admissions were associated with an adverse event, of which 51.2% were judged to have high preventability. Many countries replicated the Australian study, using one medical reviewer rather than two as in the QAHCS, which reduced the estimate by about 3%. Overall, a consistent rate of about 10% of hospital admissions associated with an adverse event was seen in New Zealand, Japan, Singapore, the United Kingdom and Denmark. In 2012, a World Health Organization study on adverse events in developing countries showed a similar result.4

The Australian Government responded with a succession of initiatives: the Australian Council for Safety and Quality in Health Care was established by Australian health ministers in 2000 and operated until 2005; the Australian Commission on Safety and Quality in Health Care (ACSQHC) was created in 2006 and written into legislation with the National Health Reform Act 2011. The ACSQHC promulgated 10 national quality and safety standards as part of national accreditation processes. Health reform has also included the Independent Hospital Pricing Authority, the National Health Funding Body and the National Health Performance Authority. Linking costs to quality outcomes, combined with national comparative performance measures of safety, efficiency, access and patient experience, has to be considered a milestone in Australia’s journey to high-quality care.

Have the rates of adverse events declined? A repeat of the same study would be costly, and the changed context of health care would complicate interpretation. However, there have been significant process changes that reflect an increasing attention to quality. Federal and state governments are reporting infection rates and triage times. The Australian Council on Healthcare Standards reports annually on 360 indicators in Australasia and, for the years 2005–2012, more indicators improved (125) than worsened (38), with no significant trend for 62 indicators.5 For example, the proportions of emergency department presentations meeting the triage benchmarks increased by about 6% over the 8-year period.

Quality principles have been introduced into medical and health professional education and expanded as a research theme. Early on, the University of Newcastle introduced a quality-of-care project, winning Australian Council on Healthcare Standards student quality improvement awards.6 Other schools have followed, and national and international curricula have been developed from Australia.

Notwithstanding the good progress, there remains much to do to improve health care systems. There is increasing focus on process re-engineering, applications of reliability science, human factor mitigation strategies, teamwork, communication, patient-based care and greater application of evidence-based medicine.

Health services for Aboriginal and Torres Strait Islander people: handle with care

This special Indigenous health issue of the MJA features stories of successful health care services and programs for Aboriginal and Torres Strait Islander people. As we seek to build on the wealth of experience outlined, it is worth considering what these contributions have to tell us about the characteristics and value of effective Indigenous health services.

It is more than 40 years since the founders of the first Aboriginal health service recognised a need for “decent, accessible health services for the swelling and largely medically uninsured Aboriginal population of Redfern [New South Wales]” (http://www.naccho.org.au/about-us/naccho-history#communitycontrol). There are now about 150 Aboriginal community controlled health services (ACCHSs) in Australia: services that arise in, and are controlled by, individual local communities, and deliver holistic, comprehensive and culturally appropriate health care. Panaretto and colleagues (doi: 10.5694/mja13.00005) describe how these services have led the way in high-quality primary care, as well as enriching both the community and the health workforce.

With the ACCHS model setting the standard, the values of responding to community need, Indigenous leadership, cultural safety, meticulous data gathering to guide improvement, social advocacy and streamlining access have gradually been adopted in other health care settings. The progress of the Southern Queensland Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care (a Queensland Health-owned service also known as Inala Indigenous Health Service), is an example (doi: 10.5694/mja14.00766). Among the hallmarks of the service’s vitality are its ever-increasing patient numbers, research output, building of community capacity, expansion into specialist and outreach services and multidisciplinary educational role.

The East Arnhem Scabies Control Program, described by Lokuge and colleagues (doi: 10.5694/mja14.00172), is a dramatic example of innovation inspired by local need. This part of Australia has the highest rates of crusted scabies in the world, and the program involved collaboration between two external organisations, an ACCHS and the Northern Territory Department of Health. Importantly, it was able to be integrated into existing health services and largely delivered by local health workers, using active case finding, ongoing cycles of treatment and regular long-term follow-up.

Mainstream health services are now beginning to take the lead from Indigenous-specific ones. For example, the repeated observation that Indigenous men and women with acute coronary syndromes are missing out on interventions and are at risk of poor outcomes inspired a working group from the National Heart Foundation of Australia to develop a framework to ensure that every Indigenous patient has access to appropriate care (doi: 10.5694/mja12.11175). The framework includes clinical pathways led by Indigenous cardiac coordinators, and it is already producing results.

There is growing evidence for the value of sound and accessible primary care for Indigenous Australians. A letter by Coffey and colleagues (doi: 10.5694/mja14.00057) highlights the significant progress towards closing the mortality gap between Indigenous and non-Indigenous Australians in the NT since 2000, temporally associated with investment in primary health care. A research report from Thomas and colleagues shows that patients with diabetes living in remote communities were more likely to avoid hospital admission if they accessed regular care at one of the remote clinics, saving both lives and money (doi: 10.5694/mja13.11316).

While the diversity of health services and the evidence of effectiveness is indeed something to celebrate, it is a fragile success. In their editorial, Murphy and Reath (doi: 10.5694/mja14.00632) highlight the need for sustained, long-term financial investment in primary health care services for Indigenous Australians and the uncertainty arising from changes to health care funding and Indigenous programs announced in the recent federal Budget (http://nacchocommunique.com/category/close-the-gap-program). The detail of how funding will be reallocated with the “rationalisation” of Indigenous programs has not yet fully emerged. Analysis indicates the cuts over 5 years include $165.8 million to Indigenous health programs, which will be added to the Medical Research Future Fund. New spending on Indigenous programs includes $44 million in 2017–18 for health as part of the Department of the Prime Minister and Cabinet Budget (Adjunct Associate Professor Lesley Russell, Menzies Centre for Health Policy, University of Sydney, NSW, personal communication).

Changes to primary care funding are of particular concern. Knowing, as they do, the importance of removing barriers to access, there is increasing public discussion that ACCHSs and large Aboriginal medical services will not pass on the proposed $7 copayment to patients (http://theage.com.au/act-news/health-service-facing-budget-blackhole-by-not-charging-copayment–20140527-zrpb7.html). This will result in a decrease in funding to services that provide vital programs and deliver high-quality outcomes. The government has stated that everyone should share the deficit burden, yet the copayment has only been targeted at general practitioners and not specialist consultations. Is this fair and equitable?

It seems ironic that this threat to access and resourcing has arisen just as it is emerging that our investment in primary care for Indigenous Australians has been well made. In an Australia where many Aboriginal and Torres Strait Islander people still face significant socioeconomic and health disadvantage, the need for “decent, accessible health services” is greater than ever.