The need for quality and quantity in emergency medical care rotations for interns

To the Editor: A national registration standard for internship
will apply from 2014.1 In addition to
10-week rotations in medicine and surgery, interns will need to obtain
8 weeks’ experience in emergency medical care. A national framework
for the accreditation of intern training programs is also being developed.2

The new standard allows emergency medical care rotations outside of emergency departments (EDs), including selected general practices. Although primary care settings can facilitate valuable training, there is limited evidence that a community placement can effectively substitute
for an emergency medicine term.

Emergency medicine terms expose interns to a broad range of acute undifferentiated illness not often encountered in other rotations.3 These terms also facilitate acquisition of key skills and knowledge, including the ability to prioritise under time pressure, recognise “sick” and “well” patients, perform common procedures and interact with other health care team members.3,4 EDs are the most appropriate setting for this generalist medical experience.

Rigorous assessment of interns is an important but under-recognised capability of the emergency medicine experience. A recent study showed that ED-based terms are crucial in detecting underperformance,5 which probably relates to the proximity of supervision, the requirement for interns to act as primary treating clinician and the necessity for decision making. EDs may be the only setting where interns’ clinical skills are directly observed.

Supervisory capacity may limit provision of ED-based experiences4 and, with expanding graduate numbers,6 demand will increase further. Although emergency medicine terms in alternative settings may improve access to placements, the accreditation framework2 must protect against
any dilution of clinical experience. Guidelines must define minimum standards for training opportunities, supervision and assessment, not just casemix.

Solutions that sustainably increase ED training capacity should be supported, including innovative models of supervision. Structured teaching and simulation also have roles.4 The More Learning for Interns in Emergency (MoLIE) program, for example, increases training capacity and simultaneously enhances the educational experience.7

Australia must continue to support learning in emergency medicine by sufficiently resourcing EDs to deliver high-quality teaching and training to interns, and the unique elements of emergency medicine rotations must be protected by robust accreditation standards.

International medical electives undertaken by Australian medical students: current trends and future directions

In response to the increasing interest among medical students and junior doctors in studying and practising medicine abroad, the Medical Journal of Australia recently published A guide to working abroad for Australian medical students and junior doctors.1 It is in the context of increasing interest in global health2 and in the spirit of supporting young medical professionals that this study examines international medical electives (IMEs), specifically the number of Australian medical students undertaking them, and the support provided to those students by Australian medical schools.

Electives are a compulsory component of all medical curricula in . They are usually undertaken during senior clinical years over 2 to 8 weeks, either in or overseas, in both high- and low-resource settings. Consistent with increasing interest in global health, IME rates have been found to be high in the and increasing in the .2,3

Many benefits of IMEs have been described. Students report less dependence on technology; improved clinical, diagnostic and communication skills; better knowledge of tropical diseases and immigrant health; and better understanding of prevention, primary care and public health.2,4 Participation in IMEs influences students’ career choices towards primary care specialties, graduate education in public health, and working with underserved populations.5,6 In contrast, the potential benefits to communities hosting students on medical electives have received little attention and are poorly understood.4

IMEs also present potential risks and harms to both the student and the host community. Risks to the student include transmission of disease, needlestick injuries, traffic accidents, crime-related injuries, and mental health problems.7 Potential harms to host communities, particularly in developing countries, emerge from a power imbalance between visiting students and host communities, and the potential for students focused on learning objectives to compromise patient care and community wellbeing.8 As a result, IMEs may falsely raise expectations, impose burdens on local human resources, and impede continuity of and access to care, ultimately compromising equity and sustainability.9

Predeparture training and post-elective debriefing can provide students with guidance and support to reduce potential harms and maximise the benefits of IMEs.10 Predeparture training prepares students with the tools to manage the ethical, cultural and logistical challenges they may encounter. Postelective debriefing provides a forum for students to discuss and explore any issues that arose, consolidate learning, and encourage the development of students as responsible doctors.

At present no study has evaluated the proportion of Australian medical students undertaking IMEs and the support offered by Australian medical schools. This study set out to remedy this evidence gap.

Methods

The Medical Schools Outcomes Database (MSOD) is a national initiative for longitudinal tracking of medical students through medical school and into prevocational and vocational training;11 it began collecting data nationally in 2006. In May 2012, we obtained data from the MSOD covering the period 1 January 2006 to to establish the number of students who undertook IMEs. Students consent to participate in the MSOD project in their first year of medical school, and are subsequently included in annual follow-ups. Therefore, the 2006 data only include Year 1 students, the 2007 data include students in Years 1 and 2, the 2008 data include students in Years 1, 2 and 3, and so on. As a result, four cohorts of students within the dataset had graduated and were used to estimate the total proportion of medical students who undertake at least one IME during their degree. Students who took more than one IME were counted once, and we estimated cohort size using the total number of students who were registered in the final year of their medical course.

We also conducted structured interviews with academic staff from 16 of the 19 Australian medical schools (those at the University of Notre Dame in Sydney and Fremantle have different curriculums and are considered as separate schools in this study). Data were collected from Australian medical schools between May and July 2012 and reflect the program status at that time.

We divided medical education programs into high-school entry (HSE) programs (5- or 6-year programs that admit students after they complete high school, although some students may have a prior degree) and graduate-entry (GE) programs (4- or 5-year programs that require students to have a prior undergraduate degree). Programs with a mid-year intake (ie, 4.5-year programs) were treated as 5-year programs.

We collected data on predeparture training and postelective debriefing independently from each medical school in . Data were collected in cooperation with the Australian Medical Students’ Association (AMSA) and the AMSA Global Health (AGH) Committee, which comprises student representatives from every medical school in Australia. AGH Committee representatives were provided with letters of introduction, information sheets, consent forms, interview scripts, and response forms. Representatives were asked to gain consent and conduct an interview with the director of their medical program.

The income status of countries where students undertook electives was based on the World Bank Atlas Method. Lower- or middle-income countries included countries with a gross national income (GNI) per capita of less than US$12 275.12 For the purposes of this analysis, states that remain protectorates were placed in the same category as the protecting country.

Ethics approval for release of MSOD data was granted by the Medical Deans Australia and New Zealand Research and Scientific Advisory Committee (SA-2012-003). Ethics approval for data collection from medical schools was granted by the Social and Behavioural Research Ethics Committee at (Project N 5561).

Results

MSOD data

Participation in the MSOD over our study period averaged 88% of students enrolled at Australian medical schools.11 The four cohorts in our study included the 5-year HSE program cohort that commenced in 2006, and three GE cohorts (the 4- and 5-year program cohorts that commenced in 2006, and the 4-year program cohort that commenced in 2007). Our findings on students in these cohorts who undertook IMEs are summarised in the Box.

Medical school interviews

Currently, 12 of the 16 Australian medical schools interviewed offer some form of predeparture training. However, in only six of these schools is predeparture training mandatory. The average duration of predeparture training is 4.7 (SD, 4.22) hours. By comparison, eight schools offer some form of postelective debriefing. However, in only three schools is this mandatory. The average duration of postelective debriefing is 1.2 (SD, 0.91) hours.

Discussion

Our findings show that a significant proportion of Australian medical students undertake IMEs, and that more than half do so in developing countries.

Our estimates show that a greater proportion of Australian medical students undertake IMEs compared with US medical students. The estimated proportion of US medical students who undertook IMEs in 2007 was about 30%, and all of these were GE program students.13 By contrast, a study from the UK (where most medical schools offer HSE programs) estimates that 90% of medical students undertake IMEs, with 44% of them doing so in developing countries.3 While a much smaller proportion of Australian GE and HSE students undertake IMEs than UK students, a greater proportion of them do so in developing countries.

Considering that a significant proportion of Australian medical students undertook electives in developing countries, it is concerning that predeparture training and postelective debriefing are not offered to all students, and that what is offered is not always compulsory. However, improvement is achievable. In 2008, only 11 of the 17 Canadian medical schools offered predeparture training, and in only six of these was such training mandatory.14 By 2010, this had increased to 16 out of 17 schools offering predeparture training, with 11 making it mandatory.15 A similar transformation in is both necessary and possible.

Our study was limited by the lack of data for Year 6 HSE students, relatively small cohort sizes in senior years, and less than full participation in the MSOD program. Nonetheless, our data provide a foundation for further research into the content of predeparture training and postelective debriefing and financial support offered by Australian medical schools, as well as the benefits and acceptability of predeparture training and postelective debriefing programs to students. We encourage medical schools to scale up predeparture training and postelective debriefing that adequately prepare students to undertake safe and ethical electives. We also recommend that a similar study be repeated in 3 to 5 years to evaluate progress in predeparture training and postelective debriefing.

Students who both commenced and graduated from an Australian medical school during 2006–2010 and who undertook international medical electives (IMEs)

Variable	All students(n = 2101)	HSE program students(n = 383)	GE program students(n = 1718)
Students undertaking an IME	1044 (49.7%)	135 (35.3%)	909 (52.9%)
IME in a lower- or middle-income country	613 (58.7%)	75 (55.6%)	538 (59.2%)
IME in country of birth*	110 (10.5%)	21 (15.6%)	89 (9.8%)

GE = graduate-entry. HSE = high-school entry.* International students.

Gaining a patient’s perspective while becoming a doctor

A medical student learns by seeing the system from the other side

Two doctors, both aged over 70 years, teach our rotation of medical students. They stress “old-fashioned” values, including accurate history-taking, thorough physical examination, punctuality and courtesy. In an era of high-technology medicine and high patient throughput, how relevant are these dated principles?

Assigned to the best private hospital in the city, crammed with top specialists for my clinical placement year, it was downhill from there, I believed. I headed off to play squash after observing a protracted total hip replacement one night and felt on top of my game. A tinge of arrogant invincibility may have been the incentive to stretch just a bit further for an impossibly low wall shot. I reached it, won the point and tore my plantaris, soleus and gastrocnemius muscles at the same time.

Rest, ice, compress, elevate; just one of countless mnemonics to implement. I attended our surgery rotation on borrowed crutches the next morning and sought an informal opinion. With the coffee table between us, the consultant proclaimed: “gastroc’s largely intact and will heal with immobilisation — no need for surgery — you’ll be fine”. In naive faith, I hobbled between operating theatres in a loaned orthopaedic boot. Pain is for wimps, doctors don’t take time off and the course very effectively weeds out those who cannot cope. By the end of the week I realised I was a wimp. My leg started to swell and I could no longer sleep so I sheepishly took myself to the hospital’s accident and emergency centre.

I was grateful to be bulk-billed and seen after a long list of the more deserving, who had paid to be there. Had I not been the patient in this scenario, I might have breezed in to solicit a clinical history and been irritated by a patient’s rambling version of events when all I needed was a concise and structured account for my case presentation. I prepared for the interrogation, determined I would impress. Finally, the big moment arrived. There were no students, only the specialist and he was clearly rushed. I felt like a freeloader. He asked how I had injured my calf, cut me off to write a request for ultrasound and vanished. After being parked in the corridor for a couple of hours, I was wheeled to ultrasound with a referral letter that stated annoyingly, “the patient showed no obvious signs of discomfort”, and made a host of other statements, some accurate, that must have been transferred from me by telepathy. The ultrasound technician was equally terse. Seeing my trousers still on, she reiterated they were “very busy”. I was wheeled back to accident and emergency for another hour until the specialist popped his head around the corner and said, “deep vein thrombosis”, and, while reading the ultrasound report, asked the nurse to give me a shot of low molecular weight heparin (you don’t need consent from a medical student). Once done, he came back with a prescription and instructed me to self-inject twice daily, purchase graduated compression stockings and make an appointment with a vascular physician. As he attempted an exit I asked about pain control and was told to continue over-the-counter preparations. I hobbled off for 2 hours of painful waiting to get the prescription, and another half hour to work out that the stockings they measured me for (twice) were not in stock. My wife drove me around the city in search of another source; a faxed prescription then had to be sought while we waited out the remaining hours of the day. No time for ice, compression or elevation!

Three days later, still in agony, unable to sleep or study, I managed with difficulty to convince the vascular specialist’s receptionist to squeeze me in between appointments 5 days early. This time there was no reduction in fees and I began to worry whether I could afford it. No examination was performed and no history taken. My request for an opiate was granted and I learned that the deep vein thrombosis was over 70 cm long and would be imaged again in a couple of months. The big fee however came with new advice: “mobilise . . . and get back to hospital if you cough blood”. I hobbled down another long corridor to the pathology lab and waited another hour for a blood test. My calf throbbed and I received a stern look from the receptionist when I attempted to elevate it onto the chair opposite. I contemplated whether one specialist’s advice to immobilise had now been trumped by new advice to mobilise. At least the opiate allowed me to sleep. I tried to study but achieved little except worrying about my medical bill and inability to continue my part-time job, not to mention that our university is inflexible — miss 2 weeks and you fail the year. So, not daring to incur the wrath of surgeons by sitting down, I dutifully perched around the surgery table for the rest of the month.

After rounds, one of the elderly doctors nominated me to present a case. I had not had the energy to get around the wards and had contemplated abandoning the course when re-imaging showed a near total rupture of the Achilles tendon that had been missed. We “de-identify” patients, so I presented my own case to cover for my failure to find a suitable case to present. He took me aside and told me that, in his opinion, it was a priority that I miss his tutorials for the rest of the week and sit with my leg up. By the following Monday, the swelling that had refused to diminish over weeks had receded. I was able to stop taking opiates and start to study again. My iconic, high-pressure, state-of-the-art mentors, thriving on challenging cases and for whom every minute is valuable had failed, over many weeks, to notice a person behind the condition.

The most valuable lesson I learned at the best private hospital in town is what it is like to be a patient.

Closing the global gender gap

Education is the key to not only better health outcomes but also less global conflict

Today, sex-based inequalities and inequities shape how individuals are disproportionately exposed to adverse determinants of health. Our sex can determine how well or ill we become, and if or how our health care needs are acknowledged and met.1 The underlying reasons for this disparity are complex and diverse, shaped by how sex and sexual customs interact within varying political and social contexts. Discriminatory values, norms and behaviours, different exposures and disease vulnerability, and health system and health research biases all interact to result in sex-based inequities in health outcomes.1 Conversely, ill health, in and of itself, can also negatively influence social and economic outcomes.

The World Economic Forum has developed a framework, the Global Gender Gap Index, to measure sex-based disparities among countries and to track these disparities over time.2 The framework outlines and examines inequities between men and women in four broad categories: economic participation and opportunity; educational attainment; health and survival; and political empowerment. These four “pillars” are considered essential in recognising the importance of the role of women in society and in diminishing the gaps between the sexes. According to this framework, no country has, as yet, achieved sex equity in all of these four categories, although some countries (eg, Scandinavian countries) are getting close to achieving this goal.

The framework also highlights that high-income countries often have fewer sex-based inequities than low-income countries.2 It is well known that, generally speaking, women in low-income countries fare far worse in terms of health outcomes, and are more likely to experience death during youth and adolescence than those in high-income countries. Maternal mortality exemplifies this, with the vast majority of maternal mortality occurring in low-income countries with weak institutional (including health) structures.

Why has no country in the world achieved sex-based equity? Is inequity between the sexes not an abuse of human rights? It is imperative that action be taken, and I would argue that the most fundamental action required is to provide all women with the opportunity of education.

Educating women has been shown not only to improve health, but also to decrease population growth, decrease child mortality, decrease child marriages and increase the participation of women in the labour force — all of which lead to faster economic growth and decreased poverty. Education is the key to building community capacity, as it provides individuals with the knowledge to participate in society.3 Education is also the key to resolving conflict, locally, regionally and globally, as it has also been shown that less conflict occurs in societies where women have higher economic and social status.4

Globally, there have been strong efforts to ensure access to primary education for all children. World Bank Group data show that, in 1999, 105.6 million children were identified as out-of-school children (ie, not enrolled in primary school); 58% of these were girls and 42% were boys. By 2009, the number of out-of-school children had decreased to 67 million; 52% of these were girls.5 Education is lacking in many regions in the world,3 so this global gap is much larger in specific regions of conflict or low-income countries.

For example, in Afghanistan, 2009 data from the World Bank Group show that the expected years of schooling for a child vary greatly by sex. Boys are in school for an average of 11.2 years; girls, 6.8 years.5 From a global perspective, sub-Saharan Africa is home to half of the world’s out-of-school girls, and South Asia to a quarter.6 Nigeria, Pakistan and India, the three countries with the most out-of-school children, are recognised for their poor treatment of women.6

We need to ask why women are treated as second-class citizens in terms of access to health care and education in developing countries. A global effort is needed to change this pattern, to change the societal view of women, with the goal of promoting equal access to education for girls. Our path forward, as men and women, is to complement each other, not to compete; to create a balance and harmony in relations, not to strengthen one over the other; for all to be strong, and to eradicate domination. Collective efforts are needed from us all, because no one person or group can do everything. Men’s participation, awareness and engagement in this goal will be vital. A global society of freedom, justice and peace will not be achieved unless all human needs are met.7