Tag: University of New South Wales

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Editorials

Telemedicine: The possibilities, practicalities and pitfalls

The internet has woven itself into the fabric of society, by offering a plethora of services which have evolved from luxuries to necessities.

Telemedicine – the use of the internet to transmit information for diagnosis and management – has garnered recent attention because of the Federal Government’s promise to provide AU$392million for its development, and the proposed national broadband network which may increase the efficiency of telemedical services. [1,2] Telemedicine, endorsed by the Australian Medical Association, [3] has a number of applications; however, the most highly publicised of these is the concept of online interactive consultations with a specialist practitioner in real-time, potentially using a Skype™-like platform.

In the coming years, telemedicine will likely play a significant role in our careers and as such, we must have an understanding of both its benefits and limitations. Despite the obvious potential of telemedicine, several questions remain in the minds of the public, doctors and also medical students. The first is: do we really require telemedicine? The costs are significant, but so is the need for the 12% of Australia’s population inhabiting outer regional and remote locales – data travels significantly faster over hundreds of kilometres than patients and their families. For example, geriatric patients even in the relatively large Queensland town of Rockhampton may need to travel over 600 kilometres to their nearest geriatrician. [4] For frail elderly patients, this is hardly practical. To help address this, the University of Queensland’s Centre for Online Health currently provides approximately 2,200 inpatient and outpatient consultations annually, primarily for geriatric and paediatric patients. A designated outpatient clinic exists at the Royal Children’s Hospital, Brisbane, and the transmission of video, radiological images, laboratory data and medical records allow distant consultants to conduct ‘video ward rounds’ for their inpatients. [4,5]

Nonetheless, even if there is a need for telemedicine, is it effective? Can doctors really diagnose and treat patients they are not in the physical presence of? Although telemedicine has been studied in several ways, two particular studies investigated these questions. A Canadian randomised controlled trial found that telepsychiatry and face-to-face psychiatry produced equivalent clinical outcomes [n = 495]. Further, when comparing the travel and accommodation costs of patients versus the cost of videoconferencing technology, the authors found the costs of the latter to be 10% cheaper. [6] Similarly, a Scottish study which compared 44 outpatient diagnoses and management plans made by a neurologist in a face-to-face…

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Editorials

National standards in medical education

Since 1999, the number of Australian medical schools has doubled.

While this has brought about diversity, it has arguably also created a worrying lack of standardisation in the skills of graduates. National curricula are currently a hot topic, with the development of a standardised Australian curriculum for Kindergarten to Year 12 well underway. Is it time to rekindle a similar debate within Australia’s medical education sector?

Presently, the only force acting to maintain a degree of standardisation between Australian medical curricula is the Australian Medical Council (AMC) and its accreditation processes. The AMC accreditation standards guide, while laudable, does not direct the specific structure or content of curricula, leaving the door open for the veritable potpourri of programs that we now have across the country. For example, the guideline for curriculum content of the basic biomedical sciences, which occupies one line of the document, does not even mention the names of the various biomedical disciplines: “[t]he course provides a comprehensive coverage of … basic biomedical sciences, sufficient to underpin clinical studies.” [1] Either the AMC is not prepared to put more specific guidelines in the public domain, or little guidance exists to direct curriculum development. The open-ended regulatory framework has seemingly acted for more than a decade to feed a process of medical schools constantly reinventing the wheel with ‘revolutionary’ medical programs.

Of all the medical science disciplines, the teaching of anatomy has been the most criticised in recent times. Anatomy provides a case study in teaching disparities between universities. In a recent national survey, striking differences were demonstrated between medical schools in several areas, including the amount of hours dedicated to formalised anatomy teaching, the delivery of lessons, the use of cadavers, and the manner of assessment of anatomy knowledge. [2] For example, eleven of the nineteen medical schools surveyed have no specific requirement that student demonstrate sufficient anatomical knowledge at examination. Most medical schools pool anatomy questions with those of other disciplines, and calculate an overall passing grade. Thus, a student could be considered competent in basic clinical sciences without passing anatomy. These and other findings have prompted recent calls for a national curriculum for anatomy. [3] However, despite being extremely topical of late, anatomy is but one example of the heterogeneity in teaching across Australia. It would be difficult to make a strong case for having a standard curriculum for one subject and not others.

The suggestion…

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Feature Articles

What’s wrong with the Nobel Prize?

Introduction

The Nobel Prize is the single greatest honour that can be bestowed upon a scientist, and yet it has received its fair share of criticism. Even Nobel Laureate, Max Dulbrück, has criticised the Prize stating “by some random selection procedure, you pick out a person and make them the object of a personality cult. After all, what does it amount to?” [1] Recently, there have been calls to reform the Nobel Prizes with ten scientists writing an open letter to the executive director of the Nobel Foundation. [2] This article presents a critical analysis of the Nobel Prize and its role in science, showing that whilst flawed the Prize is still valuable.

The origin of the Nobel Prize

The Nobel Prize is named after Alfred Nobel, who made a fortune in the munitions industry after inventing dynamite. When he died in 1896, Nobel’s estate was worth more than 33 million kronor with one year’s interest from the fortune equal to the annual budget of Sweden’s greatest university. [1] Nobel’s will, written in 1895, dedicated the majority of this estate to prizes for those who had “conferred the greatest benefit on mankind” by making “the most important discovery or invention” in the fields of physics, chemistry and physiology or medicine. In just one short paragraph, Nobel directed how the Prizes should be awarded: the Swedish Academy of Sciences was appointed to award the Physics and Chemistry Prizes and the Karolinska Institute was given responsibility for the Prize for Physiology or Medicine. [3] Nobel also included Prizes in Literature and Peace, but these will not be discussed in detail in this article. For various reasons, Nobel’s will remained in legal peril until 1898 when the Nobel Foundation was finally established as the legal legatee. [4] In 1901, five years after Nobel’s death, the first Nobel Prizes were awarded.

The role of the Nobel Prize in recognising and rewarding great discoveries

The purpose which Alfred Nobel intended his Prizes to serve remains their primary role: to recognise and reward great scientific discoveries. [5] Indeed, one of the reasons that the Nobel Science Prizes now demand so much respect is that their histories give testimony to many of science’s most significant discoveries. Only on a few occasions has a Nobel Prize in Science been awarded for an undeserving discovery. Most notably, Johannes Fibiger won the 1926 Nobel Prize for Medicine for discovering that parasites caused cancer, a discovery which later turned out to be completely unfounded. [1,6] There have also been instances in which outstanding advances in scientific thinking have gone unrecognised by the Nobel Prize. Albert Einstein, although awarded a Nobel Prize for the discovery of the photoelectric effect, received no recognition for his most important achievement, the theory of special relativity. On the whole however, the Nobel Prizes for Science have been awarded for great scientific discoveries. The prizes have found their value in the calibre of their recipients. [5]

The Nobel Prizes for Peace, and in particular Literature, have not fared as well. [1,4] In the early years the Nobel Committee for Literature favoured conventional authors and failed to recognise greats such as Tolstoy. Consequently, the reputation of the Literature Prize was damaged and still suffers. Some suggest that the Science Prizes have enjoyed more success because science is objective, and the selection of Prize winners is less arbitrary than in the subjective fields of literature and peace. This is not the case. The selection process for the science awards is also subjective and may be influenced by the bias of the decision-makers.

Is the decision-making process arbitrary?

The statutes of the Nobel Foundation dictate rules for selecting Prize winners, adding several criteria to those stipulated by Nobel. These can be summarised as follows: [7]

  • Prizes may only be awarded for work that “by expert scrutiny has been found to be of … outstanding importance” and of great benefit to mankind.
  • “The awards shall be made for the most recent achievements in the fields of culture referred to in the will and only for older works if their significance has not become apparent until recently.”
  • “To be eligible to be considered for a Prize, a written work shall have been issued in print or have been published in another form.”
  • Prizes may not be awarded posthumously but a Prize may still be presented if the Prize winner dies before the presentation ceremony.
  • Prizes may be shared between two or three co-workers or between two discoveries but not between more than three people.

The Foundation’s statutes also provide guidelines for nominations and adjudication of the awards. Nominations are not open to the public and to be considered for an award, a written nomination must be received from “a person competent to make such a nomination.” This includes all Nobel Laureates, members of the Prize-awarding bodies (the Swedish Academy of Sciences and the Karolinska Institute) and those invited to submit nominations. [6] Each Prize-awarding body sends out thousands of invitations every year to scientists world-wide, and a rotation system is used to include as many people as possible. Nominations for an award are then considered by a subset of the Prize-awarding body, the Nobel Committee, which consists of three to five persons appointed by the Prize-awarding body. After careful deliberation, the Nobel Committee votes to determine which candidate should be recommended for the award. Although the final…

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Book Reviews

Oxford Handbook of Clinical Specialities

As medical students progress through their clinical years, they are exposed to the varied streams of medicine, which not only functions as a key component in their broader medical training, but serves as a degustation for potential specialities they may choose to pursue after medical school. Students often find themselves starting a specialty term without knowing what they need to know, let alone which is the best student-friendly textbook.

The Oxford Handbook of Clinical Specialties (OHCS) is divided into twelve chapters, covering streams such as obstetrics and gynaecology, paediatrics, primary care, psychiatry and accident and emergency, which are part of the core teaching in most medical schools. It also covers a number of other important specialities, such as otolaryngology, dermatology, ophthalmology and anaesthetics.

Made as a companion to the Oxford Handbook of Clinical Medicine – often referred to as the ‘medical student’s bible’ – this book is another in the Oxford Handbook series which provides a solid summary of many clinical streams that will be encountered by medical students as part of general medicine, as well as during speciality rotations.

Like most books in the series, this book is extremely user-friendly. It is divided into different sections based upon fields, with coloured tabs used to help identify each section. Most chapters in the OHCS begin with summary pages which deal with the fundamentals of each stream, allowing students to familiarise themselves with the essentials and identify important learning areas. Following this, most chapters spend one or two pages discussing important clinical entities, covering the common, the classical and the critical conditions that medical students should be aware of. Students who have used other Oxford handbooks will be familiar with the structure used to discuss each condition. Where relevant, the book covers the basics – signs and symptoms, investigations, treatment and management, and complications.

Where this book may fail students is in its lack of detail. While the succinct nature of the OHCS is useful in the first few clinical years, its brevity also means that the level of knowledge expected of more senior students is lacking. For example, the psychiatry section is an area where this textbook fails to compete with a more comprehensive text. Since psychiatry is a stream that is quite removed from the rest of medicine, the brief summary pages on schizophrenia and affective disorders will doubtless leave students wanting. The dermatology section is also underdone, with not enough space in this pocket-sized textbook to include images of the myriad of integumentary conditions, which is vital for the inexperienced student.

Having said this, the OHCS certainly does not purport to be a comprehensive textbook of each of the streams it covers. Tutors will recommend their favourite textbook – the ‘must have’ for each speciality – which will serve to work biceps as much as brains. Like most Oxford handbooks, the selling point for OHCS is that it can fit in one’s pocket and is a handy guide to confirm what has already been learned. Overall this is a great textbook for junior-year students entering the clinical environment for the first time, and a useful reference text for senior students.

Collier J, Longmore M, Turmezei T, Mafi A. Oxford Handbook of Clinical Specialties. 8th ed. Oxford (UK): Oxford University Press; 2009.

RRP $97.95

Conflict of Interest

None declared.

Categories
Review Articles

Ovarian carcinoma: Classification and screening challenges

Removal of a large ovarian tumour

Abstract

Primary ovarian cancer is the leading cause of death from gynaecological malignancy and the sixth most common cause of cancer death in Australian women. Our understanding of the underlying pathophysiology of epithelial ovarian cancers is incomplete, which poses difficulties for screening, diagnosis and treatment. This review summarises the current knowledge and debate regarding classification of epithelial ovarian cancers, including a proposed new classification system. Current screening methods and the evidence behind them are also presented. The outcomes of large, ongoing trials are awaited to provide more conclusive evidence regarding the effectiveness of screening for ovarian cancer.

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Editorials

International medical students: Interned by degrees

The progression from university to the workforce in medicine is not comparable to any other discipline or profession.

An internship is essentially an extension of a medical degree, and the degree is redundant without one. The issue of the burgeoning numbers of Australian medical graduates, and the associated ‘crisis’ in intern placement availability, is currently the preeminent political issue for medical students. Increasingly, international students have been caught in the middle of the storm.

To put this situation in the proper context, one needs to look back to the late-1980s and 1990s. At this time, Australia was seen as being oversupplied with doctors in general. There was a strong policy reaction to this sentiment, which capped student numbers, and levied heavy restrictions on overseas-trained doctors. The turn of the century saw an abrupt turnaround in this attitude, as a different picture was painted about the country’s long-term health workforce requirements. Temporary resident visas for overseas doctors grew from 664 in 1993-1994 to 1923 in 2001-2002. [1] On the graduate front, from around 2003, government policy has allowed international medical graduates to remain in Australia. [2] Given worsening projections for future workforce shortages, one could be forgiven for thinking that this was seen as the start of a norm that would continue indefinitely. While incoming international students were never given a guarantee of placement after graduation, until recently, it was often implied that this would never be an issue.

Australia only had ten medical schools in 1999, whereas today we have twice this number. [3] International places have increased as a proportion over this time. In 2002, 161 international students graduated from Australian medical schools, representing 11% of total graduates. This year, the number is predicted to be 423 students, or 16% of the total. This is as high as 34% at one institution. [4] Unfortunately, while governments eagerly and justifiably expanded the numbers of medical places at universities, this was not matched by sufficient planning for long-term doctor training. Consequently, last year, many graduates had genuine cause for concern about receiving an intern placement. However, just because we have a bottleneck of medical graduates does not mean that we have an oversupply. Make no mistake; the future of our health system needs every single graduate we are producing. Although we are dealing with unprecedented numbers, the training system needs to come to terms with this reality as soon as possible.

Even domestic Commonwealth-supported students have had reason to worry until the Australian Health Ministers’ Conference this February, when they were given a guarantee of training places for the foreseeable future. This is to be achieved by doubling the undergraduate clinical training subsidy across all states for 2010-2011, with the annual commitment totalling $140m nationally. [5] While this is a very positive and encouraging step forward, it excludes many potential future doctors.

For international students, there are no guarantees. Worse still, some international graduates from certain Australian medical schools would not even be able to gain an internship-equivalent in their home country. One cannot underestimate the perspective of our international colleagues – after spending a fortune on living expenses and university fees, being told that they will not be able to continue their training in the country where they graduate. For some, continuing their training anywhere may be extremely difficult. This is the frightening scenario that many are now facing.

It is not a well-kept secret that many medical faculties around the country are heavily reliant on international students and their fees to fund medical programs. Can we justify milking international students for their dollars, followed by abandonment at graduation in favour of the colleagues whose degrees they subsidised? Furthermore, there is the possibility that the international student funding source could deplete if recent developments discourage new students from coming here.

Currently, governments spend enormous sums of money attracting and retraining foreign health workers. Admittedly, overseas-trained doctors are filling a more immediate gap in the system that is considerably further down the line of training than internships. This is no doubt necessary for the time being. Nonetheless, it seems senseless that we are prepared to spend such amounts bringing overseas-trained doctors into the country, but cannot bring ourselves to adequately train and retain doctors reared in our own top-class medical schools.

The ramifications extend beyond just international students. Local full-fee-paying students, who make up further 6% of medical graduates, are also excluded from the recent guarantee of training places. [6]

The challenge, of course, is not just to make places for more students, but to ensure that this does not affect the quality of teaching that all trainees receive. It is also critical that we do not simply replicate the mistakes of the past: we need to ensure that there is adequate downstream planning, not just more intern places. Recent government announcements about General Practice and specialist training places are encouraging in this regard. [7]

If governments consider international and domestic full-fee-paying students not worth retaining, then they should perhaps reconsider the approval of such medical places in the first instance. But for those already in our programs, this line of reasoning simply is not good enough. There is no adequate justification for any Australian-trained medical student being denied an intern placement. It is nonsensical to on one hand have a workforce shortage, and on the other hand be turning away the best long-term solution to that shortage. If someone is good enough to be trained in an Australian medical school, then they should be good enough to practice here.

References

[1] Hawthorne L, Birrell B. Doctor shortages and their impact on the quality of medical care in Australia. People Place 2002;10(3):55-67.

[2] Joyce CM, Stoelwinder JU, McNeil JJ, Piterman L. Riding the wave: current and emerging trends in graduates from Australian university medical schools. Med J Aust 2007; 186(6):309-12.

[3] Prideaux D. Medical education in Australia: Much has changed by what remains? Med Teach 2009;31:96-100.

[4] Medical Deans Australia and New Zealand. National Clinical Training Review: Report to the Medical Training Review Panel Clinical Training Sub-committee [Online]. 2008 Mar 26 [cited 2010 Mar 12]. Available from: URL: http://www.medicaldeans.org.au/pdf/Medical%20Deans%20National%20Clinical%20Training%20Review%20March.pdf

[5] Department of Health and Ageing. Australian Health Ministers’ Conference Communiqué [Online]. 2010 Feb 12 [cited 2010 Mar 12]. Available from: URL:http://www.health.gov.au/internet/main/publishing.nsf/Content/mr-yr10-dept-dept120210.htm

[6] Medical Deans Australia and New Zealand. Medical students may never qualify, warn Deans. [Online]. 2010 Mar 9 [cited 2010 Mar 12]. Available from: URL:http://www.medicaldeans.org.au/media_090310.html

[7] Department of Health and Ageing. Building a National Health and Hospitals Network: Training a record number of doctors [Online]. 2010 Mar 15 [cited 2010 Mar 20]. Available from: URL:http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr10-nr-nr046.htm

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Letters

The Australian Medical Student Journal is born

A group of AMSJ staff members at a meeting in Febuary, 2010

It is a delight to welcome you to the inaugural issue of Australia’s new national medical student journal.

As you will no doubt discover, this first issue of the AMSJ really is a showcase of the talent, passion and achievement of medical students from across the country.

In recent times, medical education in Australia has seen a paradigm shift to self-directed learning and evidence-based medicine, and medical students themselves have become an increasingly diverse cohort with a wide range of backgrounds and interests. The AMSJ is in many ways a response to the corresponding need for avenues of expression.

In less than a year, the AMSJ has developed from an idea to a reality of previously unimaginable quality and scale. Every stage in the journal’s development has been somewhat of a leap into the unknown. One of the critical hurdles for the concept was always going to be the response in terms of submissions. We were overwhelmed with both the quality and quantity of what was received, with the vast majority of Australia’s twenty medical schools being represented among the submissions. The only regret is that only a small proportion were able to be published in the inaugural issue. Ultimately, it is the authors who have made the AMSJ a success, and will continue to do so.

The AMSJ has been a challenging balancing act in many respects. While we wanted to steer well away from being another student magazine, we did not want to be constrained by all of the typical expectations of a biomedical journal. We are not the first such journal in the world, however we found that the whole concept of a ‘student medical journal’ still needed to be defined; such a journal needs to be student-friendly for both authors at one end, and readers at the other.

From the perspective of student authors, we aimed to provide an unintimidating forum that could be a stepping-stone into the world of academia. While all academic articles underwent rigorous internal and external review processes, being anonymously peer-reviewed by at least two experts in their particular field, a central concern was to be as constructive as possible with any author feedback. A student journal needs to avoid the type of harsh uninformative rejections that are sometimes met with in existing journals. The AMSJ offers opportunities for a wide variety of styles, and for more general-interest articles that may not find a place elsewhere. As such, in this issue, you will find what you are familiar with in existing journals, such as review articles, original research, and case reports. However, you will also find many pieces that traverse the traditional boundaries, such as reviews of student resources, career pieces, and a host of feature articles.

From the perspective of you, our readership, the central concern was to be relevant and interesting. There is little use in publishing articles, regardless of the excellence of the research behind them, if they are of an extremely specialised nature and of no appeal to the vast majority of medical students. By the same token, we needed to publish articles that could extend students beyond the limits of standard medical curricula.

None of this would have been possible without our extremely dedicated volunteer staff of twenty-two students, to whom I offer heartfelt thanks and congratulations. As we all quickly learned, being involved in a totally new professional organisation is no easy task – every single process has to be designed from the ground up, without the luxury of a predecessor to lean on for advice. But at the same time, this has imparted an amazing degree of creative freedom that everyone found most rewarding.

There are a host of other people who have made this venture possible, including the generous and dedicated academics and clinicians who became peer-reviewers, our sponsors, medical societies from around the country, and the UNSW Faculty of Medicine, particularly Dr. John Hunt.

If what follows in the next seventy or so pages represent what is possible for an inaugural issue, then the future for the AMSJ certainly seems bright. I would encourage any student who reads this issue to take inspiration from their colleagues’ work published in these pages and think of how they could contribute to future issues, and indeed to the field of medicine in general.