With a concerning number of individuals with serious health conditions favouring homeopathic medicines over conventional treatment, Australia’s National Health and Medical Research Council (NHMRC) recently declared that homeopathy was not efficacious for treating any health condition.  Given homeopathy has existed  since the 18^th century as an alternative medical approach to treatment, the declaration naturally sparked tension with leading homeopathic authoritative bodies and practicing homeopaths.  This article aims to review the laws and regulations underpinning homeopathy and its preparations in Australia, and critically appraises the opinions of major organisations for and against the use of homeopathic medicines in treating serious health conditions.  It provides a brief overview of how clinicians can address the issue of using homeopathic remedies as an alternative to mainstream medicine with patients.  Despite the positions of two leading homeopathic authoritative bodies, the Australian Homeopathy Association and Complementary Medicines Australia, against the NHMRC declaration; there is strong evidence to suggest the need for stricter industry regulations of homeopathic practice and preparations in Australia so as to maximise the health and safety of consumers.  There is also strong scientific evidence to suggest that homeopathic remedies are unlikely to have clinical effects beyond placebo.  Given this, it is up to clinicians to educate their patients and provide them with all the relevant information to not only maximise their health outcomes but also facilitate well-informed decision making regarding homeopathy.

Introduction

Homeopathy, a branch of complementary and alternative medicine founded in the 18^th century, is commonly used in Australia and worldwide on a regular basis as a form of treatment for a number of health conditions.  It is based on two principles: 1) minute doses of substances that mimic illness or symptoms in healthy individuals can be used to treat the same illnesses or symptoms in those who are unwell; and 2) highly diluted preparations retain “memory” of original substances. In March 2015, the National Health and Medical Research Council (NHMRC), Australia’s peak medical research organisation, declared that homeopathy was not efficacious for treating any health condition [1], sparking tension with practicing homeopaths.  The investigation was prompted after a concerning number of individuals with serious health conditions put their health at risk or delayed evidence-based treatment by favouring homeopathic medicines [2]. The NHMRC undertook a systematic review, overseen by their Homeopathy Working Committee (HWC) in which only controlled studies were considered i.e. those that compared a group of people who received homeopathic treatment with a similar group of people who did not receive homeopathic treatment [2]. Following this major systematic review, the latest NHMRC Strategic Plan 2013-15 has responded by broadening its aim to facilitate informed decision-making by Australians regarding their healthcare and the use of non-evidence based treatment [3]. The declaration by the NHMRC has sparked tension with leading homeopathic authoritative bodies. This article aims to review the laws and regulations underpinning homeopathy and its preparations in Australia. It critically appraises the opinions of major organisations for and against the use of homeopathic medicines for treating serious health conditions through evidence and case studies. Lastly, a brief overview of how clinicians can address the issue of using homeopathic remedies as an alternative to mainstream medicine with patients is provided.

Basic principles of homeopathy

Homeopathy, first articulated by a German physician in the 18^th century, Dr Samuel Hahnemann (1755-1843), refers to a unique scientific system of medicine based on the principle of similarity (“like cures like”) [4,5]. Hahnemann describes this principle as a reactive process whereby giving minute doses of a substance thought capable of inducing a series of symptoms in healthy individuals can be used to cure the same symptoms in those suffering (“similia similibus curantur”) [4,5]. Derived from the Greek words hόmoios meaning similar and pathos meaning suffering, disease; the aim of this “simile-based” therapy is to restore health using a “holistic” approach by individually tailoring homeopathic remedies to enhance the individual’s natural healing processes and strengthen their body’s ability to fight against susceptibility of disease [6,7].

The phenomenon underpinning homeopathy as described by Hahnemann was that for homeopathic substances, the higher the dilution, the higher the potency [8]. In Britain, for example, two common preparations are sold over-the-counter: 6C and 30C dilutions. The 30C dilutions are significantly more dilute than the 6C (1 in 100³⁰ vs. 1 in 100⁶ respectively), with the former considered to be more potent [4]. To explain this phenomenon, Hahnemann described that when the preparation is vigorously shaken between each dilution, the energy or essence of a substance is transferred to a solvent, a process called “potentiation” and “succession”, whereby a “memory” of the initial substance is retained in the solution [2,5]. This process is how the purported therapeutic effect is achieved [8]. The most common dilution factor is 10⁶⁰, which can vary depending on the constituents and strengths [5]. Homeopathy is thus a form of therapy based on similarity and dilutions that considers the person as a whole so as to enhance the body’s natural healing processes against various health conditions. However, it is important to highlight here that due to the extensive dilution, standard scientific theory would attest that the final homeopathic preparation is statistically unlikely to contain a single molecule of the original active ingredient [9,10].

Laws and regulations underpinning homoeopathy and homeopathic preparations in Australia

Originally, homeopathy was a self-regulated industry in Australia controlled by individual-state based organisations [11]. In 1997, these organisations merged to form what is known today as the Australian Homeopathy Association (AHA), which is the only national association of professional homeopaths in Australia that maintains the Australian Register of Homeopaths (AROH) [11,12].

Currently, to acquire a private health fund rebate for their services, homeopathic practitioners must be registered with AROH [13]. The AROH guidelines for registration necessitate that all registered practitioners have either passed a competency test for those who have not studied a homeopathic course accredited by AROH or have attained a three-year Advanced Diploma Course at a recognised institution; hold a current first aid certificate; maintain annual professional indemnity insurance; and undergo regular continuing professional development requirements [14]. Furthermore, homeopaths must abide by the AHA Code of Conduct as endorsed by the National Council, which requires them to refer patients with serious illnesses back to medical practitioners for evidence-based treatment [15].

The Australian national regulatory framework for homeopathic practice and its preparations is not as strict as some may anticipate. Homeopathic preparations are seldom registered with the Therapeutic Goods Administration (TGA), the national regulatory organisation that ensures the safety and quality of various therapeutic goods [16]. Those that qualify for registration are homeopathic preparations of no more than 1000-fold dilution, or contain apparent quantities of animal or human ingredients [17]. Most, however, either have undetectable amounts of the “active” ingredient or are too diluted.  Such preparations are thus deemed exempt from the TGA good manufacturing practice requirements, circumventing the rigorous testing for safety and efficacy by TGA that other drugs must undergo [17]. This, in turn, raises the question regarding the safety and efficacy of homeopathic treatment.

On the Australian Register of Therapeutic Goods, complementary medicines including homeopathic preparations can either be “registered” or “listed” depending on the level of risk that the medicines carry [17]. As “registered” medicines carry a high level of risk, they must undergo rigorous and detailed assessment and regulation of all relevant randomised controlled trials so as to provide comprehensive quality, safety, and efficacious data [17]. In contrast, “listed” medicines are not evaluated by TGA as they are of low risk, however, the products must have proven safety, quality, and efficacy as per legislative requirements [17]. Currently, no homeopathic preparations are registered and those listed and claiming to be efficacious must be labelled with the disclaimer “contains homeopathic ingredients without approved therapeutic indications” [17].

The AHA website provides a list of homeopathic medicine suppliers, which is publicly available, with most being sold through health food shops and pharmacies [18]. Such preparations are commercially manufactured and made available to homeopathic practitioners by three Australian suppliers: Pharmaceutical Plant Company, Martin & Pleasance homeopathy lab, and Brauer [18]. In addition, the AHA stress that each homeopathic practitioner has their own unique approach to making custom prescriptions [6], however, no centralised body exists to regulate such practice in Australia [5].

Opinions, the evidence, and case studies

Since the NHMRC declared homeopathy to be ineffective in treating any health condition, a number of disputes have been made by major organisations in favour of homeopathy.  Australia’s two peak industry organisations, Complementary Medicines Australia (CMA) and the AHA, both argue in their letters to the NHRMC that the position was prejudiced based on a draft position statement leaked in 2012 stating “it is unethical for health practitioners to treat patients using homeopathy, for the reason that homeopathy (as a medicine or procedure) has been shown not to be efficacious [19,20].” Furthermore, both the CMA and AHA highlight serious concerns regarding the prelude to and instigation of the work of the NHMRC’s HWC as well as the conduct of the review itself to finalise their conclusion on the use of homeopathy. Several grave issues were raised in both letters with five common key flaws cited: (1) no explanation was provided as to why level 1 evidence including randomised control trials were excluded from the review; (2) the database search used was not broad enough to capture complementary medicine and homeopathic specific content, and excluded non-human and non-English studies; (3) no homeopathic expert was appointed in the NHMRC Review Panel; (4) prior to publication, the concerns raised over the methodology and selective use of data by research contractor(s) engaged for the HWC review were abandoned for unknown reasons; and (5) no justification was provided as to why only systematic reviews were used [19,20]. Other serious accusations made by the AHA in their response letter to the NHMRC involved the blatant bias of the NHMRC evident by: the leakage of their draft position statement in April 2011 and early release of the HWC Draft Review regarding homeopathy to the media; no discussion of prophylactic homeopathy i.e. preventative healthcare; and no reference to the cost-effectiveness, safety, and quality of homeopathic medicines [19].

Despite the NHMRC findings being strongly disputed, they are further supported by positions taken by a number of large and respected organisations.  For example, in 2009, the World Health Organization (WHO) advised against the use of homeopathic medicines for various serious diseases following significant concerns being raised by major health authorities, pharmaceutical industries, and consumers regarding its safety and quality [21]. They reported the clinical effects were compatible with placebo effects [21]. Similarly, in Australia, the Australian Medical Association (AMA) further supports the NHMRC findings by stating in their position statement released in 2012 that there is “limited efficacy evidence” regarding most complementary medicines, thereby posing a risk to patient health [22]. More recently, in May 2015, the Royal College of General Practitioner’s (RACGPs) strongly advocated in their position statement against general practitioner’s prescribing homeopathic medicines, and pharmacists against supporting or recommending it, given the lack of evidence regarding its efficacy [23]. This is particularly pertinent to conventional vaccines given the recent case between the Australian Competition and Consumer Commission (ACCC) vs. Homeopathy Plus! Australia Pty Ltd.  The Federal Court found Homeopathy Plus! Australia Pty Ltd guilty of contravening the Australian Consumer Law by engaging in misleading and deceptive conduct through claiming that homeopathic remedies were a proven, safe, and effective alternative to the conventional vaccine against whooping cough [24].

The positions of the NHMRC, WHO, AMA, and the RACGPs regarding homeopathy is further supported by Cochrane reviews, which provide high-quality evidence with minimal bias [25]. Of the twelve homeopathy Cochrane reviews available in the database, only seven address homeopathic remedies directly and were related to the following conditions: irritable bowel syndrome [26], attention deficit/hyperactivity disorder or hyperkinetic disorder [27], chronic asthma [28], dementia [29], induction of labour [30], cancer [31], and influenza [32]. Given most of these reviews were authored by homeopaths, bias against homeopathy is unlikely [26-32]. The overarching conclusions from these reviews fail to reveal compelling evidence regarding the efficacy of homeopathic remedies [26-32]. For example, Mathie, Frye and Fisher show that there is “no significant difference between the effects of homeopathic Oscillococcinum® and placebo in prevention of influenza-like illness: risk ratio (RR) = 0.48, 95% confidence interval (CI) 0.17-1.34, p-value = 0.16 [31].” The key reasons given for this failure to provide compelling evidence relate to low quality or unclear data, and lack of replicability, suggesting homeopathic remedies are unlikely to have clinical effects beyond placebo [26-32].

Sadly, the ACCC vs. Homeopathy Plus! Australia Pty Ltd is not the only case that has made headlines in Australia in recent years.  An article in the Journal of Law and Medicine coincided with the NHMRC report regarding the number of deaths attributable to favouring homeopathy over conventional medical treatment in recent years [33]. One such case was that of Jessica Ainscough, who passed away earlier this year after losing her battle with a rare form of cancer – epithelioid sarcoma – after rejecting conventional treatment in favour of alternative therapies [34]. Although doctors recognise Ms. Ainscough’s right to choose her own cancer treatments and understand why she refused the disfiguring surgery to save her life, they fear her message may influence others to reject conventional treatments that could ultimately save their lives [35]. Another near death case was that of an eight-month-old boy whose mother was charged with “reckless grievous bodily harm and failure to provide for a child causing danger to death” after ceasing conventional medical and dermatological treatment for her son’s eczema as advised by her naturopath (an umbrella term that includes homeopathy) [36]. The “all-liquid treatment plan” left the boy severely malnourished and consequently, he  now suffers from developmental issues [37]. This case is rather similar to that of R vs. Sam in 2009, where the parents of a nine-month-old girl were convicted of manslaughter by criminal negligence after favouring homeopathic treatment over conventional medical treatment for their daughter’s eczema.  The girl died from septicaemia after her eczema became infected [36,37].

How clinicians can make a difference

As the aim of the latest NHMRC Strategic Plain 2013-15 is to assist Australians in making informed decisions regarding their healthcare, the NHMRC published a resource in April 2014 “Talking with patients about Complementary Medicine – a Resource for Clinicians” [38]. This was developed to facilitate discussion between clinicians and their patients regarding their use of complementary medicines so patients can make well-informed decisions about their healthcare options [38]. Available through the NHMRC website, this resource provides background information on complementary medicines and its regulation in Australia as well as suggestions on how clinicians can initiate discussion with patients regarding its evidence, reliability, effectiveness, and potential risks [38]. For example, to initiate discussion, clinicians can ask their patients if “they have tried anything else to help with their problem” [38]. Such discussion is imperative as many patients fail to disclose they are taking complementary medicines, which in itself may lead to adverse outcomes.  The resource also provides further additional information, resources, and links to help clinicians in providing patients with all relevant information so he/she can make a truly autonomous well-informed decision as per the AMA Code of Ethics [38,39].

Conclusion

Significant repercussions have followed the major review and final position statement by the NHMRC HWC regarding the efficacy of homeopathic remedies in treating health conditions.  Despite the defensive position of the AHA and CMA, there is strong evidence to suggest that there is a need for stricter industry regulations for homeopathic practice and preparations.  Furthermore, given that the efficacy of homeopathic remedies for treating any health condition is unlikely, it is now up to clinicians to provide and ensure that their patients have all the relevant information so they can make a well-informed decisions regarding their health.  With a concerning number of individuals with serious health conditions favouring homeopathic medicines over conventional treatment, collaboration between leading regulatory bodies, clinicians and patients is vital in maximising patient safety and health outcomes.

Acknowledgements

None.

Conflicts of interest

None declared.

References

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Opioids and benzodiazepines are frequently prescribed medications that carry a high risk of dependency and are commonly misused. Long-term use of these agents is associated with significant harm to the individual such as exacerbating the patient’s original symptoms, increasing mortality, and negatively impacting the community by contributing to road trauma. This paper will begin by outlining the regulation of drugs of dependence in Australia and defining misuse, dependency, and associated harms. The evidence for use of these drug classes will then be presented, with reference to best practice guidelines. Finally, the discrepancy between guidelines and prescribing behaviours will be highlighted with reference to specific challenges associated with drugs of dependency. It will be emphasised that doctors, especially the newer generations, have a responsibility to own the problems of drug misuse, and to impact individuals and the community through advocacy and evidence-based clinical governance. It will be shown that whilst opioids and benzodiazepines are effective short-term medicines, there is little support for long-term prescribing. If we are to turn the tide on drug dependency and misuse, change is needed in modern prescribing behaviours to achieve the best long-term outcomes for patients.

The problem

The most commonly misused prescription drugs in Australia are opioids and benzodiazepines, including z-drugs (zolpidem, zopiclone, and zalephon), which are non-benzodiazepines that act on the same receptors [1-3]. Access to these drugs is restricted by the Australian Therapeutic Goods Association Drug Schedule, which determines availability for public consumption [4]. Drugs of dependency include all Schedule 8 drugs (controlled drugs, such as opioids) and some Schedule 4 drugs (prescription only medicines, such as benzodiazepines) [5]. Such restrictions are regularly reviewed and subject to change. For example, alprazolam, a potent benzodiazepine with high toxicity [6], was made Schedule 8 in early 2014 due to a rise in illicit use [7], and there is current debate about the appropriateness of Schedule 4 for codeine, because of increasing codeine-related deaths [8,9].

Drug misuse is an important umbrella term to define in relation to the problems associated with drugs of dependency. Five main categories, that are not mutually exclusive, emerge in the literature:

1. Overuse: Higher dose or dose frequency than prescribed; often due to tolerance and self-adjusted dosing over long-term use [3].
2. Abuse: Overuse with the goal of intoxication [3].
3. Prolonged use: An emerging problem involving continued therapy to achieve a sense of normality. Such individuals have been termed the “hidden population” [2-3]. Similarly, the term “accidental addicts” has emerged in popular media, referring to individuals who become dependent on pharmaceuticals with continued use. Prescribers must be hypervigilant for these patients as they are often of high socioeconomic status and highly functional, in contrast to traditional drug-seeking stereotypes [10].
4. Substance use disorder: This is a formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) based on eleven symptomatology criteria across four categories (impaired control, social impairment, risky use and pharmacology) [11]. For diagnosis, use must cause clinically significant distress or impairment and occur within a twelve-month period [11].
5. Dependency: A syndrome in which an individual has: (i) a strong drive to use a substance; (ii) difficulty regulating their use; (iii) tolerance; and (iv) withdrawal symptoms on cessation [12].

Opioids and benzodiazepines are included on the World Health Organization list of essential medicines [13], indicated primarily in pain or palliative care (opioids), and anxiety disorders, seizures, acute insomnia, and alcohol withdrawal (benzodiazepines) [3].  Availability of opioids and benzodiazepines has been steadily increasing in recent decades. The number of opioid-dispensing episodes increased from 500,000 to 7.5 million from 1992 to 2012 [14]. Harrison and colleagues evaluated 4666 encounters with general practitioners (GPs) between 2010 and 2011 in which opioids were prescribed or supplied [15]. They found that 3.5% of opioids were prescribed for cancer pain, 43.9% were prescribed for chronic non-cancer pain, with the remainder being prescribed for indications classified as non-chronic [15]. For benzodiazepines, approximately 7 million scripts are written annually [16]. The 2013 National Drug Strategy Household Survey found that 3.3% of people aged 14 or over had used analgesics and 1.6% had used tranquillisers or sleeping pills over the past year for non-medical purposes, with both increasing over each three-yearly iteration of the survey since 2001 [17]. With problematic usage and availability of these drugs in the community (through either personal prescription or diversion), the harm associated with misuse has become increasingly apparent. There is a great degree of harm caused by opioid and benzodiazepine misuse to the individual and community (Table 1).

Table 1: Harms to the individual and community associated with opioid and benzodiazepine misuse

Harms	Opioids	Benzodiazepines
Individual	High risk of dependence [18] and misuse [2]	Extremely habit forming: tolerance and dependence can occur in 2-4 weeks [31-33]
	Physiological effects Constipation [19] Biliary dyskinesia [19] Cognitive impairment [19] Increased risk of death [20]/overdose (including inadvertent childhood ingestion) [2] Sleep apnoea [21] Sexual and endocrine dysfunction [22] Immunosuppression [23] Opioid-induced hyperalgesia [24] Osteoporosis/increased fracture risk [2] Dental caries and necrosis secondary to xerostomia [2] Impaired cognition [2]	Physiological effects Insomnia [7] Anxiety [7] Depression [34] Poor memory and concentration [35] Excessive / daytime sedation [36] Risk of ataxia and falls, disinhibition and amnestic effects [36] Cognitive impairment [37]/decline and dementia [38] Increased mortality with long term use [39]
	Codeine: gastric bleeding [25], severe metabolic imbalances [26-28], and risk of death [8]	Z-drugs: potentially dangerous complex sleep behaviours [16]
	Harms with intravenous abuse:  blood clots, amputation, and serious soft tissue injuries [29,30]	Harms with intravenous abuse:  blood clots, amputation, and serious soft tissue injuries [29,30]
Community	Diversion [40] Low levels of organised crime [41] Driving impairment and motor vehicle accidents [42,43] Doctor shopping affecting GPs [3]	Diversion [7] Low levels of organised crime [41] Driving impairment and motor vehicle accidents [42,43] Doctor shopping impacting GPs [3] Criminal activity through precipitating aggression and disinhibition [41]

Opioids and benzodiazepines are highly habit-forming and potentially destructive to the individual and society. Physiological side effects of long-term use of both drug classes significantly reduce quality of life and contribute to personal suffering through symptoms such as constipation and balance derangement contributing to falls. Further, opioids and benzodiazepines are both associated with increased mortality. This is through means such as deliberate overdose, accidental overdose, and motor vehicle accidents secondary to impaired driving ability [2,42,43]. In Victoria, overdose deaths involving prescription drugs outnumber deaths from road trauma [44], and alcohol and drug helplines receive nearly threefold more calls regarding prescription opioids than heroin [45]. Importantly, an Australian study investigating 320 oxycodone related deaths reported that 52% were due to unintentional overdose, 20% were deliberate self-harm, and the remainder either awaiting coronial enquiry or with indeterminable intent [46]. Victorian coronial data indicate that benzodiazepines are at least contributory in 48.8% of all drug-related deaths [47]. As such, long-term opioid and benzodiazepine use is associated with a very real increase in mortality, not only in people with the intent to self-harm. Overall, opioids and benzodiazepines carry a high risk of dependence, cause a wide range of physiological harms including increased mortality, and they negatively affect the community through diversion and contributing to motor vehicle accidents.

The evidence

Current evidence supports short-term use of both opioids and benzodiazepines for appropriate indications (for example, less than 90 days and one month, respectively). These drugs are effective when used properly and should be available for people who need them. Long-term use, however, is not supported by evidence for the indications for short-term use. Both classes of medications are known to be highly addictive and associated with poor long-term outcomes if use is not time limited. Notably, recent studies suggest that psychobehavioural interventions are at least equivalent to, or more effective than, pharmacotherapy for pain, anxiety, and insomnia [48-50].

Opioids have convincing evidence supporting their use in acute pain [51], cancer pain [52], palliative care, [53] and addiction [54]. Most of the controversy in opioid prescribing relates to use in chronic non-cancer pain, with reviews suggesting little short-term efficacy [55], and tolerance and opioid-induced hyperalgesia occurring with prolonged use [56]. Furthermore, a Cochrane Database review showed no clear gains in pain and functional outcomes when opioids were used long-term [57], and another study found no significant correlations between opioid dose adjustment and clinical pain scores over time [58]. In line with the biopsychosocial conceptualisation of chronic non-cancer pain, multimodal approaches using non-pharmacological strategies such as exercise and psychological interventions have been shown to be superior to monomodal regimens in terms of long-term impact [59]. Cognitive behavioural therapy (CBT) is recommended as first line psychosocial treatment for chronic, non-cancer pain [60]. A Cochrane review in 2012 found that CBT conferred significant improvement in pain, disability, mood, and catastrophising in comparison to wait-list controls [61]. Effect sizes were small to moderate and the only sustained impacts were seen on mood.

Short acting benzodiazepines and z-drugs are effective at managing acute insomnia [62], generalised anxiety disorder, social anxiety, and panic disorder [63]. Dependency can be rapid (for example, within 2 to 4 weeks) [64] and increased mortality has been associated with long-term use [39]. Unfortunately, randomised controlled trials for long-term use are of inadequate duration (approximately 3 months), and lack representative clinical samples [16]. Reassuringly, however, it has been shown that the majority of patients on benzodiazepine therapy for sleep and anxiety do not increase their doses over time [65]. Moreover, a recent three year follow-up study of users of benzodiazepines and z-drugs found less than 1% of patients developed problems with excessive use, which predominated in patients with a significant drug and alcohol history and increased with duration of therapy [66]. This suggests that careful evaluation of patients to identify those at risk of excessive use is important, and that monitoring and cessation plans at first prescription may be protective for this population. Of note, this paper did not assess experience of adverse effects or harms associated with long-term use of benzodiazepines. Instead, it focussed on excessive use only, defined as more than two daily doses over a three month period.

Insomnia treatment is generally recommended to proceed in a stepwise fashion, with initial management emphasising basic sleep hygiene education and stimulus control, with the latter supported by randomised controlled trial evidence for long-term efficacy [67]. If insomnia persists, more involved behavioural interventions, either with or without medications, should be offered. CBT combines sleep hygiene education, stimulus control, and progressive muscle relaxation into a cognitive therapy framework to address insomnia. A recent meta-analysis of randomised controlled trials has shown lasting benefits for establishing sleep, wake times, and sleep efficiency [68]. However, total sleep time was not significantly increased and the patient samples excluded those with medical and psychological comorbidities. As such, the magnitude of the effects needs to be interpreted with caution. CBT is recommended as first line treatment for insomnia by the Royal Australian College of General Practitioners (RACGP) and the British Association for Pharmacology [69] on the basis of previous systematic reviews, which have included randomised controlled trials and patients with medical and psychiatric comorbidities and shown reliable and sustained improvements on sleep parameters [70]. Similarly, in the treatment of anxiety disorders, CBT is supported by meta-analysis of randomised controlled trials [71] and is recommended as first line therapy, either as monotherapy or in combination with antidepressant medication [72].

Current guidelines are in line with the evidence base for long-term prescribing of opioids and benzodiazepines in Australia. The RACGP published two comprehensive documents in 2015 about prescribing drugs of dependency (with particular reference to benzodiazepines) that summarise best evidence, provide concrete guidance and examples of difficult consultations, and ways in which they can be safely and effectively negotiated [5,16]. For opioid prescribing in chronic, non-cancer pain, the Hunter Integrated Pain Service provides additional evidence-based guidelines [19]. An overview of the key prescribing guidelines can be extracted from these documents (Table 2).

Table 2: Summary of guidance for opioid and benzodiazepine prescribing from Australian evidence-based guidelines

Guideline	Authors	Summary of recommendations
Prescribing drugs of dependence in general practice, part A – clinical governance framework* [5]	RACGP	Maintain and develop skills in chronic pain, mental health, drugs of dependency (DOD) and optimise non-pharmacological interventions Inform patients DOD should be prescribed from one practice, one GP and dispensed from one pharmacy In complex cases or if situations deteriorate, be prepared to utilise specialist support Prescribing for drug dependent patients must be based on comprehensive assessment and an authority must be sought when prescribing a Schedule 8 drug Patients have the right to respectful care that promotes their dignity, privacy, and safety Provide patients with information about the purpose, realistic expectations, options, and benefits and risks Develop respectful, non-judgemental, and clear responses to inappropriate requests for DOD
Prescribing drugs of dependence, part B – benzodiazepines[16]	RACGP	Prescription of benzodiazepines (BZDs) should be with the lowest dose and shortest possible timeframe, continual monitoring, and careful consideration of risks and benefits Discuss with patients the potential for dependence, withdrawal, misuse, and known harmful effects such as falls, cognitive decline, and motor vehicle accidents Avoid prescribing to patients with comorbid alcohol or substance use disorders (these patients are more vulnerable to major harms) Use beyond four weeks should be uncommon, if no alternatives are available, long-term use must be supervised with regular attempts at reduction For insomnia, first line should be non-pharmacological (e.g. CBT) and BZDs/Z-drugs only given on an individual basis, with short-term, intermittent dosing For anxiety disorders, first line therapy should include CBT; SSRI/SNRI are suitable first line pharmacological treatments BZD use in anxiety disorders is mostly limited to severe or treatment resistant cases Short term BZD use as occasional adjunctive therapy may be effective at reducing symptoms in the first few days to weeks of SSRI/SNRI therapy BZD discontinuation can be achieved with minimal interventions (such as GP advice/advisory letters), strong therapeutic alliance and psychological therapies
Reconsidering opioid therapy: a Hunter New England perspective [19]	Hunter Integrated Pain Service	Opioid therapy is indicated for acute pain; cancer pain, palliative care; opioid dependency/addiction – NOT chronic, non-cancer pain Multidimensional pain assessment is recommended for all types of pain A drug and alcohol history, use of the risk assessment tools to gauge the risk of opioid misuse and contact with the Australian Prescription Shopping Information service is recommended Opioid therapy for acute pain: Should be time limited and coordinated between hospital and primary care Can usually be ceased within one week of surgery or injury if possible, and weaned and ceased within 90 days in complex cases A daily oral morphine equivalent dose of 100 mg should not be exceeded in primary care A treatment agreement explaining potential benefits, adverse effects, and duration of therapy should be used, with pain and functional outcomes measured Review therapy regularly with the “four A’s”: Analgesia, Activity, Adverse effects, and Aberrant behaviour Should be prescribed with ongoing non-pharmacological supportive care and a focus on evidence-based self-management strategies Involvement of a pain medicine specialist and multidisciplinary pain management team may be helpful Opioid naïve patients prescribed opioids and patients on long term opioids and BZDs should not drive

*These guidelines also provide recommendations for clinical governance and general practice systems of care not summarised here.

The need for evidence-based prescribing behaviours

Evidence does not support long-term therapy with opioids and benzodiazepines. This has been known for some years, yet the problem has only grown. Future generations of practitioners need to engender practice in accordance with guidelines, enhance utilisation of alternative, non-pharmacological interventions, and strive for better patient outcomes.

Consultations that involve the consideration of drugs of dependence present significant challenges to the GP, and usually involve complex and vulnerable patients. GPs report complicating factors such as time pressure, concerns about patient autonomy, patient-centred care and preserving the doctor-patient relationship [73-75]. Studies have shown that GPs have some ambivalence towards prescribing benzodiazepines and may lack consistency in their approach [73]. There is also referral to the notion of the “deserving patient” in the literature, whereby doctors ask themselves whether the patient deserves a prescription rather than whether they should write one [76]. Indeed, it has been reported that some GPs will provide benzodiazepines even when they do not believe it will help, giving reasons such as: having no realistic alternatives; assumptions about the patients’ expectations; problems in saying no; and succumbing to pressure [16]. Importantly, research indicates that many doctors assume that patients want prescriptions or would resist attempts at withdrawal whilst, in fact, patients report wanting explanations and discussion [73,77].

Inevitably, there is often a discrepancy between clinical guidelines and practice. There is some disagreement in the literature regarding the usefulness and clinical impact of best practice guidelines, with some findings demonstrating improved and more consistent management [78,79], whilst others show minimal impacts [80]. Recent studies are suggesting that GPs perceive clinical practice guidelines with a positive attitude [81], but that there are inconsistencies regarding which components are followed [82]. Research into the appropriate prescribing of antibiotics suggests that inappropriate prescribing is more likely to occur in high-volume practices and by those who have been in practice longer [83]. As such, to improve concordance with guidelines, it will be important for junior doctors to emerge into the workplace as proponents of evidence-based prescribing. They should take advantage of their training period, where case loads are lower, to ingrain safe prescribing habits and good clinical governance into their practice. Obviously, there is more to appropriate prescribing than simply following guidelines. There is an art to handling challenging consultations, conveying evidence in a meaningful way, inspiring trust in your patient, and establishing a collaborative management plan, which may or may not meet the patient’s original expectations. In light of this, there are some additional consultation techniques that may facilitate safe prescribing for junior doctors (Table 3).

Table 3: Practical advice for managing patients and drugs of dependency

Areas of Development	Strategies
Professional Knowledge	Engage in continuing medical education for drug dependence and safe prescribing Develop skills in cognitive behavioural strategies and structured problem solving [84,85] Familiarise with typical patient requests and responses from examples [5,16]
Consultation Skills   Time spent in early consultations will save time long-term	Encourage non-pharmacological measures Assess risk/benefits of any drug prescribed Make collaborative decision making for prescribing and non-prescribing [5] Prescribe only for supported indications Prescribe with plan for reduction [5] Be honest and explore issues [5] Involve the patient’s supports [5] Monitor use and look for signs of dependency (review ‘five As’) [5] Identify problem use and refer to specialist services [5] Provide written management plan and fact sheets [5] Seek advice if unsure
Resources	Withdrawal scales for alcohol [86], opioids [87], and benzodiazepines [88] Therapeutic Guidelines for withdrawal management Opioid risk tool [89] Specialist drug and alcohol services NPS MedicineWise Key Points for managing chronic pain [90] The patient’s pharmacist [91] Local support groups Medicare Australia prescription shopping information service (ph. 1800 631 181) [2]

Junior doctors and emerging medical professionals have the power to be agents of change in the evidence-based management of conditions such as chronic, non-cancer pain; anxiety; and insomnia. Doctors in training are often the most up-to-date on evidence-based guidelines in these areas, with greater emphasis on non-pharmacological management and multidisciplinary collaboration in undergraduate and postgraduate programs than in generations past. In addition, medical school curriculums have been modified to promote highly developed communication skills in graduates that are crucial to the ability to inspire motivational change in patients. As highlighted in Table 3, doctors can up-skill by developing their professional knowledge and consulting skills, and engaging with the wealth of resources available to them. Continuing medical education is paramount and skills in cognitive behavioural strategies such as goal setting and structured problem solving, mindfulness strategies, and motivational interviewing are vital to being an effective clinician. In addition, the RACGP provides examples of consultations and scripted responses to common questions such as “I need something to help me sleep” or “I want medication”, which are helpful for the emerging practitioner whilst they are still building clinical experience [16]. In the consulting room, the junior doctor can advocate evidence-based, non-pharmacological approaches; conduct appropriate risk assessment for dependence; and prescribe appropriately with reduction plans already in place. The ‘five As’ of pain medicine (Analgesia, Activity, Adverse effects, Aberrant behaviour, and Affect) provide a useful framework for assessing risk of dependence [5].

It is best practice to seek advice when there is suspicion of problematic use, and link patients in with specialist services. Managing patients who are substance dependent is highly challenging. Leveraging support organisations, specialist alcohol and drug services, community pharmacists, and prescription tracking services provides greater likelihood of positive patient outcomes. Furthermore, it will protect the primary medical professional from burnout.

In order to improve patient outcomes, doctors need to begin raising patient awareness of the likelihood and seriousness of adverse effects of these medications, and enthusiastically advocate and facilitate evidence-based treatments. Moreover, the right treatments need to be provided for the right indications. This is, after all, at the heart of patient-centred care, rather than allowing motivated and vulnerable patients to choose their own treatment.

Conclusion

While current prescribing behaviours are understandable because of patient expectations and time pressure, particularly limiting the opportunity for patient education, this is an area that will need to be addressed in the current generation of training doctors. Guidelines to assist in this have been provided in this paper along with some practical strategies that can be implemented to drive the changes necessary to improve patients’ long-term outcomes. Whilst opioids and benzodiazepines are drugs of dependency, neither the doctor nor the patient should depend on these drugs to treat a long-term problem that can be resolved, or at least managed, with other effective evidence-based treatments.

Acknowledgements

None.

Conflicts of interest

None declared.

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Pain is a complex and predictable component of the perioperative experience. Music, as a non-pharmacological pain management modality, is cheap and easy to implement as an analgesic adjunct to reduce patient pain, stress, and anxiety. It has particular benefit in healthcare settings where first-line pharmaceutical pain management options are less available. This review finds an increasing body of evidence supports the use of music to reduce pain in the perioperative setting.  Certain musical elements such as a constant tempo, gentle timbre, and smooth melody combined with patient musical preference have been shown to have the greatest analgesic effect. The mechanism by which music alleviates pain is not clearly defined, but may involve distraction, or regulation of the autonomic nervous system. The perioperative utilisation of music in the perioperative remains low. Standardised guidelines are required to instruct and assist with its application. Music therapy has demonstrated benefit with minimal side effects and should be used liberally in the management of perioperative pain.

Clinical scenario

Late last year, I exited a jumbo jet and took my first steps in the Kingdom of Tonga. This marked the start of a three-week adventure that I now count as one of the best experiences of my medical degree. As part of a four-member medical volunteer delegation, I travelled to the picturesque island of Vava’u, in Tonga’s far north. There, my time was divided between undertaking free community health checks and working with the doctors and staff of the Prince Wellington Ngu Hospital. The hospital was an old sprawling collection of buildings on top of a hillside overlooking the local village. The hospital was operating at capacity and despite the resourcefulness and efficiency of the staff, the hospital suffered from a marked lack of resources. It was under these circumstances, in a sparse medical ward that I first met 63- year-old, Mrs Place (pseudonym to protect patient confidentiality).

Mrs Place had presented to the hospital three weeks prior with a large, infected foot ulcer. The ulcer had first developed after she had innocuously cut her left foot four months earlier. The severity of the wound was compounded by her poorly controlled diabetes and peripheral vascular disease. After the failure of appropriate conservative and medical management, a below-knee amputation of her left leg was conducted.  When I saw Mrs Place two days after her operation, she was grimacing and moaning in pain. She reported her pain score to be 9/10 despite receiving a routine regimen of paracetamol and codeine. Her treating doctor explained that stronger opioid medication would help Mrs Place but was unavailable due to resource limitations. Instead, a novel form of pain management was used in these situations. To my amazement the nurses, doctors, and other patients began to sing local church hymns, in a contained, harmonious, and pleasant manner. No one seemed surprised and everyone was familiar with the songs. The singing continued over the course of the morning, and while doctors and nurses moved on with their daily activities and the hospital continued to operate, a constant melody echoed out of Mrs Place’s ward. Sometimes the music was loud, propagated by family members, and other times it was soft, with a lone voice maintaining the euphony.  Three hours later, Mrs Place was visibly more comfortable. She described her pain score to be 6/10 and credited the lessening of her suffering to the singing for which she was very grateful.  While it is unclear to what extent the patient’s pain improved directly as a result of the music, the apparent effectiveness of music as a pain management modality created an information gap in my medical knowledge that I was determined to explore. A literature review was performed using the electronic databases, Pubmed, Embase, and Medline. The search terms used were “music therapy”, “pain”, “postoperative”, “pain measurement” from 2000 until present.

Discussion

Pain has been described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage [1]. It is a complex problem that is compounded by its subjective nature and the wide spectrum of pain tolerance that exists within the community. The majority of people, at some stage of their life, will undergo a surgical procedure and although pain is a predictable component of the postoperative experience, pain management is often insufficient. The resultant clinical and psychological harm may affect patient morbidity [2]. Negative clinical outcomes associated with inadequate postoperative pain management include deep vein thrombosis, pulmonary embolism, coronary ischaemia, myocardial infarction, pneumonia, poor wound healing, and insomnia [3]. Effective pain management contributes to avoiding the human and economic costs of these sequelae. Pharmacological agents form the current standard of care for the management of postoperative pain [4]. These medications are best applied according to the World Health Organization’s “pain ladder” that advocates for the controlled escalation of pain relief medication [5]. Music, as a non-pharmacological pain management modality, is not widely utilised in the current healthcare environment, whether this relates to a paucity of information within the medical fraternity or an inherent scepticism towards complimentary analgesic methods is uncertain [6]. However, the paradigm is now changing due to a landmark systematic review and meta-analysis conducted by Hole et al. After synthesising the results of 73 randomised control trials, they concluded that music played in the perioperative setting can reduce postoperative pain, anxiety, analgesia requirements, and increase patient satisfaction [7]. This pivotal study adds to an existing body of research that confirms music to be a beneficial compliment to pharmacotherapy in managing perioperative pain [4,8,9].

The first use of music as a therapeutic intervention was recorded in the cuneiform writings of the early Mesopotamia, circa 4000 BC [10]. Since then the use of music in the clinical setting has been commonly employed throughout history. Notably, Florence Nightingale was a strong advocate for its use during the Crimean War, specifically citing the effectiveness of singing and flute melodies to alleviate pain [11]. Today, music may be used in the healthcare setting to reduce emotional distress and the patient’s perception of pain [12]. Given the wide spectrum of music genres and the singular nature of personal preference, determining the most effective music for alleviating pain and anxiety requires careful consideration. It is suggested that there are definitive musical elements that promote analgesia; these include a consistent tempo, gentle timbre, smooth melody, and a limited percussion component [13,14]. In addition Mitchel et al. concluded that music self-selected by the individual provides greater pain control [15]. This improved analgesic experience was postulated to stem from a greater emotional valence with music. For the greatest effect, music used to relieve pain in the perioperative setting should include the known and accepted musical components combined with patient preference [16].

The mechanism by which music alleviates pain is not clearly defined. Modern theories of pain are based on the gate control theory [17] and the subsequent neuromatrix theory [18]. Music is thought to be able to act as a distraction and dampen the patient’s experience of pain. Physiologically, pain impulses travel from the site of injury to the brain via the spinal cord.  Within the spinal cord there are neural gates that can be opened or closed to different degrees that allows for the regulation of pain impulses communicated to the brain. When these gates become obstructed, the patient’s perception of pain may be reduced. The use of music therapy may block these pain gates by causing descending signals to be sent from the brain down the efferent pathways in the spinal cord [19,20]. This means that fewer ascending pain impulses will reach the patient’s awareness. Using magnetic resonance imaging, Valet et al. showed that distraction caused an increase in the activation of the cingulofrontal cortex, the periaqueductal gray, and the posterior thalamus. Through this neural network, distraction may exert a top-down influence in order to reduce the unpleasantness or intensity of a person’s pain [21].

Music may also help reduce pain by acting on the autonomic nervous system activity within the body. Emotional distress adversely affects how an individual experiences pain; anxiety in particular has been identified as a risk factor for developing the chronic sequela of pain [22,23]. Anxiety occurs commonly in patients who are undergoing medical procedures and may decrease a patient’s pain threshold and tolerance causing them to experience more pain [24]. When a person is anxious, their pituitary-adrenal axis and sympathetic nervous system are stimulated, resulting in the release of hormones that are responsible for the patient’s experience of anxiety [25]. The physical expression of anxiety includes increases in heart rate, respiratory rate, and blood pressure [26]. Ozer et al. conducted a case control study that was designed to investigate the impact of music therapy on a number of postoperative physiologic parameters and the patient’s perception of pain. They found that patients who received music therapy had a statistically significant increase in oxygen saturation and a decrease in their reported pain score [4].  In this study, the patient’s oxygen saturation was used as a surrogate marker for their relaxation level and the effectiveness of music therapy as an anxiolytic. Other physiological parameters such as blood pressure, heart rate, and respiratory rate were not shown to have any significant association with music therapy, which corroborates the findings of other studies [27-29].

The role for music in the operating room is less certain. A small percentage of patients undergoing general anaesthetic retain unwanted intraoperative awareness throughout their procedure, which increases their likelihood developing post-traumatic stress disorder [30]. The use of music intraoperatively may benefit these patients by providing distraction. What effect music has on the medical professionals treating the patient is unclear. Allen et al. found that surgeon selected music reduced autonomic reactivity and improved surgical performance, however all of the study participants were biased towards the beneficial effect of music [31].  A more recent literature review suggests that music in the operating theatre is harmful, interrupting communication, hindering work, and risking patient safety [32]. Individual surgical teams can therefore guide the use of intraoperative music, with the option of personal electronic music players on a patient-by-patient basis.

The effectiveness of music therapy in reducing a patient’s pain has been well demonstrated. However, due to the wide range and varying complexity of pain assessment tools that have been employed, the level of analgesic impact is difficult to quantify. A rudimentary assessment has shown that music therapy may improve a patient’s pain by 10% to 40% [9,12,27,33-35]. However, despite the apparent benefit, clinical interest in the use of music remains in its infancy. As such, there are no guidelines available to instruct and assist with its application. This lack of standardisation may damage the future endorsement of this modality due to the potential for uneven application, poor compliance, and unrealistic expectations regarding outcomes. While there are no evident physical side effects from music therapy, exposure to unappealing music may irritate patients, impacting on their mental health and overall wellbeing. Legal issues involving copyright and intellectual property need to also be considered. Further research is required to clearly demarcate the biological pathways that mediate the beneficial effects of music. Without a proper understanding of the physiological basis for the observed positive effect, the most appropriate application cannot be determined and completely explored. For example, does the proposed benefit extend to all forms of audio-visual stimulus or is there something unique about music?  Active distraction through the use of electronic gaming has been shown to increase a patient’s pain tolerance as well as the amount of pain that they reported. Interestingly, this form of active distraction was shown to be superior to passive distraction (watching television), suggesting that other passive distractions, such as listening to music, might be less effective [36]. Future research should evaluate the effects of tailored music that is designed for this specific setting or for individual patients or patient groups. For example, a three-pronged comparative study could be conducted in Tonga to explore the effectiveness of spiritual music given its strong cultural background, in addition to the broader questions regarding efficacy, protocol, and utility.  Likewise, the differences in the effect of music interventions related to patients’ gender, age, and ethnicity should be further evaluated.

Conclusion

Music therapy should not be seen as a primary treatment option for the management of postoperative pain. In most clinical situations it will not completely alleviate the patient’s pain and should instead be used to facilitate patient functionality, improve quality of life, and reduce consumption of pharmacological analgesics. With no known side effects, wide applicability and the ability to be utilised in conjunction with other pain management therapies, the potential for music therapy is significant. In settings where first-line pain management options are not available, the benefits of this non-pharmacological management are magnified. Music therapy has demonstrated benefit and should be used liberally in the management of postoperative pain.

Acknowledgements

None.

Conflicts of interest

None declared.

References

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[2] Tse M, Chan MF, Benzie I. The effect of music therapy on postoperative pain, heart rate, systolic blood pressure and analgesic use following nasal surgery. J Pain Palliat Care Pharmacother. 2005;19(3):21-9.

[3] Apfelbaum JL, Chen C, Mehta SS, Gan aTJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth. Analg. 2003;97(2):534-40.

[4] Ozer N, Karaman Ozlu Z, Arslan S, Gunes N. Effect of music on postoperative pain and physiologic parameters of patients after open heart surgery. Pain Manag Nurs. 2013;14(1):20-8.

[5] World Health Organization. WHO’s Pain Relief Ladder. 2009. Available from: http://www.who.int/cancer/palliative/painladder/en/.

[6] Hupkens S. Implementation of complementary interventions in the Netherlands: experiences of pioneers. Patient Educ Couns. 2012;89(3):411-6.

[7] Hole J, Hirsch M, Ball E, Meads C. Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis. The Lancet. 2015;386(10004):1659-71.

[8] Roy M, Peretz I, Rainville P. Emotional valence contributes to music-induced analgesia. Pain. 2008;134(1-2):140-7.

[9] Bernatzky G, Presch M, Anderson M, Panksepp J. Emotional foundations of music as a non-pharmacological pain management tool in modern medicine. Neurosci Biobehav Rev. 2011;35(9):1989-99.

[10] Conrad C, Niess H, Jauch K-W, Bruns CJ, Hartl WH, Welker L. Overture for growth hormone: Requiem for interleukin-6?*. Crit. Care Med. 2007;35(12):2709-13.

[11] Nightingale F. Notes on nursing: what it is, and what it is not. London: Harrison; 1859.

[12] Zengin S, Kabul S, Al B, Sarcan E, Dogan M, Yildirim C. Effects of music therapy on pain and anxiety in patients undergoing port catheter placement procedure. Complement Ther Med. 2013;21(6):689-96.

[13] Gooding L, Swezey S, Zwischenberger JB. Using music interventions in perioperative care. South Med J. 2012;105(9):486-90.

[14] Nilsson U. The anxiety- and pain-reducing effects of music interventions: a systematic review. AORN J. 2008;87(4):780-807.

[15] Mitchell LA, MacDonald RA, Brodie EE. A comparison of the effects of preferred music, arithmetic and humour on cold pressor pain. Eur J Pain. 2006;10(4):343-51.

[16] Zhang ZS, Wang XL, Xu CL, Zhang C, Cao Z, Xu WD, et al. Music reduces panic: an initial study of listening to preferred music improves male patient discomfort and anxiety during flexible cystoscopy. J Endourol. 2014;28(6):739-44.

[17] Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150(3699):971-9.

[18] Melzack R. From the gate to the neuromatrix. Pain. 1999;Suppl 6:S121-6.

[19] Roy M, Lebuis A, Hugueville L, Peretz I, Rainville P. Spinal modulation of nociception by music. Eur J Pain. 2012;16(6):870-7.

[20] Li XM, Yan H, Zhou KN, Dang SN, Wang DL, Zhang YP. Effects of music therapy on pain among female breast cancer patients after radical mastectomy: results from a randomized controlled trial. Breast Cancer Res Treat. 2011;128(2):411-9.

[21] Valet M, Sprenger T, Boecker H, Willoch F, Rummeny E, Conrad B, et al. Distraction modulates connectivity of the cingulo-frontal cortex and the midbrain during pain–an fMRI analysis. Pain. 2004;109(3):399-408.

[22] Raichle KA, Osborne TL, Jensen MP, Ehde DM, Smith DG, Robinson LR. Preoperative state anxiety, acute postoperative pain, and analgesic use in persons undergoing lower limb amputation. Clin J Pain. 2015;31(8):699-706.

[23] Theunissen M, Peters ML, Bruce J, Gramke HF, Marcus MA. Preoperative anxiety and catastrophizing: a systematic review and meta-analysis of the association with chronic postsurgical pain. Clin J Pain. 2012;28(9):819-41.

[24] Tan X, Yowler CJ, Super DM, Fratianne RB. The efficacy of music therapy protocols for decreasing pain, anxiety, and muscle tension levels during burn dressing changes: a prospective randomized crossover trial. J Burn Care Res. 2010;31(4):590-7.

[25] Pittman S, Kridli S. Music intervention and preoperative anxiety: an integrative review. Int Nurs Rev. 2011;58(2):157-63.

[26] Nilsson U, Unosson M, Rawal N. Stress reduction and analgesia in patients exposed to calming music postoperatively: a randomized controlled trial. Eur J Anaesthesiol. 2005;22(2):96-102.

[27] Nilsson U. Soothing music can increase oxytocin levels during bed rest after open-heart surgery: a randomised control trial. J Clin Nurs. 2009;18(15):2153-61.

[28] Kshettry VR, Carole LF, Henly SJ, Sendelbach S, Kummer B. Complementary alternative medical therapies for heart surgery patients: feasibility, safety, and impact. Ann Thorac Surg. 2006;81(1):201-5.

[29] Sendelbach SE, Halm MA, Doran KA, Miller EH, Gaillard P. Effects of music therapy on physiological and psychological outcomes for patients undergoing cardiac surgery. J Cardiovasc Nurs. 2006;21(3):194-200.

[30] Leslie K, Chan MT, Myles PS, Forbes A, McCulloch TJ. Posttraumatic stress disorder in aware patients from the B-aware trial. Anesth Analg. 2010;110(3):823-8.

[31] Allen K, Blascovich J. Effects of music on cardiovascular reactivity among surgeons. JAMA. 1994;272(11):882-4.

[32] Shambo L, Umadhay T, Pedoto A. Music in the operating room: is it a safety hazard? AANA J. 2015;83(1):43-8.

[33] Simcock XC, Yoon RS, Chalmers P, Geller JA, Kiernan HA, Macaulay W. Intraoperative music reduces perceived pain after total knee arthroplasty: a blinded, prospective, randomized, placebo-controlled clinical trial. J Knee Surg. 2008;21(4):275-8.

[34] Pothoulaki M, Macdonald RA, Flowers P, Stamataki E, Filiopoulos V, Stamatiadis D, et al. An investigation of the effects of music on anxiety and pain perception in patients undergoing haemodialysis treatment. J Health Psychol. 2008;13(7):912-20.

[35] Salimpoor VN, Benovoy M, Larcher K, Dagher A, Zatorre RJ. Anatomically distinct dopamine release during anticipation and experience of peak emotion to music. Nat Neurosci. 2011;14(2):257-62.

[36] Jameson E, Trevena J, Swain N. Electronic gaming as pain distraction. Pain Res Manag. 2011;16(1):27-32.

“You have to understand

That no one puts their children in a boat

Unless the water is safer than the land” – Warsan Shire

 

Across the world, millions of people are fleeing the ravages of war and internal conflict, only to find themselves in unfamiliar territory with little to no support. By the time a refugee or asylum seeker has landed in Australia, he or she has undergone immense physical, psychological, and financial hardship. Much of the onus falls on doctors and other healthcare providers to engage with these individuals and help them piece together what they have lost along the way.

In 2014, the number of globally displaced persons was 59.5 million, a figure that is projected by this year to reach an all-time high [1]. It is estimated that one person out of every 122 in the world is fleeing home for fear of persecution or death [2], an alarming indication of the scale of what can accurately be called a global crisis. A subsequent increase in resettled refugees is expected in Australia [3,4], which will create the necessity for a healthcare system that is prepared to address the needs of such a uniquely vulnerable population. Although adequate healthcare is a crucial component for the restoration of refugees’ lives, access to essential healthcare services and medicines has been particularly restricted in this demographic [5-7]. As general practitioners (GPs) are often the first port of call for refugees with health needs, the strengthening and monitoring of primary healthcare programs have been identified as key areas for improvement by the United Nations High Commissioner for Refugees (UNHCR) [8] and by local health authorities [9]. GPs have a unique platform to bring refugee rights into daily discourse and advocate for their right to equal and affordable healthcare. This article aims to provide a brief introduction to the common health concerns faced by resettled refugees in Australia, barriers in terms of access to essential care and medications, and ways in which GPs can improve their service provision to refugees.

Common health concerns of refugees and the importance of intervention

Physical health

The compromised wellbeing of newly resettled refugees is the result of a combination of factors. These include interrupted or reduced access to healthcare before departure; prolonged exposure to harsh environments; and reduced access to basic needs, such as clean drinking water, food, shelter, education, and safety. These may be exacerbated by trauma and extended periods of deprivation, particularly if in detention [9]. Tuberculosis, hepatitis B, and intestinal parasitic diseases all occur more frequently in refugees than Australian-born residents and may complicate chronic conditions and undernutrition, which are often overlooked [10]. Refugees commonly have poor dental and optical health and are incompletely vaccinated [10,11]. Anaemia and iron deficiency are also extremely common and have been found in 10-30% of refugee children in Victoria, frequently accompanied by low vitamin D, B12, and folate levels [11].

Unfortunately, another common occurrence among refugees is the presence of the physical effects of torture and trauma. It is predicted that approximately 35% of the world’s refugees have had at least one experience of torture [10]. Patients may exhibit signs and symptoms of chronic pain, amputation of body parts, disfigurement, poor mobility, reduced hearing, and urogenital complications [12]. A further 125 million women and girls in the world are estimated to have been subjected to female genital mutilation (FGM), which greatly increases the risk of pelvic infections, menstrual blockage, sexual dysfunction, pain, secondary infertility, and complications of childbirth [13].

Mental health

Psychological trauma amongst refugees may be the result of a number of influences, including, but not limited to: violence and torture; deprivation; upheaval; and separation from, and loss of, loved ones. These commonly result in feelings ranging from guilt and shame to helplessness and anger, which often endure post-resettlement due to experiences of discrimination and hostility in their host communities and knowledge of the continued hardship of friends and family abroad [14]. Uncertainty about the future is another prevailing sentiment that inhibits the rehabilitation of many refugee families, particularly those on temporary protection visas, which expire within 3 years [15]. Refugees undergoing resettlement have an increased risk of poor mental health [14]. Although a 2008 systematic review of refugee mental health in Australia identifies that the time course of symptomatology varies greatly, a dose-response relationship between the severity of mental illness and the level of trauma experienced is consistent [16]. The conditions encountered are both complex and diverse, and include syndromes, such as posttraumatic stress disorder, acute stress disorder, anxiety, depression, somatisation, bereavement disorders, and anger reactions [16,17].

Psychiatric conditions in young people are of particular concern, as children make up more than 40% of newly arrived refugees and are particularly vulnerable to the pressures of upheaval and the stresses that accompany a journey to unfamiliar territory [6,10]. Prolonged periods of detention lead to the arrest or delay of developmental milestones, sometimes creating long-term issues in terms of behaviour, physical wellbeing, and mental health [6,10]. These are complicated by the adverse effects of detainment on parenting and family relationships [18]. Furthermore, adults often underestimate the prevalence and degree of trauma in their children and are frequently suspicious of external help [6].

Entitlements and accessibility

Given the extensive list of health needs that individuals from refugee-like backgrounds are likely to have, access to healthcare services becomes a key issue in disease management. However, several external and intrinsic factors undermine the equity of healthcare provision in this population.

Visas and entitlements

Resettled refugees and asylum seekers have reduced access to health care, in comparison to the majority of Australian residents [4-7]. This is due to a combination of institutional restrictions on entitlements and a number of cultural, economic, and linguistic obstacles experienced by the individuals. Entitlements are established by the type of visa under which the refugee has entered the country. Those who have formally sought and gained international protection are categorised as refugees and therefore, may be granted a Permanent Protection Visa (PPV) under the government-funded Offshore Humanitarian Reclamation Program [19,20]. The PPV, much like permanent residency, permits access to Medicare, a healthcare card, the Higher Education Contribution Scheme (HECS), work rights, and income support, along with services pertinent to their status as refugees, such as an initial health assessment and an early intervention program. Initial health assessments are conducted in primary care settings in most states of Australia, providing invaluable opportunities for the screening and engagement of individuals in the Australian healthcare system [10]. However, patients are only eligible for initial health assessments within the first 12 months of their resettlement [21].

Those who seek international protection but have not been granted the authority to enter another country are called asylum seekers. Asylum seekers who arrive without permission in Australia are placed in detention and may remain there for several years with few rights and little advocacy. A small percentage will be given Temporary Protection Visas (TPVs) lasting three years or less [22]. These come with work rights and Medicare assistance, as well as an initial health assessment; however, they are not eligible for other benefits, such as free settlement services, job assistance, or HECS support. Consequently, non-PPV holders rely heavily on volunteer-run and community-based services and networks. Despite these options, the detrimental psychological effects of uncertain migration status and reduced amenities are well-documented amongst these visa holders and can adversely affect their ability to cope [10,22].

Communication and cultural competence

By far the greatest barrier to satisfactory healthcare is that of communication, which affects access at every level, from first contact with a primary practice through to treatment and follow-up [7,9]. Available interpreting services are under-utilised (particularly by specialists), largely due to the extra time required in a consultation. However, it has been documented that the exclusion of this service leads to reduced patient satisfaction and quality of care [23]. Children or other family members are often used instead, causing ethical concerns that children may incorrectly interpret information that they cannot understand and may even be disturbed by the consultation’s sensitive nature [6]. On the other hand, children may also choose to censor or willingly leave out vital information.

Cultural differences also contribute strongly to difficulties in communication and should be addressed as a potential cause of misapprehension. One Australian study involving 76 GPs revealed that almost 50% of participants were confident in handling refugee cases despite having little or no experience in this area [24]. This is contrary to the pool of data highlighting the difficulty that refugees have in opening up to, and being heard by, health practitioners and other figures of authority in their settlement countries [6,25]. It is therefore important to recognise that deficiencies in cultural competence do exist and can affect patient outcomes despite any obvious signs of this.

Education and health literacy

Limited knowledge of health and healthcare systems is another factor restricting the full utilisation of services by refugees [26]. This may be due to the existence of a very different healthcare system in their countries of origin, or the interruption of health education due to oppression and upheaval [7]. Health literacy and the understanding of the need for the prevention and treatment of asymptomatic conditions are particularly important points to consider when educating a patient, and should be assessed to ensure that self-management is carried out appropriately [7].

Cost

Yet another consideration when dealing with refugee families is the often debilitating cost of relocation and unemployment, and the implications for access to some health services [6,10]. Refugees are often unwilling to use non-Medicare covered dental, allied health, and specialist services, and may face several added restrictions in the form of a lack of transport and unfavourable waiting times [6,25].

The role of primary care and available strategies

Consultation and health screening

General practitioners should make full use of the first contact they have with refugees, as there is no guarantee that the patients will be seen again in the same practice. GPs should keep in mind that initial health assessments are only available to refugees who arrived in Australia less than 12 months ago, and so should encourage eligible patients to undertake them as early as possible [21].

Mental illness makes a large contribution to the disease burden experienced by refugees. It is therefore of utmost importance to adequately screen for sources of psychosocial distress during the consultation. Table 1 is a comprehensive psychological assessment created by the Victorian Foundation for Survivors of Torture Inc [10] and is useful for this purpose.

Table 1: Comprehensive psychosocial assessment: key areas and their rationale. From Promoting Refugee Health: a guide for doctors, nurses and other health care providers caring for people from refugee backgrounds. Victorian Foundation for Survivors of Torture Inc [10]. Reproduced with permission.

Murray et al. [14] encourage a social model of treatment that involves families and the community in the management plan of individuals with psychosocial issues. This method has been found to be highly effective and may play a part in reducing stigma, increasing mental health service utilisation, and adding cultural significance to a patient’s journey through the healthcare system. Communication between community networks and local general practices should therefore be nurtured and maintained. The use of bilingual written material and multimedia have also proved to be helpful and encourage patients to approach their healthcare providers with further questions and concerns [25].

Communication

GPs should also be aware of the free Translating and Interpreting Service (TIS National), as well as the poorer outcomes observed from its omission from consultations [23]. Care should be taken to ensure that the interpreter is politically, culturally, and socially acceptable to the patient and his or her family [6]. The provision of gender-sensitive consultations has produced further improvements in patient outcomes [25]. As with any consultation, doctors should get a complete idea of each individual’s understanding and expectations of their symptoms, illness, and treatment [7]. A thorough history will also determine the barriers to access of treatment for different patients. Referral to refugee support networks can connect patients with less costly or pro bono health and social services, which are particularly helpful for temporary visa holders, who are not eligible for government-funded health programs [25].

Education and training

In 17 different studies, cultural sensitivity training resulted in an increase in patient satisfaction, reporting of symptoms, referrals, health, and access [25]. Bridging the cultural gap can thus prevent valuable missed opportunities for appropriate care and health promotion. However, if unsure about any aspect of the interaction, Bellamy et al. [7] encourage doctors to ask patients how this aspect of the consultation is usually performed in their home countries. This not only displays respect but also allows the patient to feel accepted, and in return may inspire the acceptance of Western practices.

Referral and follow-up

It is always ideal to maintain a relationship of continuing care with one’s patients; however, refugees in their first few years of resettlement will likely relocate several times, making follow-up unfeasible. To facilitate a smoother transition for these patients, GPs should provide them with hardcopies of all their medical records. When making referrals to services such as pathology, radiology, and allied health, GPs are encouraged to call beforehand to ensure that the practices are open to using interpreting services and to prepare them for patients with special needs [10].

Advocacy

Those who have direct contact with refugees have the unique privilege of seeing these groups at their most vulnerable, and often do not face the same time lag that is experienced by research and the media. This gives them the knowledge and credibility to take early action in the support of refugees in their local communities. Health professionals may consider writing to Members of Parliament and Parliamentary Committee Chairs about these issues. The Refugee Council of Australia (RCOA) is the umbrella refugee organisation in Australia and provides some useful information on methods of contact and communication with policy makers [27,28]. Those who choose to voice their concerns directly with the media must maintain patient privacy and informed consent, as many refugees may be put in grave danger if their identities and locations are revealed [27]. Several local organisations also regularly campaign for refugee rights; membership of these committees may open doors for further advocacy and activism.

Table 2 provides a brief summary of recommendations and resources for GPs who find themselves managing a patient from a refugee-like background.

Issue	Recommendations	Resources
Communication and cultural competence	Use of translating services and patient education	Atkin N, 2008 [23] Australian Government Translating and Interpreting Service [29]
	Cultural sensitivity training and further education Gender-sensitive consultations	ACEM E-learning courses [30] RACGP E-Learning course 22305 – Refugee Health [31] Victorian Foundation for Survivors of Torture Inc. courses and education [32]
		Family Planning Victoria, 2012 [12]
Medical problems	Initial health assessment Adequate history and examination	Australian Family Physician, 2016 [21] Victorian Refugee Health Network [33]
Psychosocial problems	Adequate psychosocial assessment	The Victorian Foundation for Survivors of Torture Inc., 2012 [10]
Education and health literacy	Use of bilingual reading material Patient education and counselling	Victorian Refugee Health Network [34]
Follow-up and referral	Provide copies of medical records Use of appropriate referral services Call beforehand	National Directory of Asylum Seeker and Refugee Service Providers [35] Victorian Refugee Health Network [33]
Advocacy	Contact with policy makers and media Activism	The Refugee Council of Australia [28] Refugee Action Coalition Sydney [36]

Conclusion

It is evident that providing appropriate and accessible refugee healthcare is a multifaceted task that requires the co-operation of a diverse team of skilled and dedicated professionals. The health of refugees is intrinsically linked to their migration status, education, culture, family situation, and the kaleidoscope of experiences that have landed them in their current situation. General practitioners have a central role in engaging these individuals in health care and the wider community. They must strive to use their position in society to advocate for this underprivileged group and educate resettled refugees on their rights and privileges in their new homes, thus upholding the very pillars of beneficence, autonomy, and justice that encompass the practice of medicine.

Acknowledgements

None.

Conflicts of interest

None declared.

References

[1] Kotschy G. UNHCR Mid-Year Trends 2015. United Nations High Commissioner for Refugees; 2015:3-13.

[2] Gaynor T. 2015 likely to break records for forced displacement – study [Internet]. United Nations High Commissioner for Refugees; 2015. Available from: http://www.unhcr.org/5672c2576.html

[3] World Report 2015: Australia [Internet]. Human Rights Watch; 2015. Available from: https://www.hrw.org/world-report/2015/country-chapters/australia

[4] Wright B. Asylum seekers and Australian politics, 1996-2007 [PhD thesis]. University of Adelaide, School of History and Politics; 2014.

[5] Murray S, Skull S. Hurdles to health: Immigrant and refugee health care in Australia. Aust Health Rev. 2015;29(1):25-9.

[6] Davidson N, Skull S, Burgner D, Kelly P, Raman S, Silove D, et al. An issue of access: Delivering equitable health care for newly arrived refugee children in Australia. J Paediatr Child Health. 2004 Sep 1;40(9‐10):569-75.

[7] Bellamy K, Ostini R, Martini N, Kairuz T. Access to medication and pharmacy services for resettled refugees: A systematic review. Aust J Prim Health. 2015;21(3):273-8.

[8] Bhattarai S. The UNHCR Global Appeal 2014-2015: Providing for Essential Needs. United Nations High Commissioner for Refugees; 2014.

[9] The Victorian refugee and asylum seeker health action plan 2014-2018. Department of Health; 2014.

[10] Promoting refugee health: a guide for doctors, nurses and other health care providers caring for people from refugee backgrounds. 3rd ed. Brunswick: Foundation House – The Victorian Foundation for Survivors of Torture Inc.; 2012. Table 3.3 Comprehensive psychosocial assessment: key areas and their rationale, p.58.

[11] Immigrant Health Service: Overview of health issues in immigrant children [Internet]. The Royal Children’s Hospital Melbourne; 2015. Available from: http://www.rch.org.au/immigranthealth/clinical/Overview_of_health_issues_in_immigrant_children/

[12] Improving the health care of women and girls affected by female genital mutilation/cutting: a service coordination guide. Family Planning Victoria; 2012.

[13] Female genital mutilation/cutting: a statistical overview and exploration of the dynamics of change. UNICEF; 2013.

[14] Murray K, Davidson G, Schweitzer R. Review of refugee mental health interventions following resettlement: Best practices and recommendations. Am J Orthopsychiatr. 2010;80(4):576-85.

[15] Harris M, Zwar N. Refugee health. Aust Fam Physician. 2005 Oct;34(10):825-9.

[16] Murray K, Davidson G, Schweitzer R. Psychological wellbeing of refugees resettling in Australia: A literature review prepared for the Australian Psychological Society. Australian Psychological Society; 2008.

[17] Srinivasa Murthy R. Mass violence and mental health – Recent epidemiological findings. Int Rev Psychiatr. 2007 Jan 1;19(3):183-92.

[18] Silove D, Austin P, Steel Z. No refuge from terror: The impact of detention on the mental health of trauma-affected refugees seeking asylum in Australia. Transcult Psychiatry. 2007 Sep;44(3):359–93.

[19] Australia’s Offshore Humanitarian Programme: 2013-2014. Department of Immigration and Border Protection; 2014.

[20] Guide to social security law: 9.1.2 Visas issued by DIBP [Internet]. Australian Government; [updated 2014 November 10; cited 2016 Jan 4]. Available from: http://guides.dss.gov.au/guide-social-security-law/9/1/2

[21] Benson J, Smith MM. Early health assessment of refugees. Aust Fam Physician. 2007 Jan;36(1-2):41-3.

[22] Policy Brief: Temporary Protection Visas. Refugee Council of Australia; 2013 Sep 24. Available from: http://www.refugeecouncil.org.au/r/pb/THC_140206.pdf

[23] Atkin, N. Getting the message across: Professional interpreters in general practice. Aust Fam Physician. 2008 Mar;37(3):174-6.

[21] Duncan G, Harding C, Gilmour A, Seal A. GP and registrar involvement in refugee health: A needs assessment. Aust Fam Physician. 2013 Jun;42(6):405-8.

[25] Joshi C, Russell G, Cheng IH, Kay M, Pottie K, Alston M, et al. A narrative synthesis of the impact of primary health care delivery models for refugees in resettlement countries on access, quality and coordination. Int J Equity Health. 2013 Nov 7;12(88):1-4.

[26] Cheng I, Wahidi S, Vasi S, Samuel S. Importance of community engagement in primary healthcare: The case of Afghan refugees. Aust J Prim Health. 2015;21(3):262-7.

[27] Cugati A, Lurie C, Piper M. The Advocates’ Help Kit. Refugee Council of Australia; 2002 Dec:10-31. Available from: https://www.refugeecouncil.org.au/docs/resources/VIC_ADVOCACY%20KIT.pdf

[28] Contacting Politicians: Letter Guide [Internet]. Refugee Council of Australia. Available from: http://www.refugeecouncil.org.au/take-action/contacting-politicians/

[29] The Translating and Interpreting Service Website [Internet]. Australian Government Department of Immigration and Border Protection. Available from: https://www.tisnational.gov.au/

[30] Useful Emergency Medicine Resources [Internet]. Australasian College for Emergency Medicine. Available from: http://elearning.acem.org.au/course/index.php?categoryid=29

[31] 22305 – Refugee Health: GP Learning [Internet]. Royal Australian College of General Practitioners. Available from: http://www.racgp.org.au/education/courses/activitylist/activity/?id=17726&q=keywords%3drefugee%2bhealth

[32] Courses and Education [Internet]. The Victorian Foundation for Survivors of Torture Inc. Available from: http://www.foundationhouse.org.au/webinars/

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[36] Refugee Action Coalition Website [Internet]. Available from: http://www.refugeeaction.org.au/

 

VicHealth released its Bright Futures report in December 2015 identifying youth suicide as a problem facing young Victorians over the next 20 years. Youth suicide rates have fallen in Australia since the National Youth Suicide Prevention Strategy, however, data shows that there is still room for improvement. Prevention strategies to date have been understudied for a variety of reasons, including ethical limitations and being studied as part of a broader suicide policy. The author proposes that gatekeeper training should be piloted across Victoria to determine whether it will independently reduce youth suicide rates. It has potential benefits upon integration in schools, general practices, and rural Victorian settings given that it focuses on training people who are associated with those directly at risk of suicide.

Introduction

For young Australians aged 15 to 24 years, suicide is the leading cause of death [1]. Between 1997 and 2012, suicide rates among this age group have fallen by 47% [1]. This reduction may be attributable to the introduction of the National Youth Suicide Prevention Strategy (NYSPS) in 1997, which reduced access to lethal methods of suicide, changed prescription patterns of antidepressants, and saw the introduction of catalytic converters in new cars [2]. Worryingly, however, 76% of deaths are still “considered potentially avoidable” [1], illustrating the need for further intervention nearly 20 years on.

In 2000, the Australian government established the National Suicide Prevention Strategy (NSPS), which integrated and expanded on the NYSPS [3]. Victoria has integrated this national strategy into the Victorian Mental Health Reform Strategy 2009-2019 [4]. In December 2015, the Victorian Health Promotion Foundation published the ‘Bright Futures’ report and highlighted suicide as part of a “megatrend” that may threaten the stability of young Victorians over the next 20 years [5]. It was hoped that the report would provide a foundation to guide future policies and improve community understanding of mental health, as well as explore the changing nature of service delivery models. Since this report, new data has been published by the Australian Bureau of Statistics (ABS) flagging the 2014 suicide rate as the highest in 10 years, at 12.0 deaths per 100,000 people in Australia [6]. Unfortunately, intentional self-harm continues to remain the leading cause of death in those between the ages of 15 and 44 [7].

This new data is particularly alarming as the ABS was unable to attribute the 2014 rise to administrative system changes in the coding of these deaths [8], which highlights the need to act on reducing these potentially avoidable deaths. Hence, gatekeeper training should be evaluated in a pilot study aimed at young Victorians. Gatekeeper training aims to equip individuals with the skills to “identify at-risk individuals and direct them to appropriate assessment and treatment” [9]. Gatekeepers are people who have primary contact with at risk groups and are able to identify them through recognition of suicide risk factors [10].

Summary of the Bright Futures report

VicHealth state that the future health and prosperity of Victoria is dependent upon the mental wellbeing of the youth, that is,  those aged between 12 and 25 years [5]. The report highlights that in contrast to the falling rates of suicide across other Organization for Economic Cooperation and Development (OECD) countries, there has been a rise in Australia from 6.2 deaths by suicide per 100,000 people in 2004 to 10.1 per 100,000 people in 2013 across all age groups. Vulnerable groups identified include Indigenous Australians, males, and people living in rural and remote areas, with suicide rates being 66% higher in country areas compared to metropolitan areas. Of particular concern is the alarming rate of suicide among young people aged 19-24, where suicide is the leading cause of death [5]. Finally, the report states that to reduce these risks, efforts need to be made to develop preventative programs that target mental wellbeing [5].

Suicide in Australia and around the world

In 2012, the global age-standardised suicide rate was 11.4 per 100,000 people and accounted for 1.4% of deaths worldwide. More specifically, the World Health Organisation (WHO) estimated that in 2012 the suicide rate for high-income countries was closer to 12.7 per 100,000 people [11]. For young people aged between 15 and 29 it is the second leading cause of death internationally, accounting for 8.5% of deaths in this age group [11].

According to the ABS, there were 2,864 deaths from intentional self-harm in 2014 [7]. This made suicide the 13^th leading cause of death in Australia [7]. For males, it was the tenth-leading cause of death, as approximately three-quarters of those who died by suicide were male. The overall suicide rate was 12.0 per 100,000 people in 2014, up from 10.9 in 2013 [7,12].

Suicide only accounts for a small proportion (1.9%) of deaths in Australia overall, however, it is in the context of specific age groups that the results become alarming. For example, suicide was the cause of death for “over a third” of males between the ages of 15 and 19 in 2014 [7].

Finally, the median age of death from suicide was 44.2 years, compared to a median age of 81.8 for deaths via all other causes in 2014 [7]. These figures illustrate that there are many years of life lost to suicide, particularly amongst the youth.

Suicide prevention strategies

Suicide prevention models differ around the world. The WHO divide suicide interventions into three categories that focus on: population level policies, selective preventative strategies to target vulnerable groups, and prevention strategies that target specific vulnerable individuals in a population [11]. Gatekeeper training is an example of a selective preventative strategy that targets vulnerable groups, and is the focus of this article.

Pros and cons of gatekeeper training

Gatekeeper training has been shown to be a promising initiative for suicide prevention [9,10], particularly for vulnerable groups that may be at increased risk of suicide [11]. In a 2016 article, Krysinska et al. state that gatekeeper training, as part of an overall preventative strategy, can lead to reductions in suicide [13]. Mellanby et al. demonstrated that amongst veterinary undergraduates, who are at increased risk of suicide, a suicide workshop provided confidence in identifying the signs of suicide and asking about suicide [14].

The strengths of gatekeeper training include:

• The ability to equip gatekeepers with targeted skills to work with a specific vulnerable group [10], such as Indigenous youth [15,16]
• Increasing an individual’s knowledge about suicide [17]
• Training people who are already within a population and are familiar with the environment, as opposed to “outsiders” [10]
• Addressing and reducing stigma surrounding suicide through training [9]

There are some limitations surrounding gatekeeper training. A Cochrane Collaboration states that there is an inability to demonstrate longer-term effects, and questions whether suicide prevention programs are effective in post-secondary educational institutions [18]. This is further supported by the WHO, who state that there is “no conclusive link … with reduced rates of suicide or suicide attempts”, but that gatekeeper training is “best practice” [11]. However, a study published by Isaac et al. argues that the limited evidence is attributable to the fact that gatekeeper training exists within a broader suicide prevention strategy, which makes it difficult to isolate the effect of gatekeeper training alone [10,19]. Moreover, a randomised controlled trial published subsequent to the Cochrane Collaboration, demonstrated that Applied Suicide Intervention Skills Training (ASIST), a form of gatekeeper training, was able to improve feelings of hope and reduce pro-suicidal feelings in a Lifeline call centre [20]. This is important, as feelings of hopelessness are closely related to suicidal ideation [21], and this may therefore provide some evidence to illustrate changes in suicide behaviour.

Why Victoria should trial a gatekeeper training model

Gatekeeper training, like many suicide preventative strategies, needs further evaluation [9,16]. Given Victoria’s commitment to the NSPS and their identification of suicide as part of a megatrend, there is a need to explore and develop evidence for prevention strategies.

Firstly, suicide rates are twice as high in rural areas as metropolitan areas, which is precisely why gatekeeper training in particular needs to be introduced [5]. Gatekeeper training can be deployed at the ground level and provide individuals within a regional or remote town, who are already familiar with the local environment, the skills to identify those at risk of suicide.

Moreover, gatekeepers can be introduced within the institutions that young Victorians frequent (i.e. schools and universities). This could be achieved through equipping teachers with the skills to act as gatekeepers, which has been shown to lead to an “increase in recognition” of “suicidal students who manifest explicit warning signs” [22,23].  This is especially pertinent now, as VicHealth has flagged the future rise of artificial intelligence and emerging economies as potential challenges for young Victorians to remain competitive in the job market. Such competition is likely to require young people to seek further education and remain in education institutions for longer [5].

Gatekeeper training may also be applicable to primary healthcare, and act as another avenue to target young Victorians. There is evidence to suggest that training general practitioners can substantially reduce deaths by suicide [13,19]. This is supported by Mann et al., who state that “many suicide [victims] have had contact with primary care physicians within a month of death” [9]. Unfortunately, there is some evidence to suggest that primary care physicians do not routinely screen for suicide risk amongst adolescents, and may lack sensitivity when discussing this issue due to a lack of training [10,24]. More recent qualitative evidence has shown further support for the provision of suicide risk assessment training to general practitioners [25].  Therefore, providing general practitioners with gatekeeper training may enable them to better detect, and subsequently treat, youth who are contemplating suicide.

The flexibility of this approach, the vast Australian landscape, and access to a broad range of potential trainees through the established network of general practitioners across Australia suggests that the gatekeeper training model is a suitable strategy to target the high suicide rate among young Victorians.

Challenges that will be faced in implementing suicide prevention strategies

The research to date has focused on the efficacy of suicide prevention strategies as part of a broader overarching suicide policy [13], which is pre-existent in Victoria and Australia. This is based on the understanding that suicide is multifactorial and one preventative strategy will not provide a definitive solution, as each individual is a unique and complex case [16]. To exacerbate this difficulty, suicide research in general is limited, and many preventative strategies implemented thus far have not been scientifically tested [16]. Some of the reasons for this include [10,16,26,27]:

• The complexity of causes of suicide leads to difficulty in examining interventions
• Using control groups is difficult
• Suicide is a rare event in contrast to other deaths, which limits the research designs that may be utilised
• Outcomes measured are often qualitative rather than quantitative as they can measure decreased feelings of hopelessness rather than lower rates of suicide

Given these mixed results, Suicide Prevention Australia has provided a basis for future research of gatekeeper training, with a focus on key measurements and identifiable targets [26]. Some identifiable targets include [10]:

• Quantity of training required
• Referral patterns of gatekeepers
• Retraining requirements for gatekeepers

Consequently, I urge VicHealth to undertake a pilot study that quantitatively measures the implications of gatekeeper training alone across Victoria.

Conclusion

To address suicide prevention for young Victorians, a multifaceted approach needs to be taken that ensures that all vulnerable young populations are nurtured. However, further research should focus on quantitative measurements of gatekeeper training, to determine if such policy actually yields results. Ultimately, youth suicide rates are largely avoidable, and this needs to be urgently addressed to ensure that Victoria’s youth develop resilience in the coming 20 years.

Acknowledgements

None.

Conflicts of interest

None declared.

References

[1] Australian Institute of Health and Welfare. Deaths among young people aged 15-24 [Internet]: Australian Institute of Health and Welfare; 2016 [cited 2016 June 4]. Available from: http://www.aihw.gov.au/deaths/premature-mortality/ages-15-24/.

[2] Large MM, Nielssen OB. Suicide in Australia: meta-analysis of rates and methods of suicide between 1988 and 2007. Med J Aust. 2010;192(8):432-7.

[3] Life Is For Everyone. Research and evidence in suicide prevention. Canberra: Department of Health and Ageing, 2008.

[4] Mental Health and Drugs Division, Department of Human Services. Because mental health matters. Victorian Government, 2009.

[5] VicHealth, CSIRO. Bright futures: megatrends impacting the mental wellbeing of young Victorians over the coming 20 years. Melbourne (AU): Victorian Health Promotion Foundation; 2015 48 p.

[6] Australian Bureau of Statistics. Media release: changing patterns of mortality reflect ageing population [Internet] Canberra: Australian Bureau of Statistics; 7 March 2016 [updated 2016 March 8; cited 2016 April 17]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by Subject/3303.0~2014~Media Release~Changing patterns of mortality reflect ageing population (Media Release)~10048.

[7] Australian Bureau of Statistics. Causes of death, Australia, 2014 [Internet]: Canberra: Australian Bureau of Statistics; 8 March 2016 [updated 2016 March 10; cited 2016 April 17]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mf/3303.0.

[8] Australian Bureau of Statistics. Causes of death, Australia, 2014: explanatory notes [Internet]: Canberra: Australian Bureau of Statistics; 8 March 2016 [updated 2016 March 15; cited 2016 April 17]. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/3303.0Explanatory Notes32014?OpenDocument.

[9] Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, et al. Suicide prevention strategies: a systematic review. JAMA. 2005;294:2064-74.

[10] Isaac M, Elias B, Katz LY, Belik S, Deane FP, Enns MW, et al. Gatekeeper training as a preventative intervention for suicide: a systematic review. Can J Psychiatry. 2009;54(4):260-8.

[11] World Health Organization. Preventing suicide: a global perspective. 2014.

[12] Australian Bureau of Statistics. Causes of death, Australia, 2013 [Internet] Canberra: Australian Bureau of Statistics; 31 March 2015 [updated 2016 Mar 7; cited 2016 February 7]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by Subject/3303.0~2013~Main Features~Suicide by Age~10010.

[13] Krysinska K, Batterham PJ, Tye M, Shand F, Calear AL, Cockayne N, et al. Best strategies for reducing the suicide rate in Australia. Aust N Z J Psychiatry. 2016;50(2):115-8.

[14] Mellanby RJ, Hudson NPH, Allister R, Bell CE, Else RW, Gunn-Moore DA, et al. Evaluation of suicide awareness programs delivered to veterinary undergraduates and academic staff. Veterinary Record. 2010;167:730-4.

[15] Clifford AC, Doran CM, Tsey K. A systematic review of suicide prevention interventions targetting indigenous peoples in Australia, United States, Canada and New Zealand. BMC Public Health. 2013;13:463-74.

[16] Suicide Prevention Australia. Transforming suicide prevention research: A national action plan. Volume 1. Sydney (AU): 2015.

[17] Bennett K, Rhodes AE, Duda S, Cheung AH, Manassis K, Links P, et al. A youth suicide prevention plan for Canada: a systematic review of reviews. Can J Psychiatry. 2015;60(6):245-57.

[18] Harrod CS, Goss CW, Stallones L, DiGuiseppi C. Interventions for primary prevention of suicide in university and other post-secondary educational settings. Cochrane Database Syst Rev. 2014;10:1-92.

[19] van der Feltz-Cornelis CM, Sarchiapone M, Postuvan V, Volker D, Roskar S, Grum AT, et al. Best practice elements of multilevel suicide prevention strategies: a review of systematic reviews. Crisis. 2011;32(6):319-33.

[20] Gould MS, Cross W, Pisani AR, Munfakh JL, Kleinman M. Impact of Applied Suicide Intervention Skills training on the national suicide prevention Lifeline. Suicide Life Threat Behav. 2013;43(6):676-91.

[21] Beck A, Steer R, Beck J, Newman C. Hopelessness, depression, suicidal ideation, and clinical diagnosis of depression. Suicide Life Threat Behav. 1993;23(2):139.

[22] Wyman PA, Brown CH, Inman J, Guo J, Pena JB, Cross W, et al. Randomized trial of a gatekeeper program for suicide prevention: 1-year impact on secondary school staff. J Consult Clin Psychol. 2008;76(1):104-15.

[23] Robinson J, Cox G, Malone A, Williamson M, Baldwin G, Fletcher K, et al. A systematic review of school-based interventions aimed at preventing, treating, and responding to suicide-related behaviour in yound people. Crisis. 2013;34(3):164-82.

[24] Bridge JA, Goldstein TR, Brent DA. Adolescent suicide and suicidal behavior. J Child Psychol Psychiatry. 2006;47(3):372-94.

[25] Michail M, Tait L. Exploring general practitioners’ views and experiences on suicide risk assessment and management of young people in primary care: a qualitative study in the UK. BMJ Open. 2016;6:2016.

[26] Suicide Prevention Australia. Transforming suicide prevention research: A national action plan. Volume 2. Sydney (AU): Suicide Prevention Australia, 2015.

[27] Hawton K, van Heeringen K. Suicide. Lancet. 2009;373:1372-81.

Cardiac output (CO) is an essential component in the evaluation of the critically unwell hospitalised patient’s physiological state. As an estimated measure of cardiac function, CO is of high clinical importance to determine how well nutrients and oxygen are delivered to body tissue. Additionally, as its determinants are related to circulating volume and heart rate, it can be used as a surrogate measure for any homeostatic imbalances, which may require critical medical intervention. This article compares the available clinical measurements of CO. The Pulmonary Artery Catheter (PAC) remains the most accurate and reliable method, however is a highly invasive measure. Minimally invasive techniques reduce the risk of procedural complications, but do so at the expense of reliability. Of these methods, pulse contour analysis is the most extensively studied, with precision being similar, if not equivalent to, PAC. However, until definitive, outcome-based, comparison studies have been completed, the selection of the most appropriate CO measurement modality remains the decision of the treating clinician, the patient and relevant clinical guidelines.

Introduction

When assessing critically unwell hospitalised patients, haemodynamic monitoring is an important indicator of the patient’s condition. Cardiac output (CO) assessment is an essential component of the patient’s physiological state during their perioperative period. CO is an estimated measure of cardiac function calculated by multiplying the heart rate (beats per minute) by stroke volume (volume of blood pumped out of the heart in mL) [1]. CO is of high clinical importance, as it is one of the determinants of how well nutrients and oxygen are delivered to body tissue, with a normal CO defined as 4-8 L/min in healthy individuals, varying with gender and body habitus [1,2]. Additionally, as its determinants are related to circulating volume and heart rate, it can be a surrogate measure for any homeostatic imbalances (such as haemorrhage and volume depletion or sympathetic activation in stress raising heart rate) that may indicate the need for critical medical intervention.

Importantly, CO is also a dynamic way to assess organ perfusion and cardiac function intraoperatively, in addition to providing an indication of likely expected outcomes and complications postoperatively [1].  Other important clinical aspects of care to assess and monitor include the assessment of end organ function.  This includes conscious state, respiratory rate, blood pressure, peripheral perfusion (temperature and capillary refill time), urinary output, and markers of metabolic acidosis [1,3].

Multiple invasive, semi-invasive, and non-invasive methods of assessing CO in the clinical setting are available. Five common and emerging methods are summarised and compared below (Table 1).

	Method	Principle	Advantages	Disadvantages
Invasive	Pulmonary artery catheter (PAC)	Uses the Stewart-Hamilton equation: the rate of blood flow is inversely proportional to the change in temperature over time.	Very accurate Clinical benefit in monitoring multi-factorial shock states and cardiac cases	Risk of: Dysrhythmias Cardiac perforation Tamponade Pneumothorax Valve damage Infection Emboli
Non-invasive	CO2 rebreather	Uses the Fick principle: the conservation of mass, which allows the calculation of blood flow to an organ based on the uptake of a specific marker substance.	Fewer complications Non-invasive Useful in intensive care unit setting	Requires patient intubation and mechanical ventilation Poorer accuracy than invasive methods Not reliable in perioperative cardiac cases
	Aortic and echocardiography Doppler ultrasound	Doppler ultrasound operates on the principle that the shift in frequency of a wave between two points is directly proportional to the velocity of that wave.	Non-invasive Suprasternal and oesophageal methods Simple to operate Very few complications Provides data on heart structure	Reliability depends on operator skill/consistency Requires nomogram which may miss individual variation Individual physiological variables may alter reading (such as expansion of the aorta during systole)
	Bio-impedance	Measures electrical impedance of the thoracic cavity generated during systole and left ventricular outflow into the aorta. The ratio of applied current and measured voltage equals the bio-impedence, which is measured over time.	Easy to use No risk of infection or vascular complications (such as emboli)	Sensitive to movement Unsuitable in hemodynamically unstable and arrhythmic patients Limited use in septic shock and aortic regurgitation Limited in pathology with thoracic fluid (such as pulmonary effusion)
Semi-invasive	Pulse contour analysis	Based on the hydraulic principle between flow, pressure, and time; measures pulse pressure (the difference between diastolic and systolic pressure) as proxy to volume, in order to create a picture or “wave form” that can be analysed mathematically to find stroke volume	Invasive and non-invasive models available Accuracy similar to pulse contour analysis	Requires individual patient calibration Limited in patients with arrhythmias, aortic regurgitation, and intra-aortic balloons Invasive methods have risk of infection and bleeding

Invasive methods: pulmonary artery catheter

The pulmonary artery catheter (PAC) was introduced in 1970 by Harold Swan and is often used as the gold standard for CO monitoring [1]. This technique involves the insertion of a catheter, preferably through the right internal jugular vein because of ease of insertion, proximity to the heart’s right atrium, and rarity in anatomical variation between patients in this vein, although other sites can be used, particularly the subclavian veins.  The device has an inflatable balloon at its tip, which permits it to be floated through the right cardiac chambers and into the pulmonary artery. The PAC estimates CO using a technique called thermo-dilution.  This involves administration of a bolus of 10 mL of saline (0.9% NaCl at room temperature) injected into the right atrium via a proximal catheter port. The difference in temperature is measured through the thermistor (thermally sensitive probe) on the PAC’s tip [1]. From this, a CO value is calculated using the Stewart-Hamilton equation. This equation is based on the principle that the rate of blood flow is inversely proportional to the change in temperature over time (the concentration of the indicator solution divided by the “area under the curve” or integral created by the indicator solution concentration change over time) (Figure 1) [2]. Such a reading can either be continuous or not depending on both the requirement of the clinical setting and the form of PAC [4].

Figure 1: Modified Stewart-Hamilton equation applied in PAC Thermal dilution during CO monitoring [2].

The use of the PAC method for CO monitoring has many advantages over other techniques. Conversely, due to it being an invasive device, it does carry inherent risks including an increased possibility of dysrhythmias such as complete heart block, perforation of heart chambers, cardiac tamponade, pneumothorax, valve damage, infection, and emboli [1]. Post hoc analyses of larger studies have also reported no benefit in using the PAC method, other than in elective surgical patients [5]. However, given that elective surgical patients are often healthier than non-elective intensive care patients, queries over confounding factors within the population have been raised [5]. This demonstrates that it can be used safely, but brings into question its patient-related value in situations arising from the critical care environment [6]. Despite the relatively high reliability of this device, debate still exists around whether it actually improves outcomes in various patient groups [6]. Regardless, its clinical benefit in monitoring both undifferentiated, multi-factorial shock states and cardiac cases is well documented [6].

Minimally invasive methods: CO2 re-breather, Doppler ultrasound, and bio-impedance

Indirect Fick principle (CO2 re-breather)

The pulmonary circulation is the part of the cardiovascular system that involves deoxygenated blood flowing from the right heart, through the lungs, and back into the left side of the heart (now oxygenated blood). This circulation can be used to estimate CO via the use of a mathematical equation called the “Fick” principle [7]. The Fick principle is a mathematical interpretation of gasses, based on the conservation of mass, which allows the calculation of blood flow to an organ based on the uptake of a specific marker substance [2]. In more clinical terms, it grants the ability to observe the amount of gas release, classically oxygen (O2) or carbon dioxide (CO2), that occurs in the pulmonary circuit, via the alveolar blood flow, and the difference in gas concentration in the arterial and venous circulation (by collecting venous and arterial blood samples) [7]. By measuring alveolar blood flow via the rate of carbon dioxide volume (VCO2) produced from the lungs and body over the arterio-venous carbon dioxide gradient of arterial carbon dioxide partial pressure (PaCO2) and venous carbon dioxide partial pressure (PvCO2), one can extrapolate CO from the difference between these CO2 gradients [8]. Mathematically, with Q representing CO and VO2 being volume of oxygen consumed, the generic formula is as follows:

VO2 = Q (PaCO2 – PvCO2) [8]

For example, if the concentration of CO2 being delivered to an organ is known, and the amount this concentration increases after perfusing the organ (venous and arterial difference) is also known, it is possible to divide the two in order to determine the “flow” of gas, and therefore blood, to that organ [7]. In CO monitoring, the use of the pulmonary circuit to represent “the body”, with a sample taken before (venous) and after (arterial) allows us to determine the change in CO2 concentration as the blood flows to the heart. Concurrently, the patient in which CO is being measured must be intubated and under mechanical ventilation in order to control this gas exchange and its volume parameters [8].

The advantages of using the Fick technique are largely associated with it being a minimally invasive technique (such as relatively fewer contraindications and adverse outcomes than comparable methods) [7]. However, this method has limitations in that it has a lower level of accuracy than invasive methods, and requires the patient to undergo intubation [7]. Additionally, it was found that in the determination of CO for patients undergoing cardiac surgery, an underestimation preoperatively and an overestimation postoperatively commonly occurred [9]. This brings into question its clinical reliability in the vital perioperative setting [9]. Thus, although it has clinical advantages in patients who cannot tolerate more invasive methods, its reliance clinically is not as consistent as that of PAC.

Doppler ultrasound: aortic and echocardiography

Doppler ultrasound operates on the principle that the shift in frequency of a wave is directly proportional to the velocity of the moving plasma [10]. By measuring plasma velocity, Doppler ultrasound can be used to estimate CO. Typically, Doppler ultrasound calculates CO by measuring the velocity of blood plasma at the level of the thoracic aorta, generating an estimation of blood flow (stroke volume) by measuring plasma flow across the cross-sectional area of the aortic vessel or valve. This velocity can then be multiplied by the heart rate to provide an estimation of CO [7]. This technique is commonly combined with echocardiography, which measures left-side cardiac filling pressures via a two-dimensional ultrasound, and Doppler measurement of the aortic annulus diameter [11]. Additional benefits derived from this method include the provision of clinically relevant information on the global structure of the heart, in addition to valvular anatomy and presence of pericardium pathology (including tamponade or constrictive pericarditis) [11]. This allows for accurate, non-invasive measurement of left ventricular diastolic dysfunction, which is predictive of mortality in hospitalised patients [10]. Furthermore, echocardiography can also measure the response of stroke volume to both fluid bolus and diuretic therapy, while monitoring left (trans-mitral) and right (vena cava) arterial pressure [12]. This may be critical in patients at risk of both systolic and diastolic heart failure [12].  Importantly, these changes can be monitored serially after interventions have been performed.

Significant drawbacks of this method include its inability to provide continuous monitoring and difficulty in measuring sample volume placement; probe placement and beat-to-beat variation in stroke volume both impact accuracy [11]. Additionally, in the setting of decompensated systolic heart failure, tissue Doppler imaging can be inaccurate for monitoring filling pressures [11]. Since this technique also requires particular placement of the probe, as this is an important variable for reproducible results, significant operator training and skill is required [12]. Therefore, while this method is both reliable and has multiple reasons for use in the clinical setting, consideration needs to be given to operator skill and reproducible monitoring.  An additional limitation is that echocardiography requires considerable skill to perform well.

Finally, while not commonly used in Australia, oesophageal and transthoracic Doppler methods also exist. As with Doppler echocardiography, monitoring has a similar level of reliability as more invasive methods, but is predicated upon three factors: the aortic cross-section accuracy, the parallel placement of the transducer, and the maintenance of constant beam direction between measurements [7]. Even controlling for these variables, inherent factors limit this technique, including physiological expansion of the aorta during systole, noted to be approximately 12% [10]. Furthermore, the use of a nomogram (a pre-determined graph using three or more logarithmic scales to show a relation between them, such as occurs in weight and height charts to calculate body mass index) introduces potential measurement error secondary to variation with vascular tone and volume status that needs to be considered for all measurements [10].

Bio-impedance

CO can also be estimated via bio-impedance in a technique known as impedance cardiography. This technique measures the electrical impedance of the thoracic cavity generated during systole and left ventricular outflow into the aorta through the conductive properties of blood via four electrodes placed around the thorax; two placed on the left neck and another two upon the lower thorax, focus alternating current toward the ascending and descending aorta, within which blood is the most conductive material [13]. Put simply, the electrodes emit a small electrical current that is then “bounced” off conductive tissue, of which blood produces the strongest “bounce”. This current is then received by the electrode, wherein the change of impedance (current “bounced” from the blood tissue and received by the electrode) correlates to stroke volume [1].

Similar to all minimally invasive techniques, impedance cardiography nullifies the risk of infection and haemorrhage, however, it remains particularly sensitive to movement and is unsuitable for use in patients with arrhythmias or who are haemodynamically unstable [7]. This limits its use in Australian medical settings and so it is not commonly seen in practice [7,13].

Semi-invasive: pulse contour analysis

The final, commonly used method of estimating CO is pulse contour analysis. Pulse contour analysis utilises arterial waveforms, obtained either from an arterial catheter (invasive) or a peripheral finger probe (minimally invasive), in order to extrapolate stroke volume and systemic vascular resistance [2]. This technique relies on measuring pulse pressure, that is, the difference between diastolic and systolic pressure (as proxy to volume), in order to create a picture or “wave form” that can be analysed mathematically to find the area under the curve. Initially, this method assumed compliance of aortic wall to be uniform, regardless of patient demographics and co-morbidities (as the compliance of a vessel alters its distensibility). However, via the use of an algorithm developed by Wesseling et al. [14], it become possible to gauge stroke volume by integrating the area under the curve measured during systole to minimise this error. Concurrently, the estimated stroke volume can then be multiplied by heart rate to give CO [7,14,15]. Many devices rely on the principle of pulse contour analysis, such as Pulse Contour Cardiac Output Monitoring (Pulsion Medical Systems, Munich, Germany) and Lithium Chloride Dilution (LiDCO Ltd., Cambridge, UK), are invasive, needing arterial lines. However, the Vigileo™/FloTrac™ system (Edwards Lifesciences, Irvine, CA, USA) and the Nexfin® system (BMEYE, Amsterdam, Netherlands), which uses a finger cuff to measure pulse pressure of the digital arteries, are non-invasive options. Currently, all of these devices are limited by the fact that they require inter-patient calibration [16].

As in the bio-impedance method, this technique is limited in patients with cardiac arrhythmias, aortic regurgitation and intra-aortic balloons as they alter measurement accuracy [4]. Equally, the use of arterial catheters introduces an additional risk of infection and haemorrhage. Despite this, a recent meta-analysis performed by Mayer et al. determined that a strong positive correlation exists between the contemporary pulse contour analysis devices (FloTrac/Vigileo) and the PAC method when measuring CO [16]. Concurrently, this method possesses a high clinical applicability with significant potential for future development.

In conclusion, accurate CO assessment and monitoring in the perioperative patient remains critically important. While PAC remains the most accurate and reliable method, its invasiveness and the subsequent risk of complications makes it unsuitable for specific patient subsets. Conversely, while minimally invasive techniques reduce the risk of procedural complications, this is often at the expense of reliability. Of these methods, pulse contour analysis is the most extensively studied, with precision being similar, if not equivalent to, PAC. Until definitive, outcome-based comparison studies have been completed, the selection of the most appropriate CO measurement modality remains the decision of the treating clinician, the patient, and faculty clinical guidelines.

Acknowledgements

Dr M. Peach.

Conflicts of Interest

None declared.

References

[1]  Wigfull J, Cohen AT. Critical assessment of haemodynamic data. Contin Educ Anaesth Crit Care Pain. 2005 Jun 1;5(3):84-8.

[2]  Scheer BV, Perel A, Pfeiffer UJ. Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care. 2002 Apr 18;6(3):199.

[3] Calzia, E, Iványi, Z, Radermacher P. Functional haemodynamic monitoring. Berlin: Springer Berlin Heidelberg; 2005. Determinants of blood flow and organ perfusion; p.19-32.

[4] Lavdaniti M. Invasive and non-invasive methods for cardiac output measurement. Int J Caring Sci. 2008 Sep 1;1(3):112.

[5] Harvey SE, Welch CA, Harrison DA, Rowan KM, Singer M. Post hoc insights from PAC-Man—the UK pulmonary artery catheter trial. Crit Care Med. 2008;36(6):1714-21.

[6] Harvey S, Harrison DA, Singer M, Ashcroft J, Jones CM, Elbourne D et al. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial. Lancet. 2005 Aug 6;366(9484):472-7.

[7]  Drummond KE, Murphy E. Minimally invasive cardiac output monitors. Contin Educ Anaesth Crit Care Pain. 2011 Oct 3:mkr044.

[8]  Chaney JC, Derdak S. Minimally invasive hemodynamic monitoring for the intensivist: current and emerging technology. Crit Care Med. 2002 Oct 1;30(10):2338-45.

[9]  Alhashemi JA, Cecconi M, Hofer CK. Cardiac output monitoring: an integrative perspective. Crit Care. 2011 Mar 22;15(2):214.

[10] Dark PM, Singer M. The validity of trans-esophageal Doppler ultrasonography as a measure of cardiac output in critically ill adults. Intens Care Med. 2004 Nov 1;30(11):2060-6.

[11] Porter TR, Shillcutt SK, Adams MS, Desjardins G, Glas KE, Olson JJ et al. Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiog. 2015;28(1),:40-56.

[12] Konstadt SN, Shernan SK, Oka Y, editors.  Clinical transesophageal echocardiography: a problem-oriented approach. Philadelphia: Lippincott Williams & Wilkins; 2003.

[13] Mehta Y, Arora D. Newer methods of cardiac output monitoring. World J Cardiol. 2014 Sep 26;6(9):1022.

[14] Wesseling KH, Jansen JRC, Settels JJ, Schreuder JJ. Computation of aortic flow from pressure in humans using non-linear, three element model. J Appl Physiol, 1993; 74:2566-73.

[15] Mathews L, Singh KR. Cardiac output monitoring. Ann Card Anaesth. 2008 Jan 1;11(1):56.

[16] Mayer J, Boldt J, Poland R, Peterson A, Manecke GR. Continuous arterial pressure waveform–based cardiac output using the FloTrac/Vigileo: a review and meta-analysis. J Cardiothor Vasc An. 2009 Jun 30;23(3):401-6.

Viral hepatitis has been historically under-recognised and under-addressed in the global health community. This is despite causing a serious disease burden worldwide due to chronic liver disease, cirrhosis, and liver cancer. The World Health Organization (WHO) has been involved on a global and regional level in the response to the epidemics of hepatitis B and C. A summer internship with the WHO Regional Office in Manila provided insights into modelling techniques to estimate the disease burden and treatment strategies to combat this silent epidemic. With effective antiviral treatments to cure hepatitis C and suppress hepatitis B, the prevalence, complications, and high costs of these diseases can be dramatically reduced.

Introduction

“Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity [1].”  No prizes to guess whose definition of health this is (pun intended). You’ve probably recited it word-for-word at some point in your medical studies. We look to the World Health Organization (WHO) for leadership in global health. The WHO provides technical guidelines, responds to health and humanitarian emergencies, and advocates and coordinates engagement across health, policymakers, and civil society [2].  What goes on behind the public face we see – the guidelines, press releases, and targets? How does the organisation operate on a global, regional, and country-level? How does the WHO respond to communicable threats such as polio, HIV, and viral hepatitis? What does it take in the quest to achieve the highest attainable quality of health for all?

Curious to understand and experience the well-oiled bureaucratic machine that is the WHO, and specifically to contribute in a small way to its response to viral hepatitis, I undertook a summer internship with the WHO at the Regional Office for the Western Pacific (WPRO). This Regional Office bridges Headquarters in Geneva and the 37 Member States under its care; a diverse belt of countries spanning down East and South-East Asia, the Pacific Islands, Australia, and New Zealand. For 8 weeks, I experienced life as an intern in the HIV, Hepatitis and Sexually Transmitted Infections Unit, within the Division of Communicable Diseases.

I also had a glimpse into life in Manila, the bustling metropolitan capital of the Philippines, where colonial powers and local revolutionaries have crossed for control of the island nation, and where for me, crossing the road proved to be a regular, life-threatening exercise. My first impression of Manila was stepping out of the airport into its balmy, honking embrace. From thereinafter I was accompanied in every waking moment by the cacophony of taxis, jeepneys, and motorcycles. There was not a moment of silence. Which, as it happens, is the exact opposite of the description of viral hepatitis.

The silent epidemic

Viral hepatitis is a silent epidemic in every sense of the word. The majority of people living with chronic infection, mostly hepatitis B and C, don’t know they have the disease. Left untreated, years of asymptomatic infection can lead to the deadly sequelae of liver cancer or cirrhosis. The dearth of testing services available also contributes to the “silence” around chronic hepatitis, especially in resource-limited areas where the highest burden lies. About half of the 218,000 people in Australia with hepatitis B aren’t aware they are infected [3]. This is even higher globally, 70-80% in the United States and more than 90% in many Asian countries (except Japan) [4]. In Europe, only 10-40% of people with hepatitis C are diagnosed [5]. That is to say, there are those who are living with chronic hepatitis, those who know their infection status, and those who are receiving treatment. In between, there are broad gaps, disparities in testing and treatment across both higher and lower income countries.

Whilst viral hepatitis has been unrecognised in the past, its burden is substantial. Hepatitis B and C, the biggest contributors to mortality and morbidity from the group of diseases caused by hepatitis viruses, are endemic in parts of South East Asia, Sub Saharan Africa, and South America. The Western Pacific Region, which includes Australia, bears over a third of global mortality from hepatitis – this translates to 1500 deaths every day [6]. Viral hepatitis is the seventh leading cause of mortality worldwide, according to the Global Burden of Disease Study in 2010 [7]. The WHO estimates that 2 billion people – 1 in 3 people globally – have been exposed to hepatitis B during their lifetime [6]. With 1.3 million deaths each year [6], the mortality from viral hepatitis is on par with those of better-known infectious diseases associated with poverty such as HIV, tuberculosis, and malaria.

Yet, in comparison to these conditions, hepatitis has received little to no public health and political attention. Of the 240 million people worldwide living with chronic hepatitis B [8], and the 80 million living with chronic hepatitis C [9], only a small proportion have access to life-saving antiviral treatment. Highly effective antiviral regimens are now available but high costs, local clinical trial requirements, import licensing, and a lack of drug procurement systems and treatment programs keep them out of reach for millions. Diagnostics and laboratory capacity are also challenging: hepatitis serology, DNA viral load testing, and liver function biochemistry are costly and not widely available.

How has WHO responded to combat this silent epidemic? In 2010, the World Health Assembly made a statement to the world in the form of a resolution on viral hepatitis (WHA63.18). This resolution urged member states to act through prevention, control, and management [10]. This was followed by another resolution (WHA67.6) four years later calling for more rigorous technical guidance and strategies linked to measurable targets [11]. In the Western Pacific Region, there has been significant progress over the last decade, especially in vaccination. Supporting immunisation programmes for the birth dose and triple dose, as well as catch-up vaccination, has helped to reduce childhood prevalence of hepatitis B. Global hepatitis B vaccination coverage reached 82% in 2014, and over 90% in the WHO Region of the Americas and the Western Pacific Region [12]. Indeed, as of January 2016, 13 of the 20 countries in the Western Pacific Region had achieved the target of less than 1% hepatitis B childhood prevalence by 2017. This has substantial public health benefits: from 2011–2020, hepatitis immunisation efforts in 73 countries are estimated to avert a total of 4.9 million deaths [12].

Whilst prevention through immunisation has laid important groundwork, the next challenge and opportunities lie in upscaling treatment. With the advent of new, highly effective antiviral medications that can cure hepatitis C and control hepatitis B, we are reaching a new tipping point in the response to viral hepatitis. The transition to inclusion of treatment in public health programmes is both logical and necessary.

More recently, the Sustainable Development Goals (SDGs), adopted by the United Nations in 2015, calls for the elimination of hepatitis in goal 3.3: “By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases [13].” Whilst only committing to ‘combat’ and not to end the scourge of viral hepatitis, this is still in progress: hepatitis did not receive even a mention in the Millennium Development Goals (MDGs) [14]. Part of the reason why hepatitis was not included in the MDGs was the misconception that its global burden was not as significant. Contrary, whilst the burden was high, there was limited research demonstrating prevalence and incidence, and also the link between viral hepatitis and liver cancer [15]. This was compounded by inclusion of only acute hepatitis, which accounts for only a minor proportion of mortality from viral hepatitis, and not including deaths from liver cancer and cirrhosis that were related to hepatitis B or C [16]. The SDGs present a new opportunity for public health, clinicians, policymakers, and civil society to galvanise behind the cause towards the goal of eliminating viral hepatitis. It is a promising step in the right direction, but much more is needed to tackle the epidemic.

What if? Modelling future disease burden of hepatitis

Understanding the enemy is one important facet of the response. Analysing the current burden of hepatitis, predicting future trends, and implementing prevention and treatment strategies to reduce morbidity and mortality are part of the solutions. In public health terms, this may typically start with gathering surveillance data. However, the underreported and underserviced nature of viral hepatitis has resulted in limited national data in many severely affected countries. Whilst addressing these issues in surveillance is a priority, alternate methods must be used in the interim to build the epidemiological picture of hepatitis in each country.

Disease burden modelling is successfully being used to estimate disease burden of hepatitis B and C and propose public health strategies for countries across the Western Pacific Region. The methodology uses a mathematical model created and operated by the Center for Disease Analysis (CDA) in the United States, responsible for hepatitis disease burden analysis in over 65 countries worldwide [17]. The model simulates a country’s populations (using baseline demographic statistics) and develops a baseline picture of the burden of hepatitis (using local epidemiological information), and also the costs of diagnostics and treatment. It then predicts the future trends in prevalence, complications, and mortality using the natural history of hepatitis through stages of fibrosis to cirrhosis, liver cancer, and death/liver transplantation. The information is drawn from a variety of sources including national surveys and surveillance data (where available), hospital data, unpublished studies, and local clinician consensus. As such, the process is always a collaborative effort between the CDA, local health authorities, researchers, and clinicians, as well as the WHO.

Once a baseline picture of prevalence and future disease burden is established, the model simulates various treatment strategies. It is important to emphasise that the the focus is on upscaling treatment, as many countries are on track with immunisation, however, older populations with high rates of asymptomatic carriers will be at future risk of disease and death if left untreated. The strategies may involve starting treatment programmes where none have previously existed, or replacing older antivirals with new highly effective regimens. The treatment ‘scenarios’ can be also be goal-driven, for example by increasing treatment to reduce mortality, or to achieve elimination of hepatitis by 2030. By simulating these treatment strategies, the model can predict how many lives can be saved by diagnosing and treating more people for their disease.

The disease burden analysis, together with economic analysis, transforms the case into an advocacy tool to present to policymakers. Whilst the economic analysis involves various processes, one noteworthy financing strategy (not unique to hepatitis treatment programmes) is the use of public-private co-payment. This is where the costs of treatment are shared between the public health budget, health insurance (for example, in the social security budget), and the individual patient. This is modelled at a rate that ensures that patients are able to afford care and treatment without being sent into impoverishment due to catastrophic health expenditure. The cost-effectiveness – even cost-saving – outcomes of these treatment strategies makes a strong case for investment. The reality is that treating complications of cirrhosis and cancer is very expensive. In addition to medical costs is the loss of productivity of a substantial amount of the working population, due to years lived with chronic, disabling illness. Treating earlier not only saves lives, but minimises the population progressing to those end-stage complications. The message has been clear: treating now saves lives.

Reflections

Before my internship with the WHO, I was somewhat apprehensive and sceptical about the practical impact of “epidemiology” and “policy” in public health, and specifically, global health contexts. On some level I knew they were important, but their tangible effect was a mystery. Coming away from this experience, I realise that epidemiology and disease burden modelling have a specific and powerful role in bridging the divide between public health challenges and ways for policy-makers to enact change. Presented in the right way, data becomes a case for investment, which if solidified as policy and action, can transform millions of lives through treatment and other public health measures.

Whilst at times I felt swallowed up within the intense WHO environment, I learnt a lot about the structure of the organisation and gained an appreciation for the amount of ongoing work required to keep it going. One can also feel disillusioned by the constant stream of meetings and seemingly menial details in editing and chasing publications, a sentiment shared by many an intern. Whilst my contribution during the internship was minor in the grand scheme of things, it was incredibly humbling to have a small but tangible role to play in the emerging field of hepatitis with the WPRO. I was able to meet clinicians and public health professionals dedicated to reducing the burden of hepatitis in the Philippines, the Western Pacific, and globally. This was both from day-to-day work at the WPRO as well as during a technical advisory meeting in Ha Noi, Viet Nam where experts met to discuss current challenges and strategies affecting the region. The experience showed me in ways I had never known about the impact of hepatitis on people’s lives, as well as on entire populations. I left without a doubt as to the absolute necessity of the world to listen and act. We are starting to break the silence around viral hepatitis, but it can’t stop there. Much more needs to be done if we are ever to end the epidemic and ensure that no one need suffer from this preventable disease.

The WHO offers internships from 6 – 12 weeks in duration in a variety of locations worldwide. See the website for more details http://www.who.int/employment/internship/interns/en/.

Acknowledgements

The author wishes to acknowledge the support and guidance of WPRO HIV, Hepatitis, and STI Unit, particularly Dr Nick Walsh who supervised and mentored her through the internship.

Conflicts of interest

None declared.

References

[1] World Health Organization. Constitution of WHO: principles [Internet]. 2016 [cited 2016 Mar 27]. Available from: http://www.who.int/about/mission/en/

[2] WHO Western Pacific Region. WHO in the Western Pacific [Internet]. 2016 [cited 2016 Mar 27]. Available from: http://www.wpro.who.int/about/en/

[3] MacLachlan J, Allard N, Towell V, Cowie B. The burden of chronic hepatitis B virus infection in Australia, 2011. Aust NZ J Publ Heal. 2013;37(5):416-422.

[4] Liaw Y. Antiviral therapy of chronic hepatitis B: Opportunities and challenges in Asia. J Hepatol. 2009;51(2):403-410.

[5] Harris M, Ward E, Gore C. Finding the undiagnosed: a qualitative exploration of hepatitis C diagnosis delay in the United Kingdom. J Viral Hepatitis. 2016;23(6):479-486.

[6] WHO Western Pacific Region. Hepatitis [Internet]. 2016 [cited 2016 Mar 27]. Available from: http://www.wpro.who.int/hepatitis/en/

[7] Cowie BC, Carville KS, MacLachlan JH. Mortality due to viral hepatitis in the Global Burden of Disease Study 2010: new evidence of an urgent global public health priority demanding action. Antivir ther. 2013;18(8):953-4.

[8] Schweitzer A, Horn J, Mikolajczyk RT, Krause G, Ott JJ. Estimations of worldwide prevalence of chronic hepatitis B virus infection: a systematic review of data published between 1965 and 2013. Lancet. 2015;386(10003):1546-55.

[9] Gower E, Estes C, Blach S, Razavi-Shearer K, Razavi H. Global epidemiology and genotype distribution of the hepatitis C virus infection. J Hepatol. 2014;61(S1):S45-57.

[10] World Health Organisation. Viral hepatitis [Internet]. Geneva: World Health Organisation; 2010 [cited 2016 Mar 27]. 4 p. WHA63.18: Available from http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=14027&Itemid=

[11] World Health Organization. Hepatitis [Internet]. Geneva: World Health Organisation; 2014 [cited 2016 Mar 27]. 6 p. WHA67.6: Available from http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R6-en.pdf?ua=1

[12] World Health Organization. Accelerating progress on HIV, tuberculosis, malaria, hepatitis and neglected tropical diseases. A new agenda for 2016 – 2030. [Internet]. Geneva: World Health Organization; 2015 p. 13. Available from: http://apps.who.int/iris/bitstream/10665/204419/1/9789241510134_eng.pdf

[13] United Nations. Health – United Nations Sustainable Development [Internet]. 2016 [cited 2016 Mar 27]. Available from: http://www.un.org/sustainabledevelopment/health/

[14] On Health. Hepatitis and the Sustainable Development Goals: time for an end run – On Health [Internet]. 2015 [cited 2016 Mar 27]. Available from: http://blogs.biomedcentral.com/on-health/2015/09/28/hepatitis-sustainable-development-goals-time-end-run/

[15] Adriano J. The case for keeping viral hepatitis in the SDGs [Internet]. SciDev.Net. 2016 [cited 2016 May 8]. Available from: http://www.scidev.net/global/disease/editorials/health-viral-hepatitis-sdgs.html

[16] Babbington G. Viral hepatitis more deadly than HIV, but unfunded [Internet]. SciDev.Net South-East Asia & Pacific. 2016 [cited 2016 May 8]. Available from: http://www.scidev.net/asia-pacific/mdgs/feature/viral-hepatitis-more-deadly-than-hiv-but-unfunded.html

[17] Razavi H, Waked I, Sarrazin C, Myers R, Idilman R, Calinas F, et al. The present and future disease burden of hepatitis C virus (HCV) infection with today’s treatment paradigm. J Viral Hepatitis. 2014;21:34-59.

[18] World Health Organisation. WHO employment: WHO internships. [Internet]. 2016 [cited 2016 Mar 27]. Available from: http://www.who.int/employment/internship/interns/en/

Indigenous health education is an important part of the curriculum for medical students. However, there are limited opportunities within the course for students to interact with patients from an Indigenous background. Following an Indigenous health placement in a remote community in the Eastern Kimberley region, a final year medical student reflects on how her medical education did not prepare her for the overwhelming social issues impacting on the health of Indigenous Australians. This article explores how, in the author’s experience, the current medical curriculum offers limited opportunities for first-hand exposure to Indigenous health, with a large proportion of Indigenous health content delivered in a lecture format. This style of teaching does not allow students to discuss, explore, and understand the many complex social issues that contribute to the health of Indigenous Australians. This combination of suboptimal teaching style and little or no first-hand experience results in medical students that are not well prepared to deal with these issues as junior doctors. It is necessary to review the current teaching methods and consider implementing interactive workshops to improve Indigenous Health education, which will in turn improve the health of Indigenous Australians.

This year, I spent my six-week elective rotation in Kununurra, a small town in the Eastern Kimberley region with a population of about 8,000 people [1]. Kununurra is a remote town situated approximately 500 km, 800 km, 1,000 km and 3,000 km from Katherine, Darwin, Broome and Perth respectively, which are the nearest major centres. There is a relatively large Indigenous population, with 34.8% of residents identifying as either Aboriginal or Torres Strait Islander [1]. The traditional owners of the Kununurra area are the Miriwoong Gajerrong peoples, and Kununurra is an anglicised version of Goonoonoorrang, the name of the Ord River that flows west of Kununurra. Colonisation has led to much disruption for this community, having serious impacts on health and wellbeing [2].

My placement was with an Aboriginal Health Service, a GP clinic with visiting allied health and specialist services, so the vast majority of patients that I saw were Aboriginal. I was unprepared for what I observed in this placement in remote Western Australia, in particular the social and environmental determinants of health that contribute significantly to the health of Indigenous Australians. The variety of issues that I experienced in Kununurra brought into relief the difference between my understanding of Indigenous Health from the taught medical curriculum, and the reality in Kununurra. This essay explores this gap by illustrating with anecdote some of my personal experiences of social determinants of Indigenous health, with comment on how student understanding might be improved in the teaching of medical students. The examples relate to my experiences in Kununurra only; it is important to note that each community has its own unique issues and that what is pertinent in Kununurra may not accurately reflect Indigenous health in a broader sense.

Prior to my brief placement in Kununurra, I had very little exposure to Indigenous health other than what I had learnt in the classroom. My lack of knowledge and experience became immediately apparent; I felt completely out of my depth with regard to the many complex medical and social issues that I was seeing, hearing, and learning about. One particular morning, as I left my house at quarter to eight, there was a man walking down the street with his young family; he had a bottle of wine in one hand and was pushing a stroller with the other. When I arrived at the clinic I jumped into the 4WD with one of the nurses and we drove to a community over 90 minutes away. This outreach clinic used to be serviced regularly by staff from Kununurra, but due to staff shortages it was months since the clinic had been open. In near 40-degree heat, bare-footed patients walked down the road to the clinic, which itself was covered in dirt, dust, and cobwebs, with overgrown weeds outside, broken windows, and blocked plumbing. Dead frogs were swept out from behind toilets and under desks. It was certainly not something I ever thought I would see in Australia, yet the patients were just grateful to have the clinic up and running again. We went to the school to see if any of the 11 students required immediate attention; as there was no doctor with us, anything less urgent would have to wait. While we were there, we provided dressings and antibiotics for a child with boils (a very common complaint) and removed a foreign body from a boy’s ear that thankfully turned out to be paper rather than a maggot.

Over the course of my stay in Kununurra, I saw a heavily-pregnant woman who smoked 80 cigarettes a day with no intention of stopping, a lady with a total thyroidectomy who had stopped taking thyroxine, a man who refused treatment and further investigation for a cryptococcal infection because he “felt fine”, and patients in their forties on dialysis. I had patients tell me they share a three-bedroom house with 20 people and saw children who had not attended school for weeks, and who wandered the streets with their friends at night, completely unsupervised. I had a 17 year-old boy openly tell me that he smoked cigarettes and “gunja” (marijuana), but who vehemently denied drinking alcohol because “it only causes violence”; and for the first three weeks of my placement, there was at least one person every week who presented after an attempted hanging, the youngest of which was 12 years-old. This was also highlighted in a speech given by Dr Marion Scrymgour, the CEO of the Wurli Wurlinjang Health Service and Chair of the Aboriginal Medical Services Alliance NT [3]. After six weeks in a remote Indigenous community, I was only just beginning to understand the complexity of a problem for which there is no simple solution. I began to reflect on why it had been so overwhelming; was there something missing from my education that could have better prepared me for this experience?

To understand what is lacking, we must first identify what is included in the Indigenous health curriculum. In a packed medical course, my education skimmed the surface, with lectures on culture and history that included topics such as the Stolen Generation, traditional medicine, and the different family structure of Aboriginal communities. I learned that the burden of chronic disease is much higher in the Aboriginal population, and that this is the primary reason that the life expectancy is, on average, ten years less for Aboriginal people than the rest of the Australian population. While this is worthwhile knowledge, it is an inadequate summary that only superficially touches on Indigenous health issues because it does not allow us to delve into the much more important discussion of why these discrepancies exist and how they can be rectified.

In 2004, the Committee of Deans of Australian Medical Schools (CDAMS) audited existing Indigenous health content and released the Indigenous Health Curriculum Framework, now called the Medical Deans Indigenous Health Project, which has become part of the accreditation requirements for all Australian medical schools [4]. This framework is comprehensive and meticulously developed by people with a significant amount of experience in the field. It is important to acknowledge that Indigenous health teaching is not the same across all universities and has been constantly evolving since I started my degree five years ago. However, based on my own education, I still felt very under-prepared.

There are numerous and varied reasons as to why current Indigenous health education is inadequate preparation for medical practice. Firstly, as outlined by the Indigenous Health Curriculum Framework, Indigenous people are a “non-homogenous population” with a “diversity of cultures, experiences, histories and geographical locations” [5]. It is difficult to convey that the issues encountered by urban, rural, and remote Indigenous communities seeking health care can be so vastly different. For example, the education that I received gave me essential background knowledge and an understanding of Indigenous health issues in urban areas, but failed to convey the difference between this and the difficulties faced by Indigenous Australians in remote areas. Furthermore, even within a particular setting (for example, a remote setting), there is a large variation between communities, so that the issues seen in one remote community may not be the same as those seen in other nearby communities. Secondly, thorough assessment of even the most well-constructed learning objectives is difficult to achieve. Assessment, often in the form of assignments and examinations, determines if students are meeting the desired outcomes, and from this we can extrapolate about the quality of teaching. Without this data, we are unable to accurately identify the effectiveness of teaching strategies, and are therefore unable to make appropriate changes and improvements.  Professor Richard Murray, a doctor with 14 years of clinical experience in Aboriginal health services in the Kimberley region, and the current Dean of James Cook University Medical School, illustrated this point beautifully when he said in a personal email addressing my enquiries about the Indigenous Health curriculum, “course or subject outcomes are too high level and abstract to satisfy” [6]. Therefore, not only is the curriculum difficult to implement, it is also difficult to assess its effectiveness.

One of the biggest challenges associated with Indigenous Health education is that many of the learning objectives and concepts are difficult to grasp in a classroom, especially with regard to the social determinants of health. One of the guiding principles of the Indigenous Health Curriculum Framework states that the health of Indigenous people is more associated with “historical and social determinants of health than with inherent Aboriginality” [5]. My experiences demonstrate this as well; the previously-mentioned examples are all symptoms of many complex underlying issues affecting the health of people in these communities. Many of the cases I saw would not occur if it were not for the effects of low socioeconomic status and deficits in the other social determinants of health seen across the globe: inadequate access to health care and education, health literacy and compliance issues, alcohol and drug dependence, physical and sexual assault, mental health issues and suicide, poor living conditions, and overcrowding.

For example, only 76% of Indigenous children aged 5-14 years in the Northern Territory have access to schooling, as compared to 95% of non-Indigenous children of the same age [7]. Indigenous people are less likely to drink alcohol, but twice as many drink at levels considered to be risky or high-risk for long-term harm compared to their non-Indigenous counterparts. 15% of homes with Indigenous people are considered overcrowded, which increases up to 42% in very remote areas, as opposed to 4% of other households. Furthermore, some of these houses do not have reliable water and electricity, or adequate sewerage [7]. Despite these appalling statistics, Indigenous Australians have the oldest, continuous living culture in the world, showing an incredible ability to adapt to change [8]. As a student, it is very difficult to imagine the enormity of the impact that all these factors have on health. As an example, it is difficult to explain complex health issues and the importance of treatment to patients with little or no education and health literacy.  It is even more challenging to treat and prevent the spread of communicable diseases. Consider the management of scabies or head lice which often require the entire household to be treated concomitantly; it is near impossible to achieve this in communities where overcrowding is rife. True understanding of this only comes from seeing it first-hand [9]. However, providing every student with the opportunity to go to an Indigenous or remote community is not a financially viable option for most universities, and accommodating large numbers of health science students is not necessarily feasible (or wanted) in Indigenous communities. This is one of the largest obstacles to providing the educational opportunities required to meet the outcomes outlined in the curriculum framework. Without the ability to provide the correct learning environment, it is unreasonable to expect that graduates will have an in-depth understanding of the complex interplay between these particular social determinants and health outcomes.

It is not the quality of the learning objectives and curriculum framework that limit Indigenous Health education, but rather the difficulties associated with the implementation and assessment of these objectives. The best teaching format, particularly with regard to the social determinants of health, is experience-based learning. While this is not feasible for every student, the lecture based format of Indigenous health education is suboptimal. The content is often too robust to really impart understanding of the complex health and social issues that many Indigenous people face. Other options must be considered and implemented; for example, workshops may allow educators to facilitate the discussion required to dissect more complex issues, such as why these disparities exist and how they may be overcome. Indigenous community members speaking to small groups of students about their life experiences, medical issues, and involvement with healthcare services would give students the opportunity to interact and ask questions, whilst fostering understanding and practising cultural sensitivity. Regardless of how the content is delivered, it is imperative that the social issues are emphasised within the curriculum, so that medical students graduate considering the patient in the context of their community and surroundings, because it is difficult to improve health without first improving the foundations. Students must learn that it is not enough to simply treat the presenting complaint; even our best medical efforts are not nearly as effective in promoting positive health outcomes as advocating to ensure the basic social needs (safety from violence, basic education, and adequate housing and nutrition) of our patients and communities are being met. Only when this is achieved will we see significant change in the health outcomes of Indigenous Australians. This is perhaps the biggest lesson omitted from the Indigenous health curriculum, and it is unlikely to be learnt in a classroom.

Acknowledgements

I would like to acknowledge Professor Michelle Leech and Professor Richard Murray for their helpful advice during the information gathering stages. I would like to thank Associate Professor Karen Adams, who suggested resources and ensured the article was written in a culturally-sensitive manner. I would also like to acknowledge the Deans and their representatives of all the Australian medical schools who provided me with their Indigenous health objectives or other resources. Thanks also to Dr Alexandra Van Rijn, who provided advice during the drafting stages of this project.

Conflicts of interest

None declared.

References

[1] Australian Bureau of Statistics. National regional profile : Kununurra (Statistical Area Level 2) [Internet]. Abs.gov.au. 2016 [cited 2016 Mar 28]. Available from: http://www.abs.gov.au/AUSSTATS/abs@nrp.nsf/Previousproducts/508041208Population/ People12007-2011?opendocument&tabname=Summary&prodno=508041208&issue=2007-2011&num=&view=.

[2] Mills V. How Kununurra got its name – ABC Kimberley WA – Australian Broadcasting Corporation [Internet]. Abc.net.au. 2016 [cited 2016 Apr 23]. Available from: http://www.abc.net.au/local/audio/2011/02/10/3135392.htm.

[3] Scrymgour M. Marion Scrymgour: The NT Intervention disinformation campaign – from allegations of child sexual abuse to moral panic – The Northern Myth [Internet]. Blogs.crikey.com.au. 2016 [cited 2016 Apr 23]. Available from: http://blogs.crikey.com.au/northern/2014/10/09/marion-scrymgour-the-nt-intervention-disinformation-campaign-%E2%80%93-from-allegations-of-child-sexual-abuse-to-moral-panic/.

[4] Medical Deans Australian and New Zealand. Indigenous Health Curriculum Framework [Internet]. Medicaldeans.org.au. 2016 [cited 2016 Mar 28]. Available from: http://www.medicaldeans.org.au/projects-activities/indigenous-health/cdams-indigenous-health-curriculum-framework/.

[5] Phillips G. CDAMS Indigenous Health Curriculum Framework [Internet]. 1st ed. Melbourne: VicHealth Koori Health Research and Community Development Unit; 2004 [cited 2016 Mar 28]. Available from: http://www.medicaldeans.org.au/wp-content/uploads/CDAMS-Indigenous-Health-Curriculum-Framework.pdf.

[6] Murray R. Indigenous Health Project. 2016.

[7] Wakelin B. Many ways forward [Internet]. 1st ed. Canberra: The Parliament of the Commonwealth of Australia; 2004 [cited 2016 Mar 28]. Available from: https://www.aph.gov.au/binaries/house/committee/atsia/indigenouscommunities/report/report.pdf.

[8] Cultural Heritage – Australian Museum [Internet]. Australianmuseum.net.au. 2015 [cited 2016 Apr 23]. Available from: http://australianmuseum.net.au/indigenous-australia-cultural-heritage.

[9] Benson J, Ryder C, Gill M, Balabanski A. A brief experience for medical students in a remote Aboriginal community [Internet]. Racgp.org.au. 2015 [cited 2016 Mar 28]. Available from: http://www.racgp.org.au/afp/2015/october/a-brief-experience-for-medical-students-in-a-remote-aboriginal-community/.

Modern health professionals are well versed in the value of person-centred care for their patients. However, the way we are taught to view our patients through a problem-based lens is counterintuitive to this person-centred approach. Medical professionals have learned to consider the diverse sociocultural contexts of patients as a “risk” to their overall wellbeing, rather than acknowledging the unique strengths of all individuals and communities. This focus entrenches assumptions into the way we approach patients of diverse backgrounds. These assumptions and the subsequent expectations that we hold of our patients have been evidenced to serve as powerful self-fulfilling prophecies for an individual’s overall health and wellbeing. Individuals will internalise negative health identities and have poorer health outcomes if health professionals hold low expectations of them based on their sociocultural “risks”. Strengths-based practice recognises resilience and focuses on the strengths, abilities, knowledge, and capacities of all individuals, rather than on their deficits, limits, or weaknesses. It provides a framework for health professionals to better support their patients in achieving their best health outcomes. A strengths-based approach has the ability to shift the broader deficits-based discourse that exists around the diverse sociocultural groups that exist in Australia. Changing this conversation is of immeasurable importance if we are to improve the health outcomes and agency of our patients and mitigate the persistent health inequities that exist within the Australian health system.

As modern health professionals in training, we have been well conditioned to consider all biological, psychological, and sociocultural factors that may contribute to poorer health outcomes in any given patient. We are familiar with the World Health Organisation’s definition of health as “a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity [1]”. But how does this translate into our practice? High patient caseloads and the sheer breadth of medicine compel us to streamline history-taking processes and problem formation through pattern recognition. We are taught to cluster “risk” factors – to make assumptions about disease, prognosis, compliance, and life expectancy, based upon sociocultural “risks”. We tick boxes. “Now, this is a question that we have to ask everyone, but do you have a history of previous intravenous drug use?”, “Do you identify as an Aboriginal or Torres Straight Islander?”, “Are you from a refugee or migrant background?”, and “Do you live in a rural or remote area?” We turn our attention to “vulnerabilities” and “high-risk groups” without much consideration of the impact of this focus and our subsequent assumptions on individual health identity.

The expectations we consciously or subconsciously hold of our patients, and the language we use toward or about them, inherently impact their health outcomes. In medical school, we are often taught to view our patients through a lens of deficit, by focusing on health problems rather than the opportunities that come from realising patients’ individual strengths. Strengths-based practice can shift this problem-based approach, and is a means of acknowledging the importance of our patients’ environments and diverse sociocultural contexts in the trajectory of their health attainment [2]. Strengths-based practice is an ecological approach to individuals, families, and communities that recognises resilience and focuses on the strengths, abilities, knowledge, and capacities of all individuals, rather than on their deficits, limits, or weaknesses [2]. A strengths-based approach is of immeasurable importance if we are to improve the health outcomes and agency of our patients, and mitigate the persistent health inequities that exist within the Australian health care system. This article will examine the impact of assumptions on patient health attainment and identity, the value and practicality of a strengths-based approach in the clinical setting, and the broader implications of our deficits discourse in the Australian public health arena.

Expectations and health identity

The expectations we hold of our patients can serve as powerful self-fulfilling prophecies for their overall health outcomes and identity. More than once I have heard a doctor use the phrase, “We save smart solutions for smart people”. This approach, however well intended, is damaging. Our clinical decision-making should not be influenced by expectations of noncompliance or assumptions of deficit. This is because health often exists at the nexus of societal expectations and our subsequent internalised perception of self. Essentially, if health professionals have high expectations of their patients, their patients are likely to have higher expectations of themselves, and subsequently experience better overall outcomes. This phenomenon is known in the behavioural psychology sphere as the Rosenthal effect, whereby our interpersonal expectations have been shown to significantly impact the learning, abilities, and health attainment of the subjects of our expectations [3,4]. We subconsciously facilitate “warmer” socio-emotional environments for individuals of whom we have higher expectations [3]. We have also been shown to input more effort into maximising the outcomes of individuals we see as having greater potential [3]. These subtle changes in the behaviour of care providers are internalised by patients and shape the expectations an individual holds of themselves [3]. Negative internalised expectations have been shown to directly lead to poorer mental and physical health outcomes in patients [5]. Internalised expectations may also directly act to motivate or discourage patients in their personal attainment of better health outcomes [5]. Essentially, negative health care provider assumptions and expectations demoralise an individual’s health identity, and this in turn impacts the mental and physical health outcomes of patients [3,6].

Our clinical approach to Indigenous patients in Australia offers an obvious example of how health care provider expectations may demoralise an individual’s health identity. At the beginning of any consultation, we are taught to ask all patients if they identify as Aboriginal or Torres Straight Islander. Identification of Aboriginal or Torres Straight Islander descent is essential in creating safety for our Indigenous patients. Too often however, doctors aren’t asking about Indigenous identity in order to practice their (often limited) cultural competencies, but rather to unfold a new list of differential diagnoses, and to remember to ask about smoking, alcoholism, substance use, diet, and exercise. On examination of Indigenous patients, we are also taught to check specifically for signs of cardiovascular disease, hypertension, type-2 diabetes, and chronic renal disease. While such a comprehensive approach to all patient consultations is desirable, our underlying assumptions relating to our Indigenous patients’ health-seeking behaviours, and our expectations for their health prognoses, is problematic. These assumptions are one of the means by which racism is maintained within our health system. As health professionals who work to support others in achieving their best possible health outcomes, we are terrified to talk about racism, or to consider that we might be contributing to its perpetuation in the Australian health system. However, it is important to define what racism in our health system actually means, in order to understand our role in it.

There are three levels of racism that contribute to poor health outcomes for Indigenous people: institutional, interpersonal, and internalised racism [7-12]. Institutional racism is often established in political systems and sustained by the policies of governments and health institutions that discriminate against Indigenous peoples [8]. Interpersonal racism in the health setting occurs when a health care provider makes assumptions about a patient on the basis of their Indigenous identity, or discounts Indigenous beliefs and practices [9]. These discriminatory interactions may be communicated to patients through non-verbal or verbal means, and often alter the course of care for an Indigenous patient [8,9]. Internalised racism occurs when an Indigenous patient accepts the stereotypes of interpersonal and institutional racism, and allows these stereotypes to shape their health identity. Institutional and interpersonal racism are often not intentional, but remain uninterrogated and largely invisible in our health system. Sometimes it is highly visible, but still unchallenged and unchanged. By not acknowledging or confronting the racism that exists within our health institutions, we are reinforcing negative internalisation among Indigenous individuals, leading to negative mental and physical health outcomes [6,8,9]. If a patient is conscious of interpersonal racism, this has been shown to influence their participation in unhealthy behaviours, and directly contribute to the long-term development of cardiovascular disease, hypertension, renal disease, and alter some of the neurochemical processes involved in diabetes [6,8]. The high prevalence of these chronic conditions within Indigenous populations is therefore something that is perpetuated, rather than mitigated, through our current approach to Indigenous health. As health professionals, we must challenge our conventional health paradigms and disrupt the processes that blame such systemic problems on the “unhealthy behaviours” of an entire culture [9].

By utilising reductionist techniques to simplify care provision for our patients, we are limiting our patients’ ability to attain their highest standard of health, as well as restricting their agency and self-aspiration [13]. An individual’s health is more than the sum of their medical issues – it is also determined by their personal resources. In medical school, we are not taught to identify the inherent strengths of all individuals, but rather to focus on health risks, problems, and limitations. That is, instead of seeing the potential that exists in celebrating the diverse sociocultural contexts of our patients, we regularly view sociocultural identity as a “risk” to overall wellbeing. This deficits-based understanding of health identity and our subsequent interpersonal communication is internalised by our patients, shaping their health behaviour and outcomes. We have the opportunity to change the conversation.

The strengths-based approach

Strengths-based practice is a well-evidenced approach in ensuring people have agency in their own health outcomes and identity. Strengths-based practice appreciates the centrality of people’s environments and sociocultural contexts in the attainment of their optimal health outcomes, and builds upon these strengths to reinforce health identity [2]. A strengths-based practice framework involves six core principles [2]:

1. All individuals, families, groups, and communities have strengths, and the emphasis is on these strengths rather than on pathologies
2. Communities are an abundant source of resources
3. Interventions are built on the self-determination of the patient
4. Collaboration is key, and a positive practitioner-patient relationship essential
5. Outreach is utilised as a preferred mode of intervention, and
6. All people have the inherent capacity to learn, grow, and change.

While strengths-based practice has not been formally implemented in the medical system, analysis of its feasibility in the social work setting may inform its rollout across the broader health sector. There are three developmental stages of health professional learning: socialisation, internalisation, and identification [2]. Socialisation involves health professionals learning how to enable a strengths-based dialogue among their colleagues, so that their colleagues may then develop the knowledge and skills to empower others [2]. Internalisation in this context is the process whereby health professionals internalise strengths-based principles in order to counter any barriers to enabling patients to see their strengths [2]. Identification involves the recognition of tacit assumptions about patients, and the impact of these assumptions on health provider practice and their patient’s cultural context of empowerment [2]. To shift our deficits-based approach to health care in Australia, health professionals must first be socialised to the concept of strengths-based practice, before we can then internalise its importance, and address any negative expectations we inadvertently hold of our patients.

The language we use to converse with our patients is often a product of the expectations and assumptions we hold of them. Paradoxically, our expectations are shaped by the broader public health discourse and problem-based learning that is indoctrinated into many doctors throughout their training. The rigidity of our health and medical education systems that institutionalise this deficits-based discourse make it difficult to universally adopt strengths-based practice across Australia. However as health professionals, we are still able to begin shifting this conversation and challenging the assumptions that we usually accept of our patients. Indigenous peoples in Australia are well versed in the power of strengths-based practice, and have identified three crucial ways we might enable positive change and start shifting our health discourse away from a mindset of deficit [13]:

1. Create safety: enable a space and process for robust discussion.
2. Challenge mindsets, habits, and conversations: take responsibility, find courage, and lead by example.
3. Co-create transformative pathways: engage with community groups to develop change and spread the word to engage in a national dialogue.

A deficits-based health discourse extends beyond interpersonal interactions of doctor and patient. As health professionals, our opinions are respected and hold legitimacy in public health discourse. How we talk about people matters because it plays a major role in shaping the public dialogue, and subsequently assists in setting a national health agenda for our politicians to action. We should be engaging in strengths-based health rhetoric and promoting the wellbeing of all individuals, rather than focusing on their limitations. As a result of our privilege, we have a duty to amplify the voices of individuals and communities who are working hard to shift our national dialogue to a narrative of strength, resilience, and opportunity.

Changing the conversation

Over recent decades, an emerging theme in the public health discourse has been a focus on health disparities between your “average Australian” and specific sociocultural groups. Arguably, this well-intentioned advocacy has been successful in fostering the next generation of compassionate and socially conscious health professionals. Many of my fellow students would attest that they entered their medical degree because they saw it as an effective means of helping people they perceived to be marginalised in our society. This motivation is exciting and provides fertile ground to generate unprecedented change to the inequities that persist in the Australian health system. But the fundamental assumption that our current deficits-based medical curriculum will enable us to effect positive change for marginalised groups is flawed. We assume that a medical degree, taught through problem-based learning, will provide us with the knowledge, skills, and sensitivity to offer the help that is needed. However, without realising the strengths of all individuals and communities, we are missing out on an enormous opportunity to celebrate resilience, reinforce positive health identities, and improve health outcomes for all.

Attention to sociocultural determinants of health has allowed us to raise awareness of persistent inequalities in our health system. However, focusing solely on deficits is detrimental to the broader narrative of the diverse sociocultural groups in our society. Drawing back upon the example of Indigenous health in Australia, large health promotion campaigns have been incredibly valuable in shedding light on the inequalities that persist between Indigenous and non-Indigenous Australians. These campaigns have also ensured that Indigenous health and education remain on political agendas, and they have secured funding for important programs. However, these awareness-building education and health promotion strategies have inherently focused on the “gaps” experienced by Indigenous people, and are an ineffective substitute for a whole government commitment to address the broader social determinants of health and shift our discourse away from deficit [9]. If we constantly emphasise life expectancy “gaps” in our public discourse, without closely examining our role in the discriminatory policies and practices that maintain these “gaps”, we will only perpetuate the inequities that exist between Indigenous and non-Indigenous Australians. By continuing to allow deficits to eclipse individual strengths, we are doing our patients, their communities, and our broader society, a colossal disservice.

Our health discourse does not exist in a vacuum. As modern health professionals, we have an obligation to celebrate the individual strengths of each of our patients, and a duty to use our respected voice to shape the rhetoric that currently marginalises the diverse sociocultural groups that exist in Australia. So challenge expectations, transform mindsets, and check your assumptions at the door – together we can ensure better health outcomes for all.

Acknowledgements

Scott Gorringe, for his patience, persistence, resilience, strength, and friendship.

Nicholas Fava, for his invaluable assistance in proofreading this piece.

Conflicts of interest

None declared.

References

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[10] Kelaher MA, Ferdinand AS, Paradies Y. Experiencing racism in health care: the mental health impacts for Victorian Aboriginal communities. MJA. 2014;200:1-4.

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[12] Paradies Y, Harris R, Anderson I. The impact of racism on Indigenous health in Australia and Aotearoa: towards a research agenda. Casuarina, Australia: Flinders University, 2008 March.

[13] Gorringe S, Ross J, Fforde C. ‘Will the Real Aborigine Please Stand Up’: Strategies for breaking the stereotypes and changing the conversation. Canberra, Australia: AIATSIS, Research Program; 2011 January.