Health services administration

Medical courses are inherently stressful because of the nature of the course, the workload and, for some students, financial issues. These stressors can lead to impaired judgement, reduced concentration and self-esteem, and increased anxiety, manifesting in turn in depression and even suicide. In 1997, as a first-year medical student of the graduate program at Sydney University, I attended the conference of the Australian and New Zealand ...

Gisele M L Mouret MB BS (Hons), BAppSc(Physiotherapy)

The first two breakout groups comprised medical students and prevocational trainee doctors, and the third delegates from medical boards, postgraduate councils and hospital administrators. The groups reported back on student issues, prevocational and trainee doctor issues and medical board issues. This is a condensed summary of the reports from each group. Student issuesIdentifying the distressed or impaired student is not the problem; peer groups are usually the ...

Simon M Willcock MB BS, FRACGP

The Tasmanian University Medical Students Society (TUMSS) and the Tasmanian Branch of the Australian Medical Association (AMA) have jointly run a mentor scheme linking students with doctors since 1994. However, the scheme was not meeting the needs of students. In particular, there was a lack of support for students who were distressed or affected by adverse life events, such as mental or physical illness and ...

Lisa M Barrow BSc(Hons), MPsych (Clinical), MAPS

Most members of the medical profession feel stressed at some time. If stress is ongoing, impairment may occur (defined as being unable to safely or reliably perform one's role). A continuum appears to exist between functioning well, being distressed and becoming impaired, with external (environment-related) and internal (personal-related) stressors determining where an individual will lie on the continuum. We are conducting a study which aims to ...

Michele G Daly MSc · Simon M Willcock MBBS, FRACGP

Medical Boards throughout Australia are considering amending their respective Medical Acts so that all students in each State or Territory are required to be registered with their Medical Board as a prerequisite for studying medicine. Such amendments have arisen from the increasingly litigious environment, the growing role of clinical education in traditionally preclinical years, and the recognition that medical students enjoy many of the doctor–patient ...

Stefan C Kane

Identifying the characteristics of doctors with health problems that disrupt their ability to practise medicine may help to identify young doctors and students at risk. I describe here the experience of the Health Committee of the South Australian Medical Board, which has been active for 18 years, in the hope that this might assist in formulating a prevention and early intervention program. Four main types of ...

Ross S Kalucy AM, MB BS, FRANZCP

To the Editor: In 1997 an analysis of the medical workforce in North Queensland showed that Townsville's 125 000 people were served by about 180 GPs providing about 120 full-time-equivalent (FTE) GP workloads. A doctor–population ratio (DPR) of about 1: 1000 was evidence of some sort that the community was reasonably well served, at least according to benchmarks of the time. As a result, the "area of need" status was removed from many North Queensland centres, a decision reinforced by similar findings from the Australian Medical Workforce Advisory Committee (AMWAC) report released soon after.1 Further, the AMWAC report was the basis of a decision not to increase the number of GP vocational training places in the region, even though there is spare capacity and the program is one of the more successful in terms of retention of rural GPs.2 Despite persistent claims to the present time that there is no shortage of GPs in regional centres, in 2002 the number of FTE GPs in this community appears to have fallen to about 95, despite strong population growth to about 150 000 people, resulting in a DPR of around 1: 1500. The city's two extended-hours clinics have closed, very few practices direct bill, new residents have trouble getting an appointment in any general practice, and fewer GPs are providing after-hours care. The recent Access Economics report, commissioned by the AMA, indicates that this trend is evident elsewhere. Anecdotal evidence suggests that it is not necessarily the total number of GPs that is changing, but rather their work patterns. The increasing proportion of female graduates probably reduces the available FTE workforce, and more male graduates are now opting for a lifestyle that better balances clinical work with family responsibilities and interests outside of medicine. Medical workforce research is an interesting, yet risky, academic business, beset by many complex issues relating to definitions, data sources and the measurement and interpretation of DPRs.2 Despite our best endeavours and close proximity, the report conducted by me and my colleagues in 1997 was almost certainly incorrect within a very short time. I am inclined to think that GPs have a better sense of what is happening on the ground than do the sifters of data. The biggest challenge to workforce analyses, and therefore to patient access to GP care, may be the societal changes in work patterns, not in raw numbers, and these issues need to be better understood if we are to make progress in managing workforce issues.

Richard B Hays

At the 3rd and 4th National Forums on Prevocational Medical Education, held in 1998 and 1999, it was realised that the issues surrounding students and junior doctors who are distressed warranted further attention. As a consequence, this Conference, The student and junior doctor in distress — "our duty of care", was arranged with the aim of formulating recommendations to educational bodies, health departments and medical boards. More than 100 delegates representing the diversity of stakeholders were involved in stimulating discussions over the two days of the Conference in July 2001. We were fortunate to have talented speakers and participants to address the issues involved, which pose many challenges to educational and health institutions, as well as to the health professions and workplaces. The transition from university to workplace is inherently stressful for medical students and junior doctors. However, changes in the workplace and society are making it even more stressful than in the past. The stressors include the rapid pace of change in the health system and spiralling healthcare costs, as well as the demanding nature of the job, with long working hours and heavy responsibilities. Also, there is often conflict between educational and workplace imperatives. The working environment is not always as supportive as it could be, and the traditional culture of the medical profession and its workplaces has not fostered an environment where distressed students and junior doctors are able to acknowledge their need for help. Nor does the system always make it easy for them to find appropriate help. Drug and alcohol abuse and mental illness can also affect the ability of students and junior doctors to do their job. It is not only the health and the future of young doctors that are at stake; problems which impair their performance in the workplace may also jeopardise patient safety and wellbeing. Students and young doctors who may be at particular risk include those from non-English-speaking backgrounds and those who are socially and professionally isolated. They were described by one Conference participant as "the lurkers" — those who sit at the back in lectures, do not participate in discussion and do not engage with their peers. Several case studies explored at the Conference illustrated that, with appropriate intervention and support, students and doctors in distress can be helped and can return to productive careers. However, for this to happen expeditiously and extensively requires a cultural change, so that doctors in universities and hospitals are more aware of their duty of care to colleagues and prepared to identify those in distress and help ensure that they receive appropriate care. There is also a need to encourage better self-care and systems of peer support. It was noted that medical boards can play an important role in helping students and doctors resolve serious problems and return to practice, but the widespread misperception — that the boards' roles are mainly punitive — can discourage approaches to these bodies. An important unresolved issue was whether universities should pass on information to hospitals and other employers about students who have had problems. This raises sensitive privacy and legal issues that warrant further exploration. Repeated emphasis was given to the importance of maintaining confidentiality, wherever possible, when managing the problems of students and junior doctors in distress. Fear about the career consequences of being labelled with a particular problem is a major barrier to identifying students and junior doctors in distress. Finally, the importance of using appropriate language was also stressed. It was noted that the term "impaired doctor", although enshrined in legislation, has negative connotations that could be counterproductive. It implies that a doctor is damaged, when the reality is that some doctors have health problems or other troubles that can often be resolved or managed so that they are able to maintain an appropriate practice. The issues are so complex and sensitive that it was not possible to arrive at detailed, consensus-based recommendations. Rather, the Conference participants developed broad principles, which hopefully will provide the basis for further dialogue and development into detailed strategies that can be implemented at a national, State, institutional and professional level. This report provides a summary of selected presentations at the Conference, and draws together the important themes into a broad overview of the issues. My sincere thanks go to all who took part in the Conference and helped make it such a success. I would like to particularly thank the organising committee, the South Australian Minister for Human Services for opening the Conference, and all the speakers. Thanks also for the support provided by United Medical Protection. A special tribute should be paid to the Commonwealth Department of Health and Aged Care, which, through the Medical Training Review Panel, provided much support to early postgraduate training in Australia, and not only strongly supported this Conference and the publication of these Proceedings, but also funded medical students and junior medical officers from all States and Territories to attend. Conference recommendations Recommendation 1 The medical profession has a duty of care to colleagues. There is a need to promote significant cultural change within the medical and other professions, and within workplaces, to encourage an improved acceptance and management of doctors and students in distress. This change needs to heighten the awareness of stressors in the medical profession and workplace. It also needs to encourage a sympathetic and caring approach to the person involved and to deal with the issues in a non-punitive manner. Everyone has a responsibility to identify and assist the student and doctor in distress. Recommendation 2 For people involved in managing students or doctors in distress Each institution should have a clearly identified person as the point of contact, who ideally should be independent of the student or doctor's career and studies. Further consultations with other people or bodies, such as the Director of Clinical Training, supervisors, peers, and medical administration, should be on a "need to know" basis. They should occur only with the individual's consent, unless patient or colleague safety is at risk. The importance of timely, regular and positive feedback for students, junior doctors, teachers and supervisors is paramount. When there is concern about patient safety, the Medical Board should be informed. The person who made the initial identification should be informed that the matter is being managed. Recommendation 3 Strategies for preventing distress in students and doctors should be implemented nationally, and should include: An emphasis in the student curriculum on maintaining health and wellbeing. The education of the profession and students about behaviour patterns and warning signs, especially in "at-risk" groups. A comprehensive orientation of students, junior medical officers and registrars, with clear definition of the roles and responsibilities of each. The Medical Education Officer and Director of Clinical Training actively seeking to recognise the character of the individual units in all training locations, including community placements. Effective performance appraisals of junior doctors, and feedback incorporating registrar and/or nursing perspectives where appropriate. Adequate support and provision of resources for junior medical officers (JMOs) including: – adequate staffing to cover annual and sick leave; – continuing education, particularly in areas of stress management and time management; – dedicated weekday time to allow an annual visit to a general practitioner; – appropriate location and pager-free time for junior doctors to meet; and – provision for national meetings between State and Territory JMOs and students. Recommendation 4 There is a need for further consultation between relevant bodies regarding the transfer of information about distressed students between university and hospitals. This issue needs to be further explored with discussions by all parties involved — the universities, hospital administration and medical staff, postgraduate councils and medical boards. Recommendation 5 That the management of students or doctors in distress be: confidential; independent of training or studies; clear and well defined in all medical schools and hospitals in Australia; continually re-evaluated by all parties involved; and structured to include career counselling, if appropriate.

Geoffrey W Dahlenburg MD, FRACP

A recent article noting that "unhappy doctors are a worldwide phenomenon" imputes this to ongoing changes in relationships with patients and society.1 Despite this phenomenon, many young people, for a variety of reasons, still wish to study medicine. The reasons include: parental pressure — "you've got the marks" . . . "it's a secure income" . . . "doctors are well respected" . . . "you can always sing/write later"; the challenge — both academic and personal; and the wish to help people — "to do something meaningful". Here, I outline some of the issues in the student and early postgraduate years which may influence performance, summarise the effects of recent changes in medical practice, and, finally, explore impairment issues as they affect medical students and doctors. The student yearsSelection biasWhatever the prerequisites for medical school entry, there is a selection bias towards those who are conscientious, intelligent, able to delay gratification, and have high levels of personal drive and demands on self. But they may also be unassertive and fairly compliant. Another, frequently overlooked, group entering medical school are multitalented and curious ("they could have done anything"). This latter group may be restless and impatient with others less gifted. The interaction between these character traits and student expectations will affect medical students' performance, career choice and impairment. Changes in curriculaIn the past, despite the apparent academic nature of medicine, the old model of medical education (ie, preclinical "chalk and talk" followed by a clinical apprenticeship) relied heavily on rote learning. The newer medical curricula put greater emphasis on adult learning techniques and the acquisition of life skills. This is a welcome change2 and should challenge all students and lead to greater awareness of communication skills. Educational philosophyThe philosophy underlying medical education is an important factor affecting student selection as well as distress and impairment. There are two different views: 1. Medical education can be seen as a right — a broad education for those interested in health issues, which is open to anyone who can gain entry. In this paradigm, medical education is not linked to ability or fitness to practise medicine, and the role of universities is to produce graduates with a sound knowledge and appropriate basic skills, but they have little or no responsibility for their clinical conduct after graduation. 2. The role of medical education is to maintain a flow of well qualified doctors, with education linked to workforce requirements. Here we need to consider whether the goal is to produce potential interns, general practitioners, or specialists. Each of these goals implies different training needs and priorities: if the aim is to produce junior doctors, this paradigm acknowledges the significant subsidy by the taxpayer and the physically demanding nature of the work, requiring fitness standards akin to those of airline pilots; or if the aim is to produce doctors who become specialists (in primary or secondary care), then the course is pitched beyond the first few years, with an assumption that the Postgraduate Medical Council will be responsible for early training issues. Both of these views are valid — the choice of goals with their differing underlying philosophies will influence selection and "goodness of fit" of the student with the paradigm, and will indirectly affect stress and impairment issues. Ethical pressuresA recent study3 has explored the ethical pressures on final-year medical students, and noted three main types of ethical problems: conflict between requirements of medical education and patient care; responsibility exceeding student's capabilities; and involvement in communication or procedures with patients that were deemed to be substandard. These issues are important in themselves, but the authors also noted that the areas of conflict between medical education and patient care are rarely discussed. Student concernsAgainst a backdrop of upheaval in the health system, expectations of patients, their families and society in general, there is a need to identify the concerns of students and junior doctors and to keep them motivated and inspired. Box 1 lists the concerns identified by a recent survey of medical students at the University of New South Wales by our Student Support Working Party, and some of the responses to these concerns. The early postgraduate yearsRites of passageThe first two postgraduate years have traditionally been seen as a rite of passage, and a time to assimilate with the culture of "the harder I work, the better doctor I am". The system seems to reward self-sacrifice and "driving yourself into the ground", and to discourage time for self-reflection or self-care. We know we must tell patients about the need to exercise, to reduce stress, to have a balanced lifestyle and good, restful sleep, but doctors are presumably different from everyone else! Thus, in the past, the intern year provided a significant barrier — the assumption being that, if junior doctors are emotionally and physically resilient enough to complete the early postgraduate years, then they have "earned their stripes" and are able to continue. For the survivors, again, there used to be significant mentoring and social support through association with a particular hospital. The first few postgraduate years of a medical career are still just as physically and emotionally demanding. Thus, if the threshold is lowered by making provision for an increasing range of specific impairments in interns, it may be necessary to have other methods of screening physical and emotional resilience — or else to change the prevailing medical culture and public expectations of doctors. The following questions flow from this philosophy: Can people who cannot carry out a physical examination or basic medical procedures work as interns? Can they become doctors if they cannot fulfil an internship? How should interns who become very distressed by illness or sick people be catered for? Non-practising doctors?When these questions are posed, some proffer the idea that there could be special places for doctors who will not practise. This is a matter of whether the taxpayer is prepared to fund places for people who will never be doctors. This may cause considerable difficulties later if those who said they understood the conditions on entry change their minds after graduation. The alternative is to offer different courses, for example in medical ethics, for people who have valuable contributions to make, but cannot physically do the work of a doctor. Problems of perpetual changePreviously, doctors could expect autonomy, job security, deference and respect, and a reasonable balance between private life and work commitments. There are now growing imperatives towards patient-centred care, greater accountability, evaluation by others and a growing culture of blame.1 The medical indemnity organisations and the whole medicolegal environment are in a state of flux. There is also much greater rotation of staff around hospitals, leading to less "bonding" with particular institutions, less camaraderie for interns (who are no longer "residents"), and less access to mentors important for a future career. Overall, there are fewer solo-doctor general practices, and much more emphasis on working with multidisciplinary teams. There are more female doctors forging substantial careers, more doctors who are working parents, and reports of diminished income in general practice. The impact of corporatisation of medicine is still not clear, while provision of provider numbers means more political involvement in medical workforce issues. In clinical practice, there is less opportunity for meaningful contact with patients, with shorter hospital stays and less continuity of care. Particularly in emergency departments and with home visits, doctors can face potentially dangerous incidents involving verbal and even physical abuse related to drug misuse. Associated with all of these changes is greater voicing of dissatisfaction from junior doctors. There are also significant changes in the nursing profession, with greater staff turnover in hospitals leading to less continuity, and the newer roles of nurse practitioners and practice nurses, which offer potential but are yet to be fully explored in Australia. The far greater range of paramedical and alternative practitioners may be seen as allies or potential competitors. In terms of the broader health system, there is a greater demand for transparency, and, from the general community, rising rates of medical litigation, but also more opportunities for collaboration with "informed consumers". Over the past decade, there has been a move away from an emphasis on treating acute illness to managing chronic disease. A recent article, "Are we teaching the wrong things?",4 highlights the growing need for clinicians to promote greater autonomy in their patients with chronic illness, working with them in a collaborative relationship. The authors provide a set of specific interpersonal techniques to help doctors promote effective partnerships, leading to greater mutual satisfaction. This new paradigm contains the seeds of the answers to many of the problems facing both doctors and patients. In the next decade, new ethical issues confronting medical students and young doctors will concern the Human Genome Project, the impact of pollution, the increasing burden of chronic illness and an ageing population (within the constraints of a shrinking health budget), and the prospect of an increasing role for doctors (particularly general practitioners) as budget holders and "gatekeepers". In coping with these issues, informed consumers may prove to be welcome allies. Impairment issuesStress, distress and impairment are defined in Box 2. Distress, while not necessarily linked to academic failure, is often associated with a fall in academic performance. Impairment implies some effect on performance. Many students or doctors may have short periods of distress, but they are usually not impaired. The distress is often related to some identifiable cause that can be dealt with by holiday leave, or personal or administrative change. Others may be impaired, but not distressed. For impaired doctors and students, the impact of a disorder can vary with the age of onset relative to the stage in a medical career, and may present different issues for junior doctors and for students in undergraduate and postgraduate medical courses. For many psychiatric disorders, the age of onset is in the late teens and early 20s–30s (eg, psychotic illnesses and eating disorders tend to present in late teens and early 20s, while anxiety disorders and bipolar disorders tend to present in the 20s and 30s). Furthermore, by virtue of their personality styles, their expectations of themselves and others, as well as sleep deprivation and the responsibility and nature of their work, medical students and young doctors constitute a vulnerable group for depression. There is a need for doctors involved with medical boards to have an understanding of current management of psychiatric disorders, and there may be a role for ongoing involvement of impaired doctors who have frequent relapses or severe impairment with medical board impairment programs. This in an acknowledgement that some disorders (such as bipolar disorder) may require long term, less intense monitoring during times of improvement. Medical studentsFor medical students in New South Wales, the criterion for NSW Medical Board involvement is impairment which impacts on patient welfare. Our Medical Board has developed a short, structured referral form for universities, and we are also having regular meetings with the universities to identify clear goals and feedback mechanisms. We also encourage early referral to ensure the smoothest possible arrangements for internship. The most difficult impairments to manage include intermittent psychosis, severe personality disorder and addiction. Moreover, these impairments may not be evident at a selection interview. It is also important to note that a few people will not be able to practise medicine because of their impairment. If so, there needs to be discussion about the acceptability of having these students continue in the medical course. This argument goes back to the underlying philosophy of medical education and whether it is ethical to allow someone to make the significant investment required in a medical course, knowing that they will not be able to practise medicine and that the course may not equip them for much else. If it is not considered ethical, such students should be encouraged to make other career choices and helped to do so. Using the airline pilot analogy, they would be counselled about their lack of suitability. If, on the other hand, these students are allowed to enrol in medicine and continue studying, despite significant impairment inconsistent with practising medicine, it is not sufficient to assume they will find a place in medical research — there needs to be more consideration of what appropriate, non-clinical career choices are available. DoctorsThe NSW Medical Board has recently developed a working definition of impaired doctors (Dr A Reid, Medical Board of NSW, Medical Director, personal communication). Impaired doctors are defined as those who "suffer from any physical or mental illness, disability, condition or disorder (including the misuse of drugs or alcohol) that detrimentally affects their physical or mental capacity to practise medicine, and results in risk or potential risk to the public that is not adequately managed by treatment or practice modification". The Medical Board's main interests lie in the maintenance of good standards and patient safety. A longitudinal assessment of possible impairment is important, with an accent on ability to communicate with patients and others, periods of absence from studies or work, degree of social support, and the amount of insight and personal responsibility taken by the impaired person. A recent article6 discussed the need for simple, well publicised access to a program for impaired doctors, which should include some crisis intervention. It also stressed the importance of peer support, ongoing supervision and monitoring for five subsequent years, together with frank discussions about future prescribing. An example would be doctors who have had problems with analgesic dependence, who might be required to demonstrate that they are better informed about prescribing. The NSW Medical Board requires such doctors to undergo education about pain management as part of their rehabilitation. A suggestion has been made that impaired doctors should be matched with other doctors with similar illnesses or impairments, who can assist them from their own experience.7 Other possible solutions for doctors with a chronic illness include proactive career counselling and guidance, secured funding for retraining doctors who can no longer practise, and ensuring attitudinal change as part of medical training.8 Positive trendsWe have the prospect of new graduates being a cohort of bright, interested young people with a much broader ethnic mix. They may be better placed in assisting those in distress, with more specific training, greater awareness of the stresses pre- and postgraduation and greater access to effective psychological management strategies. An article entitled "Promoting well being among doctors" has advocated moving from a disease model to focus on positive functioning.9 The authors advocate use of techniques from the growing field of positive psychology which aim to promote self-care, encourage peer support, challenge self-critical thoughts and foster optimism. This theme is also pursued in the "Career Focus" section of the British Medical Journal, with articles on looking after yourself and evaluating life roles.10,11 The goals are to help doctors influence their work environment and increase feelings of self-worth and effectiveness. Self-care techniques, combined with work practices, ensuring a balanced lifestyle and a growing focus on a more collaborative approach, both in the doctor–patient relationship and in clinical teamwork, have the potential to increase job satisfaction and resilience in doctors. Finally, I would like to pose a series of questions for us to answer at this Conference (Box 1). 1: Responding to medical students' concerns at the University of New South Wales Concerns the need to earn money; the requirement to travel between campuses; the lack of understanding by friends and family of the pressures involved; communication difficulties (especially for those from a non-English-speaking background); and the lack of an identifiable referral network for students with problems. The concerns of older students (who, with the advent of postgraduate courses, are now becoming more common) are slightly different — they may have taken a drop in income to study and already have families and mortgages. Responses Some of the responses to these concerns have included a decision to establish scholarships for those who are financially burdened (so that they can study and have a balanced lifestyle); encouraging students to have their own general practitioner; and the appointment of a Student Support Officer (who is a working general practitioner) –to improve liaison for those students in distress, –to improve the referral network for those in need, and –to coordinate services for those requiring remediation and counselling. There has also been an initiative involving mentor groups (students in Year 3 mentoring those in Year 1, and students in Year 6 mentoring those in Year 4) which has been very successful. Finally, medical students in New South Wales are registered with the Medical Board and paths for referral and review have been improved. 2: Distress and impairment "Stress" and "distress" are often used interchangeably Stress results from an event which produces physical or psychological pain.5 Stress is also applied to the autonomic arousal associated with such events. Distress is the external sign that all is not well and assistance is required. It is usually related to specific events or illness, and is understandable and acknowledged as appropriate, or considered inappropriate in the context. It may temporarily affect performance, but should be a signal for action to reverse the cause of the distress. Impairment Impairment may be acute, episodic or longstanding — the course is related to the underlying disease, condition or disability. The term implies that performance is affected by the course of the underlying physical or mental condition. An impaired but insightful student or doctor may be able to practise safely under specific conditions. 3: Questions for the Conference to address Do the universities need a statement about their goals for provision of medical education and preparation for a medical career? Should medical students be made aware of these goals at entry into medical studies? Should they be required to declare any problems in meeting the requirements? What is the purpose of identifying students in distress or with impairments? What can we offer them? Are these goals being realised? Can we provide transparent, supportive, proactive processes for those who are impaired? Is medical training consistent with current medical workforce requirements? Are we doing enough to emphasise positive functioning (at all stages of a medical career)? How much impairment will society tolerate in doctors? How much will the profession tolerate? What are the workforce implications of impairment? What is role of the Medical Registration Boards? Should boards deal with only the most impaired doctors or should they be more proactive? Can we produce some acceptable Australian policy and good documentation on proactive strategies for dealing with stress and impairment in medical students and young doctors?

Kay A Wilhelm MD, FRANZCP

It has been long recognised that the practice of medicine is stressful and that doctors are prone to anxiety, depression, drug and alcohol problems, and even suicide.1,2 Similarly, the process of medical education is stressful and medical students, too, are at risk of psychological problems.3 In New South Wales, in 1997, after a report on doctors' mental health, the NSW Medical Board convened an independent Doctors' Mental Health Implementation Committee, with wide-ranging representation from the profession. This Committee produced the NSW Doctors' Mental Health Policy to provide a framework for the NSW Doctors' Mental Health Program.4 Separate policies were developed for rural practitioners, area health services, specialist medical colleges, and for medical schools. Mental health policies for medical schoolsThe policies for medical schools included: promoting the importance of mental health — by embedding it in the curriculum; encouraging a caring culture within the medical school; identifying suitable personnel to provide assistance to students with social and psychological problems; and assisting students to obtain good medical and psychological care. Many factors may contribute to stress and distress in medical students. These include not only the intrinsic stressors within medical education, but also significant changes and conflicts in lifestyle. For example, students in graduate programs, who are often older and married with young children, may have great financial pressures placed upon them. Implementing the policies at Sydney UniversityThe policies were implemented primarily in two ways: by incorporating the theme "Personal and Professional Development and Ethics" in the curricula; and by establishing a Student Welfare Committee. Personal and Professional Development and Ethics is one of the four teaching themes in the graduate medical program, which are integrated both vertically and horizontally. The others are Basic and Clinical Sciences (pre-clinical sciences), Patient–Doctor (diagnostic and clinical skills) and Community–Doctor (epidemiology and social medicine). The Personal and Professional Development and Ethics theme is integrated into all aspects of the students' learning program, which is centred around "problem-based learning" in small groups meeting twice weekly. These groups focus each week on a specific clinical problem. The students are encouraged to develop good listening and communication skills and to be aware of the functioning of the group. In the context of these clinical problems, they are exposed both to the multiple roles of doctors — as clinicians, educators, supervisors, and patient advocates — and to the professional and ethical issues in the clinical case. Larger lecture or seminar teaching sessions cover healthy lifestyle, stress and stress management, anxiety and depression, and substance misuse. Other sessions deal specifically with mental illness and stigma in mental health, and students are encouraged to understand the political, financial, legal, and ethical impacts of these disorders. In addition, they understand the duty of care in relation to mental health problems in their colleagues and their own mental health. The Personal and Professional Development and Ethics theme is assessed at several points during the medical course, in both a formative and summative manner. (A formative assessment does not involve a pass or fail, but, if unsatisfactory, may require some remediation. A summative assessment is a pass/fail assessment). A Student Welfare Committee was established with basic principles of confidentiality regarding student information, a duty of care to students, and, in some instances, a duty of care to hospital staff and to patients. The Committee comprises the coordinators for the first two, non-clinical years of the medical course and the Associate Deans of the teaching hospital clinical schools, with the chair being a psychiatrist on the university staff. If appropriate, a member of the Medical Board is invited to attend. Information about individual students discussed in the committee is de-identified. The importance of collecting detailed information about problems has been emphasised, particularly as the Medical Board requires detailed information to be able to make the most appropriate decisions if and when students are referred. The Committee has established appropriate processes for referring students to appropriate clinicians — counsellors, psychologists and psychiatrists — outside the faculty. Other options available are referral to the Medical Board, for establishing and maintaining psychological care for the student, for placing specific requirements on the student for registration, or for deregistration. (In New South Wales, medical students are registered in a similar way to medical graduates.) Students with problems tend to come to the Committee's attention in two ways. Firstly, students may self-present to the year coordinator or to the Associate Dean's office with either social or psychological problems. Initially, a supportive identified member of that office screens the problem. The matter can then be referred to the Associate Dean or the year coordinator and discussed at the Student Welfare Committee meeting. Appropriate documentation is kept. Secondly, students may be reported to the Associate Dean by other concerned students or staff, usually when they appear quite psychologically disturbed or have significant behavioural problems. In the early days of this Committee, there were often differences of opinion, particularly in considering, firstly, duty of care to patients and other staff, and, secondly, confidentiality within the faculty. For example, should relevant university staff be notified of a student who was distressed or not coping so they could be of support and assistance in the student's next rotation? As the committee progressed, these issues were largely resolved. It was agreed that one key staff member in a rotation would be made aware of a student needing support. ConclusionsThe pressures placed on medical students during their education, which can lead to significant psychological problems, are increasingly being recognised. The consequences for the student — in distress caused, and in interruption to their education — are considerable. The problems may also adversely affect others. Medical faculties need to be aware of these problems and identify and deal with them as soon as possible. Structures should be in place to accomplish this.

Chris C Tennant MD, MPH, MRCPsych, FRANZCP

Medical courses are inherently stressful because of the nature of the course, the workload and, for some students, financial issues. These stressors can lead to impaired judgement, reduced concentration and self-esteem, and increased anxiety, manifesting in turn in depression and even suicide. In 1997, as a first-year medical student of the graduate program at Sydney University, I attended the conference of the Australian and New Zealand Association of Medical Education. The conference explored facets of stress for medical students and found that medical students were indeed stressed. However, the causes of the stress were not explored, and neither were the ways of managing this stress. I decided to examine the level of stress in students in my year. There are fundamental differences between the undergraduate and graduate medical courses and in the type of students enrolled. As opposed to the predominantly lecture-based, didactic undergraduate courses, the graduate course emphasises self-directed learning in problem-based, small-group tutorials. Graduate students have an advantage in that they have had previous experience of university education. In 1997 the average age of the students in my year was 24.5 years. They therefore had different life experiences to younger undergraduate students. I hypothesised that stress in the first year of the graduate course would reflect financial, personal and living issues; time management problems; the new format of the course and the problem-based learning structure; using computers; and, for some students, the requirement to move residence to study. Examination pressures were not applicable in the first year. The studyA study was devised to assess overall stress and the effect of these eight potential stressors. MethodsEach parameter of stress was assessed by a retrospective questionnaire, using a four-point scale ("stressed", "very stressed", "unstressed", and "very unstressed"). Students were assessed twice in their first year, at enrolment and six months later. Stress at these two time points in first-year students in 1997 was compared with that in first-year students in the two subsequent years, when an intrafaculty support network, the "Buddy Program", had been established. For this program, the medical faculty encouraged students to be involved, and supported the development of this student support network. Students finishing first year were asked to volunteer to take part in peer support — to be a "buddy" for the next year's first-year students. Volunteers were introduced to two or three students at an informal morning tea. Contact between the buddy and first-year students was maintained using the tutorial rooms, telephone and email. The students were encouraged to approach their buddy with questions, or for support, whether on an academic, social or personal level. All interactions were confidential, with support from the honours supervisors (trained in psychology and counselling) if situations demanded their intervention. The Statistical Package for the Social Sciences (SPSS) was used for all analyses of results: χ2 analyses were used to test relationships between categorical variables, and descriptive data were compared using t-tests. Because of very small numbers in sections of the four-point scale, rates for "stressed" and "very stressed" were combined, as were rates for "unstressed" and "very unstressed". Stressor frequency in the intervention years was compared with the baseline year (1997) using 95% CIs. ResultsAll students in 1997, 1998 and 1999 were included in the study. Response rates of students to the questionnaires were as follows: in 1997, 115/132 (87.1%); in 1998, 131/154 (85.1%); and in 1999, 166/201 (82.6%). The results are presented in the Box. Students in 1997 had higher stress levels than those in the two subsequent years. Across the three years, the main stressor was time management: between enrolment and six months later, the proportion of students with stress from time management problems did not decrease significantly. Financial issues also caused significant stress. There were temporal changes in overall stress. In the intervention years when the "Buddy Program" was operating, more students were not stressed at enrolment and remained so six months later ConclusionsA substantial proportion of graduate medical students find the course stressful, with the main stressors being related to time management and financial issues. Stress levels fluctuate throughout the academic year. Starting a course which acknowledges inherent stresses and has an established support network for this creates a less stressed group of students at enrolment. The "Buddy Program" maintained low stress levels in individuals who started the course unstressed. However, students commented that there was not enough access to buddies, despite the high rate of buddy volunteers for the program. Medical students need to be taught structured time management skills, and given access to financial support. Rates of overall stress and factors causing stress, by year, at intake and at six months. Data are number and proportion of first-year students in a graduate medical course, with 95% CIs for comparison of rates — 1997 v 1998 and 1997 v 1999 At intake At six months 1997 (n = 115) 1998 (n = 131) 1999 (n = 166) 1997 (n = 115) 1998 (n = 131) 1999 (n = 166) Overall stressed 60 (52.2%) 46 (35.1%) 72 (43.4%) 50 (43.5%) 52 (39.7%) 77 (46.4%) 95% CI 4.8%, 29.3% – 15.7%, 8.0% – 8.5%, 16.1% – 14.7%, 8.9% Individual stressors Time management 82 (71.3%) 75 (57.3%) 103 (62.0%) 85 (73.9%) 104 (79.4%) 123 (74.1%) 95% CI 2.2%, 25.9% – 1.8%, 20.3% – 16.1%, 5.1% – 10.6%, 10.2% Financial issues 66 (57.4%) 60 (45.8%) 88 (53.0%) 67 (58.3%) 68 (51.9%) 84 (50.6%) 95% CI – 0.8%, 24.0% – 7.4%, 16.2% – 6.1%, 18.8% – 6.9%, 22.2% New format of the course 65 (56.5%) 59 (45.0%) 80 (48.2%) 28 (24.3%) 48 (36.6%) 60 (36.1%) 95% CI – 1.0%, 23.9% – 3.5%, 20.2% – 23.7%, – 0.9% – 22.5%, –1.1% Personal issues 56 (48.7%) 51 (38.9%) 74 (44.6%) 58 (50.4%) 45 (34.4%) 73 (44.0%) 95% CI – 2.6%, 22.2% – 7.7%, 16.0% 3.8%, 28.3% - 5.4%, 18.3% Problem-based learning 51 (44.3%) 42 (32.1%) 54 (32.5%) 27 (23.5%) 31 (23.7%) 32 (19.3%) 95% CI 6.1%, 18.5% 0.3%, 23.4% – 10.8%, 10.4% – 5.6%, 14.0% Using computers 40 (34.8%) 36 (27.5%) 23 (13.9%) 9 (7.8%) 17 (13.0%) 8 (4.8%) 95% CI – 4.3%, 18.9% 8.2%, 33.6% – 12.7%, 2.4% – 2.9%, 8.9% Living conditions 36 (31.3%) 25 (19.1%) 47 (28.3%) 29 (25.2%) 18 (13.7%) 37 (22.3%) 95% CI 1.4%, 23.0% – 7.9%, 13.9% 1.6%, 21.4% – 8.0%, 12.4% (n = 44) (n = 73) (n = 82) (n = 44) (n = 73) (n = 82) Moving residence to study 28 (24.3%) 21 (16.0%) 44 (26.5%) 12 (10.4%) 10 (7.6%) 18 (10.8%) 95% CI 7.9%, 43.7% – 17.3%, 19.1% – 10.0%, 20.7% – 10.6%, 21.2%

Gisele M L Mouret MB BS (Hons), BAppSc(Physiotherapy)

The Tasmanian University Medical Students Society (TUMSS) and the Tasmanian Branch of the Australian Medical Association (AMA) have jointly run a mentor scheme linking students with doctors since 1994. However, the scheme was not meeting the needs of students. In particular, there was a lack of support for students who were distressed or affected by adverse life events, such as mental or physical illness and loss of family support. The impact of such problems was seen to contribute to the average annual loss of 11 students for the academic years 1999–2000. Here, I focus on the history and development of this model for helping students in distress. History of the schemeThe Tasmanian Branch Council of the AMA started the mentor scheme in 1992. Mentor doctors were paired with students on a one-to-one basis, and the scheme was run by a committee of doctors. In 1994, the running of the scheme was passed to the student representative on the AMA Council. As a consequence, the scheme waxed and waned for a few years, depending on the amount of time the student representative had available. In 1998, the model was altered to involve six students, one from each year of the course, with one doctor. As a final-year student left, a first-year student would be added to the group. The aims of the scheme, which have remained consistent from the beginning, are: to develop integration between the years in the course; to link students with doctors to help them appreciate the bigger picture beyond medical school; to facilitate student networking in both giving and receiving support; to provide doctors with insight into the current medical course; and to allow doctors to have a role in shaping the future for current medical students. Problems with the group formatThe most recent format — groups of one doctor and six students — did not meet these aims as successfully as hoped and many of these groups eventually foundered. Participant representatives of each group in the scheme were contacted and feedback was sought on their experiences. Some of the reasons given for the scheme's shortcomings were: The long-term commitment demanded of doctors by the continuous replacement of final-year students with first-year students gave no natural break point for mentors to "bow out gracefully". The model, being predominantly face-to-face, was not practical in the fifth and sixth years of the course, when students study in remote parts of the State. This made it very difficult for them to maintain their involvement with a group. While the group model was good for networking, it could also be restrictive for those unwilling to raise issues in a group setting. Some students indicated that they did not feel they could contact the mentor for a one-to-one meeting because the scheme was defined as a group event. Consistent contact was not maintained with each group and no central point of leadership existed to motivate the groups, or assist in resolving problems within groups. Group members were selected by a third party and demographic characteristics were used to match members. However, this system was not always as successful as hoped in finding compatible group members and mentors. Entry was limited to the start of the year, when students did not feel they had any problems. Later in the year, when they were confronting problems, students had to single themselves out to gain entry to the scheme, and often had to join established and even full groups. In summary, anecdotal evidence indicated that the scheme was a good opportunity for networking, but the number of people to network with was limited. Furthermore, the scheme provided limited scope for linking students with a suitable mentor to help them cope with a particular difficulty they were experiencing at the time. The result was that the scheme could do little to address the needs of the handful of students who were lost from the course each year for want of appropriate support. Current direction of the schemeIt was decided that this gap in student support could best be met through a model based on the Tasmanian Doctors' Health Advisory Service. Ailing students will be linked with appropriate clinicians, primarily via a web-based referral system. This system will enable "mentors" with an interest in student health to be drawn from a relevant specialty for a specified period of time on an "as-needed" basis, with confidentiality maintained. The proposed changes to the scheme present several advantages. Rather than dictating a long-term contact with a mentor, it allows for students to make brief contact with a mentor to deal with problems as and when they arise. Students are not discouraged from forming ongoing relationships with their mentors, nor from building up a network of contacts with a number of doctors. Students may approach each mentor in a selective fashion to deal with a range of issues, including health, career, medical politics and study, and do so in the way they feel most comfortable with. The use of the web in this scheme also allows rural and remote doctors and students to participate, and no longer disadvantages fifth- and sixth-year students at teaching sites far from the main campus. Instead, the opportunity now exists to locate a mentor in their local area and build new networks that should make their stay in the north or north-west of the State more enjoyable and fulfilling. International students, who have been identified as one group having particular difficulty during their time in rural areas, may gain more support and guidance from the new scheme. For doctors, the new scheme provides various categories of involvement to choose from. They are able to dictate just how much or how little they would like to be involved and the types of information or advice they feel comfortable providing. While such a model is theoretically simple, its development has highlighted a number of issues. These include: Protecting the interests of doctor mentors and preventing their being misused (or abused); Developing an adequate network of mentors to meet a range of student needs; Defining the limits of confidentiality and indicators for disclosure when student ailments prevent satisfactory ward work or study practices; and Identifying an acceptable avenue for disclosure and action by a medical school given the lack of an independent regulatory body for medical students. Features of the modified schemeSome aspects of the current one-doctor-to-six-students structure of the scheme are being retained and new components are being introduced. Face-to-face meetings are still encouraged. Technology is not being promoted as a substitute for personal meetings, although it will help to lessen the impact of distance. It is anticipated that a blend of email and telephone contact and face-to-face meetings will make this scheme invaluable for students remote from the main campus. Rather than attempting to duplicate the Doctors' Health Advisory Service, links will be developed with the service. This will allow students for whom the mentor scheme is not sufficient to draw on the expertise of professionals experienced in dealing professionally with people who are not coping well. To maintain some cohesion and motivation for the scheme, regular social gatherings and educational forums are planned. In addition to doctors acting as mentors, some senior students are being encouraged to act as mentors for more junior students. Students have a lot to offer their peers: help with understanding the direction of the course and how to survive it; how university works; and where to find practical assistance. Constraints of the schemeFor the scheme to be a success, its scope must be limited to providing effective assistance with small problems. Students with chronic problems or ailments requiring active therapy will be referred to their general practitioner or other appropriate healthcare provider. Thus, the scheme is not seen as a "bypass" for fee-for-service healthcare and students will need, and be encouraged to have, their own GP. Future directionsThe web-based mentor scheme I have described is still at its fledgling stage. Future improvements will increase the efficiency of providing mentors and decrease the level of maintenance required. Other improvements are: The gradual upgrading of the website so that it is largely self-administering. One of the burdens of the scheme to date has been the huge workload required to maintain the electronic and telephone service. The involvement of mentors from other States and overseas to represent specialties or interests not available in Tasmania. The involvement of junior doctors in the scheme, with a gradual transition as their confidence and experience grows, from being mentored to being mentors. This scheme has the potential to be valuable to students and doctors in the support it offers and in the networking opportunities it provides. However, there is a need for other structures. An independent regulatory body associated with medical student registration is required to assist when a student is no longer able to functional appropriately in a clinical setting, and requires more direction and support than mentoring can provide.

Lisa M Barrow BSc(Hons), MPsych (Clinical), MAPS

Most members of the medical profession feel stressed at some time. If stress is ongoing, impairment may occur (defined as being unable to safely or reliably perform one's role). A continuum appears to exist between functioning well, being distressed and becoming impaired, with external (environment-related) and internal (personal-related) stressors determining where an individual will lie on the continuum. We are conducting a study which aims to determine whether distress in new medical graduates can be predicted before the graduates become impaired and unable to safely or reliably perform their role. Study commencementOur study, which commenced in 1997, initially looked at predictors for "troubled" and "troublesome" interns. Hospital-based focus groups comprising interns (postgraduate Year 1), resident medical officers (postgraduate Year 2 and above), ward-based nursing staff and medical administrators reported on internal and external stressors for junior medical staff. Residents and nurses reported similar external stressors, whereas the internal stressors reported by the two groups were quite different (Box 1). Residents tended to report issues relating to "troubled" interns (eg, poor support, few outside interests), whereas nurses identified factors relating more to "troublesome" interns (eg, poor attitude, unprofessionalism). In other words, resident staff seemed to be able to identify their stressed and at-risk peers before effects on performance were observed (Box 1). Our study has subsequently moved through three distinct phases. Phase 1In Phase 1 (1997), 151 interns from seven primary allocation centres (centres which employ first-year postgraduate doctors) around New South Wales were approached and specific tools were administered, at orientation and at mid-year, to assess "burnout",1 alexithymia (not being emotionally sensitive or expressive, and having externally oriented thinking),2 and social support.3 General demographic characteristics were also obtained. These data were correlated with "assessed performance" data for the interns in the study, as determined from term evaluations by their supervisor. Results from this pilot cohort suggested that alexithymia was a possible predictor of a resident in difficulty, ultimately leading to poor performance. Phase 2In Phase 2 of the study (1998), the entire NSW cohort of interns (482) from all primary and secondment allocation centres across the State were approached and the same questionnaire tools administered. Scores for two of the subscales of the Maslach Burnout Inventory — "a sense of personal accomplishment" and "emotional exhaustion" — indicated an overall moderate level of burnout among interns at mid-year (as defined in the normative data for medical practitioners supplied by the instrument publishers). This was not surprising given the high level of emotional stress traditionally associated with the intern year. However, measurements of the third subscale, "depersonalisation", indicated a high level of this component of burnout. Furthermore, significant correlations were noted between alexithymia at mid-year and both "a sense of personal accomplishment" and "emotional exhaustion". There was a negative correlation between alexithymia (mid-year) and "personal accomplishment" (r = – 0.35; P < 0.001) and a positive correlation between alexithymia (mid-year) and "emotional exhaustion" (r = 0.25; P < 0.001) (ie, alexithymia was associated with higher levels of emotional exhaustion and lower perceived levels of personal accomplishment). This larger cohort also confirmed the presence of primary and secondary forms of alexithymia: Primary alexithymia is postulated to represent a personality trait; and Secondary alexithymia is postulated to represent a "state" characteristic relating to an induced state of alexithymia. Secondary or induced alexithymia possibly indicates a coping mechanism midway through the stressful internship year. Primary alexithymia seemed to be particularly predictive of higher burnout and poorer performance, although induced alexithymia was also associated with a lower assessed level of performance than was the case for interns who remained non-alexithymic (Box 2). Phase 3Phase 3 of the study is currently under way. One hundred and twenty students from the University of Sydney are being tested at six different times across their final medical school year (Year 4) and the internship year. The core measurement tools have again been administered and, in addition, the General Health Questionnaire,4 the International Personality Disorder Examination (IPDE, ICD-10 module) screening questionnaire5 and the Sheehan Quality of Life questionnaire.6 A key difference from previous studies is the inclusion of a one-on-one Life Events and Difficulties Scale (LEDS)7 interview at six-monthly intervals over the two-year period. Preliminary findings from the mid-internship LEDS interview indicate some issues that appear to promote stress mid-internship. Poor-quality supervision is a common issue and appears to relate to the unsupportive, "burnt-out" or overworked registrar or term supervisor providing inadequate supervision. Similar issues arise in situations where appropriate levels of supervision are lacking, including at some rural allocation centres, and particularly in emergency situations or at night. Lack of debriefing measures after a critical incident was another common theme, as was dealing with emotionally difficult situations, such as giving bad news. Above all, administrative support issues appear to be very significant. A sympathetic administration ameliorates many of the other problems, but an unsympathetic one heightens the level of stress experienced. Summary of findingsIt would appear that the performance of new medical graduates is affected by their personal responses to the experience of internship. A supportive environment potentially ameliorates this performance effect. To help students progress into the internship and minimise stress we need to: Provide good registrar and supervisory support; Have a sympathetic medical administration; and Promote awareness of burnout and personal emotional needs. 1: External and internal factors predicting distress in interns 2: Presence of alexithymia* at orientation and mid-year during internship, and related performance and burnout * Not being emotionally sensitive or expressive, and having externally oriented thinking.

Michele G Daly MSc · Simon M Willcock MBBS, FRACGP

Medical Boards throughout Australia are considering amending their respective Medical Acts so that all students in each State or Territory are required to be registered with their Medical Board as a prerequisite for studying medicine. Such amendments have arisen from the increasingly litigious environment, the growing role of clinical education in traditionally preclinical years, and the recognition that medical students enjoy many of the doctor–patient privileges of fully qualified medical practitioners and must therefore assume appropriate responsibilities. New South Wales was the first State to introduce this requirement, having done so in 1992 after broad consultation. The Board's sole concern is with impairment, not misconduct or improper behaviour. In NSW this requirement has been well accepted and is perceived as an additional support mechanism for students. Victoria passed legislation in 2000 for registration to start in 2002, but precise details are not available (at the time of the Conference). This followed extensive consultation with students over the preceding years. The model is not dissimilar to the NSW model. Again, the Board's role relates solely to impairment. In South Australia, at the time of the Conference, legislation is before the upper house of parliament. There is a perceived lack of recent student consultation on the proposal. The proposed model possesses somewhat stronger teeth than the NSW or Victorian models in that it applies to medical students the same conditions of registration as currently exist for doctors. [This Act has lapsed. There was a change of government in South Australia before the Act was passed.] In Western Australia, there is strong student opposition to universal registration. The current proposal is that the Medical Board would have jurisdiction only over students referred by the University of Western Australia Faculty of Medicine, but negotiations are continuing. The concept has been mooted in most other States and Territories. Specific time frames are unknown. The aim of registration is to facilitate early detection of impairment that would compromise patient welfare; to encourage impaired students to seek support; to facilitate alternative arrangements for medical students to enable disabled or impaired students to complete their degree; and to minimise risk to the public. The Australian Medical Students' Association (AMSA) recognises the potential value of registration of students. It should be viewed as an additional support mechanism, as a way of supporting impaired medical students through their course, or assisting them in finding another career path should medicine prove to be unsuitable. If it is perceived as punitive or adversarial, it will not be accepted by students. AMSA believes that the precise purpose of medical student registration needs to be very clearly defined given the significant additional powers that such an initiative would bestow upon State medical boards. Recognising the scope for its misuse, it is vital that the registration of medical students only be used for the initially intended purpose: to minimise risk to patients; to develop an impartial mechanism of notification and investigation of complaints against students, independent of the university; and to allow recognition of medical students by any public hospital, teaching or non-teaching, in that State. The medical boards should only initiate investigations if they believe that the ability of a registered medical student to have direct patient contact may be affected by the student's physical or mental health; if the student has an impairment; or if the student has exhibited unethical conduct. Complaints made on other grounds, such as academic performance, should not be investigated by the Board, but should instead be referred to the university. AMSA recommendations for medical board registration of medical studentsMedical student registration should be introduced only after a thorough consultative process, with endorsement from local student bodies and medical faculties. NSW and Victoria did this, and it should also be done in other States. The medical boards' role should be passive, so that they only have the right to investigate a student in the event of a complaint. In most circumstances, complaints about a medical student should only be made to a medical board when all other appropriate avenues have been exhausted. This represents a significant difference from the registration of medical practitioners. Medical board registration should not require students to prove their capacity to undertake clinical studies; this would be an unnecessary burden and an invasion of privacy. Medical board registration should be contingent solely upon enrolment in an Australian Medical Council accredited medical school. Any changes to medical board registration, such as conditions or suspensions, should only be brought about as a consequence of an investigation into a complaint or the cessation of enrolment in a medical school. Most people likely to make complaints against students will have several other avenues open to them. Academics and clinical officers can use existing university procedures in the first instance, and would only need to progress to the medical board in exceptional circumstances. On the other hand, a patient in a rural setting who identifies an impairment in a medical student, and feels obliged to report it, has few options but to approach the medical board directly. Any changes to medical board registration should have an appeals process that should not involve any financial cost to the student, and should be conducted promptly. Medical board registration should be nationally recognised by boards in other States. There is potential for the national registration of medical students in line with current proposals for practitioners. Medical boards should not charge for medical student registration, counselling or investigation or make medical indemnity a condition of registration. Finally, there is a profound need for confidentiality. Personal data should not be publicly available in that part of the register open to the public.

Stefan C Kane

Identifying the characteristics of doctors with health problems that disrupt their ability to practise medicine may help to identify young doctors and students at risk. I describe here the experience of the Health Committee of the South Australian Medical Board, which has been active for 18 years, in the hope that this might assist in formulating a prevention and early intervention program. Four main types of health problems are encountered in doctors. drug misuse, particularly narcotic drugs such as pethidine; mental health problems; general health problems that threaten vocational status; and infection with blood-borne viruses, such as hepatitis B and C and HIV. Here, I will concentrate mainly on drug misuse and mental health problems. NotificationThe Board hears of doctors with potential problems in several ways. The most common is notification by the doctor's practice partners. In addition, members of the doctor's family may seek advice or a doctor's patients may contact the Board, usually saying that their doctor seems "to be behaving strangely" or "to have changed". The Pharmacy section of the South Australian Department of Human Services often detects abnormal prescribing practices, especially in relation to pethidine, and routinely notifies the Board. Finally, about 20% of health-impaired doctors self-notify. It is perhaps reassuring that it is very unusual for a health-impaired doctor to come to the attention of the Board because of a medical misadventure or an adverse event. Procedure after notificationWhen the Health Committee is notified about a doctor with a potential health problem, it writes to the doctor (and quite often also contacts the doctor by phone) and invites him or her to meet with the Health Committee. The letter stresses that the doctor may bring his or her spouse or a friend, and informs the doctor that the Medical Defence Association lawyers are very used to working with these types of problems with the Health Committee. The aim of this initial communication is to emphasise that the interview will have the qualities of intervention, treatment and rehabilitation rather than being a disciplinary activity. Confidentiality is given very high priority and the doctor's identity is only divulged to the members of the Board's Health Committee. There are a lot of subtle issues involved in contacting doctors. It is unwise, for example, to contact on a Thursday or Friday, because this leaves them the whole weekend to worry. Indeed, there have been instances of suicide as a result of this period of isolation and concern. About half the doctors who come to the Committee meeting are accompanied by their spouse, about half by a lawyer, and about 40% come on their own. When these doctors are interviewed, it is relatively rare for them to deny that they have a problem, for example with drugs or with depression. Health Committee's responseThe Health Committee is responsible for coordinating a response to the problem. This usually involves arranging for advice from specialists, such as psychiatrists; arranging for a general practitioner for the doctor; and, in the case of drug misuse, arranging for urine tests three times a week. A health-impaired doctor usually takes at least three months' leave from work. Voluntary undertakingsVoluntary undertakings are signed at the initial meeting and include permission from the health-impaired doctor for the specialists to send their assessments to the Health Committee. The voluntary undertakings are gradually changed over time. When doctors return to work, the undertakings often include that the doctor will not prescribe S8 drugs; will not work in a solo practice; and will not prescribe for themselves or their families. OutcomesAs it has developed and matured, this program has had increasingly good outcomes — and this particularly relates to earlier detection. Relapse rates have fallen considerably and suicide has been reduced. Pethidine misuse: About half the doctors have a relapse in the course of their "first round" of treatment. In the second round, again about half relapse, and this relapse rate also applies to the very small number who go on to a third treatment program. Mental health problems: The vast majority of these involve depression or post-traumatic stress disorder, and this group of doctors generally does well in treatment and complies very well with the management program set out by their treating specialist. The program is particularly useful in the case of hypomania. The backing of the Board for the specialist's management program goes a long way towards ensuring compliance with medication in doctors with this condition (which is characterised by poor medication compliance). Some of the characteristics of health-impaired doctors that may assist in early intervention and education programs are given in the Box. Drug misuseIt is not unusual for a doctor to be introduced to the effects of pethidine during the course of a medical procedure, commonly orthopaedic procedures. The doctor comes to see that pethidine (which is by far the most abused drug) gives the patient a profound sense of relief and a false sense of objectivity. Many of the doctors misusing drugs obtain wider benefits from the Health Committee program than merely achieving abstinence. In the context of psychotherapy, it is common for them to rethink their approach to medicine and to their families. They may achieve a more mature relationship with their wife or husband, although, equally, it is not uncommon for relationships to break up at this point. Follow-up and long-term supportI have emphasised findings which might be called demographic or sociological in nature because they are easy to recognise. It is not hard to see that some special support might be provided to doctors who come from a different culture, or who have found themselves in solo practices, or whose families are struggling in the context of setting up life in a new culture. I would like to especially note here that, at least in South Australia, doctors in the community and in hospitals and other institutions are generous in providing support and help for impaired doctors, and later when they are trying to return to work. The role of the Board in this context is to facilitate the doctor's return to work; to help often new medical partners to understand the problems commonly faced; and to support the doctor concerned. It is essential for the doctor's new colleagues to feel that the Board remains interested in the long-term future of a previously health-impaired doctor. Thus, long-term follow-up is the rule. The Board's Health Committee has noted that, with long-term follow-up, the number of doctors who bring their spouse or partner with them increases as time goes on. This appears to be a good prognostic sign. SummaryWe have found that it is possible to set up a system which has the powerful backing of the Medical Board, but which is, at least in the first instance, non-punitive; to identify risk factors for drug misuse and mental health problems; and to detect these problems early if the system, especially the medical system, is made well aware of possible avenues of help. A result of the Health Committee activity, as described here, is that there is less stigma associated with the notion of impairment and therefore the opening up of more opportunities for helping impaired doctors. Assisting doctors who are isolated or not part of the culture to integrate in an atmosphere of collegiality seems to be an important part of achieving long-term favourable outcomes. Some characteristics of health-impaired doctors Working style: When these doctors describe their working style (and this is often supported by information from colleagues and their family), they appear as very conscientious people who work very long hours. They often have few friends within the medical profession and do not attend continuing medical education sessions. Sometimes an impression is gained that they have reached a point where "their only friends are their patients". Family relationships: At the time of presentation, it is common to find that the doctor's family relationships have become disturbed and dysfunctional. Isolation and alienation: A common finding is that more than half the doctors presenting with drug misuse did not train in Australia. In addition, there are a number who are sons or daughters of first-generation Australians, who are often by far the most highly educated of the extended family, and a great deal of faith has been put in their futures. In addition, solo practice is often over-represented, as is rural practice. As these doctors tell their stories, it becomes clear that they feel isolated, and perhaps even alienated, from Australian-trained doctors, and Australian customs and cultures. Their main solace as a doctor is in the actual practise of one-to-one medicine, and they do not share their experiences with their partners or in the wider setting of medical societies. They are often depressed or at least dysthymic. In the wrong career: Some doctors feel isolated and estranged because they have come to recognise that they have made a mistake in going into medicine and do not know what else to do. Some of these doctors come from families with a strong medical tradition.

Ross S Kalucy AM, MB BS, FRANZCP

There is compelling evidence that doctors are an at-risk group. Their high rates of mental illness and stress-related illness are of particular concern, and are reflected in tragically high suicide rates, high levels of drug abuse, and decreased job satisfaction and "burnout".1,2 All of these are powerful indicators of poor self-care. Junior medical officers, in particular, are at risk. The New South Wales Medical Board has only incomplete data, but these show an alarming increase in suicides of doctors in recent years, with 21 known doctor suicides occurring between 1992 and 1997 (one in 1992 and eight in 1995).3 The increase is mainly accounted for by junior doctors. In response to the increasing suicide rates and doctors' high rates of stress-related illness and depression, the NSW Doctors' Mental Health Working Group was formed in May 1997. This was a joint initiative of the NSW Health Department and the NSW Branch of the Australian Medical Association. Its policies and recommendations emphasise that doctors should be aware that they are at risk of stress and mental health problems, and that they have a responsibility to care for themselves and to seek appropriate professional medical care. Further, the Doctors' Mental Health Working Group encourages all doctors to have, and to regularly consult with, their own general practitioner and not to prescribe for themselves or their families. However, there are considerable barriers to be overcome. A NSW survey found that 26% of doctors who reported suffering from a medical condition warranting a medical consultation had not sought that consultation because they were doctors themselves. Only 42% of doctors surveyed had their own GP, and even fewer usually consulted a GP for health problems.4 Why do doctors neglect their own health and self-care? Can we identify barriers and facilitate a process for doctors to seek appropriate care? Healthcare and junior medical officersTo answer these questions, a project was initiated to determine healthcare behaviours and attitudes to healthcare among junior medical officers (JMOs). The project was supported by the Hornsby Ku-ring-gai Ryde Division of General Practice, Hornsby Ku-ring-gai Hospital and the Northern Sydney Area Health Service. The project received funding from the Innovative Projects Grants scheme for Divisions of General Practice. The aims of the project were to identify: healthcare behaviours of junior medical officers; barriers to the use of general practice services; educational needs of GPs to assist them to provide an appropriate service for other doctors as patients; and ways in which area health services could facilitate access of JMO staff to GP services. The project involved focus groups of JMOs and GPs, the development and implementation of a questionnaire survey for JMOs in the area health service, and educational sessions for GPs and JMOs. The questionnaire was developed from issues raised in the focus groups. The General Health Questionnaire (GHQ 28)5 was also administered. The survey was issued to 300 junior medical staff across the area health service from postgraduate years 1–4. The response rate was 52%. Preliminary resultsThere are high levels of self-prescribing and self-diagnosis, reliance on hospital registrars for advice and referrals, and frequent neglect of preventive health issues. Doctors are prescribing medications, for themselves and others, ranging from contraceptives, antihypertensives and sleeping tablets, up to and including narcotic analgesics and antidepressants (see Box). Doctors are legally able to write prescriptions for themselves, but these prescriptions are, of course, not part of a consultation where ongoing care is considered. Rates of self-prescribing and prescribing for colleagues among 158 junior medical staff Have prescribed or would prescribe Drug class For self For a colleague Antibiotics 81% 78% Sleeping tablets 38% 36% Antihypertensives 15% 22% Antidepressants 7% 14% Narcotic analgesics 7% 18% "Corridor consultations" are common, with 22% of respondents admitting to requesting a prescription from a work colleague. Interestingly, more than 50% of respondents said they felt uncomfortable about being asked for a prescription by a colleague. Half of the respondents indicated that they self-referred to consultants or treated themselves for conditions that warranted a medical consultation; and 30% agreed that they had suffered from a medical condition they would like to have discussed with a doctor, but had not done so because they were doctors themselves. In focus group discussions, JMOs indicated that young professionals such as themselves should have a medical checkup at least once a year; and 83% of respondents thought that all hospital doctors should have an annual health check. The survey results indicated that 30% of respondents were too busy to have a general health check, 70% could only justify seeing a doctor if they were really ill, 20% indicated that they looked after their own health needs, and 39% were overdue for some aspects of their preventive healthcare. Conclusions and recommendationsYoung doctors give their own healthcare a low priority. They feel great pressure not to miss shifts due to ill-health — as if this were not a valid reason. They have to be sure they are really sick enough before they would consider asking for help. This attitude to healthcare means that it is even more difficult for young doctors to seek help for a stress-related illness, a mental health issue or for substance misuse, as these are not seen as "real" illnesses. Some of the recommendations that have come from this research may help to overcome these barriers to appropriate healthcare. For example, 82% of respondents felt that hospital administrations should allow doctors time to have an annual checkup, while 42% of respondents agreed that it would make it easier for them if the checkup was compulsory. Certainly, the information we have indicates that hospitals should be actively encouraging their medical staff to have regular medical checkups. This would act as a reminder, create an environment in which medical checkups were seen as the norm and not requiring a reason, and perhaps set up life-long patterns of behaviour. SummaryThis short overview of our project does not include the data from the General Health Questionnaire. However, notable links with levels of stress in particular groups of doctors have emerged. This preliminary research indicates that patterns of inappropriate healthcare behaviours develop very early in doctors' careers. We have a responsibility to care for JMOs, who appear to be more vulnerable to stress and its consequences. While we have focused on this group, our results can clearly be extrapolated to the medical profession as a whole. Perhaps the culture of poor self-care that appears to be ingrained in the medical profession comes from within.

Narelle E Shadbolt MB BS, FRACGP, MFM

The training of junior doctors requires a delicate balance between "on the job" experience and quality training. . . . The preregistration year is a time in which training, skills and working role are consolidated under supervision, and it has been suggested that it may be the most stressful period in medical practice.1 In South Australian teaching hospitals, the education and training of doctors in their prevocational years is currently the domain of a team comprising a Director of Clinical Training (DCT) and a Medical Education Officer (MEO), in conjunction with a general clinical training committee. The overarching aim of the DCT–MEO team is to ensure high-quality patient care by guiding and supporting the developing junior doctor. To achieve this, the team works both in and on the system of the public teaching hospital. The DCT–MEO teamThe DCT and the MEO have different, but complementary, roles. The DCT is a senior practising clinician and mentor, whose involvement is of necessity part-time, because of clinical responsibilities within and outside the teaching hospital (Box).2 The MEO, on the other hand, can be more focused on prevocational medical education and, especially if full-time, can provide a consistent presence in the hospital for junior medical officers (JMOs) during their training. The MEO has a range of skills in healthcare education, evaluation and counselling, and gives educational credibility to the team (Box). This team is more effective than each individual acting alone. The complementary skills and roles of members of the early postgraduate medical education and training team Director of Clinical Training Medical Education Officer Multifaceted role Focused role Part-time Full-time Clinical insights Educational insights Patient care expertise Evaluation expertise Clinical teaching Quality monitoring Career advice Counselling skills The MEO in South AustraliaIn mid-1999, MEO positions were established at each teaching hospital by the South Australian Council for Early Postgraduate Training. This model was adapted from one previously developed in Queensland by the Queensland Medical Education Centre with Queensland Health. At this time, the five foundation South Australian MEOs undertook informal needs analyses at the hospitals to gain objective insights into the local system. We asked the questions "What is happening now for JMO education and training?" and "What needs to be done?". From the results of these analyses, we could tailor appropriate strategies for quality improvement of education and training in response to the particular and current needs of the JMOs at individual hospitals. Quality management and evaluation of JMO education and trainingQuality-monitoring and improvement systems are vital in a structure which is responsible for staff development, as the teaching hospitals are for JMO education and training. Quality management is an important role for the MEO with educational evaluation experience. MEOs adopt a wide range of evaluation strategies, including questionnaires, interviews and participant observation, resulting in both quantitative and qualitative data. The MEO encourages and coordinates assessment and feedback from supervisory staff on, for example, JMOs' clinical competence, but also vice versa from JMOs about their supervisors on individual term rotations. The gathering of evaluative data about the individual terms, and on the hospital's education and training program as a whole, is essential for quality improvement. Evaluation must be a continuous processEvaluation must be part of a continuously cycling process that can be managed by an MEO to ensure rapid responses to needs as they arise in a changing environment. All aspects of JMO education and training programs, and the context in which they operate, need to be monitored. De-identified data are then fed back to the program coordinators, and used to inform the process of implementing change, which, in turn, must also be evaluated. The continual gathering of data can provide evidence of systemic problems which could cause excessive workloads, dissatisfaction with rosters, and reduced training opportunities, all of which may affect JMO development and performance.3 Evaluation must result in outcomesEvaluation undertaken because it seems to be "the thing to do" is doomed to failure. People will not engage in evaluations if they never see any results, and failure to demonstrate outcomes will lead to lack of trust in the evaluators. Evaluation must be confidentialIt is difficult for a busy DCT to undertake comprehensive, continuous and confidential evaluation processes unassisted. By definition, an MEO in South Australia is not medically qualified and is thus perceived to be outside the "medical establishment". This is an advantage, enhancing his or her capacity to obtain free and frank responses to questionnaires and interviews, and increasing response rates and the usefulness of the data. An MEO is well placed to demonstrate and maintain confidentiality in evaluative processes and objectivity in reporting evaluation results to the DCT and the hospital management. Support systems for JMOsWhile formal administrative structures can be designed to facilitate the successful progress of JMOs through their service and training commitments, additional, less formal systems are also necessary. Another role for the MEO is to advocate for, initiate and organise professional, personal and educational support for JMOs. This can include: Weekly intern meetings, providing a collegial atmosphere, peer support and debriefing opportunities in a private, relaxed and caring environment;4 A program of intern tutorials specifically for and responsive to the needs of JMOs; and A JMO lounge, which is a private space for relaxation, recuperation and meetings with colleagues away from the ward environment. Provision of a supportive system and atmosphere within the teaching hospital can be facilitated by the DCT–MEO team, giving junior doctors opportunities and encouragement to support each other and themselves.4 A wider role for the MEO beyond JMO trainingA background in education and training means the MEO can help support not only doctors in training, but also their supervisors. This can be achieved through the quality improvement process described above, and by offering practical support and advice, providing, for example, skills in "Teaching-on-the-run" or "How to give constructive feedback". In South Australia, the MEOs as a group offer a wide range of skills, including expertise in education, counselling, management, project development and research. They are a resource that can be called on across campuses and along the continuum from medical school through to specialty training programs. ConclusionEmployment of an experienced postgraduate medical educator by a teaching hospital demonstrates a commitment to medical education and training of JMOs. The DCT and MEO can enhance the profile of JMO education and training within the hospital by active engagement in the work of hospital committees, encouraging mutual feedback between management and junior medical staff, advocating for education and training within the hospital environment, and helping to maintain the "delicate balance between 'on-the-job' experience and quality training" to reduce the potential for distress in junior doctors.1

Anne A Martin BSc(Hons), PhD

Despite our best efforts to create systems and organisational supports to facilitate optimal development for all junior medical officers (JMOs), some will continue to perform suboptimally and experience distress. It then becomes necessary to take an individualised approach to these JMOs. It must be emphasised that there is a clear distinction between distress and impairment. Distress does not imply impairment, although prolonged and unalleviated distress may eventually lead to impairment. North Western Adelaide Health Service (NWAHS) allocates about 50 interns (mainly from Adelaide University Medical School and from the graduate-entry program at Flinders University School of Medicine) between two main public teaching hospitals — The Queen Elizabeth Hospital, which serves a predominantly ageing multicultural population in Adelaide's western suburbs, and the Lyell McEwen Health Service, with an expanding, younger client base in the north. These two hospitals are 25 km apart and together serve some of the poorest socioeconomic areas in Adelaide. This, together with the politically uncertain future of The Queen Elizabeth Hospital, puts NWAHS low on the list of preferred placements for newly graduating medical students. (For the Year 2001 intake, only one of the top 90 graduates indicated NWAHS as first preference.) This means that NWAHS, an already stressed system, may receive a disproportionate share of JMOs at risk of poor performance. Here, I present a step-by-step overview of the processes and insights gained since the medical education officer (MEO) role was introduced at NWAHS in June 1999. Who alerts the MEO and what prompts the alert?Once the support component of the MEO role becomes known, concern about a particular JMO may be raised by the supervising registrars or consultants, the nursing staff, allied health staff, other JMOs, and, at times, a JMO contacts the MEO directly. There is often a sense of relief that there is someone in the system who can deal with these concerns. Most alerts are prompted by concerns about clinical performance. However, pastoral concerns are sometimes implicated (Box 1). Establishing the drivers of distressFollowing an alert, a wider context needs to be established. There is a need not only to check the information, but also to look beyond the obvious (eg, a seeming inability of the JMO to prioritise may disguise an avoidance issue and a host of other factors). Fact finding may involve talking with other members of the unit, or being aware of a particular unit's history with JMOs, and/or the "track record" of the person who initiated the alert, and of the JMO concerned. Of course, there is a need for discretion, whether enquiries are made directly or at a more casual level. Usually, an informal interview is conducted with the JMO to detail the issues raised and note any additional pertinent information. Once the facts are established and a picture begins to emerge, the underlying issues can be more clearly identified, and then decisions can be made and actions taken. The key drivers of JMO distress that have emerged at NWAHS are listed in Box 2. Stressors may be external (ie, to do with the outer environment), or internal (ie, to do with inner processes at a personal level). An example of an important external stressor that is crucial to a JMO's experience is the quality and continuity of registrar presence on a unit. For example, how organised is the registrar? Does the registrar involve the JMO in patient management decisions? How willing is the registrar to teach and extend the JMO? How willing is the registrar to assist and support the JMO during busy periods? And, finally, how available is the registrar when needed? In this regard, the lead-up to physicians' examinations is a particularly stressful time for JMOs. Other external stressors of note include bullying and harassment, particularly the way in which nursing staff can undermine a JMO (or a student). Once covert, these issues are now beginning to be more openly discussed. Having a supportive medical administration, too, can make a big difference to JMOs' sense of wellbeing. This has been clearly documented by end-of-year intern surveys conducted at NWAHS in 1999 and 2000. Highlighted issues included perceived unfair rostering and leave allocation, general unhelpfulness and discourtesy, and bullying and harassment issues. One of the internal stressors listed, professional ethics, has emerged from interviews and end-of-year surveys of JMOs. Issues related to the constant pressure for early — sometimes perceived as too-early — discharge of patients; how "not for resuscitation" orders are interpreted by nursing staff on some wards; and, more generally, the way patients are routinely treated by some health professionals. By the end of the year, some JMOs report disillusionment with a system which they perceive is forced to practise "conveyor belt" medicine. Given that many JMOs entered medicine for altruistic reasons, these ethical issues are a source of distress. Assessment of stressorsBefore proceeding directly to an intervention, an assessment of the stressors is useful. The distinction between external and internal stressors clearly indicates different intervention strategies, although the stressors often involve a combination of external and internal factors. Other aspects of the stressors are useful to consider as well. For instance, has the distress been triggered by a critical incident that has gone unrecognised by the unit and so the JMO has not been debriefed and supported? Also, would the stress be classified as short term, medium term or long term? Periods of short-term stress (a few days to perhaps a fortnight) tend to resolve themselves without causing any lasting problems or major performance concerns; medium-term stress, perhaps for the duration of a particular attachment, may require substantial support; and long-term stress demands attention. Tailoring individual interventionsThese assessments will influence decisions on how to tailor individual interventions to best manage each situation. Listed below are some of the strategies that have been implemented at NWAHS. Clinical learning contract (Box 3)When a JMO's difficulties are related to personal performance, it is most important that this is identified within the first month of an attachment. This allows time for the problems to be discussed by all concerned, a plan of remediation to be constructed, and a performance review to take place before the final assessment. Those involved include the supervising consultant and unit registrar, together with the JMO, and, at times, the MEO or DCT acting in a facilitating and supportive role. The clinical learning contract forms the basis for this process and serves as a simple, documented record of the JMO's progress. Focused coachingIf the medical knowledge base of a JMO is considered inadequate, research registrars can be recruited and paid to provide one-on-one tutoring. Defusing and debriefing after critical incidentsCritical-incident stress is far more prevalent among JMOs than is commonly realised. New doctors may be more affected than their more senior colleagues by the painful events they experience. Their colleagues, who may have become inured to this aspect of the profession, may fail to acknowledge this stress and give adequate support to junior doctors at these times. Often there is a delayed response. A distressing event will occur, and then perhaps a subsequent, relatively minor event will unexpectedly trigger an overwhelming stress reaction. Besides the need for professional intervention at the individual level, this also shows the need to heighten awareness at a systems level and implement training for registrars and supervising clinicians in critical incident defusing and debriefing. Panic promptsSome JMOs temporarily freeze when confronted with an unexpected clinical emergency. I have coined the term "panic prompts" for a small card carried by these JMOs which has a checklist of basic procedures that a JMO would be expected to have worked through before seeking registrar assistance and back-up. At a minimum, this means anticipating the basic information that a registrar would demand. Crisis interventionAt times, MEOs feel like they are operating as a mobile triage service. A JMO may be in such distress that immediate crisis intervention is required. For example, a JMO may need to be taken off duty at once, and the MEO must ascertain whether outside support is available within a short time span, and whether the JMO is able to drive safely or if a taxi may be required. To date there have been four such occurrences at NWAHS. First-line counselling strategiesSome of the first-line counselling strategies are listed in Box 4. The first few relate to general skills that are available to most mature and reasonably sensitive people willing to spend time with another person in distress. The second group applies to people trained in counselling. ConclusionIntegral to the whole process, and the real strength of MEOs, is their independence from medical power structures and from direct involvement in JMOs' evaluation. The MEO, however, should be able to "network" and access hospital and medical authorities. To this extent, the trust placed in MEOs by all concerned (junior doctors, registrars, senior clinicians, and administrators), and the need for confidentiality and discretion, are complex and crucial factors. Professional integrity on the part of the MEO is paramount. The Conference has focused on students and junior doctors in distress. However, it is artificial to consider the problems of students and JMOs in isolation from senior practising clinicians. To what extent are senior clinicians' performances and sense of wellbeing also affected by varying levels of distress; and of course this begs the question — does their distress have an impact on medical students' and junior doctors' wellbeing? We need answers to these questions. 1: What prompts an alert to the Medical Education Officer about a junior medical officer (JMO)? Performance-related concerns Problems with time management (eg, discharge summaries not completed in a timely manner or not adequate; working hours too long; difficulties prioritising). Problems in situations when JMOs provide cover for medical and surgical emergencies, such as during change of shift (short calls). Problems with clinical competence in a specific setting or situation. Interpersonal problems (conflicts and difficulties relating to others). Pastoral concerns Observably high levels of anxiety and tension. Inclined to "self put-down". Crying episodes. Clinical depression. Problems with attitude (eg, perceived arrogant and patronising behaviour; short-tempered, impatient outbursts; or shirking a fair share of the workload). 2: Factors affecting stress levels in junior medical officers External stressors Quality and continuity of registrar presence Helpfulness of nursing staff Nature of the work Type of working environment Medical knowledge Exhaustion — caused by long working hours, intensity of workload, and entry into full-time employment from student lifestyle Supportiveness of medical administration Internal stressors Anxiety, lack of confidence Lack of interpersonal skills (assertion) Physical illness Psychiatric illness Unresolved critical incident stress Professional ethics Personal, non-work-related problems Belief that they have chosen the wrong career 3: Clinical Learning Contract to document assessment of a JMO's performance 4: First-line counselling strategies Non-professional counselling Listening, giving emotional support and clarifying issues. Providing a confidential opportunity for pressure release — "gripe dumping". Reality checks — checking that perceptions are valid. Reframing – reorienting a skewed perception to a more positive perspective. Encouraging the JMO to ask for help and having him or her rehearse doing so confidently. Professional counselling Using problem-solving strategies and skills from a variety of psychological frameworks. Building centring and anchoring triggers which help to maintain confidence and a calm demeanour. Self-awareness and skills coaching in responsible assertion. Self-awareness and skills coaching in anger management.

Karen Grace BA, MSSc(Counselling)

All medical boards have as their primary objectives protection of the public; and maintenance of the highest possible standards of medical care. The Boards are state-based and constituted under Acts of Parliament. However, they are independent, operating at arm's length from government, and are self-funded through medical registration fees. While it is often stated that the medical profession is self-regulated, the reality is that the profession, community groups, politicians and departments of health all have input into the Acts which the medical boards administer. Therefore, it is probably more accurate to say that the medical profession is self-administered rather than self-regulated. There is a widespread misconception about medical boards — that they are populated by grey-haired, eminent, elderly men, long retired from their field of medicine. This is most certainly not true of the New South Wales Medical Board, which also recognises the vital importance of community representation: five of the 22 members of the current NSW Board are from non-medical backgrounds. Activities of medical boardsRegistration of medical practitioners (and, in NSW, medical students): The core activity of all boards is the registration of medical practitioners, ensuring that their qualifications meet a required minimum standard. In NSW, medical students are also registered. This came about when the Board recognised that, each year, a number of young doctors coming to the Board's attention because of illness had problems dating back to their student years. The Board recognised that if it could have been involved earlier the transition of these students to the workforce may have been much smoother. Student registration has been in place in NSW since 1992. The only provisions of the NSW Medical Practice Act 1992 that apply to students are those relating to impairment. Managing poorly performing practitioners: The second domain in which medical boards are active is in managing poorly performing practitioners though a variety of disciplinary and non-disciplinary processes. It is in this area that there is the most variation in the approach of the various medical boards. In NSW, there are 25 000 registered doctors. Every year about 1200 complaints are made against them. Only 20% of these are formally investigated, and less that half of the investigations proceed to a disciplinary hearing. Each year, the NSW Medical Board holds 25–30 Medical Tribunals, with about half these doctors being deregistered. Contrary to popular belief, deregistration is the outcome for only about 1% of doctors about whom complaints are made. Management of "impaired" practitioners: The third domain, and the most important in the context of this Conference, is the management of "impaired" practitioners. While the definition varies from State to State, a practitioner is generally considered to be impaired if he or she suffers from any physical or mental condition which detrimentally affects, or is likely to detrimentally affect, his or her capacity to practise medicine. It is important to recognise that doctors and students may be unwell or disabled without being "impaired", according to its statutory definition. Impairment is very specifically related to risk to the public. For example, if a surgeon develops Parkinson's disease and gives up procedural practice, then he or she is clearly unwell, but not impaired. The single most important factor in determining impairment is the practitioner's insight into his or her illness and its effect on practising medicine. The objective of impairment programs is, like all Board activities, to protect the public. However, a strong secondary objective is to maintain the doctor in safe practice whenever possible. Health ProgramDoctors: Of the 25 000 registered doctors in NSW, about 130 are currently involved with the Health Program. Half have problems with drugs or alcohol, 40% have a mental illness, and the remaining 10% have other medical problems. In the drug-dependent group, pethidine is very much the drug of choice because of its ease of access for medical practitioners. Medical students are more likely to use illicit drugs. In NSW, these registrants would be required to undergo an extended period of urine drug screening, along with other Board monitoring and treatment requirements. Other States have different approaches, and it seems that NSW and Queensland require a much longer period of monitoring than other jurisdictions. Medical students: Of the 25 medical students involved with the NSW health program, 20% have drug or alcohol problems, 70% have a mental illness, and 10% have other conditions, such as motor disability. Criteria for notification of medical studentsThere is still uncertainty in the three medical schools in NSW about which students should be referred to the NSW Board, and when. There are two important criteria: Public protection — is there a risk or a potential risk to the public? An individual with bipolar disorder may pose no risk if the condition is stable, but there is significant potential risk if the individual becomes floridly manic. The needs of the student — if the student is likely to require support or special consideration in their transition into the medical workforce, then early notification is essential. The Board does not want to know about every distressed, unwell or disabled student. Clearly, most of these students are not impaired within the Board's definition. However, if the individual has special needs, there is great value in early notification, as the Board needs time to ensure that a suitable internship can be devised. The NSW Medical Board's approach to impaired students is illustrated by the case study given in the Box. Need for a culture changeNotification of both students and doctors requires a shift in culture. The profession is historically reluctant to "dob in a mate", and problems are frequently "swept under the carpet" or poorly managed in "corridor consultations". Some States and Territories have legislated a statutory obligation to notify impaired practitioners to the Board. There are pros and cons to this approach. Of greatest concern is the potential for mandatory notification preventing unwell doctors from seeking treatment. Flexible approaches to internshipsInternships used to be extremely regimented and prescriptive. In NSW, and I believe in most other jurisdictions, there is now a much more flexible approach. Internships can be individualised in terms of hours, terms, location and duration, provided that the core competencies of internship are achieved. However, flexibility does raise important employment issues. Unimpaired interns have expressed concerns about favouritism and reverse discrimination. In addition, hospitals do not have a limitless capacity to accommodate interns with special needs. In NSW, some hospitals are very good at looking after impaired interns, but it is unfair to overload them. ConclusionsMedical boards discharge their responsibility for public protection in a variety of ways. The structured, compassionate and fair management of impaired practitioners is an important component of a board's work. The NSW Medical Board has 10 years' experience with student registration, and commends it to other jurisdictions, and to students themselves, as a valuable and mutually beneficial approach. Case study — a medical student referred to the NSW Medical Board Dr A was a final-year student when first referred to the Medical Board. He was a mature-age student in an undergraduate program who had been displaying inappropriate behaviour in his clinical terms, and had refused all offers of help by the Faculty. When he was notified by the Faculty, he was in a manic episode of bipolar disorder. The student was independently assessed by a psychiatrist nominated by the Board and placed in a monitoring program. He had a further manic episode, but it was detected early because of the support structure around him. We were able to intervene rapidly and his condition stabilised quite quickly with treatment. We required him to have a treating psychiatrist, and we had his authorisation for the psychiatrist to let us know if he did not comply with treatment or if his health deteriorated. He attended for regular review by the Board-nominated psychiatrist and for Board review interviews on a six-monthly basis. On graduation, we notified his employer of his conditions of registration, as it was important that his internship was conducted in an informed and supportive environment. He did very well, and is now in specialist training. (All colleges have stopped denying specialist training to doctors with conditional registration.)

Alison M Reid MB BS, MHA, FAFPHM

[The comments made in this article and given at the conference were appropriate at the time. Since then, the South Australian Parliament was prorogued and an election held. The proposed new Medical Practitioners Act had not passed both Houses of the Parliament and has therefore lapsed. At this time, I am not aware of what the new Government may include in a Bill it may wish to introduce.] The South Australian Medical Practitioners Act 1983 is currently being reviewed and the new Bill is before Parliament. The new Medical Practitioners Act will call for the registration of medical students with the South Australian Medical Board, and will aim to be supportive of medical students. It will also contain new provisions for protecting the public. Registration of medical studentsRegistration of students has several important pluses for students. It clearly brings them into the ambit of the profession with some status, and it helps identify students who, because of ill-health, may not be able to enter certain areas of clinical practice after completing their studies. Early counselling and input into those professional pathways that will be available can only be of benefit to all concerned. Registration of students is not a new concept. New South Wales has already adopted this approach and it is currently on the agenda of several other States. New provisions for protecting the publicThe approach of the Medical Board in South Australia has always been to support both individual members and the medical profession in general while retaining its statutory requirement of public protection. Under the new Act, the SA Medical Board will require much more information on the health of individual doctors and students, particularly in relation to infectious diseases. While transmission rates of bloodborne viruses from healthcare professionals to patients are low, such transmissions do occur, with potentially serious consequences for patients. As part of the Board's role of public protection, it is appropriate that the Board is made aware of practitioners who are infected with bloodborne viruses so that appropriate protective steps can be put in place. It should be emphasised that these steps would not necessarily or routinely mean denying the right to practise medicine. There is already a requirement in the current Act for a treating doctor to report to the Board, in writing, the details of patients who are medical practitioners, and are suffering from a condition which impairs or may impair their ability to practise medicine safely. The new reporting requirements now place a responsibility on the patient who is a doctor to also report his or her own health status to the Board. Overall, the SA Medical Board will maintain a careful balance of confidentiality, support for the medical profession, including medical students, while looking after the best interests of the general public.

David H Wilde BA(Hons), JP

The Medical Board of Queensland, through its Health Assessment and Monitoring Program, provides active support to the medical profession, particularly to doctors recovering from impairment (ie, illness which has been serious enough to affect their capacity to practise). There are about 50 new referrals to the program each year — 37% have a psychiatric illness, 45% involve drug misuse (other than alcohol), and 7% alcohol misuse. At least 60% of practitioners who come to the Board's attention have a dual diagnosis (eg, depression and drug misuse). Board databases do not specifically collect information on the stage that the doctor has reached in his or her career at the time of illness. However, approximations can be made through manual collation of recent data, with the rough figures on diagnoses in junior doctors being 17% alcohol misuse, 17% other drug misuse, 25% depression, 8% post-traumatic stress disorder, and 17% bipolar affective disorders. Case historiesThe following case histories illustrate the work of the program with doctors recovering from drug misuse and/or mental illness. Identifying details have been altered in the interests of practitioner confidentiality. However, details pertaining to significant events, milestones, Board intervention and outcomes have been reported as accurately as is compatible with maintaining confidentiality. Case 1This young doctor (less than two years after graduation) was rostered to cover ICU alone, with a consultant on remote call. In an endeavour to control stress-related symptoms, he treated himself with benzodiazepines. Their use escalated, as did his symptoms of poor sleep, poor appetite, weight loss and social withdrawal. Recognising that his symptoms were worsening, he sought relief in S8 drugs, which he obtained from the operating theatres (adjacent to ICU). His drug misuse continued (varying in severity) over several years. He was eventually found unconscious in the theatre change rooms. The Board was notified. His primary and most urgent need was for detoxification because of long-term misuse of benzodiazepines and opiates. Once this had been undertaken, an assessment of his fitness to practise was arranged by the Board. A minimum of three months off work was needed, but he had no income protection. Showing considerable initiative (particularly given the severity of his illness), he started a dog-grooming business, and managed to support himself through a lengthy period of time out of the medical workforce. When his medical condition had stabilised, he secured a new medical post with Board support. He was required to fully disclose his medical history to his supervisor, to undergo random urine drug screening (up to 16 tests per month), and was subject to monthly workplace reports from his supervisor to the Board. With the passage of time, reporting and testing requirements have been gradually reduced. He is progressing very well, and there has been no relapse. ChallengesHe needed time off without income protection. He needed to overcome the label of "impaired doctor". Once he had left the hospital he had been working in, there was no sense of duty of care elsewhere. His vulnerable position with his employer necessitated intervention and advocacy even after he was employed. LessonsThere is a need for education of peers to monitor junior doctors and, if necessary, initiate early intervention. If this doctor's drug misuse had been detected earlier, the escalation in drug taking would probably never have occurred. Income protection is essential for all medical practitioners, and should be taken out as early as possible in a career. Insurers are increasingly stringent in refusing insurance or insisting on exclusion clauses for those with a history of mental illness. There is nothing wrong with doing non-medical work for a while, and it can even assist in the recovery process. Long-term stability in the profession can be achieved after an apparent disaster. Case 2This intern developed bipolar illness in the intern year. She was absent from work for three months, and then attempted re-entry. She relapsed and, on medical advice, abandoned her internship. When referred to the Board, she was working in an unskilled, casual position in the hospitality industry. Five years had elapsed and she had been stable for three of those five years. The Board organised a three-month placement for a training clerkship. The hospital was so impressed they offered her a job. She is now in her Senior House Officer year, and has been receiving excellent reports — "She is the best resident I have ever had". As with most practitioners with bipolar affective disorder managed by the Board, it has been necessary to have a long-term prohibition on night duty. After so long "in the wilderness", this young woman has so much to contribute. There have been intermittent relapses, but she has the insight to manage these, and appropriately withdraws herself from the workforce. ChallengesDeskilling — she was away from medicine for five years. She didn't fit in anywhere — she was not a student, but, as she had not completed her internship, she was not really a doctor. There was no apparent benefit to the hospital in taking her on, so organising the initial clerkship took a lot of advocacy. Special rostering needs have remained a long-term issue — she can not do night duty. LessonsSometimes it is just too much to become a doctor and deal with illness at the same time — time out is OK. Even a protracted period away from clinical work does not mean the end of a career and may in fact save it. Sometimes an illness helps doctors bring special empathy to their work. Having been a patient and in hospital can add an extra dimension to doctoring. Case 3This student developed a psychotic illness in sixth year. He took antipsychotic medications for four months and then withdrew at the beginning of his intern year. He then had a relapse and took nine months off. The hospital was very supportive, but when he started his internship again he received very negative reports. He tried a new placement with a different employer so he could get a more objective assessment, but the negative reports continued. After six months, he had a meeting with the Director of Clinical Training, the Medical Education Officer and the Consultant. He decided to abandon internship, disclosing a dulling of cognition when taking antipsychotics. Three weeks later he phoned, relieved and grateful to be off the treadmill. He planned to resume his previous passions for mathematics and languages. His family needed debriefing, which, although outside the Board's brief, was provided with the doctor's consent. They experienced great difficulty coming to terms with what had happened to their wonderful, talented son. The Board staff continued to provide support for job seeking (ie, they continued to engage in advocacy with prospective employers and to help him with his curriculum vitae). He found part-time work in a field in which his excellent interpersonal skills were an asset, and is now studying for an alternative career. ChallengesUltimately, this doctor was just too sick with a chronic illness to embrace the challenges of internship. A small community can be supportive, but can also result in labelling, whether real or perceived. A doctor who is perceived to have "failed" may not be particularly "saleable" to other prospective employers. His family had an enormous emotional investment and no appropriate support or forum. LessonsSometimes it is not worth the personal and institutional cost of continuing to juggle a medical career with serious illness. Sometimes a "good outcome" is the appropriate redesign of career goals. Families of young doctors need support when the goals they have all worked towards are not achievable because of an illness that may not be externally visible. It is not inappropriate to hope that new medications and/or remission of illness may make it possible to revive a stalled medical career. Even when a junior doctor must abandon the profession, the profession should not abandon him or her. The following cases illustrate the need to provide support to an individual to withstand family pressures or pressures from employers, and the damage that can come from breaching confidentiality. Case 4This intern developed a psychotic illness during internship. She presented as very well after the episode, but subjectively felt very fragile, and was certain she was vulnerable to relapse should she return to work. Her family, noting the absence of symptoms, and probably fooled by the coping mechanisms adopted by this very able young woman, became quite impatient after she had taken a month away from work, and started demanding that she return. Likewise, her employer, facing staffing problems, was in regular contact, wanting to know when she would be able to resume work. When she came to the Board's attention, the acute episode had resolved, but she continued to feel vulnerable to relapse. She had not re-established a normal sleep pattern, and continued to feel somewhat dysphoric. At an initial meeting with Board staff, she outlined a timeline for return to work that she felt she could cope with. Board processes were timetabled to coincide with her timeline, allowing her to refer employer and family to the Board in the event of further disagreement about a return to work. The timeline proceeded uneventfully and on schedule. No relapses have occurred to date, and she has become a very valued member of the hospital staff. Assessments are consistently in the range "very high" to "excellent". ChallengesMaintaining a good rapport with hospital administrations, while not necessarily delivering what they need or want, can be very difficult! Dealing with families raises complex issues of confidentiality, boundaries and professional identity. For example, consider the implications of a doctor's mother ringing the Board to argue the case in favour of a return to work! LessonsIn the absence of significant secondary gain associated with prolonging work absence, a doctor who insists that he or she is not fit to return to work should be deemed not fit to return, unless assessment unequivocally refutes that assertion. Empowering a vulnerable return-to-work candidate to control his or her own timetable (with appropriate input from treating health professionals) maximises the chance of a successful return. The normal boundary which would apply to family issues (of not needing to deal with these or become involved) may not be appropriate when dealing with very young doctors still tightly enmeshed in their family of origin. Case 5This intern experienced a single episode of psychosis against a background of depression after using cannabis. She voluntarily withdrew herself from the workforce, and resigned from her intern position. When she was again well enough to return to work, she approached the hospital from which she had resigned (Hospital A), but was told that they had a full staff complement. Another hospital (Hospital B) was approached, and was interested in offering a trial clerkship. This was suddenly cancelled at short notice. Some weeks later, the Medical Superintendent of Hospital B disclosed that the Medical Superintendent of Hospital A had approached him, and had made several statements about the intern's suitability, which resulted in the withdrawal. By this time, the Medical Superintendent of Hospital A had had no association with the intern for over five months. He was not in possession of any current medical reports and, by any description, the statements he made were inaccurate and frankly defamatory. A period of protracted unemployment followed. Eventually, a third hospital was persuaded to offer a trial clerkship. They were very impressed, but unable to offer employment on the basis that they had a full staff complement, and no reserve funding. However, because of the positive reports from the placement, the intern successfully competed for a position in a subsequent open-selection process. Reports have been extremely positive, and there has been no recurrence of either depression or psychosis. ChallengesOnce this intern resigned, nobody felt she was their responsibility. Significant deskilling had occurred, making her even less attractive to prospective employers. A single ill-informed breach of confidentiality had catastrophic consequences for this young doctor, resulting in long-term unemployment and deskilling. LessonsSome senior colleagues still don't understand confidentiality. A breach of confidentiality, even made in good faith, can have unintended implications. A person should not make a comment if he or she is not prepared to put it in writing! Encourage tenacity and self-belief, even in the face of disheartening failures. It pays off in the long run.

Jillann F Farmer MB BS, FRACGP

The first two breakout groups comprised medical students and prevocational trainee doctors, and the third delegates from medical boards, postgraduate councils and hospital administrators. The groups reported back on student issues, prevocational and trainee doctor issues and medical board issues. This is a condensed summary of the reports from each group. Student issuesIdentifying the distressed or impaired student is not the problem; peer groups are usually the first to be aware of this, but don't know what to do about it. We need a "Dummy's guide to helping a mate" — a simple flowchart outlining who to contact for each particular problem. A structured process of identification and notification of distressed or impaired students is needed. All students could be interviewed, perhaps annually, and the same questions asked. If the time can be found to interview recent graduates for selection for hospital placements, then it should be possible to find time to interview students to identify distress. An independent body is needed to assist distressed or impaired students at every medical school (an example is the general practitioner program at Melbourne University). This should be completely independent of the assessment process, and should only report back to the Faculty if there is a problem that needs to be addressed. Such a GP program would need to be well advertised. The more people who become involved, the less the stigma. Visiting an independent GP is then seen as positive rather than punitive. Confidentiality is a major issue. Career prospects should not be endangered. Medical schools should develop a database of mentors or people to contact (eg, GPs or social workers who are not members of the academic staff). They should be available at all campuses, hospitals and rotations, and should provide feedback about global issues for the student cohort — not individual students' problems. This would allow for prevention. Students would also need to constantly evaluate such a system. There would be no advantage if the GP appointed was not up to the task. Mentoring eases problems during transition periods (eg, going from Year 12 at school to first year at university, and during the final two years of the medical course when clinical work predominates (Years 3 and 4 for graduate courses and Years 5 and 6 for undergraduate courses). There are logistical issues to resolve. If mentoring is voluntary for both mentor and mentoree, the "lurkers" may still miss out. Special programs are needed for high-risk groups, including non-English-speaking students. They may need extra courses, but not special courses, as this can be alienating. The Personal and Professional Development tool (ie, using course interviews and essays to identify problems) is not the answer if used in isolation. Prevocational and trainee doctor issuesWho should identify the student and junior doctor in distress? Everyone. A cultural change is needed. There is a culture in medicine of not admitting faults, and of weakness being seen as failure. Confidentiality is the key. Reporting systems should be independent of career prospects. Referral can be self-referral, or referral by peers, resident medical officers, registrars, consultants, or nursing staff. There should be a transparent pathway of events and the implications of reporting which is independent of career pathways. Who should be informed or involved in the management of those in distress? Hospitals should have a list of people available for first contact (ie, staff GP, medical education officer, and others). Management could involve the Doctors' Health Advisory Service and the junior doctor's own GP. Directors of clinical training or clinical supervisors need to be aware of individual doctors' needs, but do not need to be aware of the problem itself. It is important that those providing help are trained and have some background in the kinds of services needed. What action should be taken? Prevention. First point of contact outside of the medical framework. Independent follow-up. Half a day's paid leave each year for consulting a GP, with consideration given to making it mandatory. Regular pager-free forum for debriefing. Support and resources for JMOs (ie, adequate staffing and cover for leave or sick leave. Others should not have to take up the slack). Education of supervisors, registrars, consultants. Education about junior doctors' responsibilities. Education about time management. Comprehensive orientation. Resources, such as common room and dictating room. Management. Must be confidential, independent of training, and involve a clear pathway of processes to be followed. Information about students should be transferred from the medical school to the hospital medical administration, but this is complicated by privacy regulations. In response to a question about whether it would be defamatory if universities passed on information which might affect a doctor's career, a medical school dean said the individual student should be involved. It would be easier if the student was aware that the university was going to ask the hospital to give him or her an appropriate internship environment. Comment was made about the importance of a supportive administration. This support should extend beyond working conditions and rosters to social activities, housing and other matters. The role of medical boardsWho should identify the student and junior doctor in distress? Everyone, but colleagues have a professional responsibility for doing so. The medical board's role is not punitive; it must be seen to be supportive. Who should be informed or involved in the management of those in distress or impaired? Medical boards — but only if the student or doctor is impaired. The boards intervene when public safety issues are involved. The matter can usually be resolved at a local level. What action should be taken? There is a huge role for medical boards in promoting a culture change by providing information on the support they provide to impaired doctors, and by influencing employers to provide support and mechanisms for assisting junior doctors. Most of the profession hopes that their only contact with the medical board will be to obtain registration and to pay their annual fee; they hope never to hear from them again. Medical boards need to be more proactive in promoting their image as caring and supportive, not punitive. It was pointed out that universities need to be more aware that the faculties of medicine are training people to be doctors, with all the implications of providing safe medical care for the community. Faculties of medicine are not just producing medical graduates. With imminent registration of medical students with medical boards in other States besides NSW, there needs to be a dialogue established between medical boards and university councils.

Simon M Willcock MB BS, FRACGP

Objective: To compare the cost of ambulatory blood pressure monitoring (ABPM) with the putative savings made through treatment avoided by identification and non-treatment of those with "white coat" hypertension.Design: A cost analysis based on a model of four alternative strategies (no ABPM, yearly, two-yearly, or three-yearly monitoring) over a seven-year period applied to a case series from Australian general practice.Participants: 62 patients newly diagnosed by their GPs as having hypertension and requiring drug treatment.Main outcome measures: The proportion of patients shown to not need treatment. The discounted costs to the Pharmaceutical Benefits Scheme, Medical Benefits Scheme and patients.Results: 16 of 62 patients (26%; 95% CI, 15%–37%) were normotensive on ABPM and did not require treatment. All monitoring strategies are more expensive in the first year, but the initial costs are offset by year 3 and the monitoring strategies are cost saving thereafter. Sensitivity analysis shows that this result holds across a range of costs of pharmacotherapy and proportion of patients with white coat hypertension.Conclusion: The additional costs of 24-hour ABPM in the first year are offset by savings associated with patients with white coat hypertension who would otherwise have been treated.

Ben Ewald BMed, MMedSci(Epid) · Brita Pekarsky BEc(Hons), DipHEc

The United Kingdom National Health Service (NHS) has experienced 10 years of primary care budget holding in a variety of forms. Half of all general practitioners had joined the GP fundholding scheme by 1997, and many others had joined broader GP commissioning groups, but fundholders controlled only about 20% of the budget for hospital and community health services. Research on fundholding and commissioning groups suggests that delegation of budgets produced some gains in the range and effectiveness of services, but also had significant management costs and inequities. From 1999, all primary care professionals joined Primary Care Groups, which are now becoming Primary Care Trusts (PCTs). PCTs will control three-quarters of the healthcare budget and provide all primary and community services as well as commissioning hospital care. Control of a unified healthcare budget presents opportunities to improve quality, increase integration of services, reduce inequities and improve health. However, PCTs are threatened by a growing gap between capacity and expectations, and by continuing tension between devolution of power and increasingly prescriptive management by central government.

David Wilkin MSc, PhD

Australia needs a distinctive “rural health” approach that recognises the valuable role played by the “outback” in our economy and our national psyche The year 2002, the "Year of the Outback", is an opportune time to reflect on why rural health matters and why it continues to be important for Australia. It is the culmination of a decade of initiatives and activity by governments, health organisations and communities seeking to address the "problem of rural health". Rural health emerged in the 1990s as an identifiable field of activity focusing on improving the health status and meeting the specific health needs of people living "out back" of metropolitan areas. The key rural health issues are medical workforce supply, including appropriate training and education; transport and access to appropriate services; funding and costs to patients; and the health status of Aboriginal and Torres Strait Islander peoples in particular, which remains a national shame.1 Under strong pressure from the rural electorate and from advocacy bodies such as the National Rural Health Alliance, there has been a positive government response to rural health issues in recent years. This has included a policy framework that coordinates different levels of government;2 support for advocacy groups and rural professional associations; a significant investment in rural and remote academic infrastructure through the university departments of rural health and rural clinical schools;3 and increased funding for regional and Aboriginal health services. As it is too early to fully evaluate the outcomes of Commonwealth investment in rural health, a sustained effort is required. Rural health issues warrant specific and ongoing attention for a number of reasons. Firstly, outback Australia is different from metropolitan Australia. While the defining characteristic of rural health remains its geography (and related issues of access to healthcare services), rural and remote Australia is also sociologically, culturally, economically and spiritually different from metropolitan areas, as well as internally diverse. It is these characteristics that define the health behaviour of its residents, determine their health status and influence the way health and medical care is provided.4 Nowhere is this more evident than in dealing with the healthcare needs of Aboriginal and Torres Strait Islander peoples in rural and remote regions. Secondly, rural health matters because of health differentials between the city and the outback. Nationally, there is a trend towards a higher mortality rate with increasing remoteness, mostly attributable to the higher proportion of Aboriginal and Torres Strait Islander peoples in remote and very remote regions.5 Given the right of all Australians to optimal health and equitable access to health services, the significantly poorer health status of people in outback Australia remains a fundamental concern. Thirdly, improving rural health is integral to rural and regional development in Australia. Currently, outback Australia fares worst in statistical comparisons of the underlying social determinants of health — namely, housing, employment, income level, education, transport, and social security.6 Good health does not result from access to health services alone. Without a comprehensive regional development policy that focuses on a healthy rural economy, many outback communities face a bleak future — a future characterised by continued poor health status of rural dwellers. Complementary local initiatives based on community empowerment will also be required to address specific problems. Lastly, rural health matters because of the valuable lessons to be learned from the many innovative solutions that have arisen in response to the problems of rural health in Australia. The tyranny of distance, the deficit of resources and the passion of a number of dedicated practitioners to cater for the diverse geographical circumstances of non-metropolitan Australia have resulted in many innovative health sector responses, including the Royal Flying Doctor Service, multipurpose and regional health service models, and telemedicine. Nurse practitioners (a concept currently being trialled in several States) have been working effectively in Australia's remote communities for decades. Australia is a world leader in rural health education, particularly medical education.7,8 Implementation of a true primary health care approach has long characterised the way healthcare is practised and delivered in many small outback communities, particularly by Aboriginal community controlled health services.9 In summary, innovation born of both local need and community action is a hallmark of much rural and remote healthcare practice. Strong rural and regional representation in setting national policy is imperative. Moreover, improved coordination between government departments and between different levels of government on issues affecting rural areas is required. Metropolitan-based clinicians, educators, policymakers and those responsible for implementing health programs should at the very least have an awareness of the geographical, economic and cultural diversity of their constituents and patients. We in the medical profession can collectively continue to press for appropriate health infrastructure, improved access to education and economic opportunities for rural and remote communities. The issue of how the "outback" is defined (whether in terms of "rural" or "remote" areas) is likely to be an ongoing debate, if for no other reason than its significance in terms of resource allocation and monitoring of health outcomes. What should not be in dispute, however, is the need for a distinctive "rural health" approach and national recognition of the valuable role in the Australian economy and psyche played by a healthy "outback" in all its diversity.

John Wakerman MTH, FAFPHM, FACRRM · John S Humphreys BA(Hons), DipEd, PhD