Series: Volume 8, Issue 1 2017

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Feature Articles

School refusal: identification and management of a paediatric challenge

School refusal is not truancy, but both are serious behavioural problems that can have detrimental consequences. Management of school refusal involves ruling out organic causes and assessing contributing factors, such as anxiety and depression. Empirical treatment involves a collaborative approach of cognitive and behavioural therapies involving the child, parents, and school. This article highlights the heterogeneous nature of school refusal, its identification, assessment and management, and the implications for future research.

Introduction

At first glance, school refusal appears to be a relatively straightforward phenomenon that all youth may experience at some point during their school years. However, youth-motivated school absence is a significant public health problem affecting schools and households around Australia. Nationally, the average attendance rate of state secondary school students is approximately 85%, with the Northern Territory experiencing the lowest rate of attendance at 75% [1]. In Queensland, an estimated 30% of state secondary school students had an attendance rate below 90%, or had missed more than 20 days of school over one school-year [2]. Of the reasons given, ‘unexplained’ absences accounted for more than 25% of the total absences [3]. Due to financial and legal issues associated with chronic absenteeism, health professionals are put under increasing pressure by parents and schools to find a solution to the child’s ‘problem.’ This strain may lead doctors to write generic medical certificates or practice ‘defensive medicine’ in order to avoid professional and legal risks.

 

Table 1. Differentiating school refusal from truancy

Definition

School refusal is not a psychiatric diagnosis, but rather a symptom that encompasses a range of possible diagnoses or social problems. There are many terms in the literature that are used to describe the different types of absenteeism. Firstly, child-motivated absenteeism differs from ‘school withdrawal’ in that the latter refers to situations where a family deliberately keeps their child at home for various reasons, such as due to financial reasons or to care for an ill family member [4]. Child-motivated absenteeism is typically categorised into those with school refusal and those displaying truancy (Table 1). ‘School refusal’ is generally thought to encompass difficulties attending or staying in school, and is associated with extreme emotional distress [4–7]. The child stays home with their parents’ knowledge, despite the parents having made a reasonable attempt to encourage the child to attend school. Children exhibiting truancy, in contrast, are more likely to display antisocial tendencies, such as vandalism and theft, rather than emotional distress [4–7]. Truants’ motives for absenteeism include a lack of interest in school-work, unwillingness to conform to the school’s code of behaviour, and an over-riding desire to engage in externalising behaviour, such as disruptive acts or alternative tangible reinforcers on a school day [4–7]. In addition, parents are often unaware of or disinterested in their child’s school absence. The separation of absenteeism into school refusal and truancy has been criticised for the bias shown to children with school refusal who are often perceived sympathetically and judged to be worthy of treatment, while the term ‘truant’ raises punitive connotations and the need for discipline [8,9]. Due to this bias, children labelled truants are under-represented in current literature and it is unclear whether interventions differ between this group and children with school refusal, particularly due to a lack of strong supporting evidence with regards to the effectiveness of common psychological treatments in groups with externalising behaviour, such as truancy [10,11]. Groups inclusive of differing causes of absenteeism should be a future research objective. Until then, since management of school absenteeism is critical for all youth, it is therefore important to be aware of this bias and assess each child individually and thoroughly.

 

Epidemiology

Approximately 1–5% of all school-aged children will demonstrate school refusal behaviour at some point [6,7]. Although it can occur at any age, school refusal is more common between 5–7 years and 12–14 years of age. These age groups correspond to periods of transition to primary and secondary school, respectively [7]. The prevalence of school refusal seems to be unaffected by gender, socio-economics or intelligence [7,12]. One study showed that a high prevalence of adolescents with school refusal and co-morbid depression also experienced learning difficulties, which may have been a causal factor in their school refusal [13]. In a study assessing parental and familial risk factors for school refusal in children, physical punishment by parents, history of organic disease in parents or the child, and positive psychiatric history in a parent or relative were found to be significant [14]. There have been conflicting arguments in the literature regarding the role of family dysfunctions such as conflict, strict parenting or isolation, and school refusal [15,16]. These various aetiological factors emphasise the heterogeneous nature underlying school refusal and the necessity for future studies with larger sample sizes to assist in delineating predisposing risk factors.

 

Clinical features

The onset of school refusal can occur acutely, such as on the first day of a new school term, or gradually, such as increasing reluctance to attend school until outright school refusal. Non-attendance can occur sporadically, or continually for weeks or months [6]. The emotional distress that often accompanies school refusal can manifest behaviourally, physiologically, and cognitively [6,7]. Behaviours include remaining in bed, refusing to leave the car, crying, or having temper tantrums. Physiological symptoms include abdominal pain, nausea, vomiting, headaches, diarrhoea, sore throat, sweating, and frequent urination. On a cognitive level, children often have irrational fears about school attendance [7]. A case example of school refusal outlining the presentation, investigations, and management is included (Table 2).

Chronic school refusal has a strong association with anxiety-related disorders [17,18]. Common diagnoses include separation anxiety disorder, generalised anxiety disorder, social phobia, specific phobia, and adjustment disorder with anxiety [7,18]. There appears to also be age-related trends in regards to the diagnoses, for example younger children are often assessed to have separation anxiety whereas adolescents tend to be diagnosed with phobias [7]. These phobias are often in relation to social situations where there is an irrational fear of being criticised. People with an anxiety-related disorder often have co-morbid depression; and certainly, there is a high prevalence of school refusal in children with diagnosed or sub-clinical depression [18].

Children with school refusal can also display argumentative and aggressive behaviour when pressure is exerted upon them to attend school. This type of externalising behaviour leads to many of these children being diagnosed with oppositional defiant disorder [7]. It is important to note that in school refusal, this externalising behaviour is not displayed in multiple settings, but primarily contained to the home environment. By definition, conduct disorder-type behaviours, such as social disregard and violence, are not characteristic of school refusal, but more often associated with truancy.

Table 2. School refusal case example.

Assessment

As with any clinical presentation, a thorough history and medical examination must be taken to rule out organic causes. Only reasonable investigations relevant to the presenting physical symptoms should be conducted [19]. Obviously, if a chronic medical condition were to be uncovered, the primary focus of management would be appropriate referral and education [20].

In addition to a detailed history of the presenting physical symptoms, a health practitioner should consider the predisposing, precipitating, and perpetuating issues of the child’s school refusal in terms of individual, family, school, and community factors. Attention should be given to the family function, the reactions and responses of those surrounding the child to their school refusal, and peer relationships in school [19]. Liaising with the school for information about the child’s attendance records and academic progress would be useful to look for trends in absenteeism and potentially undiagnosed learning difficulties. In addition to days missed, it is also important to enquire about tardiness, early departures from school, missed lessons, and time spent out of class. Discussion about the child’s behaviour and social interactions are vital to exclude victimisation from bullying [21].

 

Formal assessment

Standardised behavioural checklists and mental health scales can be given to the child, their parents, and the school teachers to assist in delineating problems and comparing the severity of behaviours at school and home [19]. The School Refusal Assessment Scale-Revised (SRAS-R) is one of the widely accepted checklists used internationally to assess the functional model of school refusal behaviour, such as positive and negative reinforcements [22]. Determining the functional profile of school-refusing behaviour can also assist in identifying underlying psychiatric diagnoses [23]. The SRAS-R has been verified as having good validity, reliability, and utility [5,24]. However, a recent study has highlighted the ambiguity of certain items on the SRAS-R and suggests that some questions should be removed for improved validity and reliability [25]. The use of the scale can be extended across more generalised populations of school absenteeism, including truancy [26].

 

Child safety

Finally, health practitioners should be wary of the possibility of an unsafe home situation that the child may be exposed to, as this can contribute to school refusal. For example, a child may feel anxious and hesitant about leaving home if they feel the need to portray a protective role for a parent under domestic violence [20]. Mandatory reporting laws exist in all Australian states and territories for suspected cases of child abuse and neglect. Given the slight differences amongst states regarding child abuse legislation and protocol, it is advisable to check the details applicable to your jurisdiction [27]. Provisions within legislation protect practitioners from liability for reporting confidential information if the report was made in good faith. If a practitioner is uncertain about reporting, they can contact the local child protection unit or a paediatrician for discussion and advice [28].

 

Prognosis

A quarter of refusals are estimated to remit spontaneously or are dealt with successfully by the family and school without practitioner intervention [5]. However, school refusal has detrimental consequences for the majority of the remaining cases that go undetected and unmanaged. Short-term consequences include poor academic performance, family conflict, and damaged peer relationships. Long-term outcomes include social isolation, employment issues, and increased risk of ongoing internalising mental health problems and developing a psychiatric illness in adulthood, such as panic disorder and agoraphobia [19,29]. On first presentation, risk factors that indicate a poorer prognosis of returning to school consist of severe or long-standing school refusal, being adolescent or of older age, and having a co-morbid psychiatric illness, particularly depression [7,19].

Although there is a strong emphasis on a timely return to school for refusers, few published studies are available that report the long-term implications of return to school. One study concluded that there was enduring improvement in family relationships after the resolution of the child’s school refusal, however, there appeared to be no difference in the long-term social or emotional adjustment [30]. Another retrospective study found long-term improvement in educational and employment outcomes after school refusal treatment, except for those diagnosed with social phobia and learning difficulties; however, the study was limited by small sample size [31]. Further controlled studies investigating the long-term functional impact of managing school refusal need to be conducted.

 

Treatment

The primary objective of treatment for youth displaying school refusal is timely return to school. Behavioural therapies and cognitive behaviour therapy (CBT) have been widely studied and accepted as first line treatment where school refusal is associated with the primary diagnosis of an anxiety disorder [32–37]. Unfortunately, studies are limited by high treatment drop-out rates and inconsistent results on follow-up [33,37]. There is also a lack of randomised controlled trials investigating interventions other than CBT variants, such as group therapy or hypnotherapy [32,38,39]. These limitations indicate the need for future research with better-controlled studies and reproducible results, as well as considering other intervention types. More recent studies have found that CBT is most likely to be successful when it is incorporated into a multimodal treatment method involving the child, parents, and school [40,41]. Due to its heterogeneous nature, some cases of school refusal can be complex and persistent, therefore it is recommended that the child be referred to a paediatrician or to child and adolescent mental health services, which include inter-disciplinary teams, for holistic long-term management, which might include medication.

 

The child

Child treatment plans should be individually tailored, depending on the psychological basis of their school refusal as well as their developmental level [42]. This may initially include relaxation training for those with substantial physiological manifestations of anxiety. By reducing feelings of anxiety, children are better engaged to utilise various CBT strategies. Cognitive therapy can be used to scope the relationship between a child’s emotions and their behaviour, and ultimately facilitate school attendance by problem-solving and modifying maladaptive cognitions [7,43]. Social skills training is beneficial in addressing any deficits in social skills, which may be contributing to the school refusal, as well as managing the social anxiety associated with talking about their absence to peers or teachers [43]. Improving communication between parent and child is also an important component of CBT. Ultimately, graded exposure and planned return to school should be encouraged, involving the child and their teacher with modification of schoolwork and improved in-class support. Regular positive reinforcement should be used to assist progression, and monitoring for relapse is essential.

 

The parents

Parental and family support is crucial for successful return to school. It has been observed that improvement can be made only through positive influence and when the child is convinced that their parents are determined to achieve regular school attendance [44]. Parents should be taught to employ contingency plans and behaviour management strategies, such as ignoring inappropriate behaviour and positively reinforcing appropriate behaviours. Heeding signs of parental psychopathology and initiating anxiety management education may also help parents maintain their composure and focus when facilitating their child’s school attendance [7,43]. This may include arranging for parents to receive mental health services or marital therapy.

 

The school

The practitioner and parents should also closely liaise with the child’s school in order to enable a smooth return to school. It is important to educate school staff about school refusal behaviour and associated psychological issues, to dispel potential misconceptions about students with school attendance difficulties. School staff are encouraged to accommodate special arrangements, including modifying schoolwork and assessment, and allowing graduated attendance, such as only coming in for favourite lessons or for the first part of the day. Supportive teachers and ‘peer buddies’ are recommended to ensure the child’s experience of school is positive [43]. Complaints of somatic symptoms should be treated tentatively, and unless the child is clearly unwell, they should remain at school.

 

Pharmacotherapy

Pharmacological treatment may be considered adjunct to the cognitive and behavioural therapies, especially when the child has severe underlying anxiety or depressive symptoms, or when they have not responded to the comprehensive psychosocial treatments offered [45]. Based on existing clinical trial studies, there is little satisfactory evidence that supports the effectiveness of commonly prescribed medications. There appears to be some evidence favouring the tricyclic anti-depressant (TCA), imipramine, with concomitant psychosocial therapy as a superior therapy to placebo combined with psychosocial therapy [46–48]. Short-term outcomes consisted of improved school attendance and reduction in anxiety and depressive symptoms [47]. These positive findings were not maintained in a naturalistic one-year follow up study [48]. TCAs can be problematic due to their unpleasant side-effects and toxicity, including cardiovascular complications [49]. Selective serotonin reuptake inhibitors (SSRI), such as fluoxetine, have weaker evidence of efficacy for school-refusing children, showing no significant difference in therapeutic efficacy between combined CBT-and-fluoxetine therapy and CBT alone [50–52]. Despite this, SSRIs tend to be favourable in practice as they are shown to be effective in reducing depressive symptoms in children and adolescents, and are less likely to cause serious adverse effects [52–54]. Children on medication require regular review for response and side-effects.

 

Conclusions

School refusal is a challenging problem for health practitioners, families, and schools. Early identification and management reduces the risk of detrimental short- and long-term consequences. Management of school refusal can be complicated and arduous, and needs active participation from the child’s parents and school, as well as possibly paediatricians and mental health services. The preferred management of school refusal involves a multimodal treatment approach and CBT. There should be more awareness and understanding about this mental health risk and the potential for early intervention to promote the health and wellbeing of the future generations.

School refusal is a growing topic of interest in the literature. However, the current literature is largely limited by selection of the absentee population, lack of intervention types, poor sample sizes and follow-up, conflicting outcomes, and lack of long-term sequelae after return to school. In order to establish the efficacy of school refusal interventions, future research could benefit from further adequately powered randomised controlled studies with independent reproducible results. There should also be a focus on investigating groups with different causes of absenteeism, such as truancy, as well as management modalities other than CBT and their long-term effects.

 

Acknowledgements

My thanks to the Mt Gravatt Child and Youth Mental Health Service for their mentoring and inspiration for this review. Thanks to Dr Randal Moldrich (University of Queensland) for a critical review of the manuscript.

 

Conflicts of interest

None declared.

 

References

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Categories
Feature Articles

Pacific partnerships: exploring the Fijian healthcare and medical education systems

We walk with our host between the palm trees and brightly painted bungalows, touring the community care centre for elderly and disabled Fijians. The surrounds belie the grim conditions that must be endured by the patients who live here. There is one patient in particular whom our host wants us to meet — a middle-aged man with an intellectual disability and diabetes who has lived at the home for most of his adult life. He greets us warmly and chats with our host in Hindi whilst we take in his condition. His left foot is extensively bandaged, but the skin left visible is swollen and mottled. Our host, who is the chair of our sister-committee based in Fiji, explains that the patient’s foot has been gangrenous and in need of surgical assessment for the past five years, but they have been unable to facilitate this. His gangrenous foot has frequently been infested with maggots, despite the dedicated care of the facility’s nurse. There is just one nurse employed in the forty-bed facility. Due to limited resources, she must wash the patient’s foot barehanded with soap and water. The nurse shows us her supplies: a scanty collection of antibiotics, antihypertensive medications, metformin, and needles and syringes. Recently, she was grateful when our host provided her with latex gloves to wear whilst caring for the patients. The lack of medical resources and the understaffing of care facilities were just some of the issues we encountered during our brief, but enlightening, stay in Fiji. Through Friends4Fiji, a student-led partnership between Monash University and Umanand Prasad School of Medicine (UPSM), our Fijian counterparts, facilitated a week-long placement and education outreach program. We divided our time between undertaking a placement at the local hospital and assisting in the delivery of an anatomy teaching program for Fijian medical students, led by Dr Michelle Lazarus, a senior anatomy lecturer from our university.

Medical students in Fiji face challenges that we can scarcely imagine in Australia, extending from their academic resources to their expected time commitment. The information provided to students, and, by extension, doctors, is frequently outdated and incomplete, making it difficult to develop evidence-based medical practices [1]. Despite this, the students we worked with through the committee went beyond the required learning in order to develop a solid foundation. With limited resources, they are unable to rely on specialist journals or opinions, hence students are taught to think creatively, a skill they must rely upon in their future practice [1]. In the university we visited, frequent turnover of university administrators and lecturers had led to disruption of the curriculum such that some cohorts missed out on formal teaching of whole body systems in their anatomy course. Students described being reliant on textbooks and plastic models for anatomy teaching. There is no body donor program for dissection classes, and dissections are limited to animal carcasses at the local abattoir. Senior students must meet significant time requirements, with sixth-year students expected to perform weekly ‘on call’ shifts and night shifts, as well as attending wards on the weekends. These requirements may be explained by the inadequate hospital staffing levels, identified by comparing staff-to-population ratios with the projected numbers needed [2]. Having medical students performing intern-level tasks assists in alleviating doctors’ workloads without costing the national health budget further, as 60% of the budget already directly funds the workforce [2]. This shortage of fully qualified doctors has also been identified as impacting on medical training, causing a lack of post-graduate training opportunities, which contributes to emigration following student graduation [2,3]. With the many challenges these students face, it was deeply satisfying to observe their thirst for knowledge that extended beyond the curriculum, and we feel that we met a genuine need with the teaching program that we implemented.

As mentioned, the challenges faced by these students grow substantially when they become doctors, leading to a crisis of emigration among Fijian doctors and a subsequent growing reliance on foreign doctors [2,3]. ‘Push’ factors, which drive young professionals out of Fiji, include heavy workload and lack of promotion prospects and are coupled with ‘pull’ factors, which draw graduates to overseas positions, such as better pay and training opportunities in developed nations [4]. Ultimately, the high numbers of doctors leaving, particularly from the public sector, have been attributed to a complex career decision-making process involving work-related frustrations, with the primary motivation being income [3,5]. This interplay creates diverse problems, from workforce shortages and a lack of specialist training positions for graduates, to a lack of research conducted and published by Fijian authors. Among students we spoke with, intentions for future employment were divided. For those planning to stay in Fiji, students were motivated by a desire to give back to their community, with a student stating, “we study to help people, and Fiji needs A LOT of help,” and another explaining, “it will also be a good opportunity to actually help the people of Fiji get the best medical services from doctors.” Among students considering leaving Fiji, key motivators were gaining experience and learning advanced medicine, with one student stating, “I do tend to look forward to study and work overseas due to their high standard of education and learning programmes.” Whilst many of the students we spoke with had entered medicine with the very intention of giving back to their community by developing much needed skills, one can appreciate the frustrations they face. Every day, when these graduates go to work, they face shortages of essential medications and supplies, which interfere with patient care. There are also shortages in onshore graduate specialist training programs, which are limited to anaesthesia, medicine, obstetrics and gynaecology, paediatrics, and surgery [6]. These graduate options are a fraction of what is offered internationally, and do not meet the demand for specialists in Fijian hospitals, making it difficult for practitioners to receive adequate guidance for patient care [1,3]. The medical students we met in Fiji had diverse career aspirations. One student had greatly enjoyed her rotation at the psychiatric hospital in Suva, and was keen to pursue a career in this field, noting the dire need for more psychiatrists in Fiji. However, due to a lack of training positions, this student was contemplating leaving Fiji to pursue psychiatry training internationally. Despite the competitive nature of entering the postgraduate training programs, the number of specialists accepted into these programs does not meet public need, with only 48.5% actually working in the public sector following completion of specialist training [3]. Though there were many recognised benefits of working in Fiji, including cultural acceptance and religious responsibility, many doctors in Fiji experience significant frustrations with the facilities, bureaucratic processes, and the salaries they receive, factors that the students we spoke with already identify as concerns [3,5].

The lack of basic supplies and difficulties patients faced when accessing critical healthcare in the Fijian facilities were more significant than either of us anticipated. The Fijian public health system relies on a combination of taxpayer funding and external support through a number of United Nations agencies and nations including New Zealand, Australia, and the USA [2]. During our placement at the local hospital it quickly became apparent how underfunded and under-resourced this system is. Every investigation we considered ordering was carefully scrutinised by our supervising doctor, with a much heavier reliance placed on clinical assessment. This in turn impacts medical education, as students and doctors cannot rely on investigations being available and are hence required to think critically and to have a broad knowledge base. The lack of adequate technology to maintain evidence-based practice has also led to pressure from pharmaceutical companies presenting misleading information to doctors, placing further stress on doctors to avoid influence where possible [3,5]. This was particularly evident with medical imaging, which is limited in Fiji due to a paucity of technicians and facilities. Fiji has just three CT scanners [2] and the one located at our hospital was broken for the duration of our placement, and had been for quite some time. This stems from the fact that much of the machinery is donated second-hand from other nations and there is a reliance on this non-functional equipment, which impacts on delivering care to patients [1,2]. On the wards in the hospital, basic items which Australian doctors would consider essential for patient care were scarce. We particularly noticed the lack of access to products for safe hand hygiene practices and personal protective equipment. The lack of access to this basic equipment, combined with insufficient funds for medicines, were identified as primary concerns among the workforce, further contributing to emigration [2,5]. When it comes to ongoing care, shortages of essential medications make it difficult for the doctors to maintain a regular supply for their patients [6]. All medications are monitored monthly and sourced through the government-funded Fiji Pharmaceutical Services, however “stock-outs” are common [2]. The strategies in place for drug regulation are poor, and the quality of imported drugs is a concern to Fijian doctors due to a potential lack of stringent quality testing [1,2]. It was an incredibly steep learning curve to experience such fundamental differences in resources, and has certainly made us much more aware and grateful for what we have readily available in metropolitan Australian hospitals.

Another major difference identified during our stay was the restricted nature of mental health care in Fiji. As one student we spoke with stated, “mental health is mostly ignored in Fiji.” Despite the national emphasis on institutional care for people with ongoing mental illnesses, there is just one dedicated psychiatric hospital in Fiji, located in Suva [7]. This hospital offers generalised psychiatric services, however, like many other areas in Fiji, there are no sub-specialist psychiatric services available [2]. Within the wider community, psychiatric help is limited. At the hospital where we undertook our placement, those suffering acute psychiatric illness or at risk of committing suicide could be cared for in the euphemistically-named ‘Stress Ward’; however there was no psychiatrist or specialised staff available. As few students are able to undertake placement at the specialised mental health hospital, the stress ward and community placements comprise much of their practical experience of mental health. When asked their thoughts about mental health care in Fiji, students identified it as an improving area that still needed more work, with one student explaining, “five to seven years ago, no one bothered about mental illnesses and brushed it aside. So many women had never heard of the term ‘post-partum depression’. Now they get screened regularly. Mental health was an unaddressed issue in the past but we are getting there.” Whilst progress has been made to reduce stigma associated with mental illness through education and awareness by mental health advocacy groups, 42% of Fijians still report that they would be embarrassed to seek medical help for a psychiatric issue [2,8]. This attitude towards mental illness is far better in urban centres than in more remote regions, and level of educational attainment is positively correlated with receptiveness towards people with mental illnesses [7]. However during our visit to a community care facility, we noted residents with schizophrenia who spent most of each day bed-bound. Whilst these patients have access to antipsychotic medication, there is no access to counselling or rehabilitation workers who could help them return to the community. Standardised clinical treatment guidelines and referral protocols are still being developed by the relatively new Mental Health Clinical Services Network, which hopes to make mental health a priority through advocacy and legislation [2]. The Fijian medical students we spoke to were eager to cultivate the positive trend of increased community awareness and knowledge, combating the stigma of mental illness which predominates in Fijian society.

During our stay and discussions with the Fijian students, we learnt that similar to our own university, there was a slight female predominance of students. However, gender roles in Fiji have a clear effect on the academic and medical culture, something we particularly noticed as an all-female teaching team. In Australia, the challenges that women face in medicine are well documented, from sexual harassment to reduced earning potential [9,10]. However, in Fiji, females face even greater social and economic disadvantage, and this perception pervades many aspects of their academic and healthcare systems [2]. The majority of the lecturers and university administrators we met during our time in Fiji were male, and male authors contribute five times more than female authors in research conducted by Fijians [11]. In saying this, the ‘Learning Evidence-based Medicine and Research in Unison’ program developed by Friends4Fiji has seen an equal number of male and female students from UPSM engage with research, and many students, both male and female, spoke of a desire to develop research skills.  Within the wider health workforce, 95% of nurses are female, and despite the medical student ratio observed, two thirds of doctors are male [5]. Community health workers, poorly paid basic healthcare workers in rural village areas, are likewise predominantly female [11]. In the specialty field, however, it seems that change is occurring, with almost 40% of graduate specialists being female, and gender having little impact on decisions to resign [3]. Furthermore, the high number of female medical students may represent an exciting potential shift towards a more equitable future for Fijian women. The student response to our teaching by the end of the week was particularly rewarding. In a program of didactic teaching delivered by male academics, female students expressed being inspired to think of themselves as future educators and academics.

Fiji is a nation of two major ethnic groups; ethnic Fijians make up 57% of the population, and Indo-Fijians make up 37% of the population [2]. Something neither of us anticipated was the emphasis placed on race within the health system, where one of the key characteristics identified on each patient profile is the ethnicity of the patient: Fijian, Indo-Fijian, or other. One of the reasons cited to explain this is the differing epidemiological profiles of the two groups, with ethnic Fijians more likely to contract infectious diseases, and Indo-Fijians more likely to have ongoing non-communicable diseases, particularly cardiovascular disease [2]. However, a number of other key differentiating features have been identified within not only the wider population but also the health workforce, and it was clear that racial differentiation was a part of their culture. Within the wider community, mental health outcomes are far worse among Indo-Fijians, with a suicide rate of 24 per 100,000 compared to four per 100,000 per annum for ethnic Fijians [2]. Within the health workforce, there has been significant Indo-Fijian emigration, with much of this being attributed to the political coup in 2000 against the first Indo-Fijian Prime Minister, leading to disillusionment and ongoing concerns among Indo-Fijian doctors [3]. Conversely, among Fijian researchers, Indo-Fijians contributed more than ethnic Fijians (58% versus 40%) [11]. We observed this racial differentiation in all hospital relationships – patient to patient, doctor to patient, and doctor to doctor – as well as in the education setting. It was much more pronounced than it would be in Australia, and again it was something we needed to learn to adjust to during our stay.

Despite the brevity of our stay, we gained a profound insight into healthcare delivery in an under-resourced setting. We were extremely fortunate to have our stay facilitated by a dedicated group of medical students through the Friends4Fiji committee, and we made lasting friendships that have helped to solidify and grow our partnership. It was a challenging, but valuable, experience to be thrust into a position of responsibility that we had not yet encountered as clinical students in Australia. While on placement in Fiji, we were actively making medical decisions in consultation with our supervising doctor. We came to admire the Fijian students who, despite the challenges of their medical education, are thrust into a role of critical responsibility much earlier than in our program. To be able to apply the knowledge we have gained in our studies and also make a difference in patient care was extremely rewarding. Gaining insights into the lives of these students and seeing the issues facing their nation through their eyes was a unique experience. Given all we gained through this experience, it was extremely rewarding to also be able to help fulfil a need for further anatomy teaching, guided by our dedicated and supportive lecturer, Dr Michelle Lazarus. We also hope to engage the students in joint research projects, furthering our knowledge and developing our evidence-based medicine skills together. Our hope is to continue to grow this partnership between our two universities by fostering relationships between medical students and creating opportunities for student exchange.

 

Conflicts of interest:

None declared.

 

References

[1] Lowe M. Evidence-based medicine—the view from Fiji. Lancet. 2000;356(9235):1105-7.

[2] Roberts D, Irava D, Tuiketei D, Nadakuitavuki M, Otealagi M, Singh D et. al. The Fiji Islands health system review. Health Syst TransitTransit. 2011;1(1):6-123..

[3] Oman K, Moulds R, Usher K. Specialist training in Fiji: why do graduates migrate, and why do they remain? A qualitative study. Hum Resour Health. 2009;7(9):1-10.

[4] World Health Organisation. The world health report [Internet]. Geneva, Switzerland: World Health Organisation; 2006. 237p. Available from: http://www.who.int/whr/2006/en .

[5] Francis ST, Lee H. Migration and transnationalism. Canberra, Australia: ANU Press; 2009.

[6] Oman K, Moulds R, Usher K. Professional satisfaction and dissatisfaction among Fiji specialist trainees: what are the implications for preventing migration?. Qual Health Res. 2009;19(9):1246-58..

[7] Aghanwa H. Attitude toward and knowledge about mental illness in Fiji Islands. Int J Soc Psychiatry. 2004;50(4):361-75. .

[8] Roberts G, Cruz M, Puamau E. A proposed future for the care, treatment and rehabilitation of mentally ill people in Fiji. Pac Health Dialog. 2007;14(2):107-10..

[9] White G. Sexual harassment during medical training: the perceptions of medical students at a university medical school in Australia. Med Educ. 2008;34(12):980-6..

[10] Cheng T, Scott A, Jeon S, Kalb G, Humphreys J, Joyce C. What factors influence the earnings of general practitioners and medical specialists? Evidence from the ‘Medicine in Australia: balancing employment and life’ survey. Health Econ. 2011;21(11):1300-17..

[11] Cuboni H, Finau S, Wainigolo I, Cuboni G. Fijian participation in health research: analysis of Medline publications 1965-2002. Pac Health Dialog. 2004;11(1):59-78. .

 

Categories
Book Reviews

Medscape and iPhone apps: The stethoscope of the 21st-century medical student? App review.

Figure 1: Home page of Medscape app, displaying a current news story and available sections.

To many medical students, the ability of consultants to recall the pathogenesis of a rare condition or the dosing schedules for a myriad of medications seems unattainable. This feeling is further emphasised when we are confronted with patient questions that can make us feel grossly underqualified. If only there was a way to carry our library of textbooks into the clinic for quick consultation! Enter Medscape: a free app for iPhone, iPad and Android devices. Medscape’s comprehensive features may be an invaluable tool, whether it is in the clinic, writing assignments, or as a study aid for exams.

Table 1: Summary of Medscape features.

The Medscape application has a number of features that make it unique compared to other medical apps (Table 1). Primarily, it is a free application. All information is peer-reviewed, and in an easy to read format that is available both on- and offline. Another advantage is that the Medscape app covers a broad range of topics, providing a range of detailed information for almost every clinical scenario (Figure 1). The categories covered include:

Figure 1: Home page of Medscape app, displaying a current news story and available sections.

Drugs: A comprehensive list of pharmacotherapies, including prescription, over-the-counter, and alternative medications (Figure 2). For every medication listed, the app provides the generic and commercial names, dosage and indications, administration, adverse effects, warnings, pregnancy information, basic pharmacology and pharmacokinetics, images, and formulary.

Conditions: Medscape provides detailed information about a wide range of conditions, from allergic asthma to Zollinger-Ellison syndrome. Each condition is divided into the following sections: overview, clinical presentation, differential diagnosis, work-up, treatment and management, and follow-up (Figure 3). Over 1,000 conditions are included within the application, however it is important to note that this list is not exhaustive, as some rarer conditions are not covered. Overall, however, using this section for any disease is more than sufficient information for a medical student or junior doctor level.

Procedures: A list of many procedures listed by specialty as well as a large atlas of anatomy is included (Figure 4). Articles do however primarily use text to transmit information. Topics such as these may benefit more from greater use of visual adjuncts and illustrations.

Figure 2: Example from “Drugs” section displaying available features.

Drug Interaction Checker: This tool allows the user to add up to 30 medications concurrently and view the subsequent potential interactions that may occur between these medications. This tool will prove useful when assessing older patients, or those with multiple co-morbidities who are often subject to polypharmacy, to check for interactions.

Pill Identifier: A tool that allows the user to input information about a medication’s appearance (shape, colour, etc.), and generate a list of possible medications that match the description. While in theory this could be a useful tool for patients who cannot remember the name of their medication, in practice it is not particularly accurate, and customised towards medications available in the USA. As such, this tool appears to have limited utility in an Australian setting. For example, searching for features of Panadol capsules leads one to a page of 500 possible medications, none of which are the drug in question.

Calculators: Over 150 medical calculators and clinical decision-making scores (e.g. Glasgow Coma Scale, Warfarin Bleeding Risk, Framingham Risk Score, etc.) are provided, arranged by specialty. This section is ideal for quick calculations when a computer is not available: for example, when calculating a patient’s renal function to see if they are contraindicated for a pharmacotherapy.

Figure 3: Example from “Diseases & Conditions” showing available features.

Formulary: The formulary tab on this app is designed to provide clinicians with a reference of which medications are subsidised at their hospital or state. However, as the app is designed to suit the USA market, this feature is not applicable in Australia.

Directory: This section provides a directory that lists nearby hospitals and specialists according to GPS location of the mobile device. However, this is another feature designed for the American market and thus has serious compatibility issues for Australian users.

Conclusion
The Medscape mobile application is not perfect. As of version 5.5 it remains U.S.-centric, rendering features such as the drug formulary, directory, and pill identifier almost useless for Australian medical students and clinicians, which is a major drawback. I have also found that suggested dosing regimes can differ from Australian standards, as per the Australian Therapeutic Guidelines. Finally, by extension, Australian names of commercial medications are not listed. Aside from this, the drug pharmacology section can be very brief, so it may be more suitable for a refresher rather than learning drugs primarily through the app.

Figure 4: Example from “Procedures” section, displaying available features.

Overall, however, I have found that this app can be a fantastic tool for a medical student to have in a clinical setting, or as a reference tool for studying, and acts as far more than just a medical encyclopaedia. It is especially suited to those who wish to brush up on conditions already learned, or to extend their learning. All features other than images and pill identification are available offline, which may be useful in areas where internet access is limited, such as the clinic. The app works smoothly, and is well laid out and easy to navigate.  The app manages the delicate balance between not enough information and too much irrelevant information very well when compared to similar medical applications available on smart devices, making it indispensible to any student anticipating some difficult patient or consultant questions.

In the digital age, our patients expect the medical fraternity, and by extension, medical students, to be more knowledgeable than ever. As such, in the author’s opinion, this app is a fantastic way to provide additional information, and may help students and clinicians alike to provide better patient care.

 

Conflicts of interest: None declared.

Categories
Conference Report

Australasian Students’ Surgical Association – Launch and leadership day – event report

On Saturday, 18 March 2017, the Australasian Students’ Surgical Association executive hosted the inaugural launch and leadership day at the Royal Australasian College of Surgeons, Queensland headquarters. The day hosted twenty-two medical student representatives across Australia and New Zealand, including surgical society presidents and committee members.

The program included two keynote presentations from Doctor John Quinn and Doctor Richard Lewandowski, both internationally and domestically renowned surgeons who are based in Brisbane.

Doctor Quinn, the first Vascular Surgeon trained in Australia and the Executive Director of Surgical Affairs for the Royal Australasian College of Surgeons delivered an informative session on the requirements for acceptance into surgical training pathways. His talk was particularly useful as he kindly answered many questions from students about selection criteria and the variety of opportunities medical students and junior doctors can pursue to increase their chance as prospective applicants in future years.

Doctor Lewandowski, an esteemed plastic and reconstructive surgeon and the Co-Founder of Operation Smile, gave an eye opening discussion about the opportunities of philanthropic work outside the constraints of domestic practice. His stories and photographs of patients he’s worked with overseas were inspirational, and gave students an insight into the wide possibilities of surgical training.

Following the keynote presentations, a “RACS Specialties” panel AMSJ session was hosted, with a fantastic range of local surgeons:

  • Doctor John Quinn, vascular surgeon;
  • Doctor Richard Lewandowski, plastics and reconstructive surgeon;
  • Doctor Rosslyn Walker, paediatric surgeon;
  • Doctor Carina Chow, colorectal surgeon;
  • Doctor Rumal Jayalath, neurosurgeon;
  • Doctor Grant Fraser-Kirk, plastics and reconstructive surgeon;and
  • Doctor Damian Fry, general surgeon trainee and RACSTA representative

The afternoon comprised of four workshops, aimed at providing the student representatives with skills to assist them in working to improve their university student society to provide education and resources for students to develop a pre-vocational interest in surgery. These workshops included:

  • Mr Allan Mason, from Encore Accounting who spoke about budge ng for surgical societies and personal finances through training years;
  • Mrs Jane Clark, a Senior Marking Consultant for VIE Marketing, who ran a practical session on skills to improve advertisement of surgical societies to engage students;
  • ASSA workshop covering leadership scenarios, an overview of the upcoming Australasian Students’ Surgical Conference (ASSC);
  • ASSA strategic planning session, allowing students to collectively brainstorm beneficial resources for surgical societies, including the academic portfolio, as run by Cameron Wells on the ASSA executive.

On behalf of the Australasian Students’ Surgical Association executive, I would like to thank Thalia Nguyen, the Administrative Officer for the RACS Queensland office for her guidance in facilitating the launch. We are very grateful for ongoing support from the attending surgeons, and thank them for so kindly giving up their me to provide such insight to the medical student representatives and the executive.

Finally, I’d personally like to thank the current executive team for so diligently working to create this launch, and I hope this initiative is continued and expanded in future years.