Guest Articles

Surgery: art or science?

Professor Ian Harris AM

It’s often said that surgery is more art than science. Rubbish. Too much emphasis is placed on surgeons’ technical skills and not enough on the decisions behind them.

Any good surgeon can operate, better surgeons know when to operate and the best surgeons know when not to. Knowing when to operate and when to hold off relies on weighing up relative probabilities of success and failure between alternatives.

Good decision makers (and therefore good surgeons) base such decisions on quality evidence, and this is where science comes in. The evidence we seek is evidence of the true effectiveness of an intervention, and it is the scientific method that provides us with the most accurate and reliable estimate of the truth. Faced with alternatives, surgeons can sometimes make the wrong choice by being unscientific.

Surgeons often decide to do certain procedures because it’s what’s usually done, because it’s what they were taught, because it sounds logical, or because it fits with their own observations. If the surgeon’s perception of effectiveness and the evidence from scientific studies align, there is little problem. It’s when the two conflict that there’s a problem: either the surgeon’s opinion or the evidence is wrong. Worse, sometimes there is no good quality evidence and we are left with the surgeon’s opinion.

There is abundant evidence that surgeons overestimate the effectiveness of surgery, and considerable evidence of seemingly effective operations (based on observational evidence) turning out to be ineffective on proper scientific testing.

So what evidence should we rely on? Put simply, when you are trying to determine true effectiveness, the best method is the one that is least wrong, i.e., the method that has the least error. The scientific method is constructed to reduce error – we rarely know the truth, but we can increase the likelihood of our estimates containing the truth and we can make those estimates more precise by reducing error. In other words, we can never be certain but we can reduce uncertainty.

There are two types of error: random error and systematic error. Random error is easy to understand. If you toss a coin ten times, you may get seven heads, but that doesn’t mean the coin is unbalanced. Toss it 100 times and if you get 100 heads then you have reduced random error (the play of chance in generating such a result) and it is now very likely (and we are more certain) that the coin is unbalanced.

Systematic error (bias) is when we consistently get the wrong answer because we are doing the experiment wrong. There are many causes of bias in science and many go unrecognised, like confirmation bias, selective outcome reporting bias, selective analysis bias, measurement bias, and confounding. Systematic error is poorly understood and a major reason for the difference between the true and the apparent effectiveness of many surgical procedures.

The best way to test the effectiveness of surgery and overcome bias (particularly when the outcome is subjective, such as with pain) is to compare it with a sham or placebo procedure and to keep the patients and those who measure the effectiveness ‘blinded’ to which treatment was given. Yet such studies, common in the drug world, are rare in surgery.

In a study that summarised the research that has compared surgery to sham or placebo procedures, it was shown that the surgery in most such studies was no better than pretending to do the procedure [1]. And in the studies where surgery was better than placebo, the difference was generally small.

It’s not always necessary to compare surgery to a sham – sometimes comparing it to non-surgical treatment is sufficient. This is particularly the case for objective outcomes (survival, recurrence of disease, anatomic corrections) where blinding is less important. But you still have to compare it to something – to merely report the results of an operation with no comparator provides no reference for effectiveness beyond some historical control (of different patients, with possibly different conditions, from another place and another time). Journals are littered with case reports showing that most people got better after receiving treatment X but such reports tell us nothing about what would have happened to the patients if they did not receive treatment X, or received some other treatment. These types of non-comparative studies continue to sustain many quack therapies as well as common medical and surgical therapies, just as they sustained the apparent effectiveness of bloodletting for thousands of years.

However, even when comparative studies are done, they are not always acted upon. In a study looking at the evidence base for orthopaedic surgical procedures, it was found that only about half of all orthopaedic procedures had been subjected to tests comparing them to not operating [2]. And for those procedures that had been compared to not operating, about half were shown to be no better than not operating, yet the operations were still being done. The other surgical specialties are unlikely to be much better.

So there are two problems in surgery: an evidence gap in which there’s a lack of high quality evidence to support current practice, and an evidence-practice gap where there’s high quality evidence that a procedure doesn’t work, yet it’s still performed.

Part of the problem is that operations are often introduced before there’s good quality evidence of their effectiveness in the real world. The studies comparing them to non-operative treatment or placebo often come much later – if at all.

Surgical procedures should not be introduced or funded until there’s high quality evidence showing their effectiveness, and it should be unethical to introduce a new technique without studying its effectiveness. Instead, the opposite is argued: that high quality comparative studies (placebo controlled trials) are unethical.

Often, procedures that surgeons consider to be obviously effective are later shown to be ineffective. In the US in the 1980s, a new procedure that removed some lung tissue was touted for emphysema. Animal studies and (non-comparative) results on humans were encouraging. So the procedure became commonplace. A comparative trial was called for but proponents argued that this would deprive many people of the benefits of the procedure, the effectiveness of which was obvious.

Medicare in the US decided only to fund the surgery if patients participated in a trial comparing it to non-surgical treatment. The trial was done and the surgery was found wanting. This cost Medicare some money, but much less than paying for the procedure for decades until someone else studied it. This type of solution should be considered in Australia – only introduce new procedures if they are being evaluated as part of a trial.

The current practice of surgery is not based on quality science. If you got a physicist from NASA to look at the quality of science supporting current surgical practice they would faint. But it is getting better. It is getting better because of advancements in our understanding, because of the spread of evidence based medicine (in teaching and in journal requirements, for example), and because surgeons are understanding science better. The trials are getting better, but the incorporation of the results of those trials into practice is slow and often meets resistance because of suspicions that stem from a lack of understanding of science and the biases that drive current practice.

Billions are spent worldwide on surgical procedures that may not be effective because in many areas of surgery we still rely on surgical opinions based on biased observations and tradition. It is time for surgery to be a real science and to rely on the kind of evidence on which other scientific endeavours rely; the kind of evidence that we demand of other medical specialties and of non-medical practitioners. It’s not too hard. It’s not unethical. It’s right, and it’s time.



[1] Wartolowska K, Judge A, Hopewell S, Collins GS, Dean BJF, Rombach I, et al. Use of placebo controls in the evaluation of surgery: systematic review. BMJ. 2014;348:3253.

[2] Lim HC, Adie S, Naylor JM, Harris IA. Randomised trial support for orthopaedic surgical procedures. PLoS One. 2014;9(6):96745.

Guest Articles

Conversational EBM

Professor Frank Bowden

Medicine, to paraphrase LP Hartley, is a foreign country – they say things differently there [1]. When I started out, most of the anatomy, physiology, biochemistry and microbiology was, well, Greek to me. My undergraduate years were as much language lab as pathology lab but by the time I completed my final exams after 6 years of full immersion I was speaking Medicine in my dreams.

Then, in the 1990s, I met a tribe known as ‘Clinical Epidemiologists’ who spoke a medical dialect I had not previously encountered. Their words were familiar but the meanings were hard to exactly translate. I knew, for example, the common definition of ‘sensitive’ and ‘specific’, (indeed my wife said that at times I had too much of the latter and not enough of the former), but these strangers had something else in mind when they used the words. Some phrases seemed to be self-evident – what else could ‘positive predictive value’ be apart from the ‘predictive value of being positive’? And what on earth was a ‘meta-analysis’ or a ‘likelihood ratio’?

The Lancet, that bastion of all that is right and good in the medical world, wrote an editorial in 1995 expressing the view that the emerging EBM speakers were OK as long as they stayed ‘in their place’ [2]. Since then, two generations of medical students have learnt their trade in clinical environments that have only reluctantly and incompletely adopted EBM as the lingua franca. Some young doctors have entered the workforce truly bilingual but most have EBM as a second language. The paucity of native speakers in hospitals and general practices means that many doctors never have enough time to adequately practice their conversation skills. Some have forgotten even the most basic vocabulary.

Critics – and they are many [3] – argue that  evidence based medicine focuses on groups and averages; that  it is only about research and academia; that it is an excuse for cost-saving and external control and that it is not really about individual patients. But from the outset David Sackett, the father of EBM, defined his newborn as ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient’ [4]. Take each of the words in that sentence seriously and I believe that it would be hard to find a better way to live a medical life.

Like most doctors I struggle to stay up to date even in my area of specialty. (If they change the name of one more bacterium or fungus I will scream!) Yet it is hard to convey to people younger than 30 how precious information was in the time before the interweb. It is not surprising then, that after we graduated, virtually the only source of education about new treatments and diagnostics came from the people who made and sold them. We read clever advertisements in journals and we listened, over fine food and wine, to well-dressed experts talking about new advances. There was no Cochrane database, anything that was in Harrison’s textbook was unquestionably correct and Up to Date was something that we wanted to be, not log on to. Today we carry more information in our mobile phone than was ever imagined by Douglas Adams or Isaac Asimov.

But some things don’t change: I have observed that doctors, as a species, hate bureaucracy, administration and any form of external control, yet we are naively open to the influence of experts that look or sound like us. If a colleague we like says something, we are inclined to believe them. Even if we don’t like them, we tend to be more Mulder than Scully. If you think I’m exaggerating, consider the exponential rise of PSA testing in the 1990s [5], the explosion of thyroid cancer diagnoses in the last decade [6], the sunburst of unnecessary vitamin D measurement [7], the overuse and subsequent loss of every new antibiotic released in the last 50 years [8], the epidemic of unnecessary radiological investigations and the steely push for wider access to the unproven benefits of robotic surgery [8-10] – to name just a few examples.  On the other hand, independent sources, such as the Australian Choosing Wisely program [11], almost exclusively recommend that we do fewer investigations and treat fewer people, rather than more.

If good medical practice is the offspring of a metaphorical marriage between expert, independent professionals and autonomous, informed patients, we have to acknowledge the risk that a third party presents to the relationship. My patients have the right to know where I get my facts and who is influencing my decision making.

So, how can doctors make sense of modern practice in a world that is overflowing with information, short on knowledge, long on potential for conflict of interest and sadly wanting for wisdom? Just teach them more evidence based medicine? That it were so easy… Sorting out the treatments that really do make a difference to our health and well being is much harder than it seems. If you want doctors who are able to tease out the complex arguments about the pros and cons of prostate or breast cancer screening [12], who can make an independent judgement about the role of early thrombolysis in stroke [13], who can convey  the difference between absolute risk and relative risk in a way that is understandable to the lay person, then EBM instruction has to be integrated into all levels of medical training.

I hate to admit this but I used to watch my students’ eyes glaze over when I tried to teach them certain things in evidence based medicine. For example, and this will make the EBM purists cringe, it is very difficult to get undergraduate medical students excited about critical appraisal of research studies. It’s not that it isn’t important – understanding the fine details of clinical research methods is essential for doctors who are going to be creators of knowledge – it’s just that the vast majority of us are consumers, not makers. The well informed consumer needs to know how to safely and effectively use the product they have, more than they need to know how to manufacture it. I worry that many medical students never learn the importance of EBM (and its parent – epidemiology) if the early focus of teaching is on the laborious dissection of the mechanisms of evidence-making rather than on a more general exploration of what evidence is and how it can be applied in the real world.

Medical facts change rapidly but the principles of EBM stay remarkably stable. The range of treatments that existed when I was a medical student was nothing like that which is available today and we can only guess at the progress that will occur over the next 30 years. Nevertheless, the design of the studies needed to prove the efficacy and safety of those new treatments will be almost identical to those of today and we will still use the tools of EBM to interpret the results.

Perhaps only a small group of doctors – the creators – need to be truly fluent in EBM. But the rest of us – the users – need to make the effort to learn the basics of the language of evidence. Those who don’t may find that they have been left out of the conversation altogether.


  1. Hartley LP. The Go-between: By L. P. Hartley. 1967.
  2. Evidence-based medicine, in its place. Lancet 1995; 346: 785.
  3. Greenhalgh T, Howick J, Maskrey N, et al. Evidence based medicine: a movement in crisis? BMJ 2014; 348: g3725.
  4. Davidoff F, Haynes B, Sackett D, et al. Evidence based medicine. BMJ 1995; 310: 1085–1086.
  5. Zargar H, van den Bergh R, Moon D, et al. The Impact Of United States Preventive Services Task Force (USPTSTF) Recommendations Against PSA Testing On PSA Testing In Australia. BJU Int. Epub ahead of print 2016. DOI: 10.1111/bju.13602.
  6. McCarthy M. US thyroid cancer rates are epidemic of diagnosis not disease, study says. BMJ 2014; 348: g1743–g1743.
  7. Bilinski K, Boyages S. The rise and rise of vitamin D testing. BMJ 2012; 345: e4743–e4743.
  8. Vincent J-L. Antibiotic resistance: understanding and responding to an emerging crisis. Lancet Infect Dis 2011; 11: 670.
  9. Mayor S. Robotic surgery for prostate cancer achieves similar outcomes to open surgery, study shows. BMJ 2016; i4150.
  10. Yaxley JW, Coughlin GD, Chambers SK, et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study. Lancet 2016; 388: 1057–1066.
  11. O’Callaghan G, Meyer H, Elshaug AG. Choosing wisely: the message, messenger and method. Med J Aust 2015; 202: 175–177.
  12. Hackshaw A. Benefits and harms of mammography screening. BMJ 2012; 344: d8279–d8279.
  13. Warlow C. Therapeutic thrombolysis for acute ischaemic stroke. BMJ 2003; 326: 233–234.
Guest Articles

A different path: taking medicine beyond borders

Dr Stewart Condon

I have been interested in humanitarian work since high school. I was always looking for a career that allowed me to help people, using the combination of science and communication. Medicine seemed to fit perfectly.

By the end of my medical degree I was thinking about how I could start working in the humanitarian sector. I liked the idea of taking my skills around the world, to places like South Sudan or Pakistan. We had a field worker come and talk to our Medsoc at a symposium around “travelling with your degree”. This inspired me and showed me that I didn’t have to take a standard path in becoming a specialist or a GP, living and working in Australia for the rest of my life. Alternate possibilities were out there.

It was at this time I also started orienting my work towards building skills that would be useful overseas. Paediatrics stood out for me – being able to treat sick or injured kids in third world contexts was always going to stand me in good stead. I worked my PGY3 as a paediatric resident at Sydney Children’s Hospital at Randwick, and then half the year at Wollongong Hospital in general paediatrics. Having my diploma of paediatrics gave me a sense of confidence.

Working out bush

The next step was to get experience in remote medicine. I had lived in Sydney for all of my study years, and aside from a couple of years in the Illawarra, I’d remained city-based as I started to work. I needed to get out, and an opportunity to work in the centre of Australia came at almost the perfect time. I headed out to the Northern Territory for six months to work in the Yuendumu community, with the Warlpiri people.

Dr Stewart Condon attending an MSF refugee camp awareness raising campaign in Martin Place Sydney. Copyright: MSF

Many Australians who work with MSF have experience working remotely, particularly with the Indigenous communities in Australia. Working within these remote communities is a challenge, for so many reasons. It’s about resources, distance but perhaps most importantly a different concept of health and disease.

These circumstances exposed me to the idea that you cannot have access to everything that you need all the time, and at times it is necessary to trust your clinical gut to make a decision. You learn to be able to look at a patient and decide whether they need an urgent test today, in which case you can organise an immediate evacuation to hospital, or whether it’s something you can keep an eye on. Working in the bush gave me the confidence to be able to do that, as well as the ability to work unsupported – an essential skill in remote areas.

Working remotely also opened my eyes to those patients who live in truly difficult circumstances and don’t get the care they need. I knew about other organisations that did similar work to MSF but I was attracted to MSF because it worked right on the frontlines of international humanitarian crises, treating those patients that weren’t being reached.

It was this experience in the Northern Territory that really prepared me for my first field assignment with MSF in Bentiu, in what is now South Sudan. It was 2004 and there were only three medical doctors at our project- two were international staff, including myself, and one Sudanese doctor. We had very basic medical resources, no access to tests and some very sick patients who you had to take care of, quite often on your own. It was here I was able to challenge myself and recognise I had been taught what I needed to know – how to examine and treat a patient, and how to make a diagnosis. In modern medicine we often rely on a full battery of blood tests, x-rays, scans and specialist opinion. But from my experience in the Northern Territory I knew I could make a clinical judgement, and that not having the tests did not necessarily mean that patient care was compromised.

Dr Stewart Condon on his first field assignment with MSF in Bentiu, (now South Sudan) 2004. Copyright: MSF

My time in South Sudan gave me a taste for this humanitarian side of medicine, but it was really my second assignment in Aceh, Indonesia following the devastating tsunami in 2004, that opened my eyes up to the humanitarian issues around the patients we were seeing every day. It was in Aceh that I began to recognise that it was not just about the patients that we were seeing nor the medical care, it was just as much about humanitarian need. It was at that point I realised I was interested in becoming a Coordinator, rather than solely a doctor. During my next assignments in Pakistan, Sri Lanka and Bangladesh I took on roles as Project Coordinator and Country Medical Coordinator. In these roles I was able to work together with other humanitarian organisations, as well as government authorities. It gave me a sense of other parts of MSF that I could give value to, beyond medicine.

MSF, Amman Hospital – 2016.  This man is a 23 years old Syrian. he used to study law in Damascus. He was among the first revolutionaries in Deraa, in the ASL brigade. This is the third time he is wounded, a bomb took his leg away.

Amman hospital reconstructive surgery project is meant for the wounded of Jordan’s surrounding countries that undergo war, armed conflict or violence. The reconstructive surgery hospital offers integrated care and sophisticated surgical operations, physiotherapy and psychological support. All patients admitted are considered being “impossible to treat” in their original country, because of either access problems or technical complexity. Since the opening of the structure, MSF has been taking care of 3 600 patients. photographer: Chris Huby

Examination in the laboratory of the hospital of Souleymanieh, October 2008.In the medical bacteriological laboratory teams prepare culture media and reagents in order to carry out the bacteriological analysis. photographer: Jean Baptiste Ronat

Attacks on hospitals

I have been President of MSF Australia for nearly three years and on the board since 2011. The most important part about being President is my responsibility to our field workers and patients. One of the most alarming trends we have faced in the last couple of years is the attacks on hospitals and medical facilities. In Afghanistan, South Sudan, Yemen and Syria we have seen our hospitals repeatedly attacked. Unfortunately, these are not isolated events and the normalisation of such attacks is intolerable. For us attacking hospitals and medical workers is a non-negotiable red line. International humanitarian law protects medical facilities, the people working in them, and the people receiving treatment.

Another challenge, more medical but no less critical, is antimicrobial resistance. Drug-resistant infections are a looming challenge for our humanitarian work. We see them in the war-wounded people we treat in Jordan, in newborns in Niger, and in our burns unit in Iraq.

Kunduz Hospital After the Attack:  The remains of a bed frame in a room on eastern wing of the main Outpatient Department building.
Burnt-out corridors, collapsed roofs, twisted metal and ash, is all that remains of many building at the MSF Trauma Centre in Kunduz, northern Afghanistan, following the 03 October US airstrike on the facility which killed more than 20 MSF staff members and patients.
photographer: Andrew Quilty

Our medical staff are increasingly seeing people with infections that can only be treated with the last lines of antibiotics. When I was in Pakistan in 2006, post-earthquake, we recognised quite early on many patients were not improving after treatment. Some of these patients were already on very heavy antibiotics because in this particular community they had been given antibiotics for anything and everything. As a result, many had resistant bacteria on their skin which would then go into their bones, giving them bone infections. We were having to use heavy antibiotics (e.g. meropenem) that we are only now really starting to use in a similar way in hospitals in Australia.

Central laboratory of Koutiala hospital.  End of 2013, MSF initiated the restructuring and renovation of the central laboratory of Koutiala hospital, where MSF manages the pediatric unit. MSF has added a department of bacteriology, operational since March 2014, to improve the diagnoses made in the laboratory and meet the requirements of quality of medical care at the hospital. Through the department of bacteriology, MSF is now able to diagnose all bacterial diseases which are affected children. photographer: Aurelie Baumel
Haydan Hospital.  Haydan Hospital, March 2016, after 5 months of air strikes.
Constant bombing , blocking of aid, non-observed truces … In six months , the Yemeni conflict has claimed thousands of lives, including many hundreds of children, and reports of more than 1.5 million displaced. photographer: Atsuhiko Ochiai

There are many global challenges caused by antimicrobial resistance. Countries must do much more to better use existing antibiotics by strengthening health systems, human resources and laboratory capacity. There also needs to be improved access to existing medical tools, including reduced prices for existing vaccines to prevent infections, as well as research and development of new products that are patient-focused, affordable and appropriately available to all who need them. MSF is participating in global efforts to control drug-resistant infections by increasing our capacity to diagnose infections, improve the use of antibiotics, prevent the transmission of infections in hospitals and monitor rates of resistance, as well as supporting efforts to develop new, affordable diagnostic tools and treatments.

Northern Yemen, Oct15-Feb16.  A man clears debris revealing the Médecins Sans Frontières logo 29 October 2015 painted on the roof of MSF’s hospital in Haydan, Yemen after an airstrike on the facility. photographer: Rawan Shaif

Ask yourself “why medicine?”

For those who are looking ahead to their future in medicine and are interested in working in the humanitarian sector my advice is very simple, get out and challenge yourself. Remove yourself from the big city hospitals and work remotely. You will not typically be provided this opportunity without asking. Ask your hospital for a rotation to a regional centre or request something a bit different. Take a leap and show up.

You need to be interested in things that are not strictly just medical. I am sure that you already are, of course! Working at MSF we look at so many issues outside of the first emergency response. It can be anything from access rights to medications, the humanitarian needs of a particular context, the effects of war on communities or what happens to women after a natural disaster. This information influences how we treat a patient and what kind of patients we see.

And most importantly make sure you’re asking yourself the really important questions. Why are you studying medicine? What type of patients do you want to be treating in ten to fifteen years? Why do you think you will get a buzz out of being a doctor? Understanding your ‘why’ will help you understand how to get there and what your career will look like in the future.

Working in the humanitarian field can be dynamic and volatile. If you don’t mind that lifestyle partnered with medicine, then it’s the perfect job for you.

Guest Articles

Climate change: the challenge to medicine in the 21st century

Medicine in the early decades of the 21st century offers great promise, powered by ready access to knowledge, innovative imaging and interventional technologies, sophisticated research, and personalised pharmaceuticals. Despite this, doctors of the next decades will be faced with unique national and global challenges that they are currently ill equipped to deal with.

Climate change is predicted to be the greatest challenge to global health in the 21st century, threatening agriculture, stable food and water supplies, infrastructure, coastal communities, the economy, and national security. Optimistically, however, this also presents the greatest opportunity for prevention of harm to human health if effective and adequate actions are urgently taken.

Climate change has become fundamentally a moral problem. The scientific evidence is now so powerful and the consequences for current and future generations so dire that those who ignore, obstruct, or corrupt that evidence are guilty of great intergenerational injustice. The merchants of doubt, as Naomi Oreskes branded them, have become intellectually marooned and morally exposed [1].

Questioning the evidence

It is the nature of science to continually question, however, it is also the role of science to draw conclusions to be acted upon. Today, we are presented with objective measurements demonstrating a changing climate. For instance, CO2 levels exceeded 400 ppm for the first time in human history and are still rising, the average annual global temperature has reached a record peak, and the average temperature during each of the past four decades has exceeded the decade before [2]. Human activity has been shown to be the major factor causing these problems [3]. Apologists for inaction trawl through the literature hoping to find some variation in predicted changes such as rainfall levels, or some slight defect in methodology. In contrast, the latest International Panel on Climate Change (IPCC) Report, based upon an enormous volume of evidence from highly qualified climate scientists, has sounded a clarion call for urgent and adequate political action [4]. When we are faced with irrefutable evidence of climate change, it becomes far too dangerous to argue that the evidence is too weak to take bold and decisive action.

The obvious purpose of climate change deniers or doubters is to confuse the public, weaken political resolve, stifle transition to more sustainable economies with innovative renewable energy technologies, and encourage rampant expansion of fossil fuel mining, extraction, transportation and eventual combustion within Australia or overseas.

Health effects of climate change

It is the most vulnerable and least powerful who are increasingly bearing the brunt of climate change. Children, the elderly, and those with chronic diseases usually suffer the most. In Africa, this is mediated through the increasing likelihood of droughts, dehydration, heatstroke, declining agricultural output, starvation, diarrhoeal diseases, and vector borne diseases [5].

Pacific island nations like Kiribati are facing existential threats from sea level rises and storm surges causing abandonment. At this stage, environmental refugees are not recognised by the UN Convention on Refugees [6]. Europe is already staggering from refugees fleeing conflict and starvation. Australia will not be immune from the plight of environmental refugees if further global warming is not addressed, placing unique demands on our social and health care systems.

Extreme weather events are being felt with increasing regularity. Countries in Europe, Asia, and the Americas have experienced more than usual episodes of flooding, blizzards, tornadoes, and cyclones of increasing intensity in some regions and droughts in others [7]. The Arctic ice cap and glaciers continue to melt and the Great Barrier Reef coral is dying [8].

Australians are now realising that heat waves will become more frequent and more intense resulting in not only increasing discomfort and dehydration but also major cardiac and respiratory consequences. In major heat waves such as that in Victoria in December 2009, twice as many vulnerable people died prematurely from those effects than died in the associated devastating bushfires [9].

Most Australian state and mainland territories are experiencing bushfires of increasing frequency and severity with great loss of pastures, forests, livestock, native animals, homes, and human life on many occasions. There are virtually no climate change deniers among firefighters battling those bushfires.

Scientific solutions

Despite recent funding cuts to many successful programs, scientific studies into climate change and its effects in Australia continue to enhance the evidence. Technological advances in the quality, economic feasibility, and quantity of solar photo-voltaic (PV) panels continue to deliver increasing energy outputs nationally and globally (87% rise delivering 47 G W in 2015) [10]. Batteries able to spread solar generated energy over 24 hours are becoming much better, cheaper, and more available. These technologies will soon enable thousands of households, commercial ventures, and institutions to be freed from the need to be linked to coal powered electricity grids.

Although there has been lukewarm political support and pockets of local opposition, land based wind turbines are becoming cheaper and more available, supplying 63 GW towards global energy needs in 2015 [10]. Large solar –thermal fields have been installed in several counties whilst wave, tidal power, and geo-thermal research and development advance in many centres.

Electric cars powered by energy generated by renewable energy technologies with battery storage facilities are about to become much more widely available with major manufacturers investing heavily in these technologies. They have real potential to revolutionise motorised transportation.

Carbon capture research and development, tree planting projects, and similar measures may help but will be hopelessly insufficient. The most effective, efficient, and necessary carbon capture available is to leave most fossil fuels in the ground. Around 80% of known reserves must remain there. Renewable energy technologies need to replace fossil fuel economies and workforce dislocations must be managed adroitly during the transition process.

Political responses

What factors are now preventing urgent and adequate action in Australia on climate change? Current ideology states that unrestricted progress must be pursued for the greater economic good. This is seen in the mantra of ‘growth and jobs’ and the need for increasing consumption. Concepts such as limited resources and the need for sustainability are often regarded as radical. Environmental harms are barely mentioned, while the direct and indirect health consequences virtually unheard of when expansions of fossil fuel mining and extraction are promoted. Effective action must challenge this ideology.

Prestigious government agencies such as the CSIRO in Australia, NASA in the USA, and similar agencies in Europe and Asia have produced a wealth of valuable data about climate change. Government restrictions to their funding can cause great harm and damage the independent advice that they should provide.

Powerful rallying calls have been made internationally, such as the latest Lancet Commission Report on the health impacts of climate change last June, followed by the UN Climate Change Conference in November 2015 [11]. The Pope’s Encyclical on climate change gave additional moral weight to that call [12]. National agreements signed in the Paris Accord and recently ratified at the UN may not be legally binding but they are already being heeded. The USA and China, the two largest polluting countries on Earth at present, and many other countries, have firmed up their commitments to act urgently and on a scale designed to drive down emissions sufficiently to limit average annual global temperature rises to no more than 2.0 degrees Celsius (and hopefully below 1.5 degrees Celsius) above pre-industrial levels.

Unless our nation faces this local and global challenge with far more wisdom, vigour, and determination than present policies will deliver, the consequences will be increasingly severe, and those governments that are responsible will be rightly condemned by succeeding generations.

Democracy, divestment & individual action

Impatient with the current short-sighted national leadership, many individuals and organisations are utilising social media and acting on a variety of fronts. The divestment from fossil fuel movement is gaining momentum. Millions of individuals, thousands of corporations, multiple universities and medical organisations, philanthropic foundations, banks, and even the large Norwegian sovereign wealth fund have divested [13]. The inevitability of stranded assets in this sector has influenced astute investors.

Individuals can and are taking action to live more sustainably but political inertia is the major block. In a democracy such as Australia, with financially powerful vested interests undoubtedly influencing public policy, individuals and the organisations to which they belong still have a say. Medical practitioners and medical students, and their professional bodies, must use their intelligence, knowledge, energy, and voice to demand of governments urgent and adequate policies for tackling climate change.

The future

World citizenry is now a reality, driven by increasing global connectedness and common challenges. Medical practitioners and medical students have great opportunities and responsibilities to provide expertise and leadership. Global healthcare inequity is already great – for example, 5 billion people currently lack access to safe, timely, effective, and affordable surgical, gynaecological/obstetrical and anaesthetic care [14]. That inequity will worsen if climate change and related environmental hazards are not tackled urgently and adequately. Your generation must be at the forefront of doing so.

Medicine is a wonderful profession and I wish you all well throughout your careers.


[1] Oreskes N, Conway EM. Merchants of doubt : how a handful of scientists obscured the truth on issues from tobacco smoke to global warming. 1st U.S. ed. New York: Bloomsbury Press; 2010. 355 p. p.

[2] Hewitson BC, Janetos AC, Carter TR, Giorgi F, Jones RG, Kwon WT, et al. Regional context. In: Barros VR, Field CB, Dokken DJ, Mastrandrea MD, Mach KJ, Bilir TE, et al., editors. Climate Change 2014: impacts, adaptation, and vulnerability part B: regional aspects contribution of working group II to the fifth assessment report of the intergovernmental panel of climate change. Cambridge, United Kingdom and New York, NY, USA: Cambridge University Press; 2014. p. 1133-97.

[3] Cook J, Oreskes N, Peter TD, William RLA, Bart V, Ed WM, et al. Consensus on consensus: a synthesis of consensus estimates on human-caused global warming. Environmental Research Letters. 2016;11(4):048002.

[4] IPCC. Climate Change 2014: synthesis report. [Internet]. Geneva, Switzerland: Contribution of Working Groups I, II and III to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change, 2014. [cited 2016 May] Available from:

[5] Forrest S, Shearman D. No time for games: children’s health and climate change [Internet]. South Australia: Doctors for the Environment Australia, 2015. [cited 2016 May] Available from:

[6] UNHCR. Convention and protocols relating to the status of refugees. 60 Years. Geneva, Switzerland: The UNHCR: Communications and Public Relations Service. 2010. [cited 2016 May]. Available from:

[7] EASAC Working Group. Trends in extreme weather events in Europe: implications for national and European Union adaptation strategies [Internet]. European Academies Science Advisory Council, 2013. EASAC policy report 22. [cited 2016 May] Available from:

[8] Steffen W, Rice M. Climate Council Alert: Climate change and coral bleaching [Internet]. Australia: Climate Council of Australia, 2016. [cited 2016 May]. Available from:

[9] Cameron PA, Mitra B, Fitzgerald M, Scheinkestel CD, Stripp A, Batey C, et al. Black Saturday: the immediate impact of the February 2009 bushfires in Victoria, Australia. Med J Aust. 2009;191(1):11-6.

[10] Morris C. Wind and solar power boom worldwide 2015. [cited 2016 May]. Available from:

[11] Watts N, Adger WN, Agnolucci P, Blackstock J, Byass P, Cai W, et al. Health and climate change: policy responses to protect public health. Lancet. 2015;386(10006):1861-914.

[12] Pope Francis. Encyclical letter Laudato Si’ of the Holy Father Francis on care for our common home (official English-language text of encyclical). Vatican: The Holy See: Libreria Editrice Vaticana, 2015.

[13] Carrington D. Norway confirms $900bn sovereign wealth fund’s major coal divestment: The Guardian; 2015. [cited 2016 May]. Available from:

[14] Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624.

Guest Articles

Aiming for one hundred

A few months ago, I went to a public lecture that was the best I’ve ever had the privilege to attend. The speaker was Alan Alda – Hawkeye from the popular television series M*A*S*H – now 80 years old, and thriving. And so is the subject of his talk: his love life. He just happens to be in love with science.

My dream is for a future in which we see heroes like Alan Alda, perhaps 100 years old, standing ramrod straight at the podium. They’ll speak out with a clear voice, bright eye, sharp mind, and strong heart… and that rarest of miracles, no notes. And we’ll marvel at their wit, but barely notice their age – because living in rude health to 100 will be the norm.

Am I too bold to tack 20 years onto average life expectancy? Perhaps. Yet, look at how swiftly our expectations progress. A woman born in Australia in 1900 could expect to live to 57; and a man (even excluding those killed in war) to just 54. So the average Australian born in 1900 would die before the modern Australian has quite done with their mid-life crisis.

In just four generations, we’ve added more than 25 years to the average female life, and close to 24 years for males. Even better, as our lives extend, so too has the period we expect to enjoy disability-free. Which is just as well, given the size of the superannuation balances we’ve now got to accrue to fund two or three decades of sprightly ‘retirement’.

Science advances, and societies adjust. The challenge is to do it again. And if we achieve another 20 years, it will be in large part a testament to you: the doctors, researchers, and policymakers of the future.

You will be aided by an unimaginable suite of scientific instruments and artificial intelligence programs. Some commentators will tell you that these tools will displace the flesh-and-blood doctors we rely on today. Don’t believe them. Remember what they said about the fitness industry. First television was going to kill the local gym. Then workout videos would nail the coffin. The same for FitBits and Wi-Fi enabled rowing machines. Yet, we still choose to pay a premium for gyms and personal trainers. That premium buys the things we humans require, over and above the information we could access online: discipline, insight, and motivation. Doctors who provide those keys to health will always be in demand.

For early-career researchers, the age-old challenges of forging a career still stand. Investing in the right skills. Making the right contacts. Working out where the interest, and the money, is likely to be. Managing one of those three would be impressive. Managing all of them may not be enough in the competitive environment we operate in today.

I have seen the process of applying for a National Health and Medical Research Council (NHMRC) grant likened to The Hunger Games. I can’t speak to the experience of the young grant applicant today, but I can read the success rates, and I understand why early-career scientists express their frustration.

As Chief Scientist, I cannot offer easy answers. I do commit to work with all research funders and providers – public and private – to maximise the opportunities for Australian medical science.

There’s an old rule of thumb that science turns money into knowledge; and innovation turns knowledge into money. I’ve found that it focuses our politicians’ minds. There is bipartisan commitment at the Commonwealth level to an innovation policy framework that fosters growth in the medical device, biotechnology, and pharmaceutical sectors. It is backed by rising investment from venture capital funds in biomedical startups; and new approaches to collaboration from Vice-Chancellors and CEOs.

But all of it always comes with a rider: great science needs great equipment and great people.

If we want to build the critical mass to attract new investment in both facilities and staff, we need to keep the quality bar set high. We can pursue sensible regulatory systems that minimise the costs, for example, of clinical trials – and we need to do so to remain competitive. At the same time, our brand in the global market is excellence and reliability; a brand with particular resonance in the Asian markets we seek to develop.

Maintaining that brand calls for clarity of vision and continuity of investment. This is the principle I will emphasise across the many lines in my 2016 to-do list.

At the top of that list is the task of mapping Australia’s research infrastructure needs for the decades ahead, including the next-generation facilities. For too long, we have drifted without a long-term bipartisan commitment to funding and operating principles for our critical scientific equipment. The price we pay for uncertainty is the loss of our best people. I am honoured to be leading this landmark review, and welcome the contribution that medical researchers have already made.

So what would be my advice to you?

First, pursue medical science because you love it. Learn your discipline deeply and don’t rely on the plethora of fact-finding tools. When you are dealing with a nervous patient you need the knowledge at your fingertips. Trust me, it’s the same with a footloose investor. And when you’re brainstorming ideas with your supervisor, or lying in bed with ideas surging through your mind, deep knowledge takes the training wheels off your imagination.

Second, keep the doors of opportunity open. If you love research, why not consider an industry role? If you love making things, why not make a product or a startup? If you love engineering systems, why not engineer a company as the CEO? If I had one wish, it’s that Australians would see all the valuable transferrable skills that come with science training, and most of all, a science PhD. Employers will only be able to see those skills if graduates recognise and cultivate them within themselves.

Third, be strong in pursuit of that precious 20-year extension to the average Australian life. We need all the advocates for evidence-based science we can get, given all the snake oil we’re ingesting today. As a society, we’ll progress no further than our shared understanding of the values science allows. Stand with Alan Alda, in the advance guard.

So, I’m aiming for 100. My grandchildren will aim for more. My great-great-grandchildren might ring in the 23rd century. I thank you today, on their behalf, and wish you well.

Guest Articles

Hacking Medical Education with FOAM


“There’s no charge for awesomeness…”

­— Kung Fu Panda

Hacking medical education!?

‘Hacking Medical Education with FOAM’… ‘What?’ I hear you whisper under your breath. A title like that deserves an explanation, I agree.

To many of us, hacking means “gaining unauthorised access to data in a system or a computer” [1]. This works for me because I have often found that access to knowledge, and how to make the most of it, is not always transparent in medicine. However, the definition of ‘hacking’ that I like the best is, “to modify or write… in a skillful or clever way” [1]. I think FOAM or Free Open-Access Med(ical Ed)ucation helps do these things [2,3].

I should also clarify what I mean by medical education. I don’t mean medical school… Or at least not just medical school, which is somewhat arbitrarily bound by examinations and assessments. Indeed, I have to agree with Sir William Osler who claimed that “Perfect happiness for student and teacher will come with the abolition of examinations, which are stumbling blocks and rocks of offense in the pathway of the true student” [4]. Yet, even the great Osler, the man who brought bedside teaching to North America, knew that ‘assessment drives learning’: “I do not know of any stimulus so healthy as knowledge on the part of the student that he will receive an examination at the end of his course. It gives sharpness to his dissecting knife, heat to his Bunsen burner, a well worn appearance to his stethoscope, and a particular neatness to his bandaging” [4]. However, what I am really writing about is how FOAM can be used to achieve lifelong learning in medicine, learning that begins in medical school but, hopefully, continues forever after.


FOAM is a dynamic collection of free educational resources available online and largely shared via social media [2,3]. These resources include blogs, podcasts, videos, tweets, graphics, animations, and more. However, FOAM is more than just resources; it is an interactive community of like-minded individuals bound by a common ethos. The FOAM ethos holds high quality educational resources that can and should be available, free of charge, to anyone who helps people with health problems.

There are now at least 316 blogs and podcasts creating these resources worldwide in my specialties of emergency medicine and critical care alone [5]. It has also culminated in the Social Medical and Critical Care Conference (SMACC) [6], which provides a physical meeting place for this community and releases all talks as FOAM. The next SMACC will be held in Berlin, Germany in June 2017.

Importantly, these resources are available to anyone, anytime, anywhere. This makes them ideally suited for ‘just in time’ learning at the point of care. They help provide interpretations of the published literature by practicing clinicians as well as approaches to problems when there is no good evidence informing the topic. They also provide an additional means of tacit knowledge sharing, the ‘on the job’ ‘know how’ that can never be found in textbooks or journals [7]. Furthermore, FOAM is another way in which we can socially construct knowledge and learn from, and with, our peers [8].

Arghh, information overload!

Given this explosion of resources, many people worry about information overload – but that is a myth – the real problem is ‘filter failure’ [9]. If you determine your knowledge needs, and connect with other people you trust – via TwitterTM, for instance, the high quality, relevant resources will ‘bubble up’ through your network of filters making it likely that you will find what you need. Try searching for the #FOAMed hashtag (not #FOAM!) to see what is out there [10]. Alternatively, if connecting with people is not your thing, you can use the GoogleFOAM search engine [11] or read ‘The LITFL Review’, a weekly FOAM summary on [12]. Some people argue that they don’t have time to use social media for medical education. Others would respond that, if used correctly, you don’t have time not to [13].

Is there a curriculum?

The bare facts of life as a learner in medicine are that you have to earn your stripes – usually through passing exams… and many exams await the medical trainee. FOAM can help students master the medical school curriculum and pass the inevitable exams. Indeed, there are now resources such as specifically designed for medical students [14]. However, FOAM itself has no defined curriculum, and it does not need one [15]. To do our best for our patients we must all create our own ‘internal curriculum’. This is the path of learning we each must journey along to become the doctor we want to be, practicing the type of medicine we want, and looking after the particular patients that we will actually encounter. Textbooks and prescribed curricula are not sufficient – we must learn from our patients, our colleagues, the published literature, and FOAM.

Goodbye, bedside mentor?

As a learner it is easy to get caught up in the engaging nature of FOAM resources, the fancy graphics, and the funky podcast intro music. However, FOAM is just an adjunct to learning and nothing ever replaces the bedside mentor. One of my own former teachers was Auckland-based pathologist, Professor Tim Koelmeyer, who would constantly remind us that the patient is “our first, last, and only teacher” [16]. What he meant was that real learning takes place at the bedside, where it is facilitated by experienced clinicians who help students make sense of what patients are trying to teach them. Similarly, these experienced clinicians are vital for helping the inexperienced make sense of FOAM resources. In particular, junior trainees must always be supervised and should never institute what they have learned from FOAM without discussion with their seniors first. This is important because medical knowledge (regardless of the source) can be taken out of context and does not apply to all settings or may require a specific skill set to be safely used. In turn, learners can help their teachers by suggesting that engaging FOAM resources be used in a ‘flipped classroom’ model [17]. Learners can watch, read, or listen at home and then come prepared for meaningful discussions and active learning sessions in the workplace facilitated by an expert. In this way, FOAM does not replace the bedside mentor, but helps learning happen.

Caveat emptor!

Critical thinking skills, for some reason, are often not explicitly taught in schools or universities [18]. However, I firmly believe that critical thinking is the hallmark of the expert clinician. Critical thinking and decision making skills are what link evidence from the literature, to clinician expertise, the patient’s individual circumstances and the setting in which it occurs [18]. Importantly, if we want to thrive in medicine – and have our patients thrive too – we need to learn from multiple sources of information and we have to critically evaluate them all rather than blindly applying them. Which raises the question, how do we know if a source of information is reliable?

I have developed a brief list of questions that I use to assess the quality of FOAM resources before using them, though they can be applied to almost any source of information.

  1. Is the author identifiable?
    (If a FOAM resource is anonymous, sound the alarms!)
  2. What are the author’s qualifications?
    (This does not mean a student’s blog should be ignored, it just helps put it in context. At the other extreme, beware of ‘Arguments from Authority’ that lack any other basis.)
  3. Are there conflicts of interest?
    (Beware of financial conflicts in particular, including Big Pharma’s influence on the published medical research.)
  4. Does what I know check out?
    (I’m reassured to an extent if the author has written about topics that I do know about and did a good job, however, an expert in one sphere is not necessarily an expert in another!)
  5. Is it logical?
    (Does the author commit logical fallacies?)
  6. Is it referenced?
    (Claims should be referenced appropriately so they can be verified.)
  7. Is it supported by trusted recommendations?
    (Do other people I trust rate the resource highly?)
  8. How does the author respond to criticism?
    (No one is right all the time – and if we truly base our knowledge on science, then nearly everything we know will be falsified or revised in the future. I am reassured by authors that respond to constructive feedback openly and are willing to make improvements as part of a post-publication peer review process.)

Critical thinking is perhaps the most useful medical education hack in your armoury. It is a pre-requisite for using FOAM, or any other source of information, effectively. Unfortunately, for various reasons, even most published medical literature is false [19,20]. FOAM can be a mixed bag. Caveat emptor!

Learn using learning science

Now is an exciting time to be a learner because scientists are actually figuring out how people learn effectively [21,22]. Although much of this work from the cognitive science and educational psychology literature has yet to be validated in the world of medical education, we are silly if we ignore it. Fortunately, FOAM can neatly integrate with many of the principles of the new science of learning.

First, cognitive scientists tell us that we are actually quite good at putting things into our memories, then the challenge comes when we try to recall them at the right time and in the right form. To get good at memory retrieval, we have to practice retrieving. This can be done by testing oneself, using the so-called ‘test effect’ [21,22]. Retrieval practice is even more effective when it takes place in similar contexts to that which we are training for, such as the examination hall or the patient’s bedside. FOAM resources such as the case-based ‘show-hide’ answer blog posts on,, and are well suited for such practice [23-25]. Retrieval practice is even more effective when we combine the test effect with spaced repetition. We make stronger, more retrievable memories if we exercise our recall when we are just on the verge of forgetting. Spaced repetition software are available that have built in algorithms that allow us to do this with virtual flashcards [26]. Fortunately, FOAM resources, which are free to reuse and modify with appropriate attribution, can easily be cut-and-pasted into flashcards or linked from them for this purpose.

FOAM also lends itself to ‘interleaving’, another effective learning strategy [21,22]. An analogy is, the batsman who will see greater improvements during practice if they do not know what type of delivery is coming next. This is because they will get better at discriminating between different types of deliveries and thus perform better under real world conditions. Similarly, we can better prepare ourselves by mixing up problem types and topics when preparing for an exam and/or when preparing to work in the real world of medicine. Progress may seem slower, but the long-term benefits are likely to be greater.

Becoming a FOAM creator is also an effective way of boosting your own learning, and was a major motivation for my own involvement as a trainee. Education scientists tell us that we need to engage in reflection by taking the time to review experience so that we can learn from it [21,22]. The creation of a blog is an excellent tool for reflection, but we must ensure that anything we write is fictionalised and never based on a particular patient unless valid consent is obtained. Patient safety and confidentiality must never be compromised, whether inadvertent or otherwise.

Calibration is the last principle of effective learning that I will mention. Without calibration we can easily become self-deluded learners. Calibration involves the learners aligning their own judgements of their state of knowledge or learning with objective feedback [21,22]. This is another reason why testing yourself on questions is so effective for learning. Being subjected to post-publication peer review through the creation of FOAM resources is also a powerful learning experience. Few things sharpen your understanding or thicken your skin better than open dialogue with intelligent people about something you have just created.

Last words

There you have it, my tips for ‘hacking medical education’ using FOAM with the support of insights from the evolving science of learning and an emphasis on the importance of critical thinking skills. Ultimately, we must always remember that FOAM is simply an adjunct to learning that aims to help, rather than to replace, our bedside mentors. Furthermore, these ‘hacks’ are not shortcuts. There is no easy way in learning, indeed Osler said that, ‘work’ was the ‘Master Word’ in medicine [4]. True learning is always hard work, but this hard work is worth it, as through it we can improve patient outcomes, relieve suffering, and save lives.

“It is up to us to save the world!”
— from Peter Safar’s Laws for the Navigation of Life [27].

Author disclosures

I have no financial conflicts of interest to declare.

I am heavily involved in the creation of FOAM resources and the FOAM community described in this article. I am co-creator of the following FOAM resources mentioned in this article:, SMACC and INTENSIVE.


[1] The definition of hacking [Internet]. 2016 [cited 13 March 2016]. Available from:

[2] Nickson CP, Cadogan MD. FOAM / FOAMed – Free Open Access Medical Education [Internet]. 2012 [cited 14 March 2016]. Available from: http://lifcom/foam/

[3] Nickson CP, Cadogan MD. Free Open Access Medical education (FOAM) for the emergency physician. Emerg Med Australas. 2014;26(1):76-83.

[4] Osler W, Silverman M, Murray T, Bryan C. The quotable Osler. Philadelphia: American College of Physicians; 2002.

[5] Cadogan MD. Emergency medicine and critical care blogs EMCC [Internet]. 2016 [cited 14 March 2016]. Available from:

[6] SMACC [Internet]. SMACC. 2016 [cited 14 March 2016]. Available from:

[7] Peach P. Technology, tacit knowledge and collective competence [Internet]. SMACC. 2014 [cited 14 March 2016]. Available from:

[8] Cabrera D, Roland D. FOAM and the Rhizome: An interconnected, non-hierarchical approach to MedEd [Internet]. ICE Blog. 2015 [cited 14 March 2016]. Available from:

[9] Nickson CP. Information overload in the age of Free Open-Access Meducation (FOAM) [Internet]. 2009 [cited 14 March 2016]. Available from:

[10] News about #foamed on Twitter [Internet]. 2016 [cited 14 March 2016]. Available from:

[11] GoogleFOAM [Internet]. GoogleFOAM. 2016 [cited 14 March 2016]. Available from:

[12] LITFL review [Internet]. 2016 [cited 14 March 2016]. Available from: http://lifeinthefastcom/litfl/litfl-review/

[13] Smith R. Meet and learn from Dr Twitter [Internet]. 2016 [cited 14 March 2016]. Available from:

[14] com [Internet]. 2016 [cited 14 March 2016]. Available from:

[15] Nickson CP. We don’t need no FOAM curriculum [Internet]. 2013 [cited 14 March 2016]. Available from:

[16] Nickson CP. The Breakfast Club | LITFL: Life in the fast lane medical blog [Internet]. 2009 [cited 14 March 2016]. Available from:

[17] Prober C, Heath C. Lecture Halls without Lectures — A Proposal for Medical Education. N Engl J Med. 2012;366(18):1657-1659.

[18] Jenicek M, Croskerry P, Hitchcock D. Evidence and its uses in health care and research: The role of critical thinking. Med Sci Monit. 2011;17(1):RA12-RA17.

[19] Ioannidis J. Why most published research findings are false. PLoS Med. 2005;2(8):e124.

[20] Young N, Ioannidis J, Al-Ubaydli O. Why current publication practices may distort science. PLoS Med. 2008;5(10):e201.

[21] Dunlosky J, Rawson K, Marsh E, Nathan M, Willingham D. Improving students’ learning with effective learning techniques: promising directions from cognitive and educational psychology. Sci. Public Interest. 2013;14(1):4-58.

[22] Brown P, Roediger H, McDaniel M. Make it stick. Harvard University Press/Belknap; 2014.

[23] Clinical Cases in Emergency Medicine and Critical Care [Internet]. 2016 [cited 14 March 2016]. Available from:

[24] Parker C. Clinical Cases – Broome Docs [Internet]. Broome Docs. 2016 [cited 14 March 2016]. Available from:

[25] Labs and Lytes[Internet]. INTENSIVE. 2016 [cited 14 March 2016]. Available from:

[26] Nickson CP. Learning by Spaced [Internet]. 2011 [cited 14 March 2016]. Available from:

[27] Nickson CP. Peter Safar’s laws for navigation of life [Internet]. 2009 [cited 14 March 2016]. Available from:

Guest Articles

Why all medical students need to experience research

Prof Christine Bennett AO

Medical students are very busy. The demands of studying medicine are extraordinary. Why then is it so important, on top of all there is to learn, to bother engaging in health and medical research? It is particularly important to consider this question at a time when, nationally and internationally, medical schools are including a research project as either a requirement of their program or a highly encouraged option. In fact, the Australian government is now supporting research by medical students with a specific category of scholarship funding from the National Health and Medical Research Council (NHMRC) available to students undertaking in a combined MBBS/PhD or MD/PhD program. [1]

As a Dean of Medicine, and passionate advocate of health and medical research (HMR) in Australia, I support the inclusion of research in medical programs. Research training and experience are not just ‘nice to have’ but a ‘must’ for our doctors of the future. Increased research training in medical programs is beneficial for a student’s professional pathway, their evolving practice and, most importantly, for the health of the patients and communities they serve. [2,3]

Demonstrated research experience at medical school is increasingly important in obtaining positions in training programs post-graduation. [4] Recognition of the importance of HMR in developing and applying the skills and knowledge acquired in their medical studies has seen many of the specialist colleges including research training and productivity (for example publications) in their approach to selection of trainees. Competition for vocational and advanced training places is fierce, and a professional resume that includes research productivity and qualifications is and will continue to be important. Some colleges may even move to requiring a PhD for entry into advanced training.

A research experience may be the first time a student has had to write and record what they do, think, and find coherently, concisely and precisely. This can contribute to developing lasting habits of critical thinking. In a landmark and classic essay, C. Wright Mills commented that there was never a time he was not thinking, reflecting, analysing, and writing – he was always working on an idea. [5] This is the mindset that research can build up, and this is surely the mindset we want in clinical medicine and population health, where continuing critical appraisal of new evidence and engagement with new ideas is vital. In addition to stimulating ongoing interest in learning, this intellectually curious mindset contributes to a sense of personal satisfaction and eagerness to engage in discovery and learning as part of a team. [3,6] Research achievements are rarely made by individuals in isolation. Developing a mindset of critical inquiry in individuals and teams clearly encourages research productivity in grants and publications in the longer term, [3] which can ‘future-proof’ careers at a time when research performance is important in professional esteem and progression. Even more importantly, involvement in research appears to improve clinical practice. Research-active healthcare providers appear to provide better care and achieve better patient outcomes, [7] making the investment of time in research training for medical students potentially very important to building a healthier society in the long term. Given the potential benefits to early career clinicians and to patients, it is important to expose recent medical graduates to research as well, and successful postgraduate training programs are also taking steps to include research training. [3,8]

So, what is the best way for medical schools and postgraduate training programs to provide research training that maximises these benefits? It is clear from the literature that the most important thing is to have protected time to pursue research. Whether the research is a programmed experience as part of a course (as is increasingly the case), or something pursued independently by the individual student or trainee, giving as much time as possible is key to getting the best quality outcomes. For recent graduates, hospitals need to allow time to do research. [8] For students, time should be set aside within the program. [4] Students and trainees also need to be mentored by experienced researchers to get the best results. [3] Research experiences for students and trainees that combine mentorship and protected time can deliver the biggest benefits to our future clinical leaders and society as they are most likely to result in high quality outputs that are published and improve knowledge and practice. Where possible, trainees without research degrees should try to enrol in these at the same time as pursuing their research experiences, through a university that offers flexible research training and options to submit theses by publication, as earning a research degree such as a PhD is increasingly becoming a prerequisite for obtaining research funding that can support a clinical research career.

In summary, more than ever before, being a doctor in the 21st century is a career of lifelong learning. The combination of continued, rapid growth in knowledge and advancing technology bringing that information to your fingertips, have brought both a richness to the practice of medicine as well as a challenge. There is a growing appreciation that researchers make better clinicians. Research exposure increases understanding of clinical medicine; facilitates critical thinking and critical appraisal; improves prospects of successful application for post graduate training, grants, and high impact publications; develops teamwork skills; and increases exposure to the best clinical minds. The government is lifting its investment in health and medical researchers like never before. The establishment of the Medical Research Future Fund by the Australian Government, for example, offers the promise of continued durable investment in HMR and innovation, and the NHMRC’s substantial investment in research training scholarships for current students and recent graduates signals the Government’s commitment to developing clinician researchers for the future.

I encourage all students to make the most of research opportunities in medical school and beyond, not only for the personal and professional benefits, but in contributing to the health of their patients and to the Australian community.


[1] NHMRC Funding Rules 2015: Postgraduate Scholarships – 6 Categories of Award – 6.2. Clinical Postgraduate Scholarship. 2015. (accessed Nov 2015).

[2] Laidlaw A, Aiton L, Struthers J, Guild S. Developing research skills in medical students: AMEE guide no. 69. Med Teach. 2012;34:754–71.

[3] Lawson PJ, Smith S, Mason MJ, Zyzanski SJ, Stange KC, Werner JJ, Flocke SA. Creating a culture of inquiry in family medicine. Fam Med. 2014;46(7):515–521.

[4] Collier AC. Medical school hotline: importance of research in medical education. Hawai’i Journal Med Public Health. 2012;71(2):53-6.

[5] Mills, CW. On intellectual craftsmanship. In: Seale, C. Editor. Social research methods: A reader. London: Routledge, 2004.

[6] von Strumm S, Hell B, Chamorro-Premuzic T. The hungry mind: intellectual curiosity is the third pillar of academic performance of university. Perspect Psychol Sci. 2011;6(6):574-88.

[7] Selby P, Autier P. The impact of the process of clinical research on health service outcomes. Ann Oncol 2011;22(Suppl 7):vii5-vii9.

[8] Chen JX, Kozin ED, Sethi RKV, Remenschneider AK, Emerick KS, Gray ST. Increased resident research over an 18-year period – a single institution’s experience. Otolaryngol Head Neck Surg. 2015;153(3):350-6.

Guest Articles

Looking to the future – students and academics leading the charge in publishing innovation

Dr Virginia Barbour
Dr Virginia Barbour

As a medical student (a long time ago, admittedly), peering into the far future to wonder what publishing was going to look like when I graduated and practiced was very far down my list of priorities, if it ever crossed it.

But, as the Australian Medical Student Journal’s Editor in Chief recently described in the Australian Open Access Support Group (AOASG) blog [1], medical students today are already immersed in a rapidly evolving world of publishing, which is changing the way that they access and publish information, via journals such as the Australian Medical Student Journal. [2]

There is even more profound change going on and unlike for much of the recent history of publishing, which has been led by publishers, many for profit, the next wave is being led by academics, even students.

How has this happened? The underlying technology driving all this is, not surprisingly, the Internet. The Internet is 25 years old [3] and for most university students and younger, it was essentially always there. Even for academics in their 30s and 40s, it was there while they grew up. As well as the technology, the Internet signalled a change in mindset – academics were not just consumers of the scholarly literature, they were generators of it even in ways that could lie outside the scholarly publishing system.

So in my mind, this enabling technology also led to a profound shift in immediate behaviour, such as blogging, but also to changes in behaviour for solving problems.

What has this behaviour change led to in scholarly publishing? Several examples illustrate this well.

First, Open Access (OA) publishers such as Public Library of Science (PLOS) [4] came about as a result of academics seeing a need to make the research literature open – that is, free and shareable [5] – and starting their own publishing houses.

A second example came about when an academic needed to have a place to deposit and share his figures and data, but was not yet ready to incorporate them into a full paper. Hence, Figshare [6] was founded.

Third was when a group of medical students saw the need to get access to papers that were not OA and also to catalogue the extent of this need. Thus, the OA button [7] came into being.

Fourth, two separate groups of academics, one in New Zealand and one in Australia, saw a problem with researchers not getting credit for peer review. Publons [8] and Academic Karma [9] took up this challenge.

Fifth, and even more relevant to medical publishing, innovation has been used to specifically improve the reliability of the medical literature. This move started in the 1990s when editors and trialists began to explore how to better report research with low-tech solutions, such as checklists, to improve trial reporting. [10] Two developments have led on from that. One of these developments is known as a ‘threaded publication’ and aims to link all parts of a medical study, from protocol to trial report, to post marketing surveillance. [11] The other, following on from the AllTrials [12] initiative to get all trials registered and all results reported, is Open Trials [13], which will have a fully linked and searchable database of all trials, linked to their authors, institutions, and funders.

This growth of innovation – of academics seeing a need, designing a solution, and then building it, is now, I believe, fundamentally woven into the structure of new publishing, so much so that there is now a site that is cataloguing all these innovations [14] (not all of which are researcher-led) and this is a movement that can only grow.

What underpins the successful publishing enterprises now is, I believe, three things. First, they are built on the principle of openness – the data around the innovation itself, as well as the content is openly available, as is, increasingly, the code. Second, is the need for solid principles to build the innovation into something that works – the equivalent of making sure a revolution has functional water systems and drains. The third is the notion of interoperability – of seamless linking of all parts of the innovation with other innovations, for example, people through their ORCiD identifiers [15], trials through their registration numbers, [16] and papers [17] and funders [18] through their own unique identifiers.

In the end, all these innovations are working in one direction – to a more open, transparent and reproducible academic literature. It is not going to be perfect at every step but at least if there are novel ideas, built on transparent infrastructure, we can ensure that what is built will allow the next generation of innovation to be built upon them in turn.

Prepared for the AMSJ, © 2015 Barbour. This is an open access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.





















Guest Articles

Mental health in the medical profession: Support for students

Dr Stuart Dorney

Much has been reported about the prevalence of mental health concerns amongst medical students and doctors, both internationally and in Australia.

In 2013, beyondblue released the results from its national survey of Australian medical students and doctors. Among the survey’s key objectives was to better understand the issues associated with the mental health of Australian medical students and doctors, and to increase awareness of these issues across the profession and the wider community. [1]

The survey included questions about general mental health status, substance use, suicidal ideation and self-harm, workplace and life stressors, levels of burnout, impact of mental health symptoms, treatment and coping strategies employed to address mental health symptoms, barriers to seeking treatment and support, and attitudes regarding doctors with mental health conditions. The survey was completed by 1,811 (27%) of the 6,658 students and 12,252 (28.5%) of 42,942 doctors sampled. [2] Most of the students who participated were aged 22-25 years old (45.1%), female (62.6%), non-Indigenous (98.8%), located in a metropolitan region (66.5%), and worked part-time on average 12 hours per week (50%). [2] The responses from the survey were compared with the responses from the National Survey of Mental Health and Wellbeing, conducted by the Australian Bureau of Statistics in 1997. [2]

Dr Greg Kesby

beyondblue found that very high levels of psychological distress was three times higher in medical students than in the general population (9.2% and 3.1% respectively), and two times higher than levels reported by interns (9.2% and 4.4% respectively). [2] Students also reported higher rates of burnout and emotional exhaustion, with the highest rates being reported by females. [2]

When it came to perceptions about mental health within the medical profession, a high proportion of respondents held the view that doctors who had a mental health issue were stigmatised as a consequence, a finding particularly prevalent amongst those respondents who had been diagnosed with a mental illness themselves. Students with a current mental health diagnosis, compared with those not currently diagnosed, were more likely to report they felt doctors with a history of mental illness were less competent (52.4% and 38.2% respectively). Furthermore, 42% of students with a current mental health diagnosis felt that doctors tended to advise colleagues not to divulge their history of depression or anxiety disorders, compared to 22.6% of students who were not currently diagnosed with depression or anxiety. [2] This finding is particularly disturbing and probably explains the considerable reluctance of some medical students and members of the medical profession to seek independent help for mental health issues, and instead pursue a pathway of self-diagnosis and self-treatment with its associated risks. Too often we see students and medical practitioners only first presenting for appropriate independent care when they are acutely unwell or in crisis. This is unnecessary and needs to change.

The Medical Council of New South Wales has published a guideline for self-treatment and treating family members, which encourages all medical practitioners (and students) to have their own, independent general practitioner and advises practitioners against self-diagnosis or initiating treatment for themselves or their family members. [3] The Medical Board of Australia’s Good medical practice: a code of conduct for doctors in Australia also advises medical practitioners who know or suspect they have a health condition or impairment that could adversely affect their judgement, performance, or patients’ health not to rely on their own assessment of the risk they pose to patients and to instead consult their doctor about whether, and in what ways, they may need to modify their practice. [4]

Just as we would recommend to patients, it is important for medical students and doctors to adopt a healthy lifestyle through a balanced diet and regular exercise. It is also vital to ensure that immunisations are kept up to date, alcohol is consumed within the National Health and Medical Research Council guidelines, and that illicit drug use and prescription drug misuse is avoided. It is also helpful to have a strong personal support network and develop interests outside of medicine.

Key to addressing health issues, including mental illness, is early intervention. Medical students should feel comfortable and be encouraged to seek independent, objective advice from a general practitioner as early as possible when mental health issues arise, and in providing care medical practitioners must endeavour to provide a non-judgemental and supportive environment that good medical practice dictates for all patients. In addition to seeking advice and treatment from a general practitioner, psychologist, or psychiatrist, there are a range of early intervention services and supports available to promote optimal care, including the various university health services, university medical facilities, beyondblue, Headspace, Lifeline, and the Doctor’s Health Advisory Service, available in each state and territory.

Under the Health Practitioner Regulation National Law (NSW) (the National Law), impairment is one of the grounds under which a complaint or notification can be made about a student or practitioner. This often generates fear amongst students as to whether their mental health issues will exclude them from graduating and practising as a medical practitioner. However, it needs to be appreciated that the term “impairment” has a specific meaning under the National Law. It refers to a physical or mental impairment, disability, condition, or disorder (including substance abuse or dependence) that is linked to a student’s capacity to undertake clinical training, or a doctor’s capacity to practise medicine. [5] In some instances notification is mandatory.

While recent media reports and editorial columns have suggested that mandatory reporting laws in all states and territories excluding Western Australia may be a barrier to medical students and doctors accessing support and treatment for mental health problems, there is no reliable evidence to support such claims and no reason that this should be the case. The purpose of mandatory reporting is to act as a safeguard when medical students and doctors are unwilling or unable to seek help and manage any risk to public safety by compelling practitioners to raise serious concerns with the regulatory authorities. The threshold for making a mandatory notification about an impaired colleague is high. A practitioner treating a medical student or doctor is not automatically required to make a mandatory notification simply because they have a mental health issue. The National Law states it is only when a practitioner has formed a reasonable belief that a fellow practitioner has placed the public at risk of substantial harm in the practice of the profession because of their impairment that they are required to make a mandatory notification. [6]

Education providers also have an obligation to make a mandatory notification if they have formed a reasonable belief that a student undertaking clinical training has a health issue that may place the public at substantial risk of harm. The formation of a reasonable belief may well be influenced by factors such as whether the medical student is receiving appropriate treatment and advice or has made a voluntary notification. [6]

Medical students and doctors who believe they may have an impairment are encouraged to make a voluntary notification to the Australian Health Practitioner Regulation Agency (AHPRA). [6] For individuals with mental health issues who self-notify or who are the subject of a notification to AHPRA, there are remedial, non-disciplinary programs, which differ from state to state, that are designed to support students to remain in study and doctors to remain in practice whilst receiving appropriate treatment, provided it is safe for them to do so.

In NSW, the Medical Council’s Health Program aims to protect the public while at the same time supporting medical students and doctors affected by health issues, including mental illness. Not everyone with a mental health issue who self-notifies or is the subject of a notification to AHPRA enters into the Health Program. Many are assessed as having a psychiatric illness that is under appropriate management, with the student/doctor having appropriate insight and support networks, and are therefore not considered to place the public at a significant risk of harm. That is, they are not considered “impaired” as defined in the National Law. Most of those who do enter the Health Program remain in practice or study, subject to conditions on their registration tailored to address their particular circumstances and designed to ensure public safety while they undertake treatment and rehabilitation. Participants remain under the care of their own treating practitioners, but also undergo independent reassessment by Council-nominated practitioners from time to time. Participants in the Health Program meet with Council delegates, usually at six to 12 monthly intervals, and as they progress in their rehabilitation and recovery, the conditions on their registration are gradually eased, until the Medical Council considers that they no longer require being under the Council’s surveillance and consequently exit the Health Program. Whilst return to unconditional practice is a goal of the Program, some participants, for example those with a recurring psychiatric illness, may remain on the Program indefinitely, albeit with low level conditions and occasional review by the Council.

Many participants have had great success on the Health Program and have found the experience of significant benefit. For example, one participant, who had suffered from depression since his teenage years, found the Program’s impact on his work and personal life to be “only positive”. He said the Program encouraged him to set realistic work schedules, engage in activities outside the workplace, develop insight into the demands that he had previously placed on himself, and establish strong networks of support, both personally and professionally. Upon exiting, he said the Program had assisted him to successfully return to practice and engage in a “full and meaningful life”. Another, who had been self-prescribing and suffering from depression, and by his own assessment entered the Health Program “at a time when I was out of control and rapidly heading towards disaster”, found the Program forced him to confront his problems, encouraged him to maintain engagement with a treating psychiatrist, and enabled him to stop his prescription drug misuse and eventually return to full time work. He attributes his professional survival to his involvement in the Health Program and, at the time of exiting the Program, was receiving consistent feedback that he was excelling in his practice of medicine.

We are a caring profession, and we need to care for ourselves as well as each other. The Medical Council and other regulatory authorities encourage everyone with mental health issues, including medical students and doctors, to seek appropriate care – and seek it early. We recognise that some will be reluctant or unable to do so – through fear, or a lack of insight, or simply due to the lack of energy and initiative that may accompany their illness. You are therefore all encouraged to reach out to your colleagues if you suspect they may be suffering in silence. Offer those who appear to be troubled with life assistance in accessing appropriate support. Help them frame their thinking around whether they should self-notify to AHPRA. You can start by simply asking “Are you okay?”


[1] beyondblue. Doctors’ mental health program. (accessed Nov 2015).

[2] beyondblue. National mental health survey of doctors and medical students. 2013.—nmhdmss-exec-summary_web (accessed Nov 2015).

[3] Medical Council of NSW. Guideline for self-treatment and treating family members. 2014. (accessed Nov 2015).

[4] Medical Board of Australia. Good medical practice: a code of conduct for doctors in Australia. (accessed Nov 2015).

[5] Medical Board of Australia, Information on the management of impaired practitioners and students. 2012. (accessed Nov 2015).

[6] Medical Board of Australia, Guidelines for mandatory notifications, (accessed Nov 2015).

Guest Articles

New medical school not based on policy

About AMSA

The Australian Medical Students’ Association (AMSA) is the peak representative body for medical students in Australia. AMSA connects, informs and represents students studying at each of the 20 medical schools in Australia by means of advocacy campaigns, events, community and wellbeing projects, and the production of a range of publications.

20The Abbott Government’s announcement of a third WA medical school has been met with disappointment from medical students nationally. [1,2] It will exacerbate the bottleneck in medical training whilst doing little to help rural Australia. The decision seems to be more concerned with politics than any real plans to shape a sustainable workforce.

You  may  consider  us  hyperbolic,  but  there  is  significant  truth  to our words. Since 2001, medical student numbers have increased dramatically through the establishment of ten new medical schools and the expansion of places at existing schools. [3] In 2013, there were 3,441 medical graduates, over double the 1,400 graduates in 1999.[3] This in turn led to the internship crisis in 2012; for the first time, some locally trained graduates were unlikely to be offered an internship. [4] Through a large #interncrisis social media campaign, and political pressure from opposition political parties, the fated outcome was avoided. [5] Each year since, the Australian Medical Students’ Association, in conjunction with their state affiliates, have had to advocate strongly to ensure locally trained graduates are able to secure an internship.

The swell in medical student numbers is having flow-on effects to resident medical officer and specialist training positions. There are too few positions, and those that do exist are heavily oversubscribed. [6] It is therefore disingenuous for the Government to purport that increasing student numbers will somehow solve Western Australia’s GP shortage when they have not also funded training positions. [7]

There is a looming bottleneck in the system, with the time taken to  become  a  fully  qualified  consultant  after  graduating  medical school increasing. [8] From anecdotal evidence, we suspect that this ballooning time is due to an accumulation of junior doctors stuck in their residency unable to enter a speciality training college, including general practice. Unfortunately, there is little data to support this, which is why the AMA Council of Doctors in Training is advocating for a National Training Survey to highlight this likely problem. [9]

Given each of these difficulties, we find it incredulous that the Government has sought to increase student numbers further by opening a new medical school. The previous expansion of medical student numbers was so rapid and effective that the 2014 Health Workforce Australia report on doctors recommended that “no change should be made to the total medical student intake in 2015”. [10] The Government is ignoring its own Department’s advice for political gain.

Curtin’s proposed medical school is also unlikely to solve the rural doctor shortage.

Australian research has shown that the most effective method of encouraging local doctors to work rurally is to train medical students through a Rural Clinical School (RCS) – a program whereby students spend a year training in rural areas. [11,12] Students who participate in the RCS are twice as likely to work rurally upon graduation. [11,12] Curtin has no plans for a rural clinical school. Instead, the university intends to recruit 20% of their medical student intake from country WA. [13] This however falls short of the WA average (25%), and even shorter of the proportion of population that lives rurally (33%). [3]

There are better fiscal alternatives to promoting rural medicine than opening a new medical school. The Federal and Western Australian State   Governments   should   direct   their   expenditure   to   expand the number of RCS places. In Western Australia, there has been unprecedented interest in the RCS with applications to the school exceeding positions two to one. [11] Similarly, rural pathway places for general practice training should also increase. Ensuring that the yearly intake of medical students reflects the rural proportion of the general population could also direct further benefits to rural Australia.

Curtin has put forward the same proposal for a medical school to fix WA’s doctor shortage for the past 7 years, yet each year the Federal Health Department has knocked it back as it did not address key concerns. Why has the Government now ignored its own Department’s advice and supported it? Let us examine the state and federal electorates in which the new school will be built.

The Federal electorate of Hasluck is held by the Liberal MP Ken Wyatt by a marginal 4.3%. [14] The State electorate of Midland is held by Labor by a mere 24 votes. [15] It begs the question, is the Curtin Medical School about sound health policy or instead votes at the next election?

While the new medical school is slated to open in 2017, it is time we removed politics from the policy planning regarding our future medical workforce. We have described some of challenges to the long- term viability of the medical training pipeline in Australia, and these

need to be carefully considered to ensure its longevity for all medical graduates, including those from Curtin Medical School.


[1] New medical school will worsen medical workforce crisis [Internet]. Perth: Western Australian Medical Students’ Society; 2015 May 17 [cited 2015 Jul 28]. Available from: workforce-crisis/

[2] Media Release: NSWMSC concerned by the establishment of a new medical school [Internet]. New South Wales Medical Students Council; 2015 May 17 [cited 2015 Jul 28]. Available from: the-establishment-of-a-new-medical-school

[3] Department of Health. Medical Training Review Panel – eighteenth report. ACT, Australia; 2015. Available from: Content/work-pubs-mtrp-18

[4] National Internship Crisis. Australian Medical Students’ Association; 2012 [cited 2015 Jul 28]. Available from: https://

[5] Cadogan M. The Intern Crisis. Life in the Fast Lane; 2012 [cited 2015 Jul 28]. Available from:

[6] Jefferies F.     Western Australia: A Sorry State for Medical Education and Training. Perth, Australia: Healthfix Consulting; 2013.

[7] New Medical School for Curtin University. Canberra, ACT: Commonwealth of Australia; 2015  May  17.  Available  from:  https://

[8] McNamara S. Does it take too long to become a doctor? Med J Aust. 2012 [cited 2015 July 28];196(8):528-530.

[9] AMA Council of Doctors in Training. AMA CDT Strategic Plan 2014-16. ACT: Australian Medical Association [cited 2015 Jul 27]. Available from:

[10]  Australia’s  Future  Health  Workforce –  Doctors.  Canberra, ACT:  Health  Workforce Australia; 2014 August.

[11] Playford DE, Evans S, Atkinson DN, Auret KA, Riley GJ. Impact of the Rural Clinical School of Western Australia on work location of medical graduates. Med J Aust. 2014;200:1-4.

[12]  Kondalsamy-Chennakesavan  S,  Eley  DS,  Ranmuthugala  G,  Chater  AB,  Toombs MR,  Darshan  D,  et  al.  Determinants  of  rural  practice:  positive  interaction  between rural  background and  rural  undergraduate  training.  The  Medical  journal  of  Australia. 2015;202(1):41-45.

[13] Curtin Medical School. Frequently Asked Questions. Curtin University. Available from:

[14]   House   of   Representatives   Division   First   Preferences:   WA   Division   –   Hasluck [Internet].    Canberra,    ACT:    Australian    Electoral    Commission;    September    2013 [cited    2015    July    27].    Available    from:

[15] 2013 Midland District Results [Internet]. Perth, Australia: Western Australian Electoral Commission.;  2013  [cited  2015  Jul  28].  Available  from:  https://