Volume 202 Issue 10

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The National Review of Mental Health Programmes and Services offers clear advice in its “Contributing lives, thriving communities” report

Ian B Hickie AM, MD, FRANZCP

The managerialist organisational model has penetrated deeply into our institutions, with destructive consequences

Paul A Komesaroff MB BS, PhD, FRACP · Ian H Kerridge MPhil, FRACP, FRCPA · David Isaacs MD, FRACP, FRCPCH · Peter M Brooks MD, FRACP, FAFRM

This article is a response by the Royal Australasian College of Physicians (RACP) to an article in this issue of the Journal: Komesaroff PA, Kerridge IA, Isaacs D, Brooks PM. The scourge of managerialism and the Royal Australasian College of Physicians. Med J Aust 2015; 202: 519-521. The RACP was made aware only recently of the article, which was submitted to the Journal some time ago. Due to this unique circumstance, a rapid and simultaneous response to the article is provided in this issue of the MJA. Publication of this response should not be taken as creating a precedent at the MJA. Editorial Advisory Committee: Charles Guest MPH, PhD, FAFPHM Bruce Waxman FRACS, FRCS, MRACMA Jeffrey Zajac PhD, FRACP Charles Guest and Jeffrey Zajac declare that they are members of the RACP. A statement from the Royal Australasian College of Physicians One of the great lessons of the 20th century was the danger of ideologies that attempted to squeeze the complexity of the world into their frameworks. The authors of “The scourge of managerialism and the Royal Australasian College of Physicians”1 have fallen into this trap by attempting to portray as a “corporatisation” framework a series of structural changes being undertaken to make the Royal Australasian College of Physicians (RACP) more focused on the needs of its members. Komesaroff and colleagues argue that the College is victim to a takeover from a faceless class of managers and technocrats. Proposals for a more streamlined Board and a College Council that bring our disparate specialties together are characterised as markers on the road to a neoliberal dystopia. The fundamental flaw in the article is that it provides little attention to facts that do not fit in with its argument. In portraying the College's role as “providing a forum for physicians to communicate with each other”, it largely overlooks the objectives of the College that demand it be and remain an outward-looking institution committed to maintaining the highest professional standards, delivering robust training to its 6000 trainees and publicly advocating for the health of the public. How does the authors' analysis that the College has been captured by faceless managers account for the Australian Medical Council's recent decision to award the College 6 years' accreditation as the sole trainee of specialist physicians in Australia and New Zealand? Why would these supposed disciples of Thatcher and Reagan be allowing such a progressive advocacy agenda? At our recent Congress, the RACP adopted a progressive and controversial policy on asylum seekers; embraced the complexity of medicinal marijuana and end-of-life care; and grappled with confronting issues like gender identity and Indigenous health. The Board recently voted to divest investments identified as being directly and materially involved in fossil fuel activities. And how does an analysis about managerial control account for the many Fellow committees that directly shape the College, or the current proposal to create an influential and representative College Council that will provide a forum to bring together our disparate specialties to share insights, collaborate and drive our broader agenda? The article's portrayal of reforms championed by the Board needs to be challenged. While a minority resisted the constitutional changes proposed in 2013, a two-thirds majority supported the proposals. These facts are paid little attention because they get in the way of what appears to be an ideological critique of the College, its Board and its dedicated and professional staff. The reality is that this College, far from embracing “corporatism”, is following the lead of member-based non-for-profit associations around the world and rethinking the way it is run — focusing on the needs of our members, especially those entering the profession, harnessing technology, reviewing our committees and services to ensure they remain relevant. We cannot work to a collective vision if we do not empower a democratically elected Board to set a strategy and implement it. Change upsets people, but the risk of not changing is that an organisation will become irrelevant because of pressing external challenges. If the College were to be accused of pursuing any ideological theory or agenda it would be that of “empowerment”. Empowerment is how we engage our more than 22 000 members to train the next generation of physicians, nurture their careers and make a difference as leaders in our communities. That may not be as dramatic a story as a sinister corporate takeover of the College, but it's one that the College believes in for the benefit of our current and future Fellows and trainees, and for the communities they serve.

Royal Australasian College of Physicians

Overdependence on rapid response systems has not improved patient safety in hospitals

Michael D Buist FRACP, FCICM, MD

In reply: It's not overdependence, but a strong association of reduction in deaths and cardiac arrests with uptake of RRS

Kenneth M Hillman MD, FRCA, FCICM

Eliminating the disease in Indigenous communities depends on accurate data

Richard Speare BVSc, PhD, DVSc · Adrian Miller · Wendy A Page

Coordinated support from major national institutions is necessary

Peter Stewart · Raymond C Chan PhD, FRACP, FRCPA · Wendy Pryor PhD, FRCPA

GPs have an important role in communicable disease control

Catherine R Bateman-Steel MB ChB, BSc, MSc · Aditya Vyas MB BS, MPH · Leena Gupta MB BS, MPH, FAFPHM

One centre of research excellence is not sufficient to make a serious dent in the problem of suicide and self-harm in Australia

Helen Christensen MPsych(Hons), PhD, FASSA · Karolina Krysinska PhD · Sue Murray MStud(Ed), BEd

MRI is mostly unhelpful in diagnosing paediatric musculoskeletal complaints

Sam L Francis · Nicole Williams BMedSc(Hons), BMed, FRACS · Peter J Cundy MB BS, FRACS

In many countries, including Australia, policies have recently changed to support HIV self-testing

University of New South Wales and St Vincent's Centre for Applied Medical Research (UNSW-AMR) HIV Home Testing Assessment Group

headspace centres are providing direct and indirect access to mental health care for young people

Debra J Rickwood BA(Hons),PhD, FAPS · Nic R Telford BSocSc, MSocSc · Kelly R Mazzer PhD · Alexandra G Parker BA(Hons), MPsychol(Clin), PhD · Chris J Tanti BSW · Patrick D McGorry PhD, FRCP, FRANZCP

The first major review of outcomes for young people using mental health services at headspace centres

Debra J Rickwood BA(Hons), PhD, FAPS · Kelly R Mazzer PhD · Nic R Telford MSocSc, BSocSc · Alexandra G Parker PhD, MPsychol(Clin), BA(Hons) · Chris J Tanti BSW · Patrick D McGorry PhD, FRCP, FRANZCP

Party drugs are not always what they claim to be

David S McCutcheon MB BS, FACEM · Francois J Oosthuizen BSc(Hons), MSc,PhD · Kerry A Hoggett MB BS, GCertClinTox, FACEM · Daniel M Fatovich MB BS, FACEM, PhD

Longer training isn’t necessarily better training

John B Best AO, MD BS, PhD, DSc(Hon)

When the phone rings in the night ... His heart flinches again.

Joan Kerr MA(EnglishLanguage

Whether it is a standardised patient, a partial-task trainer, a mannequin (high-fidelity simulator), screen-based computer simulator or a virtual reality environment, medical simulation has come a long way. Verbal role-playing has served its role in medical training for centuries, as have anatomical models, but it was not until the invention of the Link flight simulator in 1929 that the possibilities for medical education via simulation began to open up. The first standardised or simulated patients — humans acting as patients with different conditions and providing feedback to the student or clinician — were used in 1963 at the University of Southern California (USC) in the United States, as a way of teaching neurology students. In 1993, the Medical Council of Canada was the first to use standardised patient examinations in their licensing procedures.1 In 1960, a partial-task simulator known as Resusci Annie, designed for teaching mouth-to-mouth resuscitation, was developed. Later, a spring was added inside her chest for practising cardiopulmonary resuscitation. Partial-task simulators really took off in the 1990s, with the advent of laparoscopic surgical techniques and more advanced computer technology leading to simple box trainers like the laparoscopic training box and the sinus surgery simulator. Software-based simulation also boomed in the 1980s and 1990s. Anaesthesia, cardiology and the management of medical emergencies benefited, and the development of interactive web-based programs led to the interactive simulated patient. The first full-scale human patient anaesthesia simulator mannequin came out of USC at the same time as standardised patients in the early 1960s. Today, mannequins such as SimMan and SimBaby offer full-scale high-fidelity, sometimes with a half-million dollar price tag. In the virtual world, environments such as Second Life, which was initiated in 2003, are being used by universities to enhance distance learning. In 2007 a Second Life simulation known as Ann Myers Medical Centre began to run medical simulations. At the recent Royal Australasian College of Surgeons’ (RACS) Annual Scientific Congress in Perth, Professor Terry Gallagher, head of Technology Enhanced Learning and the Director of Research at the ASSERT for Health Centre at University College Cork in Ireland, presented the results from a 21-site prospective, randomised and blinded study by the Arthroscopy Association of North America on simulation-based training. The results show that orthopaedic surgeon trainees randomised to proficiency-based progression simulation training performed 40%-60% better (with fewer errors) than two matched control groups. “This is the largest and best controlled clinical study of simulation-based training ever conducted. The results have important implications for patient safety and what we mean by ‘training’”, Professor Gallagher told the conference. “Simulation and technology enhanced learning are effective because they offer the opportunity for the trainee to engage in deliberate practice with metric-based performance feedback. “It also means that we can ‘quality-assure’ the performance of graduating trainees with an ‘outcome’ rather than a ‘process’ based approach to training.2 Professor Guy Maddern, professor of surgery at the University of Adelaide, and the lead on the RACS research into surgical simulation, says one of the biggest attractions of simulation training is the removal of the pressure to be perfect. “The opportunity to train and improve skills and gain experience in a non-patient environment is very attractive”, Professor Maddern tells the MJA. “You can make mistakes and experiment without the possibility of harming a patient.” The downside, he says, is that simulation training can be expensive, with little evidence that the most costly simulators produce better results. “It can be incredibly expensive — up to half a million dollars, usually around $100,000–$200,000. They can be wonderful to play with but it is hard to measure if it is any better than the simple box trainer. “In fact, during our RACS evaluation we found that for teaching basic skills, the box trainer is better than [something that requires] costly maintenance.”3 Professor Maddern maintains that the more complex the surgery, and the patient, the less suitable simulation training can be. “Simulation for complex interactions is not great”, he says. “For example in the case of colonoscopy, simulation is quite good for learning how to manipulate the machine and removing polyps, and it’s certainly better to learn in a simulator than on a patient. “But there’s no way it’s well developed for many patients with very difficult anatomy or complex situations.” There is one area in which surgical simulation is more cost-effective, he says. “There’s a myth that it takes a surgeon to train a surgeon. “What’s needed is a skilled trainer. It makes more sense to have a surgeon provide oversight to a team of trainers, who are arguably better than surgeons [at teaching], and are certainly cheaper than surgeons. “Context is critical. For a simple operation, simulation can teach suturing techniques, for example, and strategies; but it’s not sufficiently good for complex open surgeries. “That’s why we have mentors — an apprenticeship model — for more advanced work. “Simulation can enhance our ability to do things, but surgeons will never be redundant.” 1. http://www.iness.org.br/publicacoes/prg_dow.cfm?CodPub=11FC1 2. RACS press release: Simulation training – a paradigm shift in how doctors are educated and trained; Wednesday 6 May, 2015 3. http://www.ncbi.nlm.nih.gov/pubmed/22648100 A podcast with Professor Debra Nestel, Professor of Simulation Education in Healthcare for Monash University School of Rural Health, is available at mja.com.au/multimedia/podcasts.

Cate Swannell

Bond University has appointed prominent Aboriginal doctor, Associate Professor Shannon Springer, as its Academic Lead for Aboriginal and Torres Strait Islander Health, as part of its commitment to providing students with the skills to work effectively in the cross-cultural context for the benefit of future patients. http://bond.edu.au/news/46398/bond-appoints-new-indigenous-health-lead Flinders University has announced the appointment of Professor Robert Saint as its new Deputy Vice-Chancellor (Research) from 15 June 2015. Professor Saint has 118 publications to date, two patents and numerous honours and awards, including the Julian Wells Medal, the MJD White lecture and the President’s medal of the Australian and New Zealand Society for Cell and Developmental Biology. He currently holds National Health and Medical Research Council (NHMRC) research funding and has held significant grants from both the Australian Research Council (ARC) and NHMRC over a period of 25 years, including for an ARC Special Research Centre from 2000–2008. http://blogs.flinders.edu.au/flinders-news/#sthash. KsFfNMOO.dpuf The University of Melbourne has welcomed a $2 million investment by the Victorian Government to help plan and develop a National Centre for Proton Beam Therapy as part of the Victorian Comprehensive Cancer Centre. The project will be undertaken in conjunction with the university and the Peter MacCallum Cancer Centre. http://newsroom.melbourne.edu/news/university-welcomes-2m-proton-beam-therapy-development University of Newcastle Two scholarship opportunities are available for PhD students to research Translational Brain Repair and Rehabilitation under the supervision of Dr Lin Kooi Ong, Associate Professor Rohan Walker and Professor Michael Nilsson at UON. The scholarship is offered for three years, and provides a tax-free living allowance of $25 849 p.a. in 2015 (indexed annually). Applications close on 31 July 2015. http://www.newcastle.edu.au/newsroom/research-and-innovation/research-degrees/phd-scholarships/phd-scholarship-translational-brain-repair-and-rehabilitation University of New South Wales lecturer and alumna Aditi Vedi has been awarded a Gates Cambridge Scholarship to research the functional biology of stem cells to improve survival rates for children with leukaemia. Dr Vedi was one of only 54 successful candidates from 28 countries, including eight Australians, selected from 3535 applicants. Dr Vedi is one of only 13 scholars funded for a PhD. Dr Vedi’s research will investigate the role of gene networks and therapy to maintain remission and prevent relapse in children with leukaemia. http://newsroom.unsw.edu.au/news/health/unsw-lecturer-awarded-prestigious-gates-cambridge-scholarship University of Queensland Associate Professor Christine Wells has won a $50 000 prize for leadership in stem cell research. Dr Wells, from UQ’s Australian Institute for Bioengineering and Nanotechnology, is revolutionising the way stem cell researchers and bioinformaticians interact in this rapidly growing field. Dr Wells leads the Stemformatics initiative — an online encyclopaedia of detailed scientific information on how thousands of different genes shape people — putting vital data at the fingertips of stem cell researchers and their cross-disciplinary collaborators. http://www.uq.edu.au/news/article/2015/05/researchers-atlas-project-opens-world-of-discovery University of Western Australia Internationally respected researcher Dr Florian Daniel Zepf has been appointed the new Chair and Winthrop Professor in Child and Adolescent Psychiatry at UWA. Professor Zepf, affiliated with UWA’s School of Psychiatry and Clinical Neurosciences and School of Paediatrics and Child Health, will also be Clinical Director/Head of the WA Department of Specialised Child and Adolescent Mental Health Services. http://www.news.uwa.edu.au/201505157585/appointments/new-chair-focus-child-and-adolescent-mental-health UWA’s Professor Ryan Lister has been awarded a $50 000 2015 Metcalf Prize, from the National Stem Cell Foundation of Australia, in recognition of his leadership in stem cell research. Professor Lister generated the first comprehensive maps of the human epigenome, finding that the chemical signposts that comprise the epigenome differ between embryonic stem cells and specialised adult cells. http://www.news.uwa.edu.au/201505137580/fdbfdg University of Wollongong medical students embark on life-changing experiences in the bush thanks to a unique rural placement program. Associate Professor David Garne, who oversees clinical placements, said UOW has the only medical school in Australia that provides opportunities for all its students to undertake a 12-month placement in a rural or regional setting. http://media.uow.edu.au/news/UOW192610.html An Australian first “Recovery Camp” that simultaneously promotes healing for people with a mental illness while training the next generation of Australian health professionals took place from 11–15 May. The five-day therapeutic recreation camp, designed and run by a team from UOW and the UQ, paired people with a lived experience of serious and enduring mental illness, such as schizophrenia, depression and bipolar disorder, with nursing, psychology, dietetics and exercise physiology students from UOW. http://media.uow.edu.au/releases/UOW192903.html

Cate Swannell

This calendar will be updated each month. If you have an event you would like to add, please include relevant details in an email to cswannell@mja.com.au

Cate Swannell

Med J Aust 2015; 202 (10 Suppl).