Issues
Volume 185 Issue 1
Task Transfer
Quality among a diversity of health care providers
Thirty years’ experience in the US with non-physician clinicians shows they can deliver quality care Like Australia, the United States is experiencing physician shortages,1 and non-physician clinicians have become ever more important as providers of patient services. Most prominent among these are nurse practitioners (NPs) and physician assistants (PAs), as reviewed by Hooker in this issue of the Journal,2 but others also contribute to providing “physician services” in the US. They include alternative and complementary medicine providers (chiropractors, naturopaths and acupuncturists), mental health providers (psychologists, clinical social workers, counsellors and therapists) and members of several specialty disciplines (optometrists, podiatrists, nurse anaesthetists and nurse-midwives). Over the past 30 years, all have struggled to obtain licensure in the various states, to expand their practice prerogatives, and to achieve broader reimbursement from third-party payers. The progress that NPs and PAs have made is evident in Hooker’s review. The question is, do they contribute to quality? This editorial will comment on NPs, PAs and psychologists. A broader review, which forms the basis for this essay, assesses the full range of disciplines.3 Characteristics of NPs and PAs: Although commonly evaluated together, NPs and PAs are trained quite differently. Most NPs work in primary care settings, and, while having the authority to practise independently in more than a dozen states, most work within the context of physician practices. However, the goal of NPs is independence and collegiality rather than dependence and supervision. Nursing educators recognise that achieving this goal requires more advanced training. To that end, a pathway (described below) has been developed for doctoral-level nurse practitioners (DrNPs) who could become the primary care providers of choice for patients with most chronic illnesses.4 In contrast to NPs, PAs retain their dependent relationship with physicians, working in a delegated or supervised manner, and while some PAs prefer greater independence, the American Academy of Physician Assistants is committed to retaining an “interdependent relationship” with physicians. Nonetheless, the autonomy of PAs is often substantial. For example, most states allow them to practise within a radius of 50 miles or a 1-hour drive from their supervising physician, as long as the opportunity for telephone contact is maintained. While direct contact is required, its frequency varies from daily in most states to weekly in some and only monthly in a few, and several states require supervising physicians to review only 10%–15% of the PA’s patient charts. Only half of PAs work in primary care. Others span a range of specialties, including cardiology, dermatology, gastroenterology, neurology, general surgery, the surgical subspecialties and obstetrics and gynaecology. PAs assist in surgery, oversee specialty clinics and perform minor procedures, such as endoscopies and biopsies. Like NPs, they participate in patient education, counselling and chronic disease management. Their prerogatives are commonly stylised to the particular relationship that they have developed with their supervising physician. NP and PA outcomes: A rich body of literature has assessed the quality of care provided by NPs and PAs. In a landmark study published in 1974, shortly after the inception of these two professions, NPs were shown to perform within their scope of office-based practice as effectively as physicians,5 and, by the end of the 1970s, 40 studies evaluating both NPs and PAs reached similar conclusions.6 These were reconfirmed not only for NPs and PAs, but also for nurse-midwives, in an even larger body of work, which was summarised by the Office of Technology Assessment in 19867 and by Brown and Grimes in 1993.8 These assessments indicated that NPs and PAs could provide care for 60%–90% of the patients who present to primary care practices. The period after Brown and Grimes’ 1993 analysis8 has been marked by a progressive expansion of the licensed prerogatives of both NPs and PAs. While most research on quality and effectiveness continues to focus on primary care, some has assessed the performance of NPs as case managers for patients with chronic conditions, as well as their effectiveness in areas of even greater complexity, such as oncology home care, care of at-risk pregnancies and care provided in hospital emergency departments and neonatal intensive care units. Throughout these studies, health outcomes of NPs were similar to those of physicians, with equal or lower costs, shorter waiting times and higher patient satisfaction. Conclusions were similar, whether the research was performed by physicians, nurses, health services researchers or combinations of these. The same general conclusions were reached in a broad series of reports on PAs’ outcomes in both primary care and specialty practices. Collectively, they demonstrate that PAs perform competently within the framework of their delegated responsibilities, and that the levels of complexity and autonomy at which they function are greater when they have worked for sustained periods with the same physician. Doctoral-level NPs: The newly created DrNP degree is intended to further expand the capability of NPs.4 These practitioners will be trained to practise at the level of family physicians, with hospital-admitting privileges and full parity of reimbursement. Unlike NP training, which is oriented to office-based primary care, DrNPs are expected to care for their patients at a range of sites — emergency department, hospital, office, home, rehabilitation centre or nursing home. A model of such a practice has been established by faculty members at the Columbia University School of Nursing, New York.9 In a randomised study of follow-up care for patients who presented to an emergency department and had no personal physician, care by either physicians or Columbia nursing faculty showed similar outcomes at 1 year in terms of both clinical status and patient satisfaction.10 While the patients in this study had unusual demographic characteristics (most were Hispanic, female, young and poor), and follow-up was relatively brief (1 year), the remarkable success of this experience is inescapable. Psychologists: Like NP and PA training, the training of doctoral-level psychologists expanded in the 1970s in response to a desire for low-cost community services. Both counselling psychologists and primary care physicians now provide these services for patients with anxiety, mood disorders and other common psychiatric conditions. However, the care delivered has been judged appropriate in 90% of patients treated by psychologists, compared with fewer than 20% of those treated by primary care physicians.11 Indeed, primary care physicians fail to detect mental disorders 50% of the time, prescribe pharmacological agents for only 60% of those who are diagnosed correctly, and use adequate levels of treatment less than half the time.12 The value that psychologists bring to this patient population is without question. The second aspect of care by psychologists is more controversial — the use of psychopharmacological agents. Although leaders in psychology in the early 1990s looked with disdain on prescriptive authority, efforts to obtain such authority had already begun in Hawaii in 1984, and proceeded without success in 14 other states.13 In 1991, the US Congress authorised a pilot program for prescribing psychologists in the military, and 10 subsequently completed the required 2-year training program. Their prescribing was limited to a formulary, and they initially practised under the supervision of a psychiatrist, but within several years almost all were permitted to practise independently. Indeed, each became the chief of a clinic or department.14 While this program was discontinued because of the training costs and redundancies, the psychologists who participated were judged to have prescribed safely and effectively, and the quality of their care was rated as good to excellent. However, even when practising “independently”, these psychologists were working within institutional settings rather than in community practices. In 2002, New Mexico became the first state to license prescribing psychologists, patterning its program after the military.13 Similar legislation is pending elsewhere. However, even without such state action, a small group of psychologists who also trained as NPs have been prescribing under their nursing licences, and many psychologists prescribe de facto through their relationships with family physicians. Nonetheless, psychiatrists protest that psychologists are not adequately prepared for this role, and many psychologists agree. And while most psychology graduate students have no interest in pharmacotherapeutics, the profession is attempting to integrate the use of psychotropics into its training programs and to build for a future in which such practices are common. Conclusion: A large body of evidence supports the principle that NPs, PAs, psychologists and others provide quality care. Based on this experience, the expectation is that their contributions will progressively broaden over time as the US adjusts to its growing physician shortage.1 The strongest body of evidence in support of their effectiveness and safety is derived from care that is at the least complex end of the clinical spectrum or that is provided under the umbrella of physician involvement. Fewer studies have critically examined outcomes at the leading edge of their practice prerogatives and under conditions that are free of physician oversight. Therefore, as the scope of practice of non-physician clinicians continues to expand, more research will be needed to examine outcomes under conditions of greater clinical complexity and autonomy.
Richard A Cooper MD
Physician assistants and nurse practitioners: the United States experience
Approximately 11 200 new PAs and NPs graduate each year. PAs and NPs are well distributed throughout primary care and specialty care and are more likely than physicians to practise in rural areas and where vulnerable populations exist. The productivity of NPs and PAs, based on traditional doctor services, is comparable, and the range of services approaches 90% of what primary care physicians provide. The education time is approximately half that of a medical doctor and entry into the workforce is less restrictive. The interprofessional skill mix provided by PAs and NPs may enhance medical care in comparison with that provided by a doctor alone.
Roderick S Hooker PhD
Workforce substitution and primary care
We must preserve the elements of our health care system that work well All the signals in health care in the Western world point towards increasing demand and limitations on supply — a development driven by ageing populations, ever-increasing and sophisticated technologies and treatments, and a workforce that is less inclined to work the long hours of years gone by. There have been calls from governments for more flexibility in health care delivery. In the case of primary care, the arguments for substituting “traditional” general practitioner roles seem compelling — primary care in the United Kingdom and Australia is struggling to provide adequate access to care for a population with increasing needs. Surely we must expand our workforce to meet this need — especially if this can be achieved by employing less expensive health care providers? In this issue of the Journal, Sibbald and colleagues review the current status of workforce substitution between nurses and GPs.1 They point to the variety of roles that nurses have adopted in primary care settings: there seems compelling evidence that nurses can, with a great deal of autonomy, effectively deliver routine management of chronic conditions, such as asthma, diabetes and coronary heart disease. Indeed, further roles for nurses, such as cognitive behavioural therapy for psychological problems, are continually being explored.2 The new contract between GPs and the UK National Health Service (NHS), while rewarding GPs for meeting quality targets, underpins nurse-led management with specific chronic disease targets and a strong focus on clinical audit.3 There seems no doubt that nurses can take the lead on these processes effectively and produce favourable clinical outcomes — acknowledging that successful GP–nurse work substitution is, indeed, context dependent, and accepting that issues such as continuity of care, legal liability and practicalities of prescribing are paramount.1 Also in this issue, Parle et al discuss the development of a “medical care practitioner” curriculum in the West Midlands4 — there is considerable interest in bringing this North American model to the UK. On the whole, the pilot study by investigators at the University of Birmingham of the impact of US-trained “physician assistants” on the NHS indicated that introducing this new kind of health care provider into primary care can ease demand.4,5 Further, they have generally been met with positive responses from both their practice colleagues and patients. However, can we assume that because primary care capacity is insufficient there is an “overwhelming need for a mid level clinician working under the supervision of a qualified doctor”?3 The need for extra capacity is being met in part by new doctors. In common with Australia, the UK has chosen to increase student numbers to meet projected future requirements,6 and to reduce to a large extent the dependence on international medical graduates to fill both training scheme places and service posts. The number of places at UK medical schools increased by almost 60% between 1998 (when there were about 3750 places) and 2005, as a result of introducing new 4-year graduate entry programs, establishing four new medical schools, and adding places to existing schools. These new doctors are yet to have an impact on the workforce, but this greater capacity must inevitably influence access. A legitimate role for medical care practitioners seems apparent in secondary care settings, where the arguments of fluctuating skills of junior doctors and trends towards increased specialisation have more salience. In primary care it’s more complex: in Australia and the UK, primary care has been much more central to health service provision than in North America, and we know that a strong primary care focus within health systems can produce favourable health outcomes.7 The US physician assistants (the equivalent of medical care practitioners) have had a significant effect on primary care services,8 but it’s a different environment to ours. While there is something to be said for a mixed economy of approaches to workforce in primary care, there are inherent dangers in drifting towards a system in which primary care is seen as a “second tier” in the health service. A great deal of effort has been invested in trying to promote integration between primary and secondary care, and there are many efficiencies and health gains that can be achieved in doing so. A growing gap between primary and secondary care, in which the two workforces develop fundamental structural differences, can only inhibit this process.9 UK government White Paper, Our health, our care, our say: a new direction for community services13 — key features There is a strong focus on patient involvement in planning and decision making There is an emphasis on partnerships; for example, between health services and local authorities Care is to be moved out of hospitals and “nearer to patients’ homes” Encouragement is given to new entrants, including the private sector, as primary care providers Hence, we need to approach with caution any new innovation that potentially marginalises primary care. While investigating the potential of new layers of health professionals, primary care needs to diversify to meet changing needs. A great deal of diversification is already underway, much of it aimed at improving access, albeit with its own “health warnings”. For example, the development of “GPs with special interests” can improve access to much-needed specialist services. However, it needs to happen in a way that preserves continuity, and the universal, comprehensive nature of primary care.10 Similarly, in Australia, the development of primary care clinics for skin cancer, women’s health and travel medicine has both benefits for access and threats — some argue it undermines the fundamental principles of general practice.11 Developments in informatics and e-health hold further potential for improving access. Increasingly, we are looking at different models of consultation — email and telephone consulting, and greater, quality-assured use of the web hold great promise.12 The UK government’s recent White Paper, Our health, our care, our say: a new direction for community services, while provoking some controversy, has highlighted the importance government places on access to primary care, and points the way towards redesign of referral and treatment pathways, and better use of information technology — diversification of providers is highlighted as one of several options (Box).13 There is a need to keep an open mind about diversification and workforce substitution. While examining the potential of new kinds of health care providers, we should exercise caution before committing significant resources, and ensure we preserve the elements of our health care systems that work well. In the case of primary care, many innovations, which may have equal potential to improve access, are already underway (so we shouldn’t “throw out the baby with the bath water”!). So far, the detailed studies comparing these different approaches to improving access are still to be done.
David P Weller PhD, FRACGP, FAFPHM
Advanced nurse roles in UK primary care
Nurses increasingly work as substitutes for, or to complement, general practitioners in the care of minor illness and the management of chronic diseases. Available research suggests that nurses can provide as high quality care as GPs in the provision of first contact and ongoing care for unselected patients. Reductions in cost are context dependent and rarely achieved. This is because savings on nurses’ salaries are often offset by their lower productivity (due to longer consultations, higher patient recall rates, and increased use of tests and investigations). Gains in efficiency are not achieved when GPs continue to provide the services that have been delegated to nurses, instead of focusing on the services that only doctors can provide. Unintended consequences of extending nursing roles include loss of personal continuity of care for patients and increased difficulties with coordination of care as the multidisciplinary team size increases. Rapid access to care is, however, improved. There is a high capital cost involved in moving to multidisciplinary teams because of the need to train staff in new ways of working; revise legislation governing scope of practice; address concerns about legal liability; and manage professional resistance to change. Despite the unintended consequences and the high costs, extending nursing roles in primary care is a plausible strategy for improving service capacity without compromising quality of care or health outcomes for patients.
Bonnie Sibbald PhD, FRCGP(Hon) · Miranda G Laurant MSc · David Reeves PhD
The medical care practitioner: developing a physician assistant equivalent for the United Kingdom
A range of demographic, social and other factors are creating a crisis in the provision of clinical care in the United Kingdom for which the physician assistant (PA) model developed in the United States appears to offer a partial solution. Local and national moves are underway to develop a similar cadre of registered health care professionals in England, with the current title of medical care practitioners (MCPs). A competence and curriculum framework document produced by a national steering group has formed the basis for a recent consultation process. A limited evaluation of US-trained PAs working in the West Midlands region of England in both primary care and acute secondary care suggests that PA activity is similar to that of doctors working in primary care and to primary care doctors working in the accident and emergency setting. The planned introduction of MCPs in England appears to offer, first, an effective strategy for increasing medical capacity, without jeopardising quality in frontline clinical services; and, second, the prospect of increased flexibility and stability in the medical workforce. The deployment of MCPs may offer advantages over increasing the number of doctors or taking nurses out of nursing roles. The introduction of MCPs may also enhance service effectiveness and efficiency.
Jim V Parle MD, FRCGP · Nick M Ross MA · William F Doe FRCP, FRACP, FMedSci
Task substitution: where to from here?
Meeting future health workforce needs is a challenge for all health professionals There now seems little debate that the medical profession needs to accept task substitution as one solution to the health workforce crisis. The contributions in this issue of the Journal from the Royal Australian College of General Practitioners,1 Royal Australasian College of Physicians (RACP),2 the Royal Australasian College of Surgeons3 and Australian Medical Association (AMA)4 all acknowledge that reality and express a guarded acceptance of moving in this direction. They correctly emphasise that the overriding issue is the detail of how these strategies should be implemented, always bearing in mind the essential principle that patient care must not be compromised. Collectively, these organisations acknowledge that health care is delivered by a team. Who directs that team is perhaps debatable, although it will in most situations be a medical practitioner. We should, however, acknowledge the recent observations of Sir Graeme Catto, President of the UK General Medical Council: The exclusivity of medical knowledge and skill is being broken down. Interprofessional learning is now commonplace in medical education and seems likely to increase. Professional boundaries are being blurred as more and more things that were once the sole domain of doctors are being undertaken by other health care professionals. None of us works alone any longer, but in multidisciplinary teams in which we depend upon the expertise of others. This is not a diminution of medicine, but a strengthening of health care. We must acknowledge that, more than ever before, knowledge is available to patients and the public.” 5 We share the view of the AMA that it is important that health outcomes (slightly different from “health standards”) should not be compromised, but there is little or no evidence that this occurs where task substitution has been introduced. In fact, a Cochrane review of nurse practitioners6 suggested that outcomes for patients in services delivered by nurse practitioners are the same as or better than those delivered by doctors, and that nurse practitioners are well accepted by patients; however, improvements in cost-effectiveness were not as substantial as expected. The Productivity Commission report Australia’s health workforce serves as a blueprint for health workforce reform in Australia and presents task substitution as one plank in tackling what we all acknowledge is a very complex issue.7 But we need to recognise that the Productivity Commission report is about a lot more than task substitution. Certainly it comes from an economic “direction”, but to suggest that we, the providers of health services, have no economic responsibility is not acceptable in the 21st century. The issue is not principally about saving money — it is about using resources more efficiently to meet rising demand. The health workforce currently makes up about 11.3% of the total workforce in Australia, and it has been estimated (with feminisation of the health workforce, changing attitudes towards working, the ageing population, chronic disease and increasing community expectations for health) that we may need over 20% of the total workforce in health-related areas by 2025 if we are to maintain the delivery of services we currently have. Where is this workforce to come from? To date, four options for meeting increased demand in the future have been identified: extending the roles of existing health professionals (eg, nurses and allied health professionals); creating new types of health workers (eg, clinical assistants); improving efficiency by using information technology more effectively in the health industry; placing more emphasis on prevention and health promotion. Task substitution can involve the creation of new autonomous roles (eg, nurse practitioners) or roles in which non-medical practitioners work under the supervision of someone else (usually a medical practitioner) (ie, delegated care). Supervision may be in person (eg, a clinical assistant working in a primary care setting with a general practitioner) or remote (eg, nurses or physiotherapists running minor illness and injury clinics using video links for medical supervision). It appears that two very different types of clinical assistant may emerge in Australia:8 those who work in primary care, and therefore require generalist knowledge, and those who have highly specialised technical skills, such as surgical assistants and endoscopy assistants. As noted by many of the contributors to this issue of the Journal, moving current health professionals to other parts of the sinking ship will provide very limited gains. It is true that we need more health professionals, but we need to retain them and make use of them optimally. Implementing task substitution requires a combination of service redesign, using clinical practice improvement methodology, and progressive competency-based training. Underpinning task substitution is the notion of generic descriptions of health competencies that cross professional boundaries. The UK Skills Escalator9 is an important example and a potential model for adaptation and testing in Australia. The Skills Escalator is a nine-level career framework that starts with supporting roles then moves to assistants and senior assistants, assistant practitioners, qualified practitioners, senior or specialist practitioners, advanced practitioners, consultant practitioners and, finally, more senior posts. It provides a wide variety of entry points into health care careers, encourages and recognises lifelong learning and acquisition of new skills, and is used in an environment that seeks both job satisfaction and service efficiencies by “delegating roles, work and responsibilities down the escalator where appropriate”.9 The physician assistant (delegated care) model, equivalent to assistant practitioner on the Skills Escalator, seems to have been very successful in the United States10 and should be considered and tested in the Australian context. Piloting of delegated care models, including the use of clinical assistants, is already being seriously considered by one Australian state health department and was a major topic of positive debate at a recent annual general meeting of the Australian Society of Urologists. The opportunity is there for the health departments, colleges and universities to work together to identify services that lend themselves to productivity gains through the introduction of delegated care models, define the scope of new practices, develop the curriculum, deliver the learning programs, implement the redesigned services, and evaluate these new models of care delivery. Introducing delegated models of care is something that can be done now, and its focus on interprofessional care and competency-based training is likely to enhance these emerging trends in health education. The universities have the opportunity to establish inter-professional educational models at an undergraduate level so that health professionals of all persuasions learn at a very early stage that they are part of a health care team, that each has an important role, and that, in the future, all disciplines will have the potential to play leadership roles. Meanwhile, we should continue to: research and refine techniques to support health workforce innovation; explore novel techniques for training and assessing skills, including the use of synthetic environments (such as simulation and skills centres) and community-based environments; focus on competency assessment that is truly predictive of performance (as measured by patient safety and outcomes); and develop objective, reliable instruments for monitoring performance, safety and quality, especially when task substitution or role extension is newly introduced. Competencies need to be reassessed as a career progresses. Again, there are major opportunities for the colleges and universities to work together, as is already happening with the development of the Career Medical Officer program by the RACP and the Consortium of Universities for Postgraduate Health Education. As well as the future of health education, task substitution raises questions about registration and funding mechanisms, as highlighted in the Productivity Commission report. It is obvious that innovations are already occurring in the Australian health system, especially in areas under workforce pressure, from which we could learn — for example, the extended role of nurses and physiotherapists in hospitals with medical shortages.11 Further experimentation on various models of task substitution through education, service delivery and consumer partnerships would add to our knowledge. To move the issue of task substitution forward we probably need to move a little further towards accepting loss of “control” of the system. Like many professions (recall Adam Smith, who observed in 1776 in The wealth of nations that all professions tended to form self-interest groups and generally “conspire against the laity”12), we still fail to acknowledge that others may be able to do what we do — perhaps even better in some cases. We will need to reorganise the “ego systems”.13 But what an opportunity! — designing (and testing) a health system that is both patient focused and provider friendly. Surely this is a challenge that all health professions can work together on.
Niki Ellis MB BS, FAFOM, FAFPHM · Lynn Robinson MB BS · Peter M Brooks MD, FRACP, FAFPHM
Principles for supporting task substitution in Australian general practice
The workforce crisis in Australian general practice provides an impetus to consider new roles for other health professionals. Any innovations need to be appraised in advance for their potential risks and benefits. We propose six principles for this appraisal. These are the need for the new roles to: support the relationship between patients and their general practitioners; be clearly defined, aligned with competency and with relevant professional registration; be supported by practice systems providing safeguards against medical error; be underpinned by a system ensuring informed patient consent to activities being undertaken by members of the general practice team; be supported by effective medical indemnity insurance and be supported with appropriate financing.
Michael R Kidd MB BS, MD, FRACGP · Ian T Watts BSW, DipSocPlan, MBA(Exec) · Christopher D Mitchell BMed, FRACGP, FACRRM · Lynton G Hudson FRACGP, DipObsRACOG · Beres C Wenck MB BS, FAMA · Naomi J Cole BNsg, BJS
Task transfer: the view of the Royal Australasian College of Physicians
Health service imperatives such as workforce shortages of doctors and nurses and changing models of care are driving task transfer in Australia. The Royal Australasian College of Physicians (RACP) supports task transfer both across its specialty groups and to other health professionals as appropriate. The RACP’s new education standards, with explicit curricula and competency-based assessments, underpin its capacity for task transfer. Task transfer must be evidence-based, safe, cost-efficient and facilitate best patient care.
Jillian R Sewell MB BS, FRACP
Task transfer: the view of the Royal Australasian College of Surgeons
The Royal Australasian College of Surgeons (RACS) supports the evolution of appropriate task transfer in a team environment led by the most experienced clinician — in our case, the surgeon. A clear requirement needs to be identified for task transfer; it should not be used to avoid redressing the current inefficient use of existing surgeons resulting from ongoing underfunding. Maintenance of standards, defined curricula, professional titles and monitored outcomes are essential.
John P Collins MD, FRACS, FRCS · David J Hillis MHA, FRACGP, FRACMA · Russell W Stitz MB BS, FRACS, FRCS
Task substitution: the view of the Australian Medical Association
Technology, community expectations and an ageing population are driving the need for an expanded health care workforce. Doctors embrace task substitution wherever it can be done safely and effectively. Task substitution should occur in the context of: team care that synergises the different skills of doctors, nurses and other health professionals doctors retaining their central role increases in the capacity to extend medical services with efficiency gains no loss of patient safety no fragmentation of care The growth of task substitution could lead to workforce shortages in other health care areas. Public policy on task substitution must take full account of patient preferences and expectations.
Choong-Siew Yong MB BS, FRANZCP
Task transfer: another pressure for evolution of the medical profession
Since the 1960s, Australian society and the medical profession have undergone enormous change. Our society has moved from a relatively homogeneous and conservative community, supported by limited government services, to one that is multicultural, focused on the individual and consumerism, and supported by extensive government programs, with health care a top public and political priority. A defining feature of contemporary society is its mistrust of institutions, professionals, public servants and politicians. The medical profession has changed from a cohesive entity, valuing generalism and with limited specialisation, to one splintered by ultra-specialisation and competing professional agendas. The medical workforce shortage and efforts to maintain the safety and quality of health services are putting acute pressure on the profession. Task transfer or role substitution of medical services is mooted as a potential solution to this pressure. This has the potential to drastically transform the profession. How task transfer will evolve and change medicine depends on the vision and leadership of the profession and a flexible pragmatism that safeguards quality and safety and places patient priorities above those of the profession.
Martin B Van Der Weyden MD, FRACP, FRCPA
A radical new treatment for the sick health workforce
The health workforce crisis needs radical treatment; simply educating more health workers will be insufficient, and role substitution among existing health workers is untenable. We propose a new class of health worker who would take on single disease or single procedure responsibilities, working mostly to protocols; and be embedded within current structures. We also propose modular health education which has fewer entry points into the health system, allows transfer between different disciplines, and is based on modules that can be accumulated to allow progress through the system to gain more clinical responsibility.
Christopher B Del Mar DRCOG, FRACGP, FAFPHM · Naomi Dwyer BBus
Re-inventing medical work and training: a view from generation X
Medical career preferences are changing, with doctors working fewer hours and seeking “work–life balance”. There is an urgent need for creative workplace redesign if Australia is to have a sustainable health care system. Postgraduate medical education must adapt to changing medical roles. Curricula should be outcomes-based, should allow flexible delivery, and should consider future workforce needs.
Clare A Skinner MB BS, MPH, BA(Hons)
When the tide goes out: health workforce in rural, remote and Indigenous communities
There is compelling evidence for the success of the “rural pipeline” (rural student recruitment and rurally based education and professional training) in increasing the rural workforce. The nexus between clinical education and training, sustaining the health care workforce, clinical research, and quality and safety needs greater emphasis in regional areas. A “teaching health system” for non-metropolitan Australia requires greater commitment to teaching as core business, as well as provision of infrastructure, including accommodation, and access to the private sector. Workforce flexibility is mostly well accepted in rural and remote areas. There is room for expanding the scope of clinical practice by non-medical clinicians in both an independent codified manner (eg, nurse practitioners) and through flexible local medical delegation (eg, practice nurses, Aboriginal health workers, and therapists). The imbalance between subspecialist and generalist medical training needs to be addressed. Improved training and recognition of Aboriginal health workers, as well as continued investment in Indigenous entry to other health professional programs, remain policy priorities.
Richard B Murray MB BS, MPHTM, FACRRM · Ian Wronski MB BS, SM(Epi)(Harvard), FAFPHM
Research
Aboriginal health workers and diabetes care in remote community health centres: a mixed method analysis
Objective: To assess the effect of employing Aboriginal health workers (AHWs) on delivery of diabetes care in remote community health centres, and to identify barriers related to AHWs’ involvement in diabetes and other chronic illness care.Design, setting and participants: Three-year follow-up study of 137 Aboriginal people with type 2 diabetes in seven remote community health centres in the Northern Territory.Main outcome measures: Delivery of guideline-scheduled diabetes services; intermediate outcomes (glycated haemoglobin [HbA1c] and blood pressure levels); number and sex of AHWs at health centres over time; barriers to AHWs’ involvement in chronic illness care.Results: There was a positive relationship between the number of AHWs per 1000 residents and delivery of guideline-scheduled diabetes services (but not intermediate health outcomes). Presence of male AHWs was associated with higher adherence to the guidelines. Barriers to AHWs’ involvement in chronic illness care included inadequate training, lack of clear role divisions, lack of stable relationships with non-Aboriginal staff, and high demands for acute care.Conclusions: Employing AHWs is independently associated with improved diabetes care in remote communities. AHWs have potentially important roles to play in chronic illness care, and service managers need to clearly define and support these roles.
Damin Si MMed · Ross S Bailie MB BS, MPhil(MCH), MD · Samantha J Togni MA · Peter H N d'Abbs PhD · Gary W Robinson PhD
Letters
The efficacy of a nurse-led preoperative cataract assessment and postoperative care clinic
To the Editor: We believe the study by Kirkwood et al,1 investigating the use of nurse-led perioperative cataract clinics, contains flaws, and their conclusions are premature. The authors do not explain the reduction in elective surgery waiting times. Use of a nurse-led clinic should not affect surgical throughput, which is dictated by surgeon and theatre availability. The rate of postoperative complications with cataract surgery is very low.2,3 An assessment of the concordance in management between the nurse practitioner and ophthalmologist would therefore only be possible if a large number of patients were compared, not just the 18 used in the study. The authors do not justify the statements “a nurse practitioner might be more . . . experienced in managing patients with ophthalmic conditions” [than a junior registrar] and “the experienced nurse practitioner might be more efficient in use of consumables and investigations” by reference to their own clinic or the literature. In our opinion, a medical practitioner is best placed to understand and make these decisions. In Queensland, registrars perform or observe most cataract operations done in public hospitals. It is important for their training to see these patients both before and after surgery,4 making the presence of a nurse practitioner unnecessary. If the authors are interested in increasing the efficiency of the process, they could reduce unnecessary clinic visits, which is very relevant here in Australia given that patients may have to travel great distances for operations. The two preoperative visits proposed in the authors’ model could be replaced by one. Standardised referral forms can be used for screening, and facilities can be put into place so that all necessary tests can be performed on the same visit for eligible patients. The 4-week visit can be eliminated if the patient’s dispensing optometrist is aware of the expected postoperative visual acuity and can readily refer back if there are any concerns. Although the model outlined by Kirkwood et al has merits, the conclusions are misleading. Health care providers and governments must find ways to deliver high quality care during this period of workforce shortages. This should be achieved by increasing efficiency, while preserving doctor training opportunities, rather than through role substitution.
Hamish D R McKee · Glen A Gole
The efficacy of a nurse-led preoperative cataract assessment and postoperative care clinic
In reply: The points made by McKee and Gole are valid. However, the demand for eye-care services is outstripping the ophthalmological workforce. Some task substitution is necessary. The effect of the nurse-led cataract clinic has been largely to increase patient access to outpatient appointments — it helps deal with a large hidden waiting list (time to first clinic appointment), and frees up ophthalmologists to spend more time in the operating room. Registrars in training are not likely to cope with an increasing demand for services. The number of trainees is determined by the Royal Australian and New Zealand College of Ophthalmologists. Flinders Medical Centre sees 15 000 eye outpatients a year and does 1500 elective procedures — and has been allocated one first-year trainee. The nurse practitioner is more experienced and does not rotate to another hospital every few months. Nurse practitioners may not be the preferred substitute for ophthalmologists. The employment conditions of nurses can be restrictive, and senior nurses are expensive to employ compared with other professionals, such as orthoptists and optometrists. Perhaps McKee and Gole are more comfortable with the use of professionals other than nurses, as they advocate the involvement of optometrists to decrease the load on outpatient clinics.
Bradley J Kirkwood · Konrad Pesudovs · Paul Latimer · Douglas J Coster
How not to effect change in curricula
To the Editor: We read with interest two recent articles and an editorial on the state of medical education in Australia.1-3 As cancer clinicians and academics, and members of the Oncology Education Committee of the Cancer Council Australia, we have been following medical student education about cancer in Australia for almost 20 years and have learned first hand what is not sufficient to achieve change. Highlighting the need: Cancer claims more lives than any other disease4 and is set to increase in incidence by 31% over the next decade,5 yet medical curricula devote little time to cancer education because of competition with other disciplines, historical precedent, personal preferences or just lack of teachers. Developing a national curriculum: An ideal oncology curriculum,6 developed in Australia in 1999, has been endorsed by the International Union Against Cancer, yet has been taken up by a minority of medical schools in Australia. This is largely because of the lack of a national medical curriculum and the absence of a compliance mechanism through national credentialling. Demonstrating deteriorating standards: A comparative study published in 2003 highlighted the fact that recent medical graduates had less exposure to cancer patients than those who graduated 11 years earlier, and that their knowledge was inferior.7 Evidently, community awareness, recommended curricula and evidence of system failure do not effect change. Why? Perhaps because, in the present system, curriculum content is divorced from medical outcomes. There is little or no feedback linking curricula to their consumers: medical students, postgraduate training programs and patients. The Australian Medical Council, the main accrediting body for medical curricula, is more concerned with process than content or outcomes. There is no national outcomes monitoring, nor an exit exam.8 No one knows whether students achieve desired outcomes. We do not even agree on what these are. Outcomes of medical education must feed back to content and process. To do this, we must monitor outcomes nationally, provide feedback to medical schools and have mechanisms to effect change based on such feedback. Without closing the loop, medical education seems to have some features of cancer: vigorous but uncontrolled growth, and uncertain outcome.
Bogda Koczwara · Michael B Barton · Martin H Tattersall · David R Turner · Ian N Olver · Darren L Starmer
Return to workforce-based training
To the Editor: McGrath and colleagues raise important questions about medical training in Australia.1 Their solutions take an admirable overall approach to policy, but fail to fully acknowledge the current reality of training and service delivery in the health sector. The Productivity Commission is certainly taking a broad approach to these matters,2 but I wonder if more lateral thinking and a reference to the past might help provide a solution? In 1910, the landmark Flexner report recommended that universities take over undergraduate training so that a uniform standard could be achieved.3 Previously, many hospitals trained their own doctors, hence the term “teaching hospital”. I am increasingly of the opinion that the pendulum has swung too far since Flexner, and that universities now are ill-equipped to train the doctors of the 21st century. Doctors in hospitals and communities are largely responsible for the clinical training of students anyway, and it is also in these arenas that prevocational and vocational training occur. It appears that the universities are the odd ones out when the full spectrum of medical education is considered. Very little “higher education” takes place during a basic medical degree — it is hard to argue against the notion that a basic medical degree has more in common with “further education” and the training of a trade. With this in mind, might it not be sensible for hospitals to take over the training of doctors again? There have been similar recent calls for nursing and school-teacher training to return to workforce-based training, and they moved to universities far more recently than doctors. Such a move could have a number of tangible benefits. All levels of training would be in alignment, thereby achieving the educational Holy Grail of “vertical integration”. Medical students would be immersed in a clinical environment from the start, thereby experiencing a true integrated curriculum. They would also be exposed to workforce requirements and this could address a number of current concerns surrounding graduates’ readiness for work.4 It would return public hospitals to being eminent training institutions, and would give true meaning to the term “teaching hospital”. Other health professionals could be trained within a similar model, introducing an interdisciplinary approach to training from an early stage. Basic sciences could be taught by scientists and clinicians alike throughout all stages of the course, all employed by the one institution and providing many educational benefits. Community-based education would be incorporated in a “hub and spoke” model, and clinical linkages would be significantly improved. Such an innovative move could bring medical education and service delivery back into alignment. Any impediments would be purely technical and, of course, political — and easily overcome.
Geoffrey A Couser
National exit exam needed to test core knowledge
To the Editor: The article by Sanson-Fisher and Lynagh criticising problem-based learning (PBL)1 has elicited surprisingly little response, especially in light of the fact that these authors are from the University of Newcastle, the institution that first introduced PBL in Australia. The authors cite evidence that PBL students have inferior overall knowledge and competence than students taught by traditional curricula. Most medical faculties now have in-house education centres which are involved increasingly in learning process rather than content. The education centre in the Faculty of Medicine, Dentistry and Health Sciences at the University of Western Australia, for example, incorporates personal and professional development “as one of the four themes” in the curriculum2 — this includes such topics as ethical behaviour, diversity (what the patient brings to the relationship), self-evaluation (what the doctor brings to the relationship), teamwork, self-care and stress management. The old adage: “Those who can, do. Those who can’t, teach. Those who can’t teach, teach teachers” applies so appropriately to these new education centres. I support Lawson-Smith in calling on the Minister for Health, the Australian Medical Council, the Australian Doctors’ Fund, the learned Colleges, all interested colleagues and medical students to support the proposal for a national exit exam based on the most important function of a medical school: core knowledge.3 Medical students and medical schools should compete nationally in an examination to assess core knowledge. “Competition promotes the pursuit of excellence” should surely be the mantra of every medical school.
Ian N Bernadt
Medical student access to patients
To the Editor: The recent article by Olson et al1 and the accompanying editorial by Crotty2 confirm the impressions of anyone who has graduated from an Australian medical school within the past 30 years. The paucity of clinical cases has probably been more significant in teaching hospitals in cities larger than Newcastle (where Olson and colleagues are based), as there has traditionally been a preponderance of student teaching in such institutions. This is something that seems to be slowly fading as new medical schools emerge in smaller cities, such as Canberra. What is harder to measure is the time and angst associated with the process of determining which patients are accessible for medical students. Students can be frustrated not only by the concerns of the nursing staff, but also by paramedics, technicians, clerks, relatives, other students and, perhaps most discouraging of all, patients themselves. Once this minefield of obstacles is negotiated, interaction with the patients is highly variable in terms of the learning opportunities afforded. Perversely, the most “valuable” patients in this sense can sometimes be the least accessible as they spend so much of their time away from the ward undergoing investigations. Crotty’s call to expand clinical teaching into the private sector has some merit, particularly as supervising consultants would be keen to make the student–patient interaction relatively efficient. I believe a more concerted effort to tap into the clinical resources in the expanded ambulatory sector is also required. Whatever “solutions” are found, it is hard to imagine that the clinical exposure of senior medical students to patients will be adequate any time soon.
Andrew Thomson
Altruism can no longer support community-based training
To the Editor: The article by McGrath and colleagues summarised neatly the challenges facing medical education in Australia.1 One solution suggested by Crotty for meeting the training needs of medical students at a time of increasing student numbers and decreasing numbers of hospital inpatients is to move a greater proportion of medical education into the community.2 Internationally, many medical schools are adopting a more community-based curriculum,3 while in Australia, students are spending a greater proportion of their time in general practices and other community settings. However, community-based education should not come cheaply. Many general practitioners have been hosting students in their practices for years, and are motivated to do so because of an interest in education and the stimulus provided by students in keeping up-to-date.4 Rarely are they solely involved because of remuneration. While there are payments for teaching, these do not reflect the time and loss of earnings that GPs incur in providing attachments. If GPs are to be asked to be more involved in the undergraduate curriculum, there should be a true costing of the process. GPs who teach students are often involved in vocational training of GP registrars and, from this year, in supervising interns in general practice through the PGPPP (prevocational GP placement program). I am concerned that we are approaching full capacity, and that finding quality GP placements for all these students and junior doctors will become very difficult. One solution for practices that provide a substantial amount of training would be to pay them enough to employ an extra doctor either to carry the teaching load or free up others to do so. However, even if there was the funding for this, at present, there is a shortage of GPs to provide patient care, let alone education. There certainly needs to be a rethink in relation to the prestige given to clinicians who teach, adequate training in education for clinical tutors, and the necessary resources to provide good learning experiences. Not only do I believe that all medical students should have the opportunity to work and learn within general practice, but that all junior doctors should have at least one attachment in the community. GPs will need support, training and space to offer this, and we should not continue to rely on their altruism to support medical training.
Jill E Thistlethwaite
Registrars cannot provide full teaching for juniors
To the Editor: I was recently amazed to learn that the solution to the educational needs of prevocational doctors was more teaching from registrars.1 My understanding was that registrars were themselves in a predominantly learning position, desperately hoping to glean some scraps of wisdom from consultant doctors. Often, the registrar, this supposed demi-god of all knowledge, is only 1 or 2 years ahead of the prevocational doctor and permanently juggling yet another postgraduate examination and the rigours of clinical duties. Then, with Australian medical schools springing up here and there, there are the inevitable hordes of medical students. So, registrars have an inherent and significant conflict of interest, namely, self-education to be able to continue climbing the slippery slope of postgraduate vocational education versus the altruistic provision of education for others. Perhaps graduating medical students need to take personal responsibility for their own education. Continuing medical education (CME) is a lifelong process that requires individual initiative. Support from the various specialist Colleges is welcome but not essential. Weaning prevocational doctors from their dependency on “formal education” is an essential first step towards independent clinical practice. This is not to say that CME for prevocational doctors should not be supported, but rather that it is unrealistic to demand that it should all be spoon-fed from registrars. An informal verbal survey of my registrar colleagues unanimously showed that we would all like to expand our teaching load, but not at the expense of clinical care. So what can the system do to support the beginners? Nurses have clinical nurse educators, and soldiers have drill sergeants. The nursing education system and the army have both recognised the value of employing personnel purely for educational purposes. The medical profession could do likewise. The pretence that service is educational for prevocational doctors should be denounced. Routine tasks performed by prevocational doctors that do not require medical expertise, but consume much time, could perhaps be delegated to non-medical professionals. This would free up time for medical education on the job. However, protected time for teaching by adequately remunerated clinical teachers requires workforce expansion and, ultimately, public funding and political will. Finally, from within a profession that often subscribes to the view that good resident staff are seen but not heard (that is, work hard and don’t complain), recognition by consultants that they too were once beginners may lead to positive cultural changes.
Kenneth Wong
Rural internship for final-year medical students
To the Editor: Recent reports have highlighted problems with our capacity to teach medical students.1,2 Others have described workforce problems, calling for innovative approaches.3 The Rural Internship program at the James Cook University (JCU) School of Medicine may contribute to such strategies. The first regionally based medical program in Australia, the School was founded in 2000 and has recently graduated its first cohort.4 All final-year students undertake an 8-week rural internship, having previously completed 12 weeks of structured rural placements in their 2nd and 4th years, and a core 2nd-year subject — Rural, Remote, Indigenous and Tropical Health. The rural internship allows students to develop and practise clinical skills in a rural context. All students in the first cohort completed the rotation in 2005 in hospitals across northern Queensland, usually in groups of two or three, providing full-time inpatient, outpatient and after-hours duties under supervision. Hospitals were in rural and remote communities (Rural, Remote and Metropolitan Area classifications 4–7; comprising rural areas with populations < 24 999 to remote areas with populations < 5000), with demonstrated capacity to supervise and teach. Most were 2–4-doctor hospitals, although one larger hospital (Mt Isa, 35 doctors) and one smaller hospital (Moranbah, one doctor) were used. Supervision was provided by experienced rural doctors (medical superintendents and senior medical officers) holding an FACRRM or equivalent. Evaluation in the first year included student questionnaires, site visits, interviews and follow-up teleconferences with instructors. Early evaluation suggests that the rural internship provides senior students with valuable experience in the health care team. Students accept limited responsibility and further their abilities and confidence to undertake the role of the intern. Importantly, specific feedback from medical superintendents indicated that the rural interns made a net contribution to the system when teaching time and supervision were considered. The rotation appears to meet educational objectives without burdening (indeed, possibly bolstering) the local workforce. This is consistent with other reports of students undertaking extended rural experiences.5 It also addresses a common conundrum: rural instructors and communities are keen to teach students and appreciate the long-term workforce implications, but are constrained by resources, particularly time. This model extends and enhances apprenticeship-style medical education through its rural focus, distributed delivery and involvement of the entire cohort of students. The contribution to patient care by senior students and junior doctors creates a consultant–registrar–resident model, in which experienced rural doctors function as consultants providing advice, support and tuition rather than predominantly face-to-face patient care. We feel that this innovative approach should be explored in other settings.
Tarun Sen Gupta · Richard B Murray
Lessons to be learnt from general practice training
To the Editor: Three recent articles discuss Australia’s medical education arrangements,1-3 but do not propose a way forward. Dahlenburg notes “at least 10 different agencies are involved in postgraduate training”, leading to a “modern Tower of Babel”, but proposes eight more “independent” entities. McGrath et al comment timidly that a Productivity Commission suggestion for a national advisory council “has merit”, and Dowton et al simply comment: “It is time to comprehensively review the oversight and governance of postgraduate medical education and training.” None of these articles even mentions General Practice Education and Training (GPET), an innovative Australian initiative. GPET was established in 2001 as an incorporated entity with a board appointed by the federal Minister for Health. GPET has established regional training providers (RTPs) across Australia. GPET is required under its constitution and government funding arrangements to provide postgraduate training according to standards determined by medical colleges. For general practice, GPET provides features these authors find lacking in Australia’s medical education arrangements, such as “overarching governance and coordination”, “integrated mechanisms to draw together the interests of stakeholders”, “alignment between workforce planning, education and training needs” and “alternatives to teaching hospitals”.4 GPET manages the interaction between autonomous colleges and a funding agency, and conflict between the focused desires of young doctors and workforce policies, while organising training outside public hospitals. Change is difficult, perhaps more so in medicine than in other sectors. Michael Foot, once leader of the British Labour Party, reflecting on political differences with the British Medical Association, wrote: “Much the strongest bent in the medical mind was a non-political conservatism, a revulsion against all change, a habit of intellectual isolation which enabled them to magnify any proposals for reform into a totalitarian nightmare. Nothing good could ever come from the meddling of outsiders.”5 GPET was a political response to effective lobbying from rural doctors rather than imposition of some grand centralist plan. Nevertheless, the imagined threat to professional autonomy evoked gloomy foreboding about “training standards spiraling downwards”.6 Maybe Dahlenburg, McGrath and Dowton realise controversy would follow any proposal for a medical education system with attributes they see missing, such as overarching governance, more coordination, alignment of workforce needs with trainee numbers, and wider distribution of training resources. It might require some consolidation of organisations, common structures and processes across disciplines, and some direction in the distribution of training resources. Maybe these authors do enough by raising the issues and are wise to leave others to debate whether centralised control and coordination could solve the problems they describe. Maybe they took the advice of a well known Englishman and decided not to mention the war.7
William Coote
Medical student input to workforce planning
To the Editor: We surveyed current medical students and interns in Western Australia over the 5 weeks from 23 September to 30 October 2005 to determine their awareness of, and views on, the imminent increase in clinical student and intern numbers as a result of federal government plans to increase medical student numbers nationwide, and to seek opinion on proposed strategies to cope with the demand on health education resources. The study was in the form of a web-based survey. The questionnaire consisted of five sections: demographic information, awareness of changes, predicted impact of these, teaching strategies and a free-text section for comments and concerns. The predicted impact question focused on the medical profession, career prospects, teaching, training positions and programs, average income of medical practitioners and overall effect on the health care system. There were 561 responses to the questionnaire (of a possible 1083). Respondents comprised 27 interns (of 134; 20.1%) and 534 medical students (503 of 909 [55.3%] from the University of Western Australia and 31 of 40 [77.5%] from Notre Dame University). The medical students comprised 118/212 from 1st year (56%), 108/207 from 2nd year (52%), 103/151 from 3rd year (68%), 84/141 from 4th year (60%), 71/126 from 5th year (56%), and 50/112 from 6th year (45%). There were 323 women (57.6%); and 70 respondents (12.5%) were aged over 24 years and 10 (1.8%) were aged less than 18 years. Respondents’ perceptions of the impact of increased student numbers are shown in the Box. Of the 561 respondents, 501 (89.3%) believed more clinical teachers in teaching hospitals to be important in ensuring the increased number of medical students are taught effectively. Further, 246 (43.9%), 303 (54%) and 311 (55.8%), respectively, indicated that general practice, rural hospitals, and private hospitals are important additional or alternative strategies. Themes that emerged from the free-text section of the survey were dissatisfaction with problem-based learning, expanded roles for junior doctors as teachers, and concerns about high ratios of students to tutors. While it has been widely acknowledged that the current methods of teaching need revision and will not cope with the influx in medical student numbers,1-4 planning for expansion of educational roles in non-traditional settings will require input from medical students as they are the “consumers” of these resources. We therefore suggest increased student input to workforce planning be sought at all levels to ensure newer teaching strategies will be effective in educating the impending influx of medical students. Western Australian students’ perceptions of the impact of increased student numbers resulting from federal government plans to increase medical student numbers nationwide Perceived effect Positive Tending positive Neutral Tending negative Negative Overall effect on health system 28% 27% 16% 18% 12% On career prospects 3% 6% 31% 38% 22% On teaching provided 4% 4% 13% 32% 48% On training positions 4% 5% 14% 42% 35% On average practitioner income 1% 3% 53% 26% 17% On the medical profession 22% 31% 26% 13% 7% Percentages may not total 100% because of rounding.
Ruth E Blackham · Ian R Rogers · Ian G Jacobs
Departments
MJA/Wyeth Award 2005
The MJA/Wyeth Award 2005 for excellence in clinical research was awarded at the recent AMA National Conference in Adelaide in May 2006. AMA President, Dr Mukesh Haikerwal, Wyeth Australia Medical Director, Dr Michael Lee, MJA Editor, Martin Van Der Weyden, Associate Professor Paul Johnson and Professor Lindsay Grayson at the MJA/Wyeth Award presentation for 2005. It was presented to Associate Professor Paul D R Johnson and his colleagues: Rhea Martin, Laurelle J Burrell, Elizabeth A Grabsch, Susan W Kirsa, Jason O’Keeffe, Barrie C Mayall, Deidre Edmonds, Wendy Barr, Christopher Bolger, Humsha Naidoo and M Lindsay Grayson for their research paper “Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection”, published in the 21 November 2005 issue of The Medical Journal of Australia. The team’s research addressed a problem that has plagued hospital practice since the 19th century — nosocomial infection, which, of late, has become more deadly, with the emergence of methicillin-resistant Staphylococcus aureus. Dr Johnson and his team introduced a multi-faceted hand hygiene program at Austin Health in Melbourne using an alcohol/chlorhexidine solution. Through their efforts and tenacity, Dr Johnson and his colleagues produced an increased compliance with hand hygiene by hospital staff with a concomitant reduction in hospital-wide MRSA isolates and patient episodes of MRSA bacteraemia. Dr Michael Lee, Medical Director of Wyeth Australia, in presenting the Award, noted that: “. . . This year, Wyeth was particularly interested to learn that the winning publication was to be the result of work in the infectious diseases arena. Globally, we have had a long association with this therapy area, and we have been able to contribute to it in collaboration with other stakeholders in this field of medicine. . . . We are heartened by the fact that measures such as hand hygiene, an altered approach to shared equipment, education, and other ‘culture change’ initiatives can pay dividends in terms of infection rates and other parameters. The findings of the research team at the Austin have a direct impact on economic considerations and more importantly, on patient outcomes. . . . Interestingly, the publication of the 2005 Award has highlighted the very fundamental concept that prevention is better than cure”. Recipients of the MJA/Wyeth Award 1995–2005 The Wyeth Award includes a $10,000 prize for the authors of the best clinical research article published in The Medical Journal of Australia each year. 2005 Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection Paul D R Johnson, Rhea Martin, Laurelle J Burrell, Elizabeth A Grabsch, Susan W Kirsa, Jason OKeeffe, Barrie C Mayall, Deidre Edmonds, Wendy Barr, Christopher Bolger, Humsha Naidoo and M Lindsay Grayson. Med J Aust 183: 509-514. <eMJA full text> 2004 Preventing pressure ulcers with the Australian Medical Sheepskin: an open-label randomised controlled trial Damien J Jolley, Robyn Wright, Sunita McGowan, Mark B Hickey, Don A Campbell, Rodney D Sinclair, Kenneth C Montgomery. Med J Aust 180: 324-327. <eMJA full text> 2003 Effectiveness of ototopical antibiotics for chronic suppurative otitis media in Aboriginal children: a community-based, multicentre, double-blind randomised controlled trial Sophie Couzos, Traven Lea, Reinhold Mueller, Richard Murray, Margaret Culbong. Med J Aust 179: 185-190. <eMJA full text> 2002 Sharing the true stories: improving communication between Aboriginal patients and healthcare workers Alan Cass, Anne Lowell, Michael Christie, Paul L Snelling, Melinda Flack, Betty Marrnganyin, Isaac Brown. Med J Aust 176: 466-470. <eMJA full text> 2001 The effects of quality improvement interventions on inhospital mortality after acute myocardial infarction Ian A Scott, Michael D Coory, Catherine M Harper. Med J Aust 175: 465-470. 2000 Reducing premature death and renal failure in Australian Aboriginals: a community-based cardiovascular and renal protective program Wendy E Hoy, Philip R Baker, Angela M Kelly, Zhiqiang Wang. Med J Aust 172: 473-478. <eMJA full text> 1999 Impact of improved diagnosis and treatment on prevalence of gonorrhoea and chlamydial infection in remote Aboriginal communities on Anangu Pitjantjatjara Lands Penny J Miller, Paul J Torzillo, Wayne Hateley. Med J Aust 170: 429-432. 1998 Outdoor air pollution and children's respiratory symptoms in steel cities of New South Wales Peter R Lewis, Michael J Hensley, John Wlodarczyk, Ruth C Toneguzzi, Victoria Westley-Wise, Trevor Dunn, Dennis Calvert. Med J Aust 169: 459-463. <eMJA full text> 1997 A high incidence of melanoma found in patients with multiple dysplastic naevi by photographic surveillance John W Kelly, Josephine M Yeatman, Cheryl Regalia, Grahame Mason, Amanda P Henham. Med J Aust 167: 191-194. <eMJA full text> 1996 An outbreak of Japanese encephalitis in the Torres Strait, Australia, 1995 Jeffrey Hanna, Scott A Ritchie, Debra A Phillips, Jack Shield, M Clare Bailey, John S Mackenzie, Michael Poidinger, Bradley J McCall, Phillip J Mills. Med J Aust 165: 256-260. <eMJA full text> 1995 Gastric emptying in acute overdose: a prospective randomised controlled trial Susan M Pond, David J Lewis-Driver, Gail M Williams, Adèle C Green, Noel W Stevenson. Med J Aust 163: 345-349.
Book reviews
Thyroid disorders laid bare
Fast facts: thyroid disorders. Gilbert H Daniels, Colin M Dayan. Oxford: Health Press, 2006 (143 pp). ISBN 1 903734 65 7. Thyroid disorders are common, and encountered by all in clinical practice. In the population, evident hyperthyroidism is present in 0.5% and subclinical hyperthyroidism in a further 0.7%. Frank hypothyroidism (treated and untreated) has a prevalence of 0.3% and subclinical hypothyroidism is present in over 4%. Clinically evident thyroid nodules or goitre are found in 5%, with ultrasonographically detectable nodules in over 50% by the age of 60 years. The incidence of new thyroid nodules is one per 1000 per year and about one in 25 is malignant. Mild iodine deficiency has re-emerged in Australia, at least in the south-eastern states. Forty million dollars worth of thyroid function tests are ordered every year in Australia. Despite all this, recognition and treatment of thyroid disease could still be much improved throughout Australia. While Werner and Ingbars The thyroid, now in its eighth edition, remains the authoritative text, at over 2.5 kg it is not likely to become the bedside reading of any but the most devoted subspecialists. Various brief books have been produced to serve patient education on thyroid disease but we lack a brief text specifically on the thyroid for the non-endocrinologist. This book sets out to fulfil this need and does so admirably. Gil Daniels and Colin Dayan are eminent endocrinologists, well credentialled in the thyroid field, from the United States (Massachusetts General Hospital) and the United Kingdom (University of Bristol), respectively. They have produced a practical and very readable account of clinical thyroidology. As I agree completely with virtually all of their text, I think they have a remarkably clear understanding of thyroid disease and its treatment options. In addition to a clearly written text, the book is well provided with tables, figures, key point summaries, and key references. Duncan J ToplissDirector, Department of Endocrinology and Diabetes, The Alfred Hospital, Melbourne, VIC Order this book
Duncan J Topliss
Integrating complementary medicine
Complementary medicine in clinical practice. David Rakel, Nancy Faass. Massachusetts: Jones and Bartlett, 2006 (xvii + 552 pp). ISBN 0 7637 3065 3. There is mounting evidence to demonstrate increasing consumer use and acceptance of complementary and alternative medicine (CAM). Further, the evidence suggests that health care consumers are not seeking CAM therapies to the exclusion of dominant Western medicine approaches. Rather, they are choosing to integrate various forms of health care to suit their perceived health needs. It is in this context that Rakel and Faass discuss the concept of integrative medicine, providing information about eight major forms of CAM and methods of integrating their use into routine medical practice. Because the landscape of the public seeking health care is changing, conventional medical practice needs to change. The authors not only recognise this but embrace it and propose a new model of integrative medical care. As a chiropractic clinician and an educator, I was interested to learn how the authors defined integrative medicine. Many CAM practitioners can be somewhat defensive and sceptical, fearing that their therapy may be consumed by the dominant Western medicine practice. So it was refreshing and comforting to read that this text advocates a collaborative approach to health care, where CAM therapies are encouraged to work alongside Western medicine to deliver holistic health care to the patient. This text also walks the talk. It embraces an evidence-based approach to medical practice, using such an approach to argue the case for incorporating complementary therapies and services. The list of contributors is impressive those that are leaders in their field. The reader can therefore be confident that they are receiving up-to-date, best practice information. I am very comfortable recommending this text. It has an easy reading style. It introduces CAM and integrative medicine in a logical and informative way, provides strategies for integrating them into current medical practice, and then gives succinct information about the eight major systems of CAM from research, educational and practical perspectives. Complementary medicine in clinical practice is suitable not only for the Western medical practitioner but also for their allied health practitioner colleagues. Barbara I Polus Associate Professor of Chiropractic, RMIT University, Melbourne, VIC
Barbara I Polus
Lung cancer for rookies
Dx/Rx: lung cancer. Christopher G Azzoli. Massachusetts: Jones and Bartlett, 2006 (viii + 134 pp). ISBN 0 7637 2641 9. This small, single-author American text in pocket-book format provides a succinct but comprehensive overview of lung cancer including its epidemiology, diagnosis and treatment. There are also brief sections on mesothelioma and thymoma. Reflecting the authors specialty, the content is heavily skewed towards medical oncology. Surgical and radiation oncology aspects are given limited coverage. The style and level of detail suggest that this book would be most useful for medical students and junior hospital doctors, or even lay consumers with some scientific background. The information is presented as dot points hardly literature, but readable. A brief list of up-to-date key references is provided at the end of each chapter. In general, the information presented is accurate, although there are a few howlers: Asbestos is ... used as inflammable building material. Anyone with a first degree relative with a smoking related cancer should not smoke cigarettes. It is irritating to see myths perpetuated, such as carcinoid tumours are highly resistant to chemotherapy and radiotherapy and large cell neuroendocrine tumours carry a poor prognosis compared with other types of non-small cell lung cancer. What is the evidence for these statements? There are good practical hints on the management of complications of lung malignancy (these would be most useful for junior hospital doctors). There is, however, no mention of the use of lasers or stents for the treatment of major airway obstruction. So, in summary, a concise and contemporary overview, but too superficial for the practising clinician managing lung cancer. If the reader requires an evidence-based manual that contains statistics and treatment recommendations more relevant to Australian practice, I would suggest the NHMRC-endorsed Clinical practice guidelines for the prevention, diagnosis and management of lung cancer, recently published by the Australian Cancer Network. David L Ball Chair of Lung Service and Radiation Oncologist, Peter MacCallum Cancer Institute, Melbourne, VIC
David L Ball
Neurological order
The neurology short case. 2nd ed. John G L Morris. London: Hodder Arnold, 2005 (155 pp +CD-ROM). ISBN 0 340 88516 5. The neurology short case. 2nd ed. John G L Morris. London: Hodder Arnold, 2005 (155 pp +CD-ROM). ISBN 0 340 88516 5. The first edition of The neurology short case was one of my regular companions during the lead-up to the 2002 FRACP clinical examination. So when I was asked to review this second edition, I felt a sense of anticipation — it would be interesting to see what revisions had been made. The author is Professor John Morris, Chairperson of the Education and Training Committee of the Australian Association of Neurologists, and a past examiner of the RACP. Widely regarded as one of the great masters and teachers of the traditional art of clinical examination, he is well qualified to write on this topic. Thirteen brief chapters address different clinical presentations (eg, wrist drop, gait disturbance and ptosis). Morris successfully conveys the essence and subtleties of neurological examination in a simple, concise and practical style, while outlining some of the underlying concepts. It is easy to read, understand and put into practice. In the first edition, I found the Tips section at the end of each chapter especially useful. In this second edition, my favourite feature is the collection of good quality video clips to be found on the accompanying CD-ROM. With additional chapters on involuntary movement disorders and assessment of the higher function, the new edition is enhanced. The chapter on abnormalities of vision and eye movement will be popular with many clinicians who find the eye examination daunting. Although the target audience is primarily clinical examination candidates, medical students and perhaps general practitioners, neurologists might find The neurology short case a useful teaching tool, particularly with the CD collection. Retailing at $67.95, this book is value for money and I have no hesitation recommending it to my junior colleagues. Lay Kun KhoNeurology Registrar Royal Perth Hospital, WA
Lay Kun Kho
Correction
Abdominal pain and eosinophilia in suburban goat keepers — trichostrongylosis
Correction Re: “Abdominal pain and eosinophilia in suburban goat keepers”, by Anna Ralph, Matthew V N O’Sullivan, Nicholas C Sangster and John C Walker in the 1 May issue of the Journal (Med J Aust 2006; 184: 467-469). The Acknowledgements were accidentally omitted from this article, and are printed below: Further, it has been decided to add the word trichostrongylosis to the title of the electronic (eMJA) version of this article, so it becomes: “Abdominal pain and eosinophilia in suburban goat keepers — trichostrongylosis”. The html and pdf versions of this article were corrected on 14 June 2006.
Anna Ralph · Matthew V N O'Sullivan · Nicholas C Sangster · John C Walker
Uncertainty in general practice: a sure thing
Ruth M Armstrong BMed · Martin B Van Der Weyden MD, FRACP
Accessing oral health care in Australia
Roderick I Marshall BDSc, MDSc, FRACDS(Perio) · A John Spencer MDSc, PhD, MPH
The Chronic Disease Strategy for Australia
Christopher Dowrick BA, MD, FRCGP
Patients presenting to the general practitioner with pain of dental origin
Mohammed H Mansour MSc, MD · Stephen C Cox OAM, MSc, FRACDS
Questioning medical education
Martin B Van Der Weyden
Emergency department frequent flyers: unnecessary load or a lifeline?
Gordian W O Fulde FRACS, FRCS, FACEM · Martin Duffy MB BS, FACEM
Killing the messenger: should scientific journals be responsible for policing scientific fraud?
Ana Marušić MD, PhD · Matko Marušić MD, PhD