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Preference: Education

190

Indigenous health: radical hope or groundhog day?

Professor Ernest Hunter explains why learning from the past and investing strategically will have the best chance of success

In his book Radical hope: education and equality in Australia, Aboriginal lawyer, academic and land rights activist Noel Pearson contends:

Governments and their bureaucracies are informed by everything other than memory of what was done five years ago, ten years ago and eighteen years ago. Politics are remembered, policies are not.1

It also includes his 2004 Judith Wright Memorial Lecture, in which, reflecting on the political forces necessary to drive national change in Indigenous affairs, he notes:

it will take a prime minister in the mould of Tony Abbott to lead the nation to settle the “unfinished business” between settler Australians and the other people who are members of this nation: the Indigenous people.1

A decade on, Tony Abbott, as Prime Minister, delivered the Closing the Gap report.2 Having identified that his government’s new engagements will involve centralising responsibility for Commonwealth-funded programs in the Department of the Prime Minister and Cabinet, setting up the Prime Minister’s Indigenous Advisory Council and fostering linkages between bureaucrats, business and Indigenous leaders, he details mixed outcomes across four key areas — health, education, employment and safe communities. The outcomes were consistent with the Closing the Gap Clearinghouse report released a year earlier,3 which identified key high-level principles and practices characterising programs that worked: flexibility to meet local needs and contexts; community involvement and engagement; building trust and relationships; a well trained and resourced workforce; and continuity and coordination. Themes associated with less successful initiatives included: programs implemented in isolation; short-term funding and high staff turnover; lack of cultural safety; and inflexible program delivery. Similar issues emerged in a recent review of early childhood parenting, education and health intervention programs.4

Clinicians working in remote Australia will not be surprised. There have been health gains, but they are uneven: remote Indigenous Australia is clearly behind. Furthermore, it can be argued that for some conditions and in some areas the situation is worse despite significant clinical investments. For instance, when I began work as a psychiatrist in Cape York and the Torres Strait over 20 years ago, there were no mental health or substance misuse services. Now there are well over 100 workers across Queensland Health, Education Queensland, the Royal Flying Doctor Service, Medicare Locals, community-controlled services and Commonwealth-funded programs, plus contracted private clinicians. This does not include the dozens of residents trained variously in community and personal wellbeing, empowerment, mental health literacy, suicide prevention and more. Sadly, the situation in terms of mental illness is worse, probably reflecting both contemporary social contexts and delayed effects of neurodevelopmental adversity.5,6

Our understanding of the developmental determinants of chronic disease in Indigenous Australians has been evolving for more than half a century7 and there is accumulating evidence on childhood social factors increasing the risk of adult-onset mental disorders. For example, bereavement stress in mothers during the first years of life (particularly after suicide in the family) increases the risk of affective psychosis.8 Research on such topics involves controlling for potential confounders. In the real world of remote Indigenous communities, many children are exposed to serial adversity: pregnancies affected by high levels of stress; poor nutrition and inadequate antenatal care; prematurity; infant environmental instability and attachment difficulties; hospitalisation and other forms of separation from caregivers; bereavement stress; exposure to violence; early-onset substance misuse; and more. We can only presume that the consequences of such risk amplification will be substantial.

In 2006, soon after Pearson commended him, Tony Abbott called for a new form of “paternalism” that would be “based on competence rather than race” to address unrelenting Indigenous health problems associated with failed past policies such as self-determination.9 Now, he holds the reins. But whatever happens, the economic agenda will weigh heavily; Indigenous Australians will not be quarantined from budget cuts, changes to Medicare and welfare entitlements, privatisation, and the continuing feud between federal and state governments over health funding. In Queensland, public sector services (particularly population health and health promotion) sustained dramatic losses in the 2012–13 financial year that will be most consequential for remote Indigenous communities. Career public sector employees are giving way to locums, casual workers, agency nurses and project workers funded by non-government organisations. While this may bring new ideas, it risks losing domain knowledge and incremental improvement based on practice-based evidence.10

While there is no doubt that greater economic self-reliance will be critical to Indigenous futures, I believe that there is complacency regarding the flow-on effects of the contraction of federal and state public sectors for Indigenous health in remote Australia. Indeed, to support self-reliance in the long term, it is critical that we increase and sustain strategic investment in public health and clinical programs for pregnancy and early childhood to optimise neurodevelopmental potential. Is it “radical hope” to suppose that the new paternalism and new engagements will deliver? Or, as Pearson suggests in his chapter on cycles of policy reinvention in Indigenous affairs, will it be groundhog day?

Reports indicate that changes are needed to close the gap for Indigenous health

In reply: The letter from Coffey and colleagues helps make my case that a major role for Aboriginal community controlled health organisations (ACCHOs) in providing health care to Indigenous communities makes a real difference in the effectiveness and efficiency of service delivery. However, we cannot be certain that the progress made in reducing Indigenous mortality rates in the Northern Territory is the result of better health care; it may reflect improvements in the social determinants of health, such as education, housing and community violence.

Hospital data highlight that success is still a long way off. The ratio of Indigenous to non-Indigenous aged-standardised hospital separations for the NT is 7.9, compared with 2.5 for all jurisdictions.1 There is a clear relationship between the number of primary care visits and hospitalisation for Indigenous residents of the Territory who live in remote communities. For patients with diabetes, ischaemic heart disease and renal disease, around 22 to 30 primary care visits a year are needed to reduce hospitalisations to a minimum.2 That is why an increased role for ACCHOs is one of the keys to closing the gap.

Cost of best-practice primary care management of chronic disease in a remote Aboriginal community

The health of Australian Aboriginal and Torres Strait Islander people is very poor, and their access to primary care is inadequate, especially in remote areas.1–3 Prevalence of and mortality from type 2 diabetes (hereafter diabetes) and chronic kidney disease (CKD) are extremely high in remote Aboriginal communities in the Northern Territory.4 Chronic disease is responsible for 80% of the mortality gap between Indigenous and non-Indigenous Australians, with diabetes accounting for 12%.5 For all Indigenous Australians, the self-reported prevalence of diabetes is more than three times, and the incidence of end-stage CKD six times, the non-Indigenous rates.3 In remote Aboriginal communities in the NT, CKD prevalence is up to 25% of the population,4 or 46% of adults.6 Diabetes prevalence is in the order of 13%7 to 16%4 of the population, or up to 29% of adults.6 Both conditions are major contributors to cardiovascular disease, the greatest single contributor to the mortality gap.5

The origins of the chronic disease epidemic in Indigenous populations and, more broadly, the health gap are complex,3,6 and actions addressing both the social determinants of health3,4,7,8 and systematic primary clinical care6,9 are needed. In this study, we focused on the need for systematic clinical care, which is essential to reduce complications and delay the progression of diabetes and CKD.6,9

The rate of avoidable hospitalisations, a key marker of access to and effectiveness of primary care, is highest in remote communities.10 Australian and international evidence shows strong primary care systems result in better health outcomes, lower rates of avoidable hospitalisations, avoidance of dialysis, and significant cost savings.9–13 Many hospitalisations for complications of diabetes and CKD can be avoided through systematic primary care treatment, with significant medical cost savings.10,13–15 However, there are few estimates of the resources required to sustain primary care management of these conditions.

Particular difficulties for remote primary care include isolation, long distances to services, understaffing and a high turnover of clinical staff.16 Remote health care also requires special skills in chronic disease management, acute care, public health and intercultural communication.13,14,16,17

Our study was initiated by an Aboriginal community controlled remote health service because, despite its own perceptions of competent staff and clinical systems, staff still struggled to satisfy existing clinical protocols within given resources. The service received funding primarily from the then federal Office for Aboriginal and Torres Strait Islander Health and the then NT Department of Health and Families. Other sources included Medicare and a small university research grant. The aim of our study was to estimate the resources required by a remote health service to optimally manage diabetes and CKD — with adherence to the local Central Australian Rural Practitioners Association Standard Treatment Manual (CARPA STM) guidelines15 and with full population coverage.

Methods

The study took place between July 2010 and May 2011 in a remote Central Australian community. The methods were adapted from the models of care health service planning approach18 and an earlier NT cost study.10 Using the models of care approach, Segal and colleagues18 began with local best-practice protocols and estimated the staff time required to complete each of the recommended tasks for a given population. The population health status was assessed and the best-practice health care tasks required for that population were defined for each health profession involved. The time required per patient per year for each task was then determined, and the health care staffing resources then calculated for the population. Zhao and colleagues10 used an analogous approach to estimate the total operating costs of a “reasonably efficient” remote Aboriginal health service. Population needs were defined in terms of the CARPA STM protocols.15 The time estimate given in the definition of each linked Medicare Benefits Schedule item was used in quantifying the population’s staffing needs.10

The target population was resident adults (> 18 years of age) with diabetes or CKD. Best practice was defined in terms of the CARPA STM protocols.15 These protocols are used by all NT primary care providers: government clinics and Aboriginal community controlled health services.19 The tasks recommended by the CARPA STM include history taking, health promotion, education, physical examination, biochemical investigations and prescription of medication.15

First, prevalence of diabetes and CKD was estimated using the health service electronic health record, which represents not only patients presenting for diabetes and CKD management but also those identified in community screening. Prevalence at multiple levels of severity was estimated for both conditions. For CKD, levels of severity were stages 1–5 (estimated glomerular filtration rate range, > 90 [stage 1] to < 15 mL/min/1.73 m2 [stage 5]), with early CKD defined as stages 1–3. For diabetes, early was defined as non-insulin-treated and advanced was defined as insulin-treated. This enabled us to calculate, at the community level, the total annual number of diabetes and CKD care tasks recommended by the clinical protocols.

Second, semistructured interviews informed two aspects of the study. Clinicians were asked to estimate the time required for each protocol task, as well as any unremunerated out-of-hours time essential for the chronic disease management program. Clinicians’ descriptions of their role in chronic disease care helped to structure the final staff-funding model and also to identify other barriers to best-practice care.

Third, the daily work and chronic disease consultations undertaken by a cross-section of clinicians were directly observed in a detailed time-and-motion study. We measured the time taken by each clinician for each task defined by the relevant CARPA STM protocol. We then used a combination of these observations and interview data to estimate an average time for each item (such as measuring blood pressure or discussing diet). Supplies were itemised for each protocol and costed using the clinic’s supply orders or representative prices.

Fourth, financial records provided clinicians’ wage rates and administrative fixed costs. The wage rates, together with the estimates of time-per-task and annual community care requirements, were used to calculate the total cost of clinical staffing for primary care of diabetes and CKD.

We considered costs that, while non-clinical, are part of the overall cost footprint of diabetes and CKD care. Using data from direct observation of clinicians’ workdays, we estimated the proportion of total clinical time spent on diabetes and CKD. This proportion was then applied in a top-down fashion to the health service’s non-clinical costs, so that part of the cost of clerical staff and clinic vehicles was attributed to diabetes and CKD. These data collection and cost estimation methods are summarised in the Appendix.

Finally, we compared the estimated 2009–10 expenditure on diabetes and CKD with the projected annual expenditure using our best-practice model, reflecting full protocol compliance. For this, we assessed the level of clinicians’ adherence to the guidelines using the One21seventy health record audit tool, which is widely accepted in Indigenous health services in Australia and is based on the CARPA STM protocols.20 Per capita figures were calculated as total staff hours required for tasks specific to each group (eg, staff hours per patient per week to manage insulin treatment) divided by the number of patients with CKD or diabetes.

We distinguished between costs met out of the health service budget and expenses met directly by the federal and NT governments and other agencies. Examples of the latter are medications provided free to Indigenous patients under s 100 of the National Health Act 1953 (Cwlth), and visiting allied health services. The increased cost of such items in our model of care was separated from any additional funding needed by the health service to provide that model.

For comparison with the study by Zhao et al we adjusted the 2003–04 NT-wide figures for inflation occurring between financial years 2003–04 and 2009–10 (using the Consumer Price Index for health care in Darwin), and only included comparable aspects of our study (eg, insulin treatment was excluded).10,21

Approval was received from the remote community’s health board and the Central Australian Human Research Ethics Committee (ref: 2010.08.07). Written consent was obtained from all individual participants. Verbal and written feedback was provided to the health board at the conclusion of the study.

Results

In this remote community with a population of 542, 519 (96%) were Aboriginal.22 Of the 297 adults, 74 (25%) had diabetes and 86 (29%) had CKD; 45 (15%) had both conditions. Thirty-one adults (10%) had CKD stages 3–5. Of the 74 adults with diabetes, 13 (18%) were prescribed insulin.

The clinic was staffed by four Aboriginal health workers (AHWs), three remote area nurses (RANs), a general practitioner, a chronic disease educator (CDE) and an exercise physiologist. Twelve staff interviews were completed, and 14 workdays and seven clinical consultations were directly observed.

Quarterly chronic disease checks with an AHW or RAN were recommended for most patients with diabetes or CKD. A GP reviewed clinical findings and investigations, prescribed medication where necessary, and oversaw treatment planning. A full-time CDE educated individual patients and groups and managed insulin treatment. Interviewed staff identified education as crucial for patients’ control of their chronic disease. Locating patients in the community and delivering and explaining their medications were also a significant part of clinicians’ work. According to the medical record audit, 75% of all recommended protocol tasks for diabetes management and 79% for CKD were completed in 2009–10. Based on 2009–10 staffing, our model results in 29% of total clinical hours being used for diabetes and CKD care.

The total projected annual primary care cost of clinical management of diabetes and CKD management with full adherence to the protocols for all patients would be $900 792 (Box 1). On average, the annual cost per patient would be $7856, ranging from $4062 (for people with previously diagnosed early CKD without diabetes and without high cardiovascular risk) to $15 241 (for people with stage 5 CKD and advanced diabetes, with a recent diagnosis of either condition) (Box 2). Including only the costs met through the health service-allocated budget, the projected cost to the centre would be $645 313, or $5628 per patient on average, based on estimated total annual direct clinical staff hours specifically for diabetes and CKD of 4226 hours, or 2.37 full-time equivalents. (The difference between the cost to the centre and the total projected annual cost consists of costs met directly by other sources, including the federal and NT governments, rather than through the health service budget.) Expenditure in 2009–10 by the remote health service for diabetes and CKD care was estimated at $446 585, or $3895 per patient (Box 1). The health service would thus require an additional $198 728 (ie, an additional $1733 per patient) for best-practice management of diabetes and CKD. Overall funding received by the health centre in 2009–10 was $3413 per patient.

Interviews with staff identified a number of other barriers to optimal care. The high turnover of RANs necessitated frequent intensive orientation and teaching for new staff. The clinic was also rarely fully staffed. On-call night work, cross-cultural communication and cultural differences can present difficulties for RANs. AHWs may face a conflict of duties and values between the community and the health centre and a heavy responsibility in the role. A high acute caseload and the reticence of many patients to attend checks, for reasons including low health literacy and long waiting times, also hinder adequate management of chronic disease. There is a perceived need to allow more time for clinicians and patients to build relationships and for community-building work.

Discussion

Our study identified a high prevalence of diabetes and CKD in a remote community. As this is the community’s only clinic and the community health screening coverage is high, the clinic-based prevalence approximates population prevalence and is consistent with other remote community studies.4,13

This service is relatively well funded compared with other NT primary care services. Expenditure in 2009–10 was $3413 per capita per annum. The mean per capita figure for NT Government remote clinics for 2011–12 was $2329. This service has a higher than average compliance with the protocols for CKD and diabetes (77%, compared with the territory-wide figure of 73% for clinics participating in the One21Seventy audit). In response to low health literacy and patient mobility, the clinicians engage in very active outreach, health education and opportunistic screening. Most remote communities do not employ a CDE or exercise physiologist.

Despite these positive factors, 2009–10 expenditure was insufficient to provide optimal management by a margin of 44%, or an average of $1733 per patient with diabetes or CKD. Quantitative data were consistent with clinicians’ perceptions at interview that additional staff members were required to work with the CDE and AHWs to adequately meet community needs. Additional staff could increase the crucial quarantining of AHWs’ and RANs’ chronic disease care time from acute care time, possibly contributing to enhanced retention of staff. It would also allow greater allied health coverage, increasing exposure of patients to consistent health messages, and additional informal staff education.

The costs calculated in our study were higher than the inflation-adjusted (2003–04 to 2009–10) NT remote community estimates produced by Zhao et al.10,21 Possible reasons include the conservative estimates by Zhao et al of clinical time needed in remote health services for chronic disease care and staff training, and the higher administrative and salary costs at the studied remote clinic compared with those used in the earlier study.10

Strong primary care systems result in better health outcomes and significant cost savings.9,11–13 There is a strong argument for adequate funding of primary care services like the subject of our study. Our findings also highlight the lack of benchmarks that might indicate appropriate levels of funding to meet community needs and provide cost-effective care.

The strength of this study is its rigour and comprehensiveness, using multiple data sources (qualitative and quantitative). However, the methods are resource intensive and replication at other locations or with other disease groups would be expensive. Other limitations include the fact that costs were kept constant in our modelling. It is likely that unit and, possibly, fixed costs will increase as 100% community coverage and adherence to protocols is approached. It may be that 100% coverage and compliance is uneconomical.

Limitations to generalising these findings to other remote Indigenous health centres are the wide variation in transport costs, the availability of allied health care, and the feasibility of indicated insulin treatment given limited staffing resources. The small sample size also means that caution must be taken in generalising the results.

Nevertheless, this community is not unrepresentative of many remote Indigenous communities, and our study provides the best available evidence about the funding gaps for optimal management of two prevalent chronic diseases in such communities. It documents a significant shortfall even in a relatively well funded and effective primary care service, close to the regional centre. We would expect that the documented shortfall is a conservative estimate. These findings should inform funding bodies in their allocation of health resources for remote Indigenous communities. It may also be of use to this and other remote communities in advocating for their health care needs.

1 Estimated 2009–10 and projected annual costs* for the primary care management of type 2 diabetes and chronic kidney disease in a remote Aboriginal community

 

Annual costs ($)

Category

2009–10

Projected

Remote health centre costs

    

Clinical staff

228 906

340 392

Remote area nurses and Aboriginal health workers

62 011

68 592

General practitioners

38 799

74 439

Chronic disease educators and visiting dietitians

128 096

197 362

Administrative staff

76 383

108 507

Medical supplies

4079

5795

Other operating costs

137 217

190 618

Maintenance

1240

1762

Vehicles

27 758

35 123

Other supplies

1635

2322

Other administrative (including computers, power)

106 584

151 411

Total

446 585

645 313

Direct costs to federal and NT governments†

234 424

255 479

Grand total

681 008

900 792

NT = Northern Territory. * Full coverage and full adherence to protocol. † Includes dental (NT), and optometry, non-vehicle and vehicle capital costs, and medications provided to Indigenous patients under s 100 of the National Health Act 1953 (federal).

2 Total projected annual costs per patient* for the primary care management of type 2 diabetes and chronic kidney disease (CKD) in a remote Aboriginal community, by stage of disease and comorbidity

 

Cost, by severity of CKD ($)

Condition and case type

No CKD or stage 1–3

Stage 4

Stage 5†

CKD without diabetes

      

New cases

4345

4547

5200

Existing cases

     

Without high cardiovascular risk

4062

4175

5042

With high cardiovascular risk

4125

–

–

Non-insulin-treated diabetes

      

New cases

4428

4601

5252

Existing cases

     

Without high cardiovascular risk

4133

4228

5093

With high cardiovascular risk

4196

–

–

Insulin-treated diabetes

      

New cases

14 417

14 590

15 241

Existing cases

     

Without high cardiovascular risk

14 122

14 218

15 083

With high cardiovascular risk

14 185

–

–

* Full coverage and full adherence to protocol. † Dialysis costs excluded.

What can circle sentencing courts tell us about drug and alcohol problems affecting Aboriginal communities?

In New South Wales, circle sentencing courts take place outside of the courthouse, in a more informal community setting. The circle is made up of the magistrate, prosecutor, victim, offender (and his or her supporters), four respected Aboriginal Elders (who are significant to the offender), a representative of the support agencies and a lawyer from the Aboriginal Legal Service. The group talks about the impact of the crime on the victim and looks at the background of the offender and what caused him or her to get on the wrong path. The discussion can last up to 3 hours, after which the group develops a circle sentencing outcome plan, upon which all parties agree. The most important recommendations are made by the Elders. The outcome has to be acceptable to the magistrate. Nowra’s circle sentencing court has been operating for close to 12 years and the magistrate there has never yet disagreed with the Elders. The circle outcomes also need to suit the ability of offenders to comply with the conditions, as we don’t want them to fail.

How the circle relates to the Aboriginal traditional way of dealing with offenders

Up until the 1860s in the Shoalhaven region, we had a council of karadji men to administer tribal law. A locally known karadji man was Johnny Burriman. Keith Campbell wrote of him in the South Coast Register:

The work of Johnny Burriman to gain recognition for an important place for Aboriginal law in the Australian legal system failed, but the issue has remained. A significant step taken appropriately in the Shoalhaven district in recent years has been the introduction of circle sentencing.1

I believe this was a small but significant step towards recognition of the authority of a council of Elders, if not our traditional lore.

The Nowra circle sentencing court provides for sensitivity in reaching a sentence with as much compassion as the crime allows, but without frustrating Parliament’s intention. The justice carried out is a combination of criminal law and traditional values. Whereas the criminal justice system regards crime as something to be punished, Aboriginal people view it as something that requires healing. The regular courts have recently adopted a similar approach: their concept of it is therapeutic jurisprudence.2

How effective has it been?

The greatest achievements of the circle sentencing courts have been bringing down the barriers between the courts and the Aboriginal community, gaining mutual respect and also gaining a great deal of knowledge around the root causes of crime within Aboriginal communities, especially as it relates to alcohol and drug misuse.

The knowledge that has been obtained through open and honest dialogue between the Elders, the offenders and the victims could be regarded as revolutionary. Information is received “from the horse’s mouth” — from the people who have committed the crime, who are experiencing the disadvantages and suffering of alcohol and drug misuse. They are open and honest about it. Sometimes they break down and cry and volunteer insights about their lives. Some circle members even reveal information about themselves for the first time in their lives.

Aboriginal Elders effectively use the Koori way of obtaining comprehensive information from offenders, through the narrative form rather than questions and answers, as it is our cultural way of communicating. The Elders are also very clever in their use of shame: they make the offenders ashamed of their actions rather than of themselves. They say to an offender, “Be a proud Koori: you come from a good family and a rich culture, but you have got to be ashamed of your actions; this is bad”.

Understanding what underlies drug and alcohol problems

It is well known that the underlying causes of crime are unemployment, poor housing, poor education and poor health. As a result of the honest and open dialogue in each circle sentencing case, we have been able to identify some of the further underlying causes of this for Aboriginal people. We have discerned much self-depreciation, low confidence and low self-esteem, derived from 200 years of demonisation by the media and government and only learning about the negativity of Aboriginality. There is also direct trauma from sexual abuse, assault, other types of violence and racism. Being told you are lazy and good for nothing becomes a self-fulfilling prophecy over time. Additionally, there is indirect transgenerational trauma. Many of our offenders are from the Stolen Generations or are affected by family members who were. Aboriginal and Torres Strait Islander people who have been removed from their families often suffer feelings of abandonment and rejection. Their reactions take numerous forms, including anger, grief, loss of identity, alcohol and substance misuse, violence and other socially unacceptable behaviour, problems in relationships, psychological difficulties and isolation. Lack of identity can be linked to mental illness. As Aboriginal people operate on a collective or community level, the extended family is integral to the recovery process. Many often find themselves feeling caught between two worlds — their Koori heritage and the white world they grew up in. This can lead to a sense of not belonging, or feeling unwelcome in either world, with a crippling sense of isolation.

Problems like these need to be taken into account by the court system. This information does not supply the court with an excuse for an offence but it does supply an understanding of the root causes of crime, which is subsequently helpful in developing and delivering crime prevention programs. It is our belief that if clients have the opportunity to work on these problems, it gives them a chance to heal and not repeat the behaviour that led them to the court.

Often Aboriginal people use alcohol and drugs as an anaesthetic for the pain, fear and loss of cultural identity they are experiencing. The “dual diagnosis” which may result does not just refer to clients with hard-core drug problems and schizophrenia. It also refers to clients with a lifetime history of alcohol use disorder and coexisting mental or other drug disorder. The most common mental disorders among offenders with any drug use disorder are anxiety disorders. Some evidence of the intensity of this problem was provided in the 2009 NSW Young People in Custody Health Survey, which found, among other important and disturbing findings, that 92% of young Aboriginal people in custody had a psychological disorder and 83% were risky drinkers.3 Young Aboriginal people make up 49% of the juvenile population in custody.4 Drug and alcohol problems are not easy to overcome if you don’t know much about the causes. Service providers can learn more about the underlying causes of this problem and how to deal with them by participating in cultural awareness training.

After the circle — providing care

In circle sentencing courts, most offenders, and particularly those who commit the more serious offences, are people with a dual diagnosis. This is where the crime problem really becomes a health problem. To deal with it, Justice Health provides liaison nurses who work in courts and corrective services. We also have drug courts to deal with drug-addicted criminals. However, there still appears to be a problem in dealing with offenders with dual diagnosis, mainly because they don’t recognise or accept their illness. Within our Koori communities, there is a stigma around mental illness that leads to self-medicating with illicit drugs. There are also cultural barriers in accessing mental health services in NSW. Clients move between drug and alcohol and mental health services, and dual diagnosis clients are at risk of falling through the gaps. Most importantly, we need a model to promote community-based recovery rather than reliance on inpatient services, as Aboriginal people won’t remain away from their families for long periods of time.

Overcoming the root causes of drug and alcohol use and resultant crime

We need to develop wellbeing programs that focus on physical, psychological, spiritual and personal wellbeing, so that offenders are able to overcome their drug and alcohol dependency and move on to employment, housing, education and good health. We need to tackle the root of the problem if we are to break the cycle of welfare dependency and drug taking that ends in crime and despair.

In a circle, Elders can only direct offenders to do something about their problems; but these directions are taken seriously by the offenders because they are delivered by their respected Elders. However, Aboriginal and mainstream support services are needed to assist offenders to heal afterwards. Aboriginal organisations act as a link between clients and professional and mainstream services and are able to advocate, refer and liaise as necessary. But mainstream services can be limited by a lack of resources and training of support workers about the cultural and communication barriers that prevent them from working effectively with Aboriginal offenders. Some of our clients have experienced judgemental and patronising staff, including psychiatrists, psychologists, drug and alcohol counsellors and general health workers, who have lacked patience, empathy or cultural insight. Cultural bias still remains in the literature of psychology. We need culturally appropriate training for service providers — training that takes into account our differences in experiences, ways of communicating, values, kinship and families, along with insight into healing that recognises the impact of transgenerational trauma, our history and experiences on the current life situations of our people. At the end of the day, our clients have to access these mainstream services. If we fail in these areas, what good are all the efforts we put into getting our people to these services in the first place?

The need for additional support and training

I believe that the programs and training I am calling for represent the way forward. We need to train those who work in mainstream services to be competent when dealing with our people. In the criminal justice system, we are mostly dealing with Aboriginal people with very poor education who are often isolated from the rest of society. In the past, Aboriginal people were denied an education in Standard English and were only taught a modest amount of the English language, from which developed Aboriginal English. This language is still spoken frequently within Aboriginal communities. There is also the matter of poor health to contend with.

Although there is no one solution to the problem of crime, we have to try a combination of what is working in some areas. We need circles accompanied by cultural programs and specialist counsellors to help our people deal with dual diagnosis and trauma. Men’s group programs such as Red Dust Healing (http://www.thereddust.com) and Rekindling the Spirit (http://www.rekindlingthespirit.org.au) are very effective. The Waminda women’s organisation health and wellbeing program is also very effective for Aboriginal women.5 We need to promote pride in Aboriginal identity and culture, based on the belief that this is central to the health and wellbeing of our people and that knowing who you are as an Aboriginal person is central to any positive life. We also need to forge strong partnerships between organisations and agencies so that our clients don’t fall through the gaps.

Conclusion

When we lost our lore and important cultural and traditional way of life, we reached a point where we began to normalise abnormal behaviour such as substance misuse. This is not our traditional way. It is happening mainly because we have lost our structural system of learning and control. Circle sentencing operates on the understanding that the underlying causes of crime are often broader than a single incident and that they need the active participation of the whole community to fix them.

Circle sentencing highlights a need to develop effective cultural programs that educate our people about the positive aspects of our culture and Aboriginality and enable us to take pride in ourselves. These programs should improve the overall health standards of our people by promoting social and emotional wellbeing, acknowledging culture and identity as pivotal in reaching positive outcomes, and prioritising wellbeing as a vital foundation for belonging and identity. Service providers also need to be educated about Aboriginal communication styles, to ensure equality of access to justice and health services. Courts in NSW have developed a program to overcome this problem at a grassroots level, by employing Aboriginal client service specialists in local courts to service Aboriginal clients directly at the counter, in the registry and in the courtroom. Their most important and demanding task is interpreting court rulings. Only when all of these initiatives are put in place will the statistics on our people coming into contact with the criminal justice system begin to decrease.

Above all, the circle teaches us the need to recognise that the past still affects us today. The trauma and dispossession of colonisation compound the harmful effects on our health and culture. The summary statement of the International Symposium on the Social Determinants of Indigenous Health identified colonisation of Indigenous peoples as a central and undeniable causal factor in ill health.6 Colonisation has resulted in the decimation of much traditional Indigenous culture and customary practices, rituals and systems, particularly for Aboriginal people living in urban and regional areas (Mary Goslett, Masters student, Australian College of Applied Psychology, unpublished research paper).7

We are behind the eight ball when it comes to economic and social status. It is only very recently that our culture has begun to be celebrated and accepted to an extent that will assist our next generation to take pride in themselves as Aboriginal people of this country. Reconciliation is the way forward for us, but it will take time and a lot of effort on both sides to reconcile our differences. Circles, I believe, are reconciling our differences within the criminal justice system. Thoughtful and intelligent people from all walks of life will continue to make true reconciliation happen in this country.

Register4: an Australian web-enabled resource created by the National Breast Cancer Foundation to facilitate and accelerate cancer research

To the Editor: Register4 is an online register of Australian men and women that aims to reduce the costs and time involved in recruitment for cancer research studies by matching researchers with willing participants, harnessing the speed and reach of the internet. An initiative of the National Breast Cancer Foundation, Register4 was launched in 2010 and is modelled on the US Army of Women (http://www.armyofwomen.org) and the Australian Twin Registry.1 To date, there are nearly 40 000 members (> 96% women) with a broad demographic representation: aged from 18 to over 70 years (most 30–59 years); residing in all states and territories (most in New South Wales, Victoria and Queensland); and 80% born in Australia. The membership is highly motivated to participate in research: over 20% of members are willing to provide DNA samples or participate in a clinical trial, and nearly 15% are willing to provide a sample of breast tissue.

Data on lifestyle and family health history (including reproductive history, history of breast or other cancers, and chronic illness) have been collected for more than 20% of members through the online EPI-Q Health and Lifestyle Questionnaire. Of the more than 7300 members who completed the EPI-Q, 20% have a prior history of breast cancer, and 75% have no history of any cancer. Other chronic health conditions covered by the questionnaire include asthma (20% of members), high blood pressure (16%), and osteoarthritis and osteoporosis (12%). Over 60% of participants have never smoked.

To contact Register4 members or access their data, cancer researchers join Register4 as a researcher member, then submit proposals to the Register4 Access Committee for approval. All projects must be fully funded and approved by a human research ethics committee (HREC). The operation of Register4 has HREC approval.

To date, Register4 has been used to recruit participants for 18 cancer research projects, involving nearly 13 000 members. Ample and appropriate participants were recruited within days — dramatically faster than conventional recruitment, which typically takes years.

More information about Register4 can be found at the website (https://www.register4.org.au) or obtained via email (info@register4.org.au) or by telephone (1300 709 485).

Learning by MOOC or by crook

Massive open online courses are a new way of learning and offer potential in the health field

For those who have not been keeping up with recent developments in education, MOOCs, or “massive open online courses”, are the latest potential benefit — or threat — to higher education, depending on your point of view.1 The idea is that someone puts their course of lectures online for free and thousands of people access and learn from them. There had been some early courses placed online and open to all, but the term “massive” came into its own when two Stanford University lecturers put a course online and 160 000 people enrolled. Education by the world’s best can be made available to all, although most courses do not yet offer university credits. Students can join discussion forums with the tutor and with other students. Individualised feedback to students is limited by class size, although social networks evolve between students. This type of education has advanced rapidly, and companies have been established to develop or, alternatively, exploit, this trend — again depending on your point of view. As might be imagined, this has caused some universities to fear that they may be replaced by the advance of the MOOC, and, probably as insurance, many Australian universities are now partners in the various MOOC companies. A recent literature review found “Formal comprehensive analyses of MOOCs mostly concur that they are disruptive and possibly threatening to current HE [higher education] models” although the review concludes: “MOOCs are heading to become a significant and possibly a standard element of credentialed University education, exploiting new pedagogical models, discovering revenue and lowering costs.”1 The Open University in the United Kingdom showed it was possible to enrol all-comers into tertiary education and to educate them successfully to graduation and successful academic and professional careers. The Open University now owns a private company that provides a platform through which many UK universities, one Australian university and one New Zealand university offer MOOCs.2

This development builds on two major advances — the internet, with its almost ubiquitous reach; and the open source revolution,3 which has allowed computer software to be freely shared and has led on to open publishing, including free sharing of research findings in open access journals,4 and open educational resources (OER)5 — of which there are many thousands available on the internet to be freely accessed and shared.

What is the global reach of MOOCs? There is a fear, since some of the companies formed to develop and distribute MOOCs are for-profit, that the business model will inhibit global spread to where they could do most good by providing very low-cost access to high-quality education — such as in Africa.6 Coursera is one of the main companies offering MOOCs (with over 80 universities as partners, including at least one from Australia). An exploration of their global footprint reveals a very low uptake of students and partners from the developing world to date, although there are plans to expand.7

What is the relevance of MOOCs to health workforce capacity building? A previous editorial in the MJA described the development of a low-cost, fully online program for public health capacity building for health professionals in developing countries.8 The Peoples-uni (http://peoples-uni.org) is a totally online program, led by volunteers and using OER to keep costs low.9 There have been over 1000 students registered, and a number have graduated with a Master of Public Health granted by a partner university in the UK. Students come from more than 40 countries, mostly from Africa. There is a strong Australian presence among staff, with 30 of the 120 tutors and support staff in Australia. (If any Australian university or other institution is interested in partnering, please make contact.) The Peoples-uni is a “mOOC”, which differs from a MOOC in that it has smaller student numbers and offers formal credentials to the masters level — reflecting depth of commitment by tutors to run discussion forums and set and mark assignments.

MOOCs and other forms of OER provide considerable scope for online learning. Many resources and courses are available, including many health-related MOOCs created by some of the world’s best universities, and a vast array of OER in the health field. It is an area of massive potential for continuing professional development (CPD) as well. As far as I can see, most Australian colleges have, to date, ignored the potential for the use of online resources for CPD, as well as for discussions through social networking.

The use of open resources, including MOOCs, with modern social networking, has the potential to reshape CPD and shake up the higher-education sector.

Impact of the Rural Clinical School of Western Australia on work location of medical graduates

In the face of severe and ongoing medical workforce shortages in rural Australia, initiatives have been introduced to improve recruitment and retention in rural practice.1 These have included pathways for international medical graduates to enter the rural workforce, incentives for existing rural doctors, rural-bonded medical school places, quarantined rural student places in medical schools, scholarships for rural medical students, and undergraduate immersion in rural medicine through rural clinical schools (RCSs). The RCSs were intended to influence the future career choices of medical students and so contribute to a self-sustaining locally trained workforce.

It is clear in the international literature that multiple factors are associated with medical graduates’ career destinations. A prospective longitudinal study of medical graduates followed up 30 years after they graduated showed that selecting rural-origin undergraduates with a declared interest in primary care and providing rural-immersion programs each independently and linearly increased graduates’ likelihood of working rurally.2,3 Rural immersion has been favoured by some programs in the United States.4,5

Based on this collective evidence, the Australian Government initiated RCSs in 2002, with a mandate to produce rural doctors. Participating universities are financially supported to train 25% of medical graduates for at least 1 academic year in a rural setting.

Early Australian data showed that RCS exposure increases graduates’ stated intention to work rurally.6 RCS graduates are also more likely than their peers to work rurally as prevocational doctors,7,8 and studies of small numbers of RCS graduates have found they are more likely to work in rural areas and to have a preference for primary care.9,10 However, longer-term outcomes for large numbers of RCS graduates have yet to be reported.

Here, we report the impact of participation in the Rural Clinical School of Western Australia (RCSWA) on graduates’ rural work relative to their non-RCSWA peers. Our hypothesis was that RCSWA participation is associated with increased rural work.

Methods

The RCSWA commenced at the University of Western Australia (UWA) in 2002, and expanded in 2007 to include the University of Notre Dame Australia medical school at Fremantle. The RCSWA is based at 13 sites across rural and remote WA. Participation in the RCSWA is based on application and an interview that selects those students most informed about the RCSWA and living independently.

For this study, the cohort comprised medical graduates from UWA who completed their fifth year between 2002 and 2009 and graduated by 2010. This ensured graduates were in at least their third postgraduate year at the time of data collection in 2013. Medical students from the University of Notre Dame Australia were not included. RCSWA graduates were defined as those who undertook a fifth-year rural placement. The control group comprised graduates who had not participated in an RCSWA placement. The study was approved by the UWA Human Research Ethics Committee.

Students recruited into the UWA medical school through a quarantined rural pathway were identified as having a rural background. At the time, this was defined as having lived in a rural area of WA (towns > 75 km from the Perth central business district, all of which are classified as rural by the Australian Standard Geographical Classification — Remoteness Areas [ASGC-RA]11) for a minimum of 2 years and having completed Year 12 at a rural secondary school. All other students were classified as having an urban background. The few students who may have come from a rural background but did not enter through the rural pathway were included in the urban-background group.

Between March and June 2013, we accessed information in the Australian Health Practitioner Regulation Agency (AHPRA) database to identify graduates’ work locations. Graduates were designated as working rurally if their primary practice location was in an area defined by the ASGC-RA as RA2–5, and urban if RA1. Graduates with an urban practice address were conservatively considered to be working in an urban location, even though many will have spent part of their year working on rural rotation. A previous comparison of the more detailed RCSWA work location database with AHPRA information showed at least 89% agreement.12

Univariate comparisons were made using the χ2 test for categorical variables and the Kruskal–Wallis test for age, as this showed marked kurtosis and a tail towards the upper range. We used logistic regression to analyse predictors of the probability of working rurally by maximum likelihood estimation. Factors of current age, sex, rural background and RCSWA participation were considered. All interactions between covariates were included, but only interactions between rural background and RCSWA participation remained significant and were included in the final model. Further logistic regressions were run within the RCSWA cohort to identify the effect of covariates independently of RCSWA participation. Analyses were also run within the rural-background group, to identify any independent effect of RCSWA participation. All analyses were conducted using SAS version 9.3 (SAS Institute).

Results

We identified 1187 graduate doctors who had completed Year 5 between 2002 and 2009 (Box 1). After excluding those who had not been eligible for the RCSWA or were working overseas, 1116 graduates were eligible for inclusion in the study. Of these, 99 could not be traced (three RCSWA graduates and 96 controls), leaving 1017 graduates (91.1%) who were included in the study. The 96 control graduates not found on the AHPRA database were not statistically different from other controls by rural background, sex and age.

Of the 1017 graduates, 258 (25.4%) had participated in the RCSWA and 759 (74.6%) were controls. The RCSWA graduates differed from the control group in that more RCSWA graduates were from rural backgrounds, female and younger (Box 2).

Of the 258 RCSWA graduates, 42 (16.3%) were working as rural doctors, compared with 36 of the 759 controls (4.7%) (P = 0.001) (Box 3). Overall, there was no significant association between the proportion of graduates working rurally and the year in which they completed Year 5 of medical school. However, smaller proportions of graduates who had completed Year 5 in the 2 most recent years had a rural work address.

Univariate analyses found significant associations between rural work and RCSWA participation, rural background, sex and older age (≥ 40 years) (Box 4). Further analysis showed that 16.7% (15/90) of those who were aged over 35 years at enrolment in Year 5 were working rurally, compared with 6.8% (63/927) of their younger classmates (P = 0.003).

RCSWA graduates from an urban background were working as rural doctors at a similar rate as those from a rural background who did not participate in the RCSWA (Box 5). There may have been some additional benefit of the RCSWA program for graduates from a rural background, but this was based on small numbers and was not statistically significant (P = 0.28).

The RCSWA was oversubscribed from 2006 onwards by a total of 67 UWA graduates. Unsuccessful RCSWA applicants were not significantly different from successful applicants in terms of sex, age or rural background. However, only five unsuccessful applicants (7.5%) had a rural work address, significantly less than the RCSWA graduates for this period (P = 0.04).

In the final logistic regression model, the combination of having a rural background and participating in the RCSWA was the strongest predictor of being a rural doctor (odds ratio [OR], 7.5; 95% CI, 3.5–15.8), followed by RCSWA participation without a rural background (OR, 5.1; 95% CI, 2.9–9.1) (Box 6). A rural background without RCSWA participation (OR, 4.2; 95% CI, 1.8–9.2) was also significant, as was older age (30–39 years: OR, 2.2; 95% CI, 1.3–3.7 v ≥ 40 years: OR, 6.6; 95% CI, 2.8–15.0). Women remained more likely to work rurally (OR, 1.6; 95% CI, 0.9–2.6), but this was no longer statistically significant.

Further analyses within the group of RCSWA graduates showed that the major factors associated with rural work were age ≥ 40 years (OR, 17.0; 95% CI, 3.3–130.1) and being female (OR, 2.6; 95% CI, 1.2–6.3). Rural background was not independently significant (OR, 1.4; 95% CI, 0.6–2.9).

Within the smaller group of 131 rural-background doctors, no covariate was significantly associated with rural work. However, both older age (≥ 40 years, OR, 4.1; 95% CI, 0.9–17.3) and RCSWA participation (OR, 1.8; 95% CI, 0.7–4.9) may have important effects.

Discussion

While RCS programs are known to increase intention to practise rurally, we found that substantial proportions of RCSWA graduates actually do return to rural areas to practise. The clear increase in the number of graduates practising rurally in this study, if sustained across all RCS programs, will make a significant contribution to Australian rural medical workforce shortages.13

This finding corroborates results of previous smaller studies. Graduates of the Flinders University Parallel Rural Community Curriculum (PRCC) program were overwhelmingly more likely to be in rural work relative to non-PRCC graduates.9 In this small cohort of 29 doctors contacted 5 years after graduation, there was a strong preference for primary care, similar to findings in the North American literature.3 In a study with more detail but also with small numbers, University of Queensland RCS graduates have shown similar positive rural return and preference for primary care.10

We also found that medical graduates from urban backgrounds who undertook an RCSWA year were nearly four times more likely to be working rurally up to 10 years after graduation than those not exposed to the RCSWA. The observed outcome for urban-background RCSWA graduates was as strong as that for rural background alone. It is similar to the previously documented positive effect of rural background on medical graduates’ future rural practice.14 This result is significant, given the limited pool of rural-background students available to be recruited into medicine. Our study demonstrates that some of the substantially larger pool of future medical students from urban backgrounds can also, with appropriate experience, be convinced to pursue a rural career. Qualitative research could explore which aspects of the RCSWA experience are associated with future rural practice.

Our study methods were conservative and are likely to have underestimated rural work, especially for more recent graduates. The finding that fewer graduates from the 2 most recent years had a rural work address is likely related to the limited number of full-year positions available in rural WA for junior doctors. WA has relatively small rural population centres and most junior doctors who work rurally do so on rotation from urban centres. Our unpublished, detailed follow-up of RCSWA graduates documents that many are still in training programs undertaking brief placements in rural areas. These short rural placements are less likely to result in a change of primary practice address on the AHPRA database and hence will not be included as rural work in this analysis.12

Although all cross-sectional study designs have the potential weakness of sampling bias, overall sampling bias is unlikely in this study as we had data on 91% of graduates. Our finding that untraceable controls did not differ from other controls further decreases this likelihood. However, the small sample size of rural-background students who participated in the RCSWA and collinearity between rural background and RCSWA participation meant that statistically significant relationships could not be established. Larger numbers are required to better investigate the possible associations between rural background and rural practice. It would be worthwhile to increase the sampling of rural-background RCS students by including graduates from all RCSs and medical schools in Australia.

It can be argued that RCSWA graduates already had rural practice intentions as medical students and may have practised rurally anyway. However, it has been widely documented that urban-background graduates only become rural doctors in small numbers.2,3,15,16 In addition, our study shows that students who applied for but did not attend the RCSWA were not working rurally in significantly increased numbers. The size of the observed difference on urban-background graduates who participated in the RCSWA suggests an impact that is substantially greater than just initial intention or positivity towards rural practice.

The proportion of RCSWA graduates who returned to rural practice in this study compares well with results from a 30-year-old program in the US, which has a threefold higher return for its selective rural program relative to standard-intake graduates.17 It also compares well with results from several retrospective studies for rural general practitioners having had rural undergraduate experiences (OR range, 2.0–3.7).15,16,18,19

We add to the literature with our finding that women and older graduates are more likely to enter rural work after RCS exposure. Women were initially recruited into the RCSWA in higher numbers and, contrary to findings about mature male practitioners already in rural practice,19 female RCSWA graduates were more likely to enter rural practice, although this did not quite reach statistical significance in our multivariate model. In a field that has been male-dominated, this is a very positive result. Our finding that older entrants were more likely to work rurally is in line with results from the Flinders University PRCC program.9 The increasing numbers of graduate medical programs in Australia may well be good for future rural workforce.

This study is an important addition to the evidence for RCS success in contributing to the Australian rural medical workforce. It provides strong support for the Australian Government to maintain the program and to increase RCS funding to expand the number of places. This would allow increased rural recruitment from the large pool of urban-background medical students. Given the expense of using locums and fly-in fly-out workers to overcome rural workforce shortages, state and territory governments should add to RCS capacity by investing targeted additional funding to increase RCS-based training in sites of greatest workforce shortage. Our finding that the RCS program is producing a new rural workforce indicates this would be well placed.

1 Description of University of Western Australia medical graduates

Year completed Year 5

2002

2003

2004

2005

2006

2007

2008

2009

Total

Graduates

131

121

121

109

140

163

193

209

1187

Ineligible for inclusion in study

Ineligible for RCSWA*

4

1

2

2

4

10

13

27

63

Working overseas†

3

0

4

1

0

0

0

0

8

Unable to be traced†

23

13

19

12

7

13

7

5

99

Included in study

101

107

96

94

129

140

173

177

1017

Completed RCSWA year

7

21

28

32

36‡

42

43‡

49

258

RCSWA = Rural Clinical School of Western Australia. * Temporary residents and those with student visas. † From information in the Australian Health Practitioner Regulation Agency (AHPRA) database, accessed March–June 2013. ‡ Excludes two RCSWA graduates in 2006 and one in 2008 who were unable to be located in the AHPRA database.

2 Demographic characteristics of RCSWA and control University of Western Australia graduates

RCSWA graduates (n = 258)

Control graduates (n = 759)

Total (n = 1017)

P

Working rurally*

42 (16.3%)

36 (4.7%)

78 (7.7%)

0.001

Female

162 (62.8%)

380 (50.1%)

542 (53.3%)

0.004

Rural background

63 (24.4%)

68 (9.0%)

131 (12.9%)

0.001

Median age in 2012 (IQR)

29.0 (27.7–31.2)

30.0 (27.6–32.1)

29.7 (27.6–31.9)

0.007†

Age group

0.006

< 30 years

157 (60.9%)

381 (50.2%)

538 (52.9%)

30–39 years

94 (36.4%)

336 (44.3%)

430 (42.3%)

≥ 40 years

7 (2.7%)

42 (5.5%)

49 (4.8%)

RCSWA = Rural Clinical School of Western Australia. IQR = interquartile range. * Defined as RA2–5 in the Australian Standard Geographical Classification — Remoteness Areas.11 † Based on a Kruskal–Wallis test because the age distribution showed marked kurtosis and a tail towards the upper range. Age was recoded into 10-year groups for further analysis.

3 Work location* of RCSWA and control University of Western Australia graduates

RCSWA graduates (n = 258)

Control graduates (n = 759)

Year completed Year 5

Rural work
location†

Urban work
location‡

Rural work
location†

Urban work
location‡

2002

2 (28.6%)

5 (71.4%)

7 (7.4%)

87 (92.6%)

2003

4 (19.0%)

17 (81.0%)

5 (5.8%)

81 (94.2%)

2004

4 (14.3%)

24 (85.7%)

6 (8.8%)

62 (91.2%)

2005

4 (12.5%)

28 (87.5%)

1 (1.6%)

61 (98.4%)

2006

8 (22.2%)

28 (77.8%)

4 (4.3%)

89 (95.7%)

2007

12 (28.6%)

30 (71.4%)

3 (3.1%)

95 (96.9%)

2008

5 (11.6%)

38 (88.4%)

6 (4.6%)

124 (95.4%)

2009

3 (6.1%)

46 (93.9%)

4 (3.1%)

124 (96.9%)

Total

42 (16.3%)

216 (83.7%)

36 (4.7%)

723 (95.3%)

RCSWA = Rural Clinical School of Western Australia. * From information in the Australian Health Practitioner Regulation Agency database, accessed March–June 2013. † Defined as RA2–5 in the Australian Standard Geographical Classification — Remoteness Areas (ASGC-RA).11 ‡ Defined as RA1 in the ASGC-RA.11

4 Univariate associations for working in a rural location

Number (%)

Odds ratio (95% CI)

P

RCSWA

Yes

42/258 (16.3%)

3.91 (2.44–6.25)

0.001

No

36/759 (4.7%)

1.0

Rural background

Yes

23/131 (17.6%)

3.22 (1.87–5.39)

0.001

No

55/886 (6.2%)

1.0

Sex

Female

51/542 (9.4%)

1.72 (1.07–2.83)

0.03

Male

27/475 (5.7%)

1.0

Age group

< 30 years

30/538 (5.6%)

1.0

0.002

30–39 years

37/430 (8.6%)

1.59 (0.97–2.64)

≥ 40 years

11/49 (22.5%)

4.90 (2.20–10.3)

RCSWA = Rural Clinical School of Western Australia.

5 University of Western Australia graduates participating in the RCSWA and/or having a rural background

RCSWA
participation

Rural
background*

Total

Working
rurally

No

No

691

26 (3.8%)

No

Yes

68

10 (14.7%)

Yes

No

195

29 (14.9%)

Yes

Yes

63

13 (20.6%)

RCSWA = Rural Clinical School of Western Australia. * Defined as living in a rural area of WA for at least 2 years and having completed Year 12 at a rural secondary school.

6 Final logistic regression model for working in a rural location*

RCSWA = Rural Clinical School of Western Australia. * Log scale. Bars represent 95% confidence intervals.

Get back to work

A quote from literature is a time-honoured trope used in editorials to exemplify a chosen theme. Literature, however, is often negative about the idea of returning to work, which many doctors are now doing. Indeed, work itself is usually considered a black hole of mundanity. In the real world, any new year’s resolutions to do things better this time may already be starting to dissipate under the influence of such negativity. However, work, though at times uninspiring, does somehow get things done.

Unfortunately, despite our best efforts, any resolution
to stop the introduction into Australia of microorganisms resistant to multiple antimicrobial agents has probably been in vain. The case of a man repatriated from Greece with complications from perforated diverticulitis has brought home to clinicians that Australia has not averted the threat of multidrug-resistant (MDR) organisms. In their case report (doi: 10.5694/mja13.10592), Chua and colleagues describe the stormy and protracted course of “last line of defence” antimicrobials, complex operations and costly isolation and cross-infection prevention protocols. They identified 10 patients admitted to Austin Health between December 2011 and February 2013 with MDR organisms and a history of recent overseas travel. The larger implications of such cases for Australian health care are becoming clearer.

In hospitals across Australia, many wards and emergency departments will have welcomed new additions to their medical teams as this year’s interns started their first clinical term. All doctors well remember their first foray into paid clinical work, for reasons good and bad, and everyone can think of how their own apprenticeship could have been better supported and more focused on learning and practice. We all recognise that interns need ongoing structured education, protected from their clinical duties. In 2008, the Garling inquiry recommended interns spend 20% of their rostered time in a formal clinical training program (http://www.lawlink. nsw.gov.au/Lawlink/Corporate/ll_corporate.nsf/vwFiles/E_Overview.pdf/$file/E_Overview.pdf). Oates and colleagues (doi: 10.5694/mja13.10213) have estimated how much their education costs the New South Wales health system and found the total was close to $15 000 per intern. They also found that, in NSW, only 6% of an intern’s time is allocated to these educational activities, well short of the 20% recommended nearly 6 years ago. Interns are better supported educationally than previously, but there is still a considerable way to go in improving our investment in this area of health care.

Getting the right mix of people in medical school admissions is an area of ongoing interest. The University
of Queensland dropped the requirement for applicant interviews from 2009. Wilkinson and colleagues (doi: 10.5694/mja13.10103) show that the proportion of male students admitted grew substantially thereafter, up to almost three-quarters of domestic graduate-entry students in 2012. Male candidates’ better performance in the section of the Graduate Medical School Admissions Test (GAMSAT) on biological and physical sciences reasoning is thought to play a role. There are several ways to interpret these findings, but medical school interviews appear to have
a function in ensuring gender equity. This is also a discussion that has to go beyond the medical school.

Outside of hospitals and medical schools, the fight
for better community health continues. Elliott and colleagues (doi: 10.5694/mja13.11240) assess the “progress” made by the federal government’s Food and Health Dialogue over the past 4 years to improve the nutritional profile of foods and enhance consumer education about healthy diet choices. Depressingly, none of the agreed goals have been achieved. The authors argue for the Dialogue to have stronger transparency and accountability in its initiatives and targets, and to manage commercial vested interests whose involvement is essential, but whose goals are different to public health objectives. Improving the food environment needs sustained commitment but, in Australia, interest and focus is in danger of fizzling out. Let us hope that everyone involved can keep a lid on the influences that may stymie progress and get back to the work needed to renew this resolution to make Australians healthier.

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

Selection processes for entry into medical school are continually under scrutiny, not only for predictive validity, but also for equity and fairness.1–3 The importance of equitable selection criteria that can identify candidates who will succeed academically and negotiate the transition into professional practice is widely acknowledged.3,4 Simultaneously, broadening the admissions base is an important part of social accountability, and selection processes at some schools include mechanisms to select students based on background, social status and personal qualities, as well as academic performance.5,6 Mechanisms employed to do this include quotas, personal statements, portfolios and interviews.1,4,7

Internationally, debate continues about who to admit to medical study, and how to admit them.3 Equity issues identified include gender, age, socioeconomic status, rurality and Indigenous status.8,9 Prior academic performance has the highest predictive validity for performance in medical school but has itself been shown to be influenced by gender, educational background and social class.1,3,9,10 Despite their widespread use, evidence suggests that interviews have poor predictive validity and limited practicality and are subject to bias, including gender bias.11–14

Australian medical schools use various combinations of factors in making selection decisions, including prior academic performance (at high school or university), performance on standardised tests including UMAT (Undergraduate Medicine and Health Sciences Admissions Test) or GAMSAT (Graduate Medical School Admissions Test), a written statement or portfolio and an interview.15,16 All medical schools admitting graduates make use of the GAMSAT.15 Although the criterion validity of the GAMSAT is continually reviewed, questions remain about its predictive value and gender bias.15–18 Reports have shown a modest but statistically significant gender bias in favour of male students.17

In 2009, after analysis of the format, validity and utility of the interview, this component of the selection process was discontinued at the University of Queensland (UQ).18 Here, we report a consequent change in the gender ratio among enrolled students and analyse the reasons for this shift.

Methods

Setting and subcohorts

The medical degree at UQ is a 4-year graduate-entry program, with an intake in 2012 of 543 students. The full cohort is made up of distinct subcohorts:

  • domestic students: about 300 places are available each year, as determined by the federal government; and

  • international students: about 120 places for students who spend all 4 years in Australia, and (in 2012) about 85 places for students from the United States who spend the first 2 years of their program in Australia and the second 2 years in the US.

In addition, there are two distinct entry pathways:

  • graduate-entry pathway (domestic): about half of all domestic places are available to students with a prior degree who apply for direct entry into the MB BS program; and

  • school leaver pathway, which is also called a dual degree (domestic): about half of all domestic places are available to students provisionally accepted directly from high school who first study a non-medical undergraduate degree before commencing their MB BS.

Admissions criteria

Admissions criteria are found on the UQ website (http://www.uq.edu.au). Before 2009, selection to the domestic graduate-entry pathway was based on exceeding a defined GPA (grade point average) in a prior degree, and then on ranking based on a composite score of performance in the GAMSAT and the interview. Entry to the domestic school leaver pathway was based on attaining the highest level of high school score (called an Overall Position 1 or equivalent), and then ranking based on the UMAT total score. (There has never been an interview for this subcohort.) From 2009 onwards, the interview was not used for graduate entry, but other criteria remained the same. International students are selected in a similar manner, but may take the North American MCAT (Medical College Admission Test) instead of the GAMSAT and the ISAT (International Student Admissions Test) instead of the UMAT. There have never been interviews for international students.

Graduate Medical School Admissions Test

The GAMSAT has been used since 1996 in Australia and is a written aptitude test developed and administered by the Australian Council for Educational Research (ACER) on behalf of the consortium of graduate-entry medical schools (GAMSAT Consortium Universities).19,20 The GAMSAT is divided into three sections: section I, reasoning in humanities and social sciences; section II, written communication; and section III, reasoning in biological and physical sciences. The GAMSAT overall score is computed as a weighted average of the three section scores in the ratios 1:1:2, respectively.19 Each university determines its own cut-off value, and at UQ (at the time of this analysis) a minimum score of 50 in each of the three sections of the GAMSAT test was required to be eligible for entry, with ranking done on overall score and then by GPA within the GAMSAT score band.20

Student cohorts

We studied nine consecutive cohorts (2004–2012) comprising 4051 enrolments in the medical program. We examined student characteristics and GAMSAT scores over this period, and any changes from the period when an interview was in place (2004–2008) to the period after the interview was discontinued (2009–2012). Student characteristics studied included gender, entry pathway (graduate or school leaver) and international or domestic status.

Statistical analysis

Statistical analysis was performed using SPSS version 21 (SPSS Inc). Descriptive statistics were calculated and Pearson χ2 tests performed to test for differences in gender proportion for all entry years combined, for each year and between the interview and no-interview periods. Results are reported with 95% CI, and a P value < 0.05 is regarded as significant. Preliminary Pearson correlations were run to determine the associations between GAMSAT sections (I–III) and the overall score (weighted average) as well as an unweighted mean score. A two-way, multivariate analysis of variance (ANOVA) was conducted to test for gender differences in GAMSAT section scores and to compare differences between gender over the years of the study period (Bonferroni-adjusted P = 0.017). Gender differences between the interview and no-interview periods in GAMSAT overall scores were examined using two-way ANOVA. Mean scores with 95% CI, standard errors, F, P and effect sizes are reported. Preliminary analyses were performed to test for violations of the assumptions of normality, linearity and homoscedasticity; where necessary, significance levels were reported at a more stringent level of P < 0.01.21

Ethics approval

Ethics approval was provided by the UQ Behavioural and Social Sciences Ethical Review Committee. No funding was sought for this study.

Results

Changing characteristics of subcohorts of enrolled students

In all, 4051 students were admitted to study medicine between 2004 and 2012 (3698 students at the School of Medicine and 353 school leavers provisionally accepted into medicine but still completing their first degree) (Box 1). The annual intake into the School of Medicine increased substantially between 2004 (307 students) and 2012 (543 students). The median age of enrolled students was 23 years (interquartile range, 3 years), with no observed differences in mean age between the interview and no-interview periods (24.4 years and 24.5 years, respectively). The proportion of international students increased from 9.8% (30 students) in 2004 to 44.0% (239 students) in 2012. The proportion of domestic students enrolled as direct graduates fell from 100% in 2004–2007 to 71.1% in 2008–2012 (and reached 40.1% in 2012).

Changes in gender ratio

Between 2004 and 2008, 891 enrolled students (51.4%) were male, whereas between 2009 and 2012, 1134 (57.7%; χ2 = 15.01; df = 1; P < 0.001) were male. There was a notable shift in the gender ratio (in favour of males) in 2009, when the proportion of male students jumped from 52.2% in 2008 to 57.7%. This proportion has remained stable within 1% since 2009 (Box 1). In the international subcohort, the proportion of enrolled males has been consistently higher than that of females (by about 5%–10%) across the entire study period, especially since 2007, when the number of international students increased, but this difference is not statistically significant (χ2 = 2.41; df = 8; P = 0.97). There was no significant difference in gender ratio within the international student subcohort between the interview and no-interview periods (χ2 = 0.59; df = 1; P = 0.45). As shown in Box 1, the gender ratio for the domestic school leaver pathway between 2008 and 2012 is almost balanced. However, for the domestic direct graduate-entry pathway, the male proportion rose from 50.9% in 2004–2008 to 64.0% in 2009–2012 (χ2= 35.19; df = 1; P < 0.001). In 2011 the proportion of male students enrolled through the domestic direct graduate-entry pathway was 73.1%, and in 2012 it was 73.8% (Box 2).

GAMSAT scores by gender

Of the 2187 domestic students enrolled by the direct graduate pathway, 2047 GAMSAT scores were available (special admissions were excluded). Mean GAMSAT section scores are reported in Box 3, by gender (for 1151 male and 896 female students). The difference in mean scores in sections I and II between male and female students is small (less than 1 unit), while the difference in mean scores for section III is more than 3 units (71.5 for males v 68.5 for females). The Pearson correlation calculation showed that section III is more strongly correlated with GAMSAT overall scores (r[2045] = 0.85; P < 0.001) than sections I–II (r[2045] = 0.48 for section I, and 0.31 for section II; P < 0.001). By comparison, the correlations between sections (I–III) and an unweighted mean score were closer (r[2045] = 0.64 for section I, 0.57 for section II and 0.62 for section III; P < 0.001).

A two-way, between-group, multivariate ANOVA of GAMSAT section scores, applying Bonferroni adjustments, showed significant gender differences in section III (Box 3). The test showed a significant difference between male and female students on the combined GAMSAT sections I, II and III (F3,2027 = 25.18; P < 0.001; Wilk l = 0.96; partial eta-squared = 0.036), but when the section scores were considered separately, the only difference in gender was in section III (P < 0.001). There was no significant interaction between gender and year of entry on the combined three sections (P = 0.12) or on any of the sections when considered separately (P = 0.19 for section I, P = 0.16 for section II and P = 0.26 for section III), indicating that the influence of gender on differences in scores remained consistent across all years studied. A two-way ANOVA confirmed a significant difference between gender in GAMSAT overall scores (F1,2043 = 34.03; P < 0.001; partial eta = 0.016) but no difference in overall scores by gender between the interview and no-interview periods (P = 0.55).

Discussion

Our analysis shows that the proportion of male students enrolled in the medical program at UQ has increased substantially in recent years. This change is isolated to the domestic direct graduate-entry subcohort of students, and the change started in the first year that the interview was not included in the selection process. The increased proportion of males enrolled overall has persisted since the change in selection practice, and the proportion among domestic direct-entry graduates has increased to 73.8% in 2012.

Our observations are in stark contrast to the general trend in Australia where between 2009 and 2012, 51.7% of all enrolments in Australian medical schools were female students.22 Further, using data supplied by ACER, we found no evidence of an increased proportion of males sitting the GAMSAT or applying for entry to medical school between 2007 and 2011 (Appendix 1; online at mja.com.au). Indeed, among the 12 graduate-entry medical programs, between 2007 and 2011, in only two cases was the proportion of males applying higher than 50% (and the highest of these was 54.1%) (Appendix 2; online at mja.com.au).

The reason for the shift at UQ seems to be the influence of higher scores achieved by male applicants in section III of the GAMSAT. Higher scores on section III have been shown to be associated with higher GAMSAT overall scores, on which candidates are ultimately ranked for selection to medical school.17,20 The results from our analysis of GAMSAT scores are consistent with prior reports of a significant (but relatively small) gender effect favouring males on both section III and overall scores.17 We also reported strong correlations between section III and the overall score but when a mean score (using unweighted sections) was calculated for the UQ cohort, this effect was noticeably moderated.

Alternatively, the strong influence of academic background on GAMSAT performance is well documented.9,16,17 For example, graduates from disciplines such as engineering, where students are predominantly male, perform better on section III.17 While it is important to acknowledge the substantial effect of prior learning, the academic backgrounds of GAMSAT candidates have remained relatively stable over the study period.16 Further, the academic selection criteria at UQ have not changed. The one factor that has changed has been the discontinuation of the admissions interview at UQ.

Our findings have significant policy implications. Currently, all GAMSAT Consortium medical schools in Australia rank applicants using the weighted overall score calculated by ACER. The exception is the University of Melbourne, which uses an average (unweighted) GAMSAT score.20 GAMSAT section III focuses on reasoning in biological and physical sciences, and we find it difficult to rationalise the continued weighting of scores in this section if this practice leads to significant gender bias, as it seems to have done here. Our view is that cohorts of admitted medical students should be representative of the communities from which they are drawn, and which they will later serve.

There is consensus that selection processes aimed at broadening access to medical school have not been extensively studied.3 There are limited studies focusing on gender and the interview process; however, the literature does indicate a shift in attitudes from an earlier bias favouring males.13,14 We were not able to present data on gender differences in interview scores at UQ, but our study does lend support to the more recent studies suggesting that personal interviews favour female applicants.14 Apparently, without the moderating effect of the interview, gender bias in GAMSAT performance has led to a marked increase in the proportion of male medical students enrolled at UQ.

How to best select medical students remains challenging and contentious. Like other medical schools, we use quotas for specific groups, such as Indigenous students, those with a rural background and those following different pathways. We are now considering how best to ensure a balanced gender ratio among enrolled students in our direct-entry graduate pathway and recommend that schools monitor changes to selection policy and practice carefully.

1 Proportions of male and female students, by subcohort, in each year between 2004 and 2012

Domestic students (n = 2626)

International students (n = 1072)†

All students
(n = 3698)*

Graduate students
(n = 2187)‡

School leaver pathway group§ (n = 439)

School of Medicine entry year

Total

Female

Male

Female

Male

Female

Male

Female

Male

2004

307

156 (50.8%)

151 (49.2%)

145 (52.3%)

132 (47.7%)

—

—

11 (36.7%)

19 (63.3%)

2005

304

146 (48.0%)

158 (52.0%)

118 (48.0%)

128 (52.0%)

—

—

28 (48.3%)

30 (51.7%)

2006

313

153 (48.9%)

160 (51.1%)

126 (48.5%)

134 (51.5%)

—

—

27 (50.9%)

26 (49.1%)

2007

387

186 (48.1%)

201 (51.9%)

157 (48.8%)

165 (51.2%)

—

—

29 (44.6%)

36 (55.4%)

2008

423

202 (47.8%)

221 (52.2%)

133 (47.7%)

146 (52.3%)

12 (48.0%)

13 (52.0%)

57 (47.9%)

62 (52.1%)

2009

454

192 (42.3%)

262 (57.7%)

116 (41.1%)

166 (58.9%)

9 (42.9%)

12 (57.1%)

67 (44.4%)

84 (55.6%)

2010

500

216 (43.2%)

284 (56.8%)

99 (40.7%)

144 (59.3%)

34 (50.7%)

33 (49.3%)

83 (43.7%)

107 (56.3%)

2011

467

193 (41.3%)

274 (58.7%)

42 (26.9%)

114 (73.1%)

76 (52.8%)

68 (47.2%)

75 (44.9%)

92 (55.1%)

2012

543

229 (42.2%)

314 (57.8%)

32 (26.2%)

90 (73.8%)

90 (49.5%)

92 (50.5%)

107 (44.8%)

132 (55.2%)

Total medical students

3698

1673 (45.2%)

2025 (54.8%)

968 (44.3%)

1219 (55.7%)

221 (50.3%)

218 (49.7%)

484 (45.1%)

588 (54.9%)

School leaver pathway group (studying first degree)

167 (47.3%)

186 (52.7%)

—

* χ2 = 16.18; df = 8; P = 0.04. † χ2 = 2.41; df = 8; P = 0.97. ‡ χ2 = 51.95; df = 8; P < 0.001. § χ2 = 0.929; df = 4; P = 0.92. School leavers with guaranteed entry into medicine but still completing their first non-medical degree at the University of Queensland at the time of analysis and not yet commenced medical course. These students are not included in the column totals.

2 Proportions of male and female medical students enrolled through the direct graduate-entry pathway

3 Mean GAMSAT scores by gender for 2047 medical students enrolled through the direct graduate-entry pathway in 2004–2012

Mean (SEM; 95% CI)

GAMSAT score

Female students

Male students

F (df)

P*

Partial
eta-squared

Section I

63.32 
(0.21; 62.92–63.73)

62.76 
(0.16; 62.44–63.07)

4.62 
(1,2029)

0.03

0.002

Section II

64.27 
(0.27; 63.73–64.80)

63.59 
(0.21; 63.17–64.00)

3.84 
(1,2029)

0.05

0.002

Section III

68.45 
(0.30; 67.87–69.04)

71.53 
(0.23; 71.07–71.98)

65.42 
(1,2029)

< 0.01

0.031

Overall score†

66.07 
(0.17; 65.74–66.41)

67.35 
(0.14; 67.08–67.62)

34.03 
(1,2043)

< 0.01

0.016

GAMSAT = Graduate Medical School Admissions Test. * Bonferroni-adjusted level = 0.017. † Overall score = (1 × section I score + 1 × section II score + 2 × section III score)/4.

The cost of teaching an intern in New South Wales

In Australia, the first year after medical graduation is called the intern year, a transition between formal medical school education and subsequent vocational training. Its successful completion is a requirement for medical registration.

In New South Wales, the Health Education and Training Institute (HETI), a statutory health corporation, is responsible for setting and monitoring standards for internship and postgraduate training. HETI allocates interns to one of 15 prevocational training networks. Each network provides a mixture of rotations at metropolitan, rural, and regional hospitals to ensure wide clinical experience. Intern training is supervised by Directors of Prevocational Education and Training (DPETs).

Teaching received by interns can be regarded as formal or informal. Formal teaching is organised by the DPET in each hospital, who is assisted by Junior Medical Officer (JMO) managers in each network. It consists of timetabled teaching sessions in protected time, delivered as lectures, tutorials or practical sessions. This requires infrastructure and financial support. Some of this is provided at HETI, such as training grants and the committees and staff required for statewide governance of intern teaching. Some is provided where the interns work, such as JMO managers, education support officers, DPETs, teaching facilities and skills-training facilities.

We defined informal teaching as being spontaneous, non-timetabled and sporadic. It may occur during a ward round, a walk along a corridor or at the end of a consultation. It can be initiated by the intern or the intern’s supervisor as well as registrars, staff specialists and other health care professionals.

Intern education also includes department meetings and grand rounds, which interns may be encouraged to attend but which are not aimed specifically at them. A further mode of education involves the acquisition of skills and knowledge by observation and practical experience. These forms of education were not included in this study.

The aims of this study were to determine: the salary-related and infrastructure costs of timetabled, formal teaching provided specifically for interns; the amount of non-timetabled informal teaching received by interns and its salary-related cost; the total cost per intern of providing teaching, by combining these estimates; and how much of an intern’s time is committed to formal and informal teaching.

Methods

Formal teaching

The cost of formal intern teaching for 2012 was estimated by HETI after wide consultation with administrators, educators and clinicians within HETI and the prevocational training networks. It included costs of medical and administrative staff responsible for the organisation and local delivery of formal, timetabled intern teaching, infrastructure costs and governance costs. In NSW, the prevocational training program manages teaching for resident medical officers (RMOs) as well as interns, but costs were allocated on a pro-rata basis depending on what proportion of the program was allocated to intern teaching. Time involved in preparing teaching sessions was not included.

A telephone survey of JMO managers in the sampled networks (see below) was conducted to determine the number of hours of formal, structured teaching provided each week for interns in their networks.

Informal teaching

The salary-related cost of non-timetabled teaching was estimated from a self-completed internet cluster sample survey of interns in May 2012. The clusters were the 15 prevocational training networks. These were numbered sequentially and a sample of five was drawn by random numbers. During 2012, the total number of interns in the 15 networks was 870. Every intern within each of the five sampled networks was invited by email to participate in the survey. Those who agreed were sent an online survey form that asked for separate estimates of the amount of non-timetabled teaching received in a typical week during their current rotation from five categories of teacher:

  • RMO, registrar or Fellow;

  • general practitioner;

  • visiting medical officer (VMO), staff specialist or university academic;

  • nurse;

  • allied health or other professional.

Respondents could report an estimate of teaching time received in steps of 5 minutes, ranging from zero to 60 minutes, then in categories of 1.5 hours, 2 hours and 3 or more hours. Those who had agreed to participate but who did not complete the survey initially were reminded on two occasions.

The times reported for each category of teacher were summed across all respondents and the total multiplied by an appropriate hourly dollar rate to give an estimated weekly total dollar value for each teacher category. These were then summed over all teacher categories to give an overall estimated weekly total cost for the whole sample. The various hourly rates were determined as follows. As the senior staff specialist rate1 with all on-costs is about midway between the VMO (specialist) rate2 and the senior academic rate3 with on-costs, the senior staff specialist hourly rate ($160.06) was used for calculating the value of teaching by these three groups. The GP rate ($167.35) was based on the NSW Health Award 2012 rate for a GP with at least 5 years’ experience.2 Junior hospital staff teaching costs were based on the second-year registrar rate plus on-costs ($58.31).4 Because of the variation between different awards for nursing, allied health and junior hospital staff, the junior hospital rate was used as an approximation for these three groups.

Results were expressed as total time or dollar values, means and standard deviations or medians as appropriate. Confidence intervals were at the 95% level.

The study was approved by the University of Sydney Human Research Ethics Committee.

Results

Formal teaching

For 2012, HETI estimated the expenditure provided by the NSW Ministry of Health for the teaching of 870 interns to be $10 345 829 (Box 1), equivalent to $11 892 for each intern.

The telephone survey of JMO managers showed that an intern received an average of 2 hours of formal, structured teaching. This figure validated the 0.25 days per week (2 hours) provided by HETI for formal teaching sessions.

Informal teaching

Of the 243 interns in the five sampled networks, 154 responded, giving a response rate of 63%. The response rate differed significantly among the networks (P = 0.001; χ2 test), ranging from 45% to 79%. In all networks the distributions of estimated total weekly teaching time were distinctly positively skewed with maxima ranging from 75 to 255 minutes but medians ranging from only 20 to 30 minutes (Box 2). The overall weekly median was 28 minutes, with no significant difference among the five networks (P = 0.21; Kruskal–Wallis test).

The 154 respondents received a total of 101 hours of teaching per week. Slightly over half (51.4%) of the total teaching time was from RMOs, registrars or fellows, and slightly over a third (34.5%) was from VMOs, staff specialists or academics. Slightly less than 10% (9.3%) was from nurses, and less than 1% (0.7%) was from GPs. Allied health and other professionals contributed slightly less than 5% (4.3%). At the relevant hourly salary rates for the various categories of teacher, the total cost of informal teaching to the 154 sampled interns in a typical week was $9513 (Box 3). Assuming 48 working weeks per year, the annual cost of providing informal teaching for the 154 interns sampled was $456 624, or $2965 per intern.

The combined cost of formal ($11 892) and informal ($2965) teaching was $14 857 per intern per year.

The time allocated to formal intern teaching (2 hours per week) and the median for informal teaching (28 minutes per week, Box 2) show that in the networks sampled, 2 hours and 28 minutes of teaching was received by interns each week. Assuming a 40-hour working week, this amounts to 6.2% of their time.

Box 4 shows how the total cost would increase if a proportion of an intern’s salary was considered to be a teaching cost. For example, assuming that an average 20% of an intern’s time was spent receiving teaching would add an additional $15 303 to the cost, totalling $30 160.

Discussion

Most of the $14 847 overall cost of teaching an intern was for formal teaching ($11 892), and most of this was provided by professionals (staff specialists, VMOs, nurses and clinical academics) whose payment came from NSW Health. Relatively little was provided by university-paid staff.

The cost is based on an assumption that none of an intern’s salary is related to teaching and that the intern performs a service role only.

Alternatively, it could be argued that part of the intern salary is a teaching expense, with intern work being part of their education rather than for service provision. For example, in the emergency department, interns are effectively supernumerary: their work provides them with invaluable educational experience, but adds little to patient throughput. In contrast, in surgical wards, interns free residents and registrars from clerical and ward duties and increase total work capacity. The real contribution of interns to work productivity in health services would require a different study.

There is much more involved in intern education than the formal and informal teaching considered in this study. The intern’s experiential learning includes observation, self-learning practical experience, self-reflection and the influence of role models. The importance of these experiences should not be underestimated.

NSW Health makes a significant contribution to medical student teaching as well as intern teaching. At Sydney Medical School, we recently showed that the cost of medical education was $90 576 per student per year. The cost to the university was $56 250 and the cost of non-university-paid staff (mainly from the NSW Health Department) was $34 326 per student per year.5,6

Considerable concern has been expressed in Australia and overseas that relatively little time is spent on education during the intern year,7–16 and it has been suggested that the intern year should have a greater educational emphasis than service emphasis.15 There are few estimates in the literature of the proportion of interns’ time devoted to education. It has been reported that, on average, junior doctors in the Netherlands spent about 5% of their time per week receiving organised formal education.7 In the United Kingdom, junior doctors’ spent most of their time on routine work and most considered that training constituted less than 10% of their working time.11 A survey of Australian junior doctors found that half spent 1–2 hours per week receiving education, and 10% reported spending no time receiving education, including bedside teaching, tutorials or grand rounds.9

Regarding a 2009 survey of junior doctors conducted by the Australian Medical Association (AMA), the chair of the AMA Council of Doctors in Training concluded,

We are concerned that the survey shows that the obligation of hospitals to teach and train junior doctors is being outweighed by the demand for service delivery, and this trend is worsening.17

Workload issues are regarded as a major factor in reducing the emphasis on education.7,10,12,15,16 This is not helped by the fact that the Medical Board of Australia currently has no minimum attendance or participation requirements to qualify interns for progression to general registration.18 However, the Australian Medical Council is currently completing work for the Medical Board of Australia aimed at providing a standard framework for intern training in the national registration and accreditation scheme which came into effect in July 2010.19

Our finding that 6% of an intern’s paid time is spent in formal and informal teaching is consistent with these findings. It is in stark contrast with the recommendation of the Special Commission of Inquiry in its final report on acute care services in NSW public hospitals that prevocational clinical staff in Year One should spend a minimum of 20% of their ordinary rostered time participating in training programs.20 This recommendation recognises that better education will enhance patient care.

Considerable public benefit could result from intern positions being restructured so that 20% of interns’ time was spent receiving formal and informal teaching: doctors would be better trained and more competent; medical errors would be fewer; and the care of patients managed by interns would improve.21 However, this raises the question of who would pay for this additional teaching, as well as the problem of finding the required extra number of interns to provide a service role if 20% of their time were devoted to education rather than direct service.

Quarantining 20% of intern time for education would require hospitals to increase their intern numbers. This would help to resolve the current imbalance between new graduates and available intern posts.

However, there would be a cost. The first step in determining this increased cost would be to unravel the current cost of intern training. Understanding the true cost of intern training is complex, as some of it is hidden within the cost of providing clinical services. While we have looked specifically at formal and informal teaching costs, the current work of the Independent Hospital Pricing Authority may be able to “unbundle” some of the hidden education on-costs, resulting in a suitable mechanism to provide activity-based funding for education and training.

A component of activity-based funding for intern education and training would defray some of the cost of increased intern positions. This would be a federal government contribution, similar to the federally funded direct and indirect graduate medical education payments provided to hospitals in the United States.22

It could be argued that universities could also contribute to better intern education if universities saw their medical degree courses as just one step in the medical education process.

Finally, private hospitals could fund some intern positions. Interns are now taking up positions in private hospitals, some supported by federal funds. Private hospitals would benefit from the service interns could provide and be expected to contribute to their training costs.

Whatever funding mechanism is determined, it should be recognised that adequate funding of intern teaching is an investment in the future, as many of these interns will continue to provide services to patients in hospitals in NSW and other states throughout their professional careers.

1 New South Wales Ministry of Health costs for intern teaching*

Item

Proportion towards intern teaching

Amount ($)

Basis for calculation

Expenses at HETI

HETI Medical Director

20%

$86 564

Senior staff specialist with 30% on-cost plus private practice allowance

Accreditation program and surveys

66%

$901 825

Salaries, expenses and overheads

Clinical Chair, accreditation

66%

$43 948

Senior staff specialist plus all costs, 0.2 weeks

Prevocational training program

66%

$316 680

Salaries, expenses and overheads

Clinical Chair, training council

66%

$54 935

Senior staff specialist plus all costs, 0.25 weeks

Prevocational training grants

66%

$548 055

Subsidy from HETI for prevocational training costs

Intern assessment process

100%

$11 597

Printing, distribution and collection of forms

Prevocational committees

66%

$50 708

Secretariat and committee members’ time

Expenses at workplace

JMO managers and support officers

66%

$1 853 280

2 days/week at 60 sites at $90 000 per annum

Term supervisors for interns

100%

$1 976 279

Average of 1 day of work/term

Directors prevocational education and training

66%

$1 948 878

0.8 days/week at 60 sites, senior staff specialist plus all costs

Intern training committees

100%

$48 447

Committee members’ time

Formal education sessions specifically for interns

100%

$998 810

0.25 days/week at 60 sites, senior staff specialist plus all costs

Orientation, venepuncture, cannulation and plastering training

100%

$875 163

Staff time plus disposables

Teaching facilities

100%

$870 000

Infrastructure, maintenance and depreciation, estimated at $1000 per intern

Total

$10 345 829

HETI = Health Education and Training Institute. JMO = junior medical officer. * Workforce-related costs, such as intern allocation, intern accommodation while on rotation, and human resources management of interns are not included in these calculations.

2 Distribution of total teaching time (min) over the five categories of teacher among the five sampled networks

Network

Minimum

Maximum

Median

Skewness

A

0

200

20

2.5

B

0

165

25

2.0

C

0

75

30

0.5

D

0

255

23

2.7

E

0

180

30

2.1

Median

–

–

28

2.5

3 Estimates, by 154 interns who responded to the survey, of non-timetabled one-to-one or small-group teaching received in a typical week of their current rotation

Provider of teaching

Received teaching, no. (%)

Did not receive
teaching, no. (%)

Total hours/week
(% of overall total of 101 hours)

Hourly
rate

Total
cost/week

Resident medical officer, registrar or fellow

129 (83.8%)

25 (16.2%)

51.9 (51.4%)

$58.31

$3026

General practitioner

3 (2.0%)

151 (98.0%)

0.7 (0.7%)

$167.35

$117

Visiting medical officer, staff specialist, or academic

115 (74.7%)

39 (25.3%)

34.8 (34.5%)

$160.08

$5571

Nurse

61 (39.6%)

93 (60.4%)

9.4 (9.3%)

$58.31

$548

Allied health professional or other professional

23 (14.9%)

131 (85.1%)

4.3 (4.3%)

$58.31

$251

Total

–

–

101.1

–

$9513

4 Cost of intern education, by proportion of an intern’s salary considered to be teaching cost

Proportion of intern salary* considered as teaching cost

Formal teaching costs (HETI and health services)

Informal teaching provided during work hours

Total cost
of intern teaching

0

$11 892

$2 965

$14 857

10% ($7 651)

$11 892

$2 965

$22 508

20% ($15 303)

$11 892

$2 965

$30 160

30% ($22 954)

$11 892

$2 965

$37 811

50% ($38 257)

$11 892

$2 965

$53 114

* $76 515 per annum including on-costs. HETI = Health Education and Training Institute.