Topics

Ethics and law

Victoria's voluntary assisted dying law will soon come into effect; a remaining challenge is effective clinical implementation

The Voluntary Assisted Dying Act 2017 (Vic) (VAD Act) will become operational on 19 June 2019. A designated 18‐month implementation period has seen an Implementation Taskforce appointed, and work is underway on projects including developing clinical guidance, models of care, medication protocols and training for doctors participating in voluntary assisted dying (VAD).1 While some have written on the scope of, and reaction to, the VAD legislation,2,3,4 there has been very little commentary on its implementation. Yet, important choices must be made about translating these laws into clinical practice. These choices have major implications for doctors and other health professionals (including those who choose not to facilitate VAD), patients, hospitals and other health providers. This article considers some key challenges in implementing Victoria's VAD legislation.

Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, QLD

Correspondence: bp.white@qut.edu.au

Competing interests:

Ben White and Lindy Willmott have been engaged by the Victorian Government to design and provide the legislatively mandated training for doctors involved in voluntary assisted dying. Lindy Willmott is also a member of the board of Palliative Care Australia, but this article only represents her views.

1. Victorian Government Department of Health and Human Services. Implementation Taskforce. https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/end-of-life-care/voluntary-assisted-dying/vad-implementation-taskforce (viewed Sept 2018).
2. Yoong J, Franco M, William L, Poon P. Perspectives of cancer treatment providers regarding voluntary assisted dying in Victoria. Intern Med J 2018; 48: 770–773.
3. Beardsley C, Brown K, Sandroussi C. Euthanasia and surgeons: An overview of the Victorian Voluntary Assisted Dying Act 2017 and its relevance to surgical practice in Australia. ANZ J Surg 2018; 88: 956–958.
4. Karapetis CS, Stein B, Koczwara B, et al. Medical Oncology Group of Australia position statement and membership survey on voluntary assisted dying. Intern Med J 2018; 48: 774–779.
5. Premier Daniel Andrews. Voluntary assisted dying model established ahead of vote in Parliament [media release]. https://www.premier.vic.gov.au/voluntary-assisted-dying-model-established-ahead-of-vote-in-parliament/ (viewed Sept 2018).
6. White BP, Willmott L, Cartwright C, et al. Comparing doctors’ legal compliance across three Australian states for decisions whether to withhold or withdraw life‐sustaining medical treatment: does different law lead to different decisions? BMC Palliat Care 2017; 16: 63.
7. Van Wesemael Y, Cohen J, Onwuteaka‐Philipsen BD, et al. Establishing specialized health services for professional consultation in euthanasia: experiences in the Netherlands and Belgium. BMC Health Serv Res 2009; 9: 220.
8. Australian Medical Association. AMA Code of Ethics 2004; editorially revised 2006; revised 2016: para 2.1.13. https://ama.com.au/system/tdf/documents/AMA%20Code%20of%20Ethics%202004.%20Editorially%20Revised%202006.%20Revised%202016.pdf?file=1&type=node&id=46014 (viewed Sept 2018).
9. Downie J. Medical assistance in dying: lessons for Australia from Canada. QUT Law Review 2016; 17: 127–146.

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Perspectives

“Better health in the bush”: why we urgently need a national rural and remote health strategy

John Wakerman and John S Humphreys

Med J Aust 2019; 210 (5): . || doi: 10.5694/mja2.50041
Published online: 25 February 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Health services administration

What are the problems in rural health service delivery and what can we do about them?

For decades, the Australian Government has been wrestling with how to “fix the rural health problem”. Long‐standing problems of workforce shortages and maldistribution, difficulties with recruitment and retention, and inadequate access to, and availability of, appropriate services persist.1 These contribute to the poor health status of many non‐metropolitan Australians, especially Aboriginal and Torres Strait Islander populations, despite the fact that governments spend millions of dollars annually on specific rural and remote health programs.2

1 Flinders Northern Territory, Flinders University, Darwin, NT
2 School of Rural Health, Monash University, Bendigo, VIC

Correspondence: john.wakerman@flinders.edu.au

Acknowledgements:

John Wakerman receives funding from the Australian Government Department of Health, the Northern Territory Government Department of Health and the Medical Research Future Fund through the Central Australian Academic Health Science Centre.

Competing interests:

No relevant disclosures.

1. Mason J. Review of Australian government health workforce programs. Canberra: Australian Government Department of Health; 2013. http://www.health.gov.au/internet/publications/publishing.nsf/Content/work-review-australian-government-health-workforce-programs-toc (viewed Feb 2019).
2. Australian Institute of Health and Welfare. Australia's health 2018 (Australia's health series no. 16; Cat. No.AUS 221). Canberra: AIHW; 2018. https://www.aihw.gov.au/reports/australias-health/australias-health-2018/contents/table-of-contents (viewed Feb 2019).
3. Australian Health Ministers Conference. National rural health strategy. Canberra: Australian Government Publishing Service; 1994. http://ruralhealth.org.au/sites/default/files/healthy-horizons/national%20rural%20health%20strategy%2C%20march%201994.pdf (viewed Feb 2019).
4. Kwan MMS, Kondalsamy‐Chennakesavan Ranmuthugala G, et al. The rural pipeline to longer‐term rural practice: general practitioners and specialists. PLoS ONE 2017; 2017(12): e0180394.
5. Playford D, Ngo H, Gupta S, Puddey IB. Opting for rural practice: the influence of medical student origin, intention and immersion experience. Med J Aust 2017; 207: 154–158. https://www.mja.com.au/journal/2017/207/4/opting-rural-practice-influence-medical-student-origin-intention-and-immersion
6. McGrail MR, Russell DJ, Campbell DG. Vocational training of general practitioners in rural locations is critical for the Australian rural medical workforce. Med J Aust 2016; 205: 216–221. https://www.mja.com.au/journal/2016/205/5/vocational-training-general-practitioners-rural-locations-critical-australian
7. Buykx P, Humphreys J, Wakerman J, Pashen D. Systematic review of effective retention incentives for health workers in rural and remote areas: towards evidence‐based policy. Aust J Rural Health 2010; 18: 102–109.
8. Thomas SL, Wakerman J, Humphreys JS. Ensuring equity of access to primary health care in rural and remote Australia: what core services should be locally available. Int J Equity Health 2015; 14: 111.
9. Wakerman J, Humphreys JS, Wells R, et al. Primary health care delivery models in rural and remote Australia: a systematic review. BMC Health Serv Res 2008; 8: 276.
10. Humphreys JS, Wakerman J, Wells R, et al. “Beyond workforce”: a systematic solution for primary health service provision in small rural and remote communities. Med J Aust 2008; 188: S77–S80. https://www.mja.com.au/journal/2008/188/8/beyond-workforce-systemic-solution-health-service-provision-small-rural-and
11. National Rural Health Alliance. Australia's health system needs re‐balancing: a report on the shortage of primary care services in rural and remote areas. Canberra: NRHA, 2011. http://ruralhealth.org.au/document/australias-health-system-needs-re-balancing-report-shortage-primary-care-services-rural-and (viewed Feb 2019).
12. Zhao Y, Russell DJ, Guthridge S, et al. Cost impact of high staff turnover on primary care in remote Australia. Aust Health Rev 2018. https://doi.org/10.1071/ah17262. [Epub ahead of print]
13. Reeve C, Wakerman J, Humphreys JS, et al. Strengthening primary health care: achieving health gains in a remote region of Australia. Med J Aust 2015; 202: 483–487. https://www.mja.com.au/journal/2015/202/9/strengthening-primary-health-care-achieving-health-gains-remote-region-australia
14. Buykx P, Humphreys JS, Tham R, et al. How do small rural primary health care services sustain themselves in a constantly changing health system environment? BMC Health Serv Res 2012; 2: 81.
15. Carey TA, Sirett D, Wakerman J, et al. What principles should guide visiting primary health care services in rural and remote communities? Lessons from a systematic review. Aust J Rural Health 2018; 26: 146–156.
16. Humphreys JS, Wakerman J. Primary health care in rural; and remote Australia: achieving equity of access and outcomes through national reform. A discussion paper for the national health hospitals reform commission. 2008. https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id%3A%22library%2Fjrnart%2FTAAS6%22 (viewed Feb 2019).
17. Humphreys J, Wakerman J. Learning from history: how research evidence can inform policies to improve rural and remote medical workforce distribution. Aust J Rural Health 2018; 26: 329–334.

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Letters

Increasing registrations on the Australian Organ Donor Register

Gail Moloney, Michael Sutherland, Maddison Norton, Alison Bowling and Iain Walker

Med J Aust 2019; 210 (3): . || doi: 10.5694/mja2.50000
Published online: 18 February 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Health occupations

Environment and public health

Social determinants of health

To the Editor: Many people are aware that Australia has an opt‐in system for recording organ donation decisions; and many are also aware that, historically, donation decisions were recorded on the driver's licence. What is not well known is that, in 2000, the Australian Organ Donor Register (AODR) was introduced as a register of consent (or objection), and that, between 2005 and 2012, the recording of donation decisions (except for South Australia) was transitioned from the driver's licence to registration on the national register, the AODR.1

1 Southern Cross University, Coffs Harbour, NSW.
2 Organ and Tissue Donation Service, Mid North Coast Local Health District, Coffs Harbour, NSW.
3 University of Canberra, Canberra, ACT.

Correspondence: Gail.Moloney@scu.edu.au

Acknowledgements:

This research was supported by NSW Organ and Tissue Donation Service.

Competing interests:

No relevant disclosures.

1. Thomas M, Klapdor M. The future of organ donation in Australia: moving beyond the “gift of life” Department of Parliamentary Services, Parliamentary Library; 2008. http://www.rssfeeds.aph.gov.au/binaries/library/pubs/rp/2008-09/09rp11.pdf (viewed Dec 2018).
2. Moloney G, Sutherland M, Norton M, Walker A. When is the gift given? Organ donation, social representations and an opportunity to register. J Community Appl Soc Psychol 2019. In press.
3. Department of Human Services. AODR Intent registrations 2018 [website]. https://www.humanservices.gov.au/organisations/about-us/statistical-information-and-data/medicare-statistics/australian-organ-donor-register-statistics/australian-organ-donor-register (viewed Dec 2018).
4. Organ and Tissue Authority. Why is registration important? Canberra: OAT; 2017. http://www.donatelife.gov.au/sites/default/files/5_Why%20is%20registration%20important.pdf (viewed Dec 2018).
5. Sharpe E, Moloney G, Sutherland M, Judd A. The power of an immediate donor registration opportunity: translating organ donation attitudes into registration behavior. Basic Appl Soc Psych 2017; 39: 49–59.

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Research

Iodine status of Indigenous and non‐Indigenous young adults in the Top End, before and after mandatory fortification

Gurmeet R Singh, Belinda Davison, Gary Y Ma, Creswell J Eastman and Dorothy EM Mackerras

Med J Aust 2019; 210 (3): . || doi: 10.5694/mja2.12031
Published online: 18 February 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Nutritional and metabolic diseases

Environment and public health

Indigenous health

Statistics, epidemiology and research design

Abstract

Objective: To assess the median urine iodine concentration (UIC) of young adults in the Top End of Northern Territory, before and after fortification of bread with iodised salt became mandatory.

Design, setting: Analysis of cross‐sectional data from two longitudinal studies, the Aboriginal Birth Cohort and the non‐Indigenous Top End Cohort, pre‐ (Indigenous participants: 2006–2007; non‐Indigenous participants: 2007–2009) and post‐fortification (2013–15).

Participants: Indigenous and non‐Indigenous Australian young adults (mean age: pre‐fortification, 17.9 years (standard deviation [SD], 1.20 years); post‐fortification, 24.9 years (SD, 1.34 years).

Main outcome measure: Median UIC (spot urine samples analysed by a reference laboratory), by Indigenous status, remoteness of residence, and sex.

Results: Among the 368 participants assessed both pre‐ and post‐fortification, the median UIC increased from 58 μg/L (interquartile range [IQR], 35–83 μg/L) pre‐fortification to 101 μg/L (IQR, 66–163 μg/L) post‐fortification (P < 0.001). Urban Indigenous (median IUC, 127 μg/L; IQR, 94–203 μg/L) and non‐Indigenous adults (117 μg/L; IQR, 65–160 μg/L) were both iodine‐replete post‐fortification. The median UIC of remote Indigenous residents increased from 53 μg/L (IQR, 28–75 μg/L) to 94 μg/L (IQR, 63–152 μg/L; p < 0.001); that is, still mildly iodine‐deficient. The pre‐fortification median UIC for 22 pregnant women was 48 μg/L (IQR, 36–67 μg/L), the post‐fortification median UIC for 24 pregnant women 93 μg/L (IQR, 62–171 μg/L); both values were considerably lower than the recommended minimum of 150 μg/L for pregnant women.

Conclusions: The median UIC of young NT adults increased following mandatory fortification of bread with iodised salt. The median UIC of pregnant Indigenous women in remote locations, however, remains low, and targeted interventions are needed to ensure healthy fetal development.

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1 Menzies School of Health Research, Darwin, NT
2 Western Sydney University School of Medicine, Penrith, NSW
3 Sydney Thyroid Clinic, Sydney, NSW
4 Sydney Medical School, Sydney, NSW
5 Food Standards Australia New Zealand, Canberra, ACT

Correspondence: gurmeet.singh@menzies.edu.au

Acknowledgements:

This investigation was supported by the National Health and Medical Research Council (APP1046391). We acknowledge past and present study teams who traced participants and collected the data, particularly the late Susan Sayers, founder of the ABC study. We thank Victor Uguoma for his statistical advice. We especially thank the young adults in the Aboriginal Birth and Top End Cohorts and their families and communities for their cooperation and support, and all the individuals who helped in urban and rural locations.

Competing interests:

Dorothy Mackerras is employed by Food Standards Australia New Zealand, the agency that introduced mandatory iodine fortification.

1. Li M, Waite KV, Ma G, Eastman CJ. Declining iodine content of milk and re‐emergence of iodine deficiency in Australia. Med J Aust 2006; 184: 307. https://www.mja.com.au/journal/2006/184/6/declining-iodine-content-milk-and-re-emergence-iodine-deficiency-australia
2. Clements F, Gibson H, Howeler‐Coy J. Goitre prophylaxis by addition of potassium iodate to bread: experience in Tasmania. Lancet 1970; 295: 489–492.
3. Li M, Eastman CJ, Waite KV, et al. Are Australian children iodine deficient? Results of the Australian National Iodine Nutrition Study. Med J Aust 2006; 184: 165–169. https://www.mja.com.au/journal/2006/184/4/are-australian-children-iodine-deficient-results-australian-national-iodine
4. Food Standards Australia New Zealand. Proposal P1003. Mandatory iodine fortification for Australia: approval report. 6 Aug 2008. http://www.foodstandards.gov.au/code/proposals/documents/AppR_P1003_Mandatory_Iodine_Fortification_Aust%20AppR.pdf (viewed Feb 2018).
5. World Health Organization. Assessment of iodine deficiency disorders and monitoring their elimination: a guide for programme managers. Third edition. Geneva: WHO, 2007. http://www.who.int/nutrition/publications/micronutrients/iodine_deficiency/9789241595827/en/ (viewed Feb 2018).
6. Australian Bureau of Statistics. 4364.0.55.006. Australian Health Survey: biomedical results for nutrients, 2011–12. Iodine. Dec 2013. http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4364.0.55.006Chapter1202011-12 (viewed Sept 2018).
7. Hynes KL, Seal JA, Otahal P, et al. Iodine adequacy in Tasmania sustained after 7 years of mandatory bread fortification. Med J Aust 2018; 208: 126. https://www.mja.com.au/journal/2018/208/3/iodine-adequacy-tasmania-sustained-after-7-years-mandatory-bread-fortification
8. Rahman A, Savige GS, Deacon NJ, et al. Urinary iodine deficiency in Gippsland pregnant women: the failure of bread fortification. Med J Aust 2011; 194: 240–243. https://www.mja.com.au/journal/2011/194/5/urinary-iodine-deficiency-gippsland-pregnant-women-failure-bread-fortification
9. Australian Bureau of Statistics. 4727.0.55.003. Australian Aboriginal and Torres Strait Islander Health Survey: biomedical results, 2012–13. Iodine. Sept 2014. http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4727.0.55.003~2012-13~Main%20Features~Iodine~117 (viewed Sept 2018).
10. Mackerras DE, Singh GR, Eastman CJ. Iodine status of Aboriginal teenagers in the Darwin region before mandatory iodine fortification of bread. Med J Aust 2011; 194: 126–130. https://www.mja.com.au/journal/2011/194/3/iodine-status-aboriginal-teenagers-darwin-region-mandatory-iodine-fortification
11. Sayers SM, Powers JR. Birth size of Australian Aboriginal babies. Med J Aust 1993; 159: 586–591.
12. Davison B, Cunningham T, Singh G. Engaging adolescents and young adults in a longitudinal health study: experience from the Top End cohort. Aust N Z J Public Health. 2011; 35: 86–87.
13. Sayers S, Singh G, Mackerras D, et al. Australian Aboriginal Birth Cohort study: follow‐up processes at 20 years. BMC Int Health Hum Rights 2009; 9: 23.
14. Sayers SM, Mackerras D, Singh GR. Cohort profile: the Australian Aboriginal Birth Cohort (ABC) study. Int J Epidemiol 2017; 46: 1383–1383f.
15. Davison B, Nagel T, Singh G. Life, lifestyle and location: examining the complexities of psychological distress in young adult Indigenous and non‐Indigenous Australians. J Dev Orig Health Dis 2017; 8: 541–549.
16. Australian Institute of Health and Welfare. Monitoring the health impacts of mandatory folic acid and iodine fortification (Cat. No. PHE 208). Canberra: AIHW, 2016.
17. Zimmermann MB. Iodine deficiency. Endocr Rev 2009; 30: 376–408.
18. DePaoli KM, Seal JA, Burgess JR, Taylor R. Improved iodine status in Tasmanian schoolchildren after fortification of bread: a recipe for national success. Med J Aust 2013; 198: 492–494. https://www.mja.com.au/journal/2013/198/9/improved-iodine-status-tasmanian-schoolchildren-after-fortification-bread-recipe
19. National Health and Medical Research Council. Iodine supplementation for pregnant and breastfeeding women. NHMRC Public Statement [online], Jan 2010. Archived: https://web.archive.org/web/20180329041755/https://www.nhmrc.gov.au/guidelines-publications/new45 (viewed May 2018)
20. Australian Bureau of Statistics. 4727.0.55.003. Australian Aboriginal and Torres Strait Islander Health Survey: biomedical results, 2012–13. Explanatory notes. Sept 2014. http://www.abs.gov.au/AUSSTATS/abs@.nsf/Latestproducts/4727.0.55.003Explanatory%20Notes12012-13?opendocument&tabname=Notes&prodno=4727.0.55.003&issue=2012-13&num=&view (viewed May 2018).
21. Australian Bureau of Statistics. 4727.0.55.006. Australian Aboriginal and Torres Strait Islander Health Survey: updated results, 2012–13. June 2014. http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4727.0.55.006Explanatory%20Notes12012%E2%80%9313?OpenDocument (viewed May 2018).

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Editorials

Reducing the dangers of e‐cigarettes for children: opportunities for regulation and consumer education

Ryan D Kennedy and Vanya C Jones

Med J Aust 2019; 210 (3): . || doi: 10.5694/mja2.50007
Published online: 18 February 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Poisoning

Pediatric medicine

Health services administration

The importance of packaging, storage, and product design must be reflected by legislation

Electronic nicotine delivery systems (ENDS), including e‐cigarettes, are devices that heat a liquid (e‐liquid) that usually includes propylene glycol or vegetable glycerine, nicotine, and other constituents, such as colourants and flavourings. Nicotine is a naturally occurring toxin in tobacco plants that affects mammalian nervous and cardiovascular systems.1 E‐liquids containing nicotine are a poisoning risk because small amounts of nicotine can induce vomiting, cause seizures, and be lethal, particularly if ingested by young children.2 As Chivers and colleagues3 report in this issue of the MJA, e‐liquids may also contain a range of other toxic and dangerous constituents, including insecticides. In Australia and overseas, ENDS products are subject to regulations similar to those for tobacco products, including minimum age of purchase and restrictions on advertising.4 However, mitigating the risk of poisoning by ENDS products and their e‐liquids has not been the primary object of legislation.

Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States

Correspondence: rdkennedy@jhu.edu

Competing interests:

No relevant disclosures.

1. National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention (USA). Nicotine: systemic agent. Updated 12 May 2011. https://www.cdc.gov/niosh/ershdb/emergencyresponsecard_29750028.html (viewed Dec 2018).
2. Richtel M. Selling a poison by the barrel: liquid nicotine for e‐cigarettes. New York Times, 23 March 2014. https://www.nytimes.com/2014/03/24/business/selling-a-poison-by-the-barrel-liquid-nicotine-for-e-cigarettes.html (viewed Dec 2018).
3. Chivers E, Janka M, Franklin P, et al. Nicotine and other potentially harmful compounds in “nicotine‐free” e‐cigarette liquids in Australia. Med J Aust 2019; 2019(210): 000–000.
4. Kennedy RD, Awopegba A, De León E, Cohen JE. Global approaches to regulating electronic cigarettes. Tob Control 2017; 26: 440–445.
5. Brown CJ, Cheng JM. Electronic cigarettes: product characterisation and design considerations. Tob Control 2014; 23 (Suppl 2): ii4–ii10.
6. Food and Drug Administration (USA). FDA warns company for selling e‐liquids that resemble kid‐friendly foods as part of the agency's ongoing Youth Tobacco Prevention Plan [media release]. 29 Nov 2018. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm627123.htm (viewed Dec 2018).
7. Buettner‐Schmidt K, Miller DR, Balasubramanian N. Electronic cigarette refill liquids: child‐resistant packaging, nicotine content, and sales to minors. J Pediatr Nurs 2016; 31: 373–379.
8. Herzog B, Kanada P. Our evening with blu: takeaways from Imperial Brands’ e‐cig event [report]. Wells Fargo Securities, equity research: tobacco. 28 Mar 2018. https://www.wellsfargoresearch.com/Reports/ViewReport/6dd7ce28-1708-4b56-9c05-cd59ca71fb40?source=WFR.COM&ght=bc605b8a-3f2e-4903‐ (viewed Dec 2018).
9. Euromonitor International. Smokeless tobacco and vapour products in Australia [report]. Aug 2018. https://www.euromonitor.com/smokeless-tobacco-and-vapour-products-in-australia/report (viewed Dec 2018).
10. Kong AY, Derrick JC, Abrantes AS, Williams RS. What is included with your online e‐cigarette order? An analysis of e‐cigarette shipping, product and packaging features. Tob Control 2018; 27: 699–702.
11. Hua M, Talbot P. Potential health effects of electronic cigarettes: a systematic review of case reports. Prev Med Rep 2016; 4: 169–178.
12. Wylie C, Heffernan A, Brown JA, et al. Exposures to e‐cigarettes and their refills: calls to Australian Poisons Information Centres, 2009–2016. Med J Aust 2019; 210: 000–000.
13. Hughes A, Hendrickson RG. An epidemiologic and clinical description of e‐cigarette toxicity. Clin Toxicol 2018; 9: 1–7.

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Medical education

Translating health professional education research evidence into effective continuous professional development

Ruth M Sladek, Sue McAllister and Kieran M Walsh

Med J Aust 2019; 210 (3): . || doi: 10.5694/mja2.12111
Published online: 18 February 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Medical education

Biases and assumptions often arise from past experiences and, when unquestioned, can negatively influence the development of effective educational strategies

Knowledge is frequently considered as the panacea for all ills, and its acquisition is often proposed as the solution for ensuring we deliver the best quality health care. For example, training and continuing professional development (CPD) have been proposed as the first steps for medical colleges to address some troubling variations in health care practice in Australia.1 However, while proposing educational strategies to address health outcomes is logical, appropriate and defensible, it is well established that “knowing” something is quite different from “doing” something.2 Nevertheless, CPD curricula are frequently limited to “knowing”.3 While knowledge is a key prerequisite to transforming practice, how do we maximise CPD effectiveness as a strategy to improve care? And is changing individual practice through education all that is needed to change health practices and outcomes?4

1 Prideaux Centre for Research in Health Professions Education, Flinders University, Adelaide, SA
2 University of Sydney, Sydney, NSW
3 BMJ Learning, London, UK

Correspondence: RuthSladekAdelaide@gmail.com

Competing interests:

No relevant disclosures.

1. Francombe H, Buchan HA, Duggan A. Health care variation: the next challenge for clinical colleges. Med J Aust 2017; 207: 277–278. https://www.mja.com.au/journal/2017/207/7/health-care-variation-next-challenge-clinical-colleges
2. Le Maistre C, Paré A. Learning in two communities: the challenge for universities and workplaces. Journal of Workplace Learning 2004; 16: 44–52.
3. Boud D, Hager P. Re‐thinking continuing professional development through changing metaphors and location in professional practices. Stud Contin Educ 2012; 34: 17–30.
4. Whitehead C, Kuper A, Webster F. The conceit of curriculum. Med Educ 2012; 46: 534–536.
5. Greenhalgh T, Howick J, Maskrey N et al. Evidence based medicine: a movement in crisis. BMJ 2014; 348: g3725.
6. Schuwirth LWT, Durning SJ. Educational research: current trends, evidence base and unanswered questions. Med J Aust 2018; 208: 161–163. https://www.mja.com.au/journal/2018/208/4/educational-research-current-trends-evidence-base-and-unanswered-questions
7. Hager P. Metaphors of workplace learning: more process, less product. Fine Print 2004; 27: 7–10.
8. Husmann PR, O'Loughlin VD. Another nail in the coffin for learning styles? Disparities among undergraduate anatomy students’ study strategies, class performance, and reported VARK learning styles. Anat Sci Educ 2018; https://doi.org/10.1002/ase.1777. [Epub ahead of print]
9. Bohmer RM, Edmonson AC. Organizational learning health care. Health Forum J 2001; 44: 32–35.
10. Lingard L. What we see and don't see when we look at “competence”: notes on a god term. Adv Health Sci Educ Theory Pract 2009; 14: 625–628.
11. McAllister S, Lincoln MI, Ferguson A et al. A systematic program of research regarding the assessment of speech‐language pathology competencies. Int J Speech Lang Path 2011; 13: 6, 469–479.
12. Edmondson AC. Learning from failure in health care: frequent opportunities, pervasive barriers. Qual Saf Health Care 2004; 13 (Suppl): ii3–ii9.
13. Allegranzi B, Gayet‐Ageron A, Damani N et al. Global implementation of WHO's multimodal strategy for improvement of hand hygiene: a quasi‐experimental study. Lancet 2013; 13: 843–851.
14. van Merrienboer JJ, Sweller J. Cognitive load theory in health professional education: design principles and strategies. Med Educ 2010; 44: 85–93.
15. Hattie JAC. Visible learning: a synthesis of over 800 meta‐analyses relating to achievement. London, UK: Routledge; 2009.

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Perspective

Emerging diabetes and metabolic conditions among Aboriginal and Torres Strait Islander young people

Angela Titmuss, Elizabeth A Davis, Alex Brown and Louise J Maple‐Brown

Med J Aust 2019; 210 (3): . || doi: 10.5694/mja2.13002
Published online: 18 February 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Endocrine system diseases

Pediatric medicine

Indigenous health

Anatomy and physiology

Health occupations

Intersectoral collaboration is needed to engage communities and design effective culturally and age‐appropriate interventions

The gap between the health of Aboriginal and Torres Strait Islander and non‐Indigenous Australians is well documented, with many policies and programs currently working towards improving outcomes. Despite these efforts, life expectancy is 10–11 years less than that of non‐Indigenous Australians,1 and 65% of deaths occur before 65 years of age, compared with 19% in the non‐Indigenous population.1

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1 Royal Darwin Hospital, Darwin, NT
2 Menzies School of Health Research, Darwin, NT
3 Princess Margaret Hospital for Children, Perth, WA
4 Aboriginal Health Research Accord, South Australian Health and Medical Research Institute, Adelaide, SA
5 University of South Australia, Adelaide, SA

Correspondence: angela.titmuss@menzies.edu.au

Acknowledgements:

We acknowledge other members of the Hot North Diabetes in Youth collaboration (Northern Australia Tropical Disease Collaborative Research Program, NHMRC project grant 1131932): Peter Azzopardi, Elizabeth Barr, Paul Bauert, Gavin Cleland, Christine Connors, James Dowler, Sandra Eades, Keith Forrest, Aveni Haynes, Renae Kirkham, Elizabeth Moore, Vicki O'Donnell, Glenn Pearson, Lydia Scott, Jonathan Shaw, Sally Singleton, Ashim Sinha and Mark Wenitong. Angela Titmuss is supported by an NHMRC Postgraduate Scholarship and RACP Woolcock Scholarship. Alex Brown is supported by an NHMRC Research Fellowship (1137563). Louise Maple‐Brown is supported by an NHMRC Practitioner Fellowship (1078477).

Competing interests:

No relevant disclosures.

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Guideline summary

New guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand for the diagnosis and management of venous thromboembolism

Huyen A Tran, Harry Gibbs, Eileen Merriman, Jennifer L Curnow, Laura Young, Ashwini Bennett, Chee Wee Tan, Sanjeev D Chunilal, Chris M Ward, Ross Baker and Harshal Nandurkar

Med J Aust 2019; 210 (5): . || doi: 10.5694/mja2.50004
Published online: 11 February 2019

Correction(s) for this article:

Erratum | Published online: 17 February 2020

ARTICLE
AUTHORS
REFERENCES

Topics

Hematologic diseases

Abstract

Introduction: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common cardiovascular disease and, globally, more than an estimated 10 million people have it yearly. It is a chronic and recurrent disease. The symptoms of VTE are non‐specific and the diagnosis should actively be sought once considered. The mainstay of VTE treatment is anticoagulation, with few patients requiring additional intervention.

A working group of experts in the area recently completed an evidence‐based guideline for the diagnosis and management of DVT and PE on behalf of the Thrombosis and Haemostasis Society of Australia and New Zealand (www.thanz.org.au/resources/thanz-guidelines).

Main recommendations:

The diagnosis of VTE should be established with imaging; it may be excluded by the use of clinical prediction rules combined with D‐dimer testing.
Proximal DVT or PE caused by a major surgery or trauma that is no longer present should be treated with anticoagulant therapy for 3 months.
Proximal DVT or PE that is unprovoked or associated with a transient risk factor (non‐surgical) should be treated with anticoagulant therapy for 3–6 months.
Proximal DVT or PE that is recurrent (two or more) and provoked by active cancer or antiphospholipid syndrome should receive extended anticoagulation.
Distal DVT caused by a major provoking factor that is no longer present should be treated with anticoagulant therapy for 6 weeks.
For patients continuing with extended anticoagulant therapy, either therapeutic or low dose direct oral anticoagulants can be prescribed and is preferred over warfarin in the absence of contraindications.
Routine thrombophilia testing is not indicated.
Thrombolysis or a suitable alternative is indicated for massive (haemodynamically unstable) PE.

Changes in management as a result of the guideline: Most patients with acute VTE should be treated with a factor Xa inhibitor and be assessed for extended anticoagulation.

1 Alfred Health, Melbourne, VIC
2 Monash University, Melbourne, VIC
3 Waitemata District Health Board, Auckland, New Zealand
4 Haemophilia Treatment Centre, Westmead Hospital, Sydney, NSW
5 Auckland District Health Board, Auckland, New Zealand
6 Monash Medical Centre, Melbourne, VIC
7 Royal Adelaide Hospital, Adelaide, SA
8 Monash Health, Melbourne, VIC
9 Royal North Shore Hospital, Sydney, NSW
10 Perth Blood Institute, Perth, WA
11 Australian Centre of Blood Diseases, Melbourne, VIC

Correspondence: huyen.tran@monash.edu

Competing interests:

No relevant disclosures.

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