Medical education

Paracentesis is a low bleeding risk procedure which can be carried out safely even in patients with advanced cirrhosis

John J Harvey · Ralley Prentice · Jacob George

Medical practice weights clinical staging models, so why not a staging model for medical practitioners themselves?

Gordon B Parker

Health professionals must be prepared to address the health risks and impacts of climate change

Hayden Burch · Laura J Beaton · Grace Simpson · Ben Watson · Janie Maxwell · Kenneth D Winkel

To the Editor: Data from the United States, the United Kingdom, and Canada have highlighted rapidly rising medical education and specialty training costs as a key deterrent to diverse and lower socio‐economic medical graduates from pursuing specialty training. Australia is likely to be experiencing similar patterns, but there have been little published data or research in the domain. For example, a study into costs of specialty surgical training in the United Kingdom and Ireland revealed that medical officers can spend up to £71000 on mandatory training costs during their Fellowship,1 on an average junior medical officer salary of £41000 pounds per year.2 This does not include the additional expected costs such as conferences and postgraduate degrees. In the background, mean debt on graduation from medical school has increased by 55%, from £17892 in 2004 to £27655 in 2014.3 A 2015 study predicted that most English medical students will be unable to repay their student loan before reaching the 30‐year write‐off.4 Australia is experiencing similar forces. When university fees were deregulated in 2014, the then Australian Medical Association president Brian Owler5 and the Grattan Institute6 predicted that full‐fee domestic places in Australian medical schools could rise by up to 270% to $70000 per annum. As foretold, a full‐fee domestic student now pays up to $77888 per year tuition, for a total estimated course fee of $335707 (Doctor of Medicine, University of Melbourne, 2022),7 which exceeds the combined HELP (Higher Education Loan Program) loan limit of $156847.8 Unlike overseas, there are no reports on medical specialty training cost trends in Australia. However, archived publicly available data give a general sense that local costs are rising much like those overseas. For example, annual training fee sums range from $483 (Royal Australian College of General Practitioners9) to $5714 (Australasian College of Dermatologists10) between colleges. This fee covers mandatory trainee subscription or membership to the college but does not include all the other mandatory costs such as exam and elevation fees, which vary between training programs. There is undoubtedly considerable difference in fee structures, and such numbers are difficult to compare between colleges. Nevertheless, without transparent data, we are unable to interrogate the concerns that have been identified in overseas studies. The ramifications are potentially vast and varied. New Zealand data show that student loan debt is a common influence on choice of specialty and is a consideration when choosing to stay in the country to practise once trained.11 This may lead to long term consequences for the structure of the medical workforce and appropriate service delivery for patients. As a first step, it is critical that we take action to improve collection and transparency of medical training cost data in Australia.

James Brown

Coordinated systemic change and enhanced access to care are needed to improve doctors’ wellbeing

Chanaka Wijeratne · Margaret P Kay · Mark H Arnold · Jeffrey CL Looi

To the Editor: The concepts presented by Coman and colleagues1 parallel international trends within anatomical societies, where attitudes on human remains used for educational purposes are under scrutiny.2 Illuminating issues around legacy collections, and pressing for further clarity, transparency and appropriate cultural and ethical solutions, is important for the proper treatment of these precious resources. It is also necessary given recent events that have raised concerns within the public about how human remains and anatomical collections are treated under the guise of education.3 We strongly support the points made by Coman et al around development of repatriation policies for privately held bones, but we respectfully suggest additional considerations. The suggestion “Medical ethicists assert that in the absence of consent, anatomical specimens … should be destroyed”1 is not congruent with current suggestions and practice.4 Anatomical collections that have no provenance or consent are often used as teaching resources and represent the tangible legacies of histories of this field of science. As such, they serve the additional educational purpose of eliciting discussions on contemporary ethical and professional practice.5 There are also benefits associated with using real bones as opposed to three‐dimensional or plastic copies that do not retain the same weight, detail or nuanced anatomical features. Arguments do exist for disposition of unconsented collections, but these should be considered against the educational value these remains deliver and the social, ethical and cultural concerns around their ongoing use. In proposing consultation across various groups to clarify appropriate practice around “managing the legacy of human bone use in education,“1 we suggest it is necessary to include other specific interest groups to ensure community‐appropriate practices are developed. It is essential that community input is acquired, with indigenous representatives contributing knowledge and perspective. In addition, input from organisations that contribute expertise specific to national and international standards and practice are necessary. This should include local organisations, the Australian Institute of Anatomical Sciences and the Australian and New Zealand Association of Clinical Anatomists, and globally, the International Federation of Associations of Anatomists ethics committee. Such broad input is necessary to ensure guidelines are fit for purpose in a global education community.

Jon Cornwall · Sabine Hildebrandt · Thomas Champney

No consensus on research skills in medical curricula perpetuates the unmet need for clinician researchers

Diann S Eley · Wendy Hu · Nicholas J Talley

Cradle-to-grave regional programs featuring immersive community engaged education are needed to ensure a sustainable rural medical workforce

Roger P Strasser

To the Editor: We read with interest the letter by Withers and colleagues1 highlighting the research waste generated by the inclusion of research in the selection criteria for specialist training in Australia and Aotearoa New Zealand. We agree the inclusion of research for selection or completion of specialty training produces unintended incentives that contribute to poor quality studies and research waste. We also support the notion that “research utilisation, research training, or participation in large research teams” should be prioritised by colleges. Selection criteria for medical specialty training should incentivise contribution to high quality projects and the development of research literacy and skills, rather than publishing many small, low impact articles. Student‐ and trainee‐led collaborative research groups, such as the TASMAN (Trials and Audit in Surgery by Medical Students in Australia and New Zealand) Collaborative, provide a promising solution to this research waste.2,3 Similar groups have emerged locally and internationally and have successfully delivered large randomised controlled trials and cohort studies.2,3,4 These high impact publications have provided practice‐changing results4 as well as training and opportunities for collaborators to develop research skills. Locally, medical students, junior doctors and surgical trainees have contributed to the recent SUNRRiSE (Single Use Negative Pressure Dressing for Reduction in Surgical Site Infection Following Emergency Laparotomy) randomised controlled trial,5 and POSTVenTT (Postoperative Variations in Anaemia Treatment and Transfusions) prospective audit,6 the results of which are eagerly awaited. Despite this, the contribution to collaborative research studies is not currently recognised for selection into most specialty training programs in Australia or Aotearoa New Zealand. We echo the calls of our international counterparts for participation in collaborative research to be accounted for in applications for postgraduate training.7 We applaud the Royal Australasian College of Surgeons and General Surgeons Australia for incorporating collaborative research as part of the selection criteria and the points‐based research requirements during General Surgical Education and Training in 2022,8,9 and hope that other specialties follow suit. We look forward to the emergence of student‐ and trainee‐led collaborative groups from other medical specialties in Australia and Aotearoa New Zealand. Further recognition of collaborative research will improve research skills in medical graduates, reduce research waste and, most importantly, generate meaningful data to improve patient outcomes.

TASMAN Collaborative

Information from trusted influential messengers that is clear and consistent might be successful in addressing patients’ beliefs in health-related conspiracy theories

Mathew D Marques · Karen M Douglas · Daniel Jolley

Recruitment to and retention in rural practice were higher among graduates with extended RCS experience

Alexa N Seal · Denese Playford · Matthew R McGrail · Lara Fuller · Penny L Allen · Julie M Burrows · Julian R Wright · Suzanne Bain‐Donohue · David Garne · Laura G Major · Georgina M Luscombe

Medical educators and representatives of medical student associations in Australia and New Zealand are collaborating on an initiative on climate change and health in medical education

Diana L Madden · Graeme L Horton · Michelle McLean

My senior colleague is starting to wind down toward retirement and hasn’t fully adjusted to having our department meetings on Zoom

Mark Lavercombe

Increasing same-day procedure rates will involve a complex interplay of pre-and post-operative decisions by hospitals, surgeons, and patients

Joanna MZ Mills · Georgina M Luscombe · Thomas J Hugh

The general practitioner supervisor is a key element of the apprenticeship model, ensuring the development of a strong and capable GP workforce

Gerard Ingham · Caroline Johnson

Medical providers who learn physical examination techniques early in medical training can spend years honing the craft of observation, palpation and auscultation

Stephen W Russell · Maja K Artandi

Clinicians, the experts in care delivery, are well placed to drive health system improvements

Sabe Sabesan · Lynden Roberts

Bananas are not only healthy snacks during breaks, but also good for improving simple and vertical mattress suturing skills

Geoffrey Murphy · Muhammad A Khan · Adil Lathif · John Preddy

To the Editor: A significant driver of research waste is the incentive to do research for career progression, rather than for its relevance and patient impact, especially when volume is rewarded over quality.1 We previously found that most specialty training colleges mandate that trainees conduct research, often without requiring research training and appropriate supervision. The focus tends to be on completing projects and leading research, rather than on learning fundamental research principles.2 We also wanted to understand how these incentives are built into the selection process for specialty training programs before the training even begins. In 2020, we reviewed the research‐related selection criteria on publicly available documents and websites for the training programs of 63 Australian and New Zealand specialty colleges and their subspecialty divisions. These were categorised as mandatory or encouraged; for those that used a points‐based system to grade the application, we extracted the proportion that research was worth to the overall application. While no colleges stated that research was a mandatory requirement to apply to a training program, 46 encouraged research on the prospective trainee’s application and 12 used a points‐based system to quantify their research activities (Box). Only five did not mention research. Of the 12 colleges using a points‐based system, 11 allocated points only to leading research — where the application specifically states that the applicant must be first or second author on journal articles, primary presenter at conferences, or take a leadership role in research — nine of which required this research to be conducted in the previous 4–5 years. Ten made some reference to quality, although these were often vague or generic (Box). Research was worth a median of 25% of the curriculum vitae (CV), and 7% of the overall application. This represents a numerically small but critical proportion of the overall application, since research is often used to differentiate candidates, despite number of publications at training entry being negatively correlated with clinical performance.3 As put by Doug Altman, “The length of a list of publications is a dubious indicator of ability to do good research; its relevance to the ability to be a good doctor is even more obscure”.4 No colleges allocated points for research utilisation, research training, or participation in large research teams. It appears to be far more advantageous for applicants to complete several small, low impact projects within a short time frame as first author than a single well designed randomised controlled trial as middle author. This focus on leading research leaves junior doctors vulnerable to poor quality research experiences and outputs without structured guidance and supervision.5 The current selection criteria for college training programs encourage high volume, CV‐padding research with little regard for quality or value‐adding to their field. The value of using or participating in research is apparently ignored, reducing incentives for doctors to learn good research practices and progressively acquire research skills. We posit that this is contributing to research waste. Box – Research selection criteria for applications to Australian and New Zealand medical specialty college training programs Research selection criteria Colleges n (%) Total number of colleges 63 Colleges with publicly available application documents 61/63 (97%) Mandatory 0/63 (0%) Encouraged 46/63 (73%) Encouraged with points 12/63 (19%) Authorship priority* 11/12 (92%) Research topic must be specialty‐specific 5/12 (42%) Time limit (median) 9/12 (75%)† Quality 10/12‡ (83%) Not mentioned 5/63 (8%) * First or second authorship on journal articles or primary presenter at conferences. † One college had a limit of 4 years; all others had a limit of 5 years. ‡ Quality — any mention, including peer‐reviewed, impact factor of journals, and fewer points for case reports.

Caitlyn Withers · Christy Noble · Caitlin Brandenburg · Paul P Glasziou · Paulina Stehlik

Medical students with disabilities bring lived experience as patients, with a positive impact on school culture and learning

Liz Fitzmaurice · Kenneth Donald · Carl Wet · Dinesh Palipana

Fragmented patient care can lead to missed diagnoses, inappropriate prescribing and failure of preventive medicine

Jack Marjot · Georgie Haysom · Penny Browne

To the Editor: A 35‐year‐old man born in Dire Dawa, Ethiopia, with childhood exposure to swimming in rivers, migrated to Australia 18 years ago. He presented with recurrent gastrointestinal bleeding. His index gastroscopy revealed portal hypertensive gastropathy and large oesophageal varices with high risk stigmata of recent bleeding requiring banding. Abdominal ultrasonography and transient elastography excluded liver cirrhosis. Six weeks later, he re‐presented with recurrent severe haematemesis associated with dark maroon rectal bleeding. Repeat urgent gastroscopy and flexi‐sigmoidoscopy revealed oesophageal varices without active bleeding. On sigmoidoscopy, a large amount of dark blood was seen, presumed to be related to rapid transit from recent oesophageal variceal bleeding. In the next 48 hours, a repeat colonoscopy was performed. Colonoscopy identified yellowish nodules throughout the colon with diffuse telangiectasia (Box, A and B). Mucosa was oedematous and friable. Aphthous ulcers were seen in the transverse colon and biopsies were obtained. No polyps or focal source of colonic bleeding were evident. Histopathology confirmed the presence of cystic ova resembling Schistosoma in the lamina propria immediately adjacent to crypts. Although classical granuloma formation was absent, aggregation of eosinophils was seen around a ruptured ovum (Box, C and D). Indirect assay via serology testing was positive for Schistosoma mansoni antibody (titre of 1:640). His eosinophil count was normal and stool microscopy was negative. He was treated with praziquantel. Four months later, a follow‐up gastroscopy revealed stable appearance of grade 1 oesophageal varices without high risk features. Routine variceal surveillance had been organised but not further colonoscopies. Schistosomiasis affects over 200 million people worldwide but is not acquired in Australia. In a national survey in Ethiopia, 37.3 million individuals were living in endemic areas.1 Schistosoma mansoni is the commonest species to cause intestinal and hepatic schistosomiasis. In the 2016 national census, there were 11 795 people in Australia who were born in Ethiopia, 64.3% (7584) of whom were Australian citizens.2 Most screening data for schistosomiasis in Australia are based on African refugees, with 37% in Newcastle, 38% in Hobart and 12% in Melbourne.3 Despite anecdotal knowledge, there are no published cases of non‐cirrhotic portal hypertension related to schistosomiasis in Australia. As a multiracial country with high immigration and tourism, increased recognition in Australia is paramount. Box – Colonoscopy showing widespread yellowish nodules (arrows) with oedematous and friable mucosa (A) and diffuse telangiectasia (B); and histopathology showing aggregation of eosinophils surrounding a Schistosoma ovum(C) and a cross‐sectional image of a Schistosoma ovum (D)

Julia Lim · Shweta Sharma · Damian Dowling