AMSJ Volume 10, Issue 1 2020

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Australian Medical Student Journal Volume 10, Issue 1

www.amsj.org Guest Navigating medicine with a physical challenge Dinesh Palipana Research Organisational process and patient factors contributing to hospital outpatient clinic non-attendance Irushi Ratnayake, Lyn- Li Lim Feature AHPRA, mistrust, and medical culture in Australia David Arroyo


Design and layout Š 2020, Australian Medical Student Journal Australian Medical Student Journal, PO Box 2119, Carlington Court, Carlington NSW 2118 enquiries@amsj.org www.amsj.org Content Š 2020, the authors ISSN (Print): 1837-171X ISSN (Online): 1837-1728 Editor-in-chief Dr Robert Ellis Typesetting Isabel Lee The Australian Medical Student Journal is an independent not-for-profit organisation. The Australian Medical Student Journal can be found on the EBSCOhost databases. Responsibility for article content rests with the respective authors. Any views contained within articles are those of the authors and do not necessarily reflect the views of the Australian Medical Student Journal.


Volume 10 Issue 1 2020


CALL FOR SUBMISSION • Original Research • • Review Articles • • Research Articles • • Case Reports • • Letters • • Book Reports • The AMSJ accepts submissions from all medical students in Australia. What makes the AMSJ unique is that it provides the opportunity to show-case your work within the academic rigours of a peer-reviewed biomedical journal whilst sharing your ideas with thousands of students and professionals across the country. Whether your passions lie in advocacy, education or research, you can submit to the AMSJ today.

Submissions open now! AMSJ.ORG


Australian Medical Student Journal Volume 10, Issue 1 2 Editor’s welcome Robert J Ellis Guest Articles

3 Navigating medicine with a physical challenge Dinesh Palipana

7 The competency matrix and use of reflection and reflective practice to develop your learning and understanding Stuart Lane Editorials

11 An interview with Professor Alicia Jenkins – endocrinologist, researcher and President of Insulin for Life David Chen, Alicia Jenkins Original Articles

13 Change in cardiopulmonary exercise testing response in patients with coronary artery disease who do not choose to participate in cardiac rehabilitation Nikhil Kumar, Andrew Victor 19 Organisational process and patient factors contributing to hospital outpatient clinic non-attendance Irushi Ratnayake, Lyn- Li Lim Review Articles

26 Intravenous magnesium therapy for treatment of severe asthma in adults Jackson W. Newport, The Lan Bui Feature Articles

34 AHPRA, mistrust, and medical culture in Australia David Arroyo

40 Biopsy of the skin Linda Chan, Elizabeth Dawes-Higgs

45 BT shunts, Berlin Hearts and brave decisions Nicole Da Cruz

50 Collaboration between doctors and veterinarians for the greater good of all species Subhashaan Sreedharan, Silverio Nanni Letters

54 Could drinking tea cure acne? Courtney Haller Book Reviews

56 A Compendium of Histology: a book review Sue Sritharan

58 Clinical Cases in Obstetrics, Gynaecology and Women’s Health: a book review Chinelo Aghanwa


Editor’s Welcome Dr Robert J. Ellis MD, PhD Editor-in-Chief, AMSJ

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elcome to Volume 10, Issue 1 of the Australian Medical Student Journal (AMSJ). Since 2010, our journal has served as a platform for medical students to showcase their research, discuss perspectives in medicine, and apply knowledge acquired through their study and clinical work to identifying and tackling some of the challenges faced by medical professionals and students. In this issue of the AMSJ, we had the privilege of publishing a broad selection of articles submitted by medical students and junior doctors, covering topics from the management of severe asthma with intravenous magnesium, to the role of green tea in the management of acne. We were also fortunate enough to hear from two guest authors in this issue. Dr Dinesh Palipana, Queensland’s first quadriplegic medical intern, provides us with a unique insight into the personal challenges he has faced traversing medical school and employment, and discusses his thoughts on inclusivity in the medical profession. A/Prof Stuart Lane also returns with his third article in a series on professional development, this time elaborating on the importance of reflective practice in learning. Over the last 12 months, the AMSJ has taken a number of important steps forwards. I am excited to announce that, for the first time, we have been able to publish articles online ahead of print, vastly reducing the time from submission to publication, and hopefully improving the author experience, as well as expediting access to our content. I also have the pleasure of advising that in July 2019 the AMSJ hosted its second annual research symposium at the Translational Research Institute in Brisbane, where we heard from a number of excellent speakers about the role of research across a variety of professional and training pathways in medicine. As the AMSJ continues to grow and develop as an organisation, there is always a need for enthusiastic volunteers. I would like to take this opportunity to say that if you have an interest in medical research, would like to get a bit of experience in writing or editing, or simply would like a chance to be part of a national organisation of medical students, the AMSJ would love for you to be part of the team. There are so many people and organisations who have made this issue possible that are deserving of thanks. First, I would like to express my gratitude to all the authors for their high-quality submissions, which I am confident our readers will enjoy perusing. I also unreservedly thank the many peer reviewers who dedicated a substantial amount of their time to providing comments on all our submissions. I also thank our sponsors, who have provided us with the financial support needed to produce this publication, along with assisting with operational costs. Finally, I would like to show my appreciation for the wonderful AMSJ team, all of whom volunteer innumerable hours to the development of this journal; your dedication assists in allowing Australian medical students to continue having a voice in the national and global conversation of academic medicine. To our readers, I hope that you enjoy this issue of the AMSJ. We are always on the lookout for submissions, and if you would like to contribute an article, I would encourage you visit our website: www. amsj.org. Correspondence: r.ellis@amsj.org

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Navigating Medicine with a Physical Challenge Dr Dinesh Palipana OAM, LLB, MD Senior Resident, Emergency Department, Gold Coast Hospital and Health Service Lecturer, Griffith University Dinesh was the first quadriplegic medical intern in Queensland and the second person to graduate medical school with quadriplegia in Australia. Dinesh earned a Bachelor of Laws (LLB) prior to completing his Doctor of Medicine (MD) at Griffith University. He has completed an Advanced Clerkship in Radiology at Harvard University. Halfway through medical school, he was involved in a catastrophic motor vehicle accident that caused a cervical spinal cord injury. As a result of his injury and experiences, Dinesh has been an advocate for inclusivity in medicine and the general workplace. He is a founding member of Doctors with Disabilities Australia. Dinesh is currently a resident medical officer at the Gold Coast University Hospital. He is a lecturer at the Griffith University and adjunct research fellow at the Menzies Health Institute of Queensland. He has a research interest in spinal cord injury, particularly in novel rehabilitation techniques. Dinesh is the Gold Coast University Hospital’s representative in the Australian Medical Association Queensland’s Council of Doctors in Training. He is a member of the scientific advisory committee of the Perry Cross Spinal Research Foundation, disability advisory council at Griffith University, and the Ambassador Council at the Hopkins Centre. Dinesh was the Gold Coast Hospital and Health Service’s Junior Doctor of the Year in 2018. He was awarded the Medal of the Order of Australia in 2019. Globally, the landscape for medical students and doctors with physical challenges is changing. In nations such as the United Kingdom (UK) and United States of America (USA), initiatives like Welcomed and valued [1] and #DocsWithDisabilities [2] have encouraged inclusivity in medicine. In Australia, the environment remains in a state of transition. After sustaining a spinal cord injury during medical school, I have had the opportunity to explore the positive changes that we can make locally to improve accessibility in medicine. Dr Dinesh Palipana

My journey In 2008, I started medical school at Griffith University. On 31 January 2010, early in the third year, I was involved in a single vehicle motor vehicle accident. The accident was caused by something on the road that made the vehicle aquaplane. The fire truck approaching the scene also lost control from the road conditions. As a result of the accident, I sustained a cervical spinal cord injury. The injury affected my fingers, triceps, and all sensorimotor function below the chest. I was a patient at Brisbane’s Princess Alexandra Hospital for the better part of a year. I convalesced for another four years. In 2015, I again started my third year at medical school. Griffith University carried out detailed preparation before formally re-commencing my medical education.

Preparing to return The first step was to confirm that the Australian Health Practitioner Regulation Agency (AHPRA) accepted my re-enrolment as a medical student. This also began an early but long-term discussion about obtaining registration as a medical practitioner at the end of medical school. Secondly, the medical school arranged time for developing clinical skills in the laboratory. Funding was provided by disability services. Clinicians and simulated patients gave time to develop techniques for utilising my physical function to safely perform clinical skills to maximal effect. This was a valuable exercise, as I was able to, for example, learn ways to insert a cannula with assistance, which was thought to be an impossible task.

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Thirdly, we met with the relevant clinical supervisors at the hospital to plan each rotation. The school then developed a suitable rotation pattern, beginning with the less physically demanding specialty of psychiatry. The elective rotation was taken in radiology at the Harvard Medical School and Massachusetts General Hospital, where no issues were raised during initial inquiries about hosting a student with a spinal cord injury. Finally, the medical school planned for exams and performed other activities, such as installing an automatic door in the medical school. The disability services obtained a licence for a medically-oriented voice recognition package. Outside the medical school, I secured appropriate equipment and necessities for life to ensure success. For example, due to the requirements of a spinal cord injury, I sometimes needed to wake up at 3:30AM to get to the hospital in time. These challenges required detailed personal planning. Traversing medical school With a well-planned approach, traversing medical school revealed no unexpected challenges. However, there are some surprising developments in the Australian environment for medical students with physical challenges. Shortly after I commenced medical school again in 2015, the Medical Deans of Australia and New Zealand (MDANZ) developed the Inherent requirements for studying medicine in Australia and New Zealand [3]. The first iteration of this document prescribed physical characteristics that a medical student should have. If applied strictly, I could have been excluded from studying medicine. The document has since undergone some revision, but some medical schools have adopted it in spirit. Similarly, the Australian Council for Educational Research (ACER) has recommended the inherent requirements document for potential candidates considering the Graduate Medical School Admissions Test (GAMSAT) [4]. Nonetheless, I successfully completed all clinical rotations and examinations, including objective structured clinical examinations (OSCEs). The OSCEs retained external observers from other institutions to ensure the integrity of the assessment. I graduated with awards in 2016. AHPRA was thorough, methodical, and prompt with granting me provisional registration. Despite this, the next challenge was employment.

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Employment Generally, domestic medical graduates are guaranteed an internship in their home state [5]. Due to the injury, my application was removed from the pool and entered into a separate process. This process continued until two days before the 2017 interns commenced, leaving uncertainty whether an internship would be offered to me at all for that year. While this was the approach in Queensland, the Australian Capital Territory noted that they do not consider interns differently due to physical challenges. Two hospitals in New South Wales and Victoria offered to talk to me with a view of potentially offering an internship in a later year. This was a challenging time. Despite passing exams, performing well in clinical rotations, and earning awards, merit did not seem to matter in securing an internship. However, with the support of advocates, the community, and the media, I commenced an internship in 2017. I have worked in vascular surgery, emergency medicine, radiology, general medicine, psychiatry, and obstetrics and gynaecology during my time as a doctor. Radiology was the most resistant department to having a doctor with physical challenges. The emergency department has been supportive since I was a student. It is where I have spent the majority of time. In 2019, it was the busiest department in the country. An inclusive approach by the department has allowed me to practice independently and, hopefully, effectively. I was awarded the Junior Doctor of the Year Award for 2018. My discussions with specialty training colleges have been positive. By and large, the specialty training colleges of Australia appear to have an inclusive approach. Training sites have variable approaches as employers. The main challenge from my experience, and that of others in similar situations, is employers. For example, I have been working with an anaesthesiologist in New South Wales. His hospital noted that there would be a risk associated with having someone in a wheelchair on the hospital grounds. In contrast, an emergency department in the same state went to great lengths to accommodate an emergency doctor with a more significant injury.


Policy in Australia compared to its international counterparts The policy environment in Australia is still developing. The document detailing inherent requirements for studying medicine, for example, is still undergoing change. As of 2019, the Australian Medical Association Queensland is leading some changes to promote inclusive employment and training in medicine. In 2019, the General Medical Council (GMC) of the UK launched an initiative called ‘Welcomed and valued’. Per their website, “Welcomed and valued provides advice for medical schools and postgraduate educators on how to support disabled learners, and those with long term health conditions. We firmly believe disabled people should be welcomed to the profession and valued for their contribution to patient care. A diverse population is better served by a diverse workforce that has had similar experiences and understands their needs” [1]. As a regulator for doctors in the UK, the GMC encourages medical schools and employers to progress the careers of medical students and doctors with physical challenges through guidelines launched within this initiative. Despite powerful overarching policy changes, I have had discussions with UK doctors who have been met with significant challenges in maintaining employment and training following physical injuries. In 2018, the Association of American Medical Colleges (AAMC) in the USA released a report titled Accessibility, Inclusion, and Action in Medical Education: Lived Experiences of Learners and Physicians With Disabilities [6]. The report explored experiences of medical students and doctors with disabilities and laid the foundation to create change. The reports made suggestions such as including disability in statements that welcome diversity and developing outcomes-based technical standards. The University of Michigan developed technical standards in 2016 that demonstrated such an approach [7]. Where a standard is outlined, it is qualified at the end by a line similar to “the candidate must demonstrate alternative means and/or abilities to” completing the task. The impetus created by changemakers in the US has also lead to successful campaigns, such as #DocsWithDisabilities [8]. However, some countries still remain in a state of development in this area.

The Medical Council of India made a decision to exclude people with a greater than 80% disability in selected disability categories from practicing medicine [9]. It is unclear how such percentages are calculated. This decision is being fought in the courts as of 2019. Parting thoughts In a publication for the British Medical Association in 2007, Sir Bert Massie stated that “By welcoming more disabled medical students, and by retaining more disabled doctors in employment, the profession will improve its outward facing service and better reflect modern society” [10]. Historically, the medical profession has been a thought leader in what is just and right. We are at a transitionary point in our society, where everyone is encouraged to be included in education, employment, and the community. During my journey, I have found us to be falling short. What we do may have an effect for other professions. It may influence other parts of the community. I hope that, in Australia, we soon become leaders and leave discrimination as a thing of the past.

DWDA Doctors with Disabilities Australia (DWDA) advocates for inclusivity in medical education and employment. http://www.dwda.org.au

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References [1] General Medical Council. Welcomed and valued: Supporting disabled learners in medical education and training. [Internet]. United Kingdom. 2019 May [cited 2019 Sept]. Available from: https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/ welcomed-and-valued/welcomed-and-valued-supporting-disabled-learners-in-medical-education-and-training [2] Cook H. #DocsWithDisabilities campaign highlights diversity among healthcare professionals. Becker’s Hospital Review [Internet]. 2018 Aug 7 [cited 2019 Sept]. Available from: https://www.beckershospitalreview.com/hospital-physician-relationships/docswithdisabilities-campaign-highlights-diversity-among-healthcare-professionals.html [3] Medical Deans Australia and New Zealand. Inherent requirements for studying medicine in Australia and New Zealand. [Internet]. 2015 [updated 2015 Oct 8; cited 2019 Sept]. Available from: https://cdn.auckland.ac.nz/assets/auckland/fmhs/study-with-us/docs/7-4-inherent-requirement-statement-20151014.pdf [4 Australian Council for Education Research. Reasonable adjustments (GAMSAT). [Internet]. [updated 2019; cited 2019 Sept]. Available from: https://gamsat.acer.org/register/reasonable-adjustments [5] Queensland Government. Guaranteed offer graduates (applicant group A). [Internet]. Brisbane: Queensland Health. [updated 2019 July 26; cited 2019 Sept]. Available from: https://www.health.qld.gov.au/employment/work-for-us/clinical/medical/recruitment/intern/applicant-categories/ guaranteed-offer-graduates-applicant-group-a [6] Meeks LM, Jain NR. Accessibility, Inclusion, and Action in Medical Education. [Internet]. Association of American Medical Colleges. 2018 [cited 2019 Sept]. Available from: https://sds.ucsf.edu/sites/g/files/tkssra2986/f/aamc-ucsf-disability-special-report-accessible.pdf [7] University of Michigan. University of Michigan Medical School Technical Standards 2016. [updated 2016 May; cited 2019 Sept]. Available from: https://medicine.umich.edu/medschool/sites/medicine.umich.edu.medschool/files/assets/md_technical_standards_2016.pdf [8] Gordon E. Doctors With Disabilities Push For Culture Change In Medicine. NPR [Internet]. 2018 Aug 6 [cited 2019 Sept]. Available from: https:// www.npr.org/sections/health-shots/2018/08/06/635414552/doctors-with-disabilities-push-for-culture-change-in-medicine [9] Nagarajan R. MCI norms for disabled arbitrary: Foreign doctors. The Times of India [Internet]. 2019 Aug 11 [cited 2019 Sept]. Available from: https://timesofindia.indiatimes.com/india/mci-norms-for-disabled-arbitrary-foreign-doctors/articleshow/70625294.cms [10] British Medical Association Equal Opportunities Committee. Disability Equality in the Medical Profession. London, UK: British Medical Association; 2007.  

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The Competency Matrix and the Use of Reflection and Reflective Practice to Develop your Learning and Understanding. A/Prof Stuart Lane MBBS PhD FCICM MQHR Coordinator of Clinical Studies & Chair of the Personal and Professional Development (PPD) Theme, Sydney Medical Program; Senior Staff Specialist in Intensive Care Medicine, Nepean Hospital A/Prof Stuart Lane is coordinator of Clinical Studies, and chair of the PPD theme for the Sydney Medical Program. He has a decorated record for teaching, and has developed a national and international reputation in researching human experience using qualitative methodologies. His PhD thesis explored the experiences of medical interns who had been involved in open disclosure. He is an examiner for the College of Intensive Care Medicine (CICM), Senior NSW CICM Supervisor of training, and Deputy Chair of the NSW CICM Regional Committee. He is a keen swimmer and successfully swam the English Channel in 2017.

Introduction In the most recent edition of AMSJ I discussed the concepts of intellectual humility, growth mindset, and situational awareness, and their roles in the development of a person’s professionalism and professional identity. In this edition of AMSJ I will discuss some theories of reflection and reflective practice, which are required to utilise the concepts previously discussed, and enable the optimal development of your learning and professional development. In doing this I will discuss the competency matrix, which is a learning development theory that is referred to frequently in healthcare learning, especially in the context of simulated learning environments. I will also discuss some of the flaws in the current theory that are preventing the recognition of optimal reflective practice. The competency matrix The ability or inability to recognise one’s limitations, and therefore subsequent learning, is described in a learning framework called ‘the competency matrix’, which relates to the learning of a new skill, behaviour, ability, or technique [1]. The framework is outlined in Figure 1 below:

Learners begin at stage 1: ‘unconscious incompetence’. As their skills increase they enter stage 2 of ‘conscious incompetence’. With greater skill acquisition, they attain stage 3 of ‘conscious competence’. Finally, as they master their skill, they attain stage 4 of ‘unconscious competence’. This framework has a vitally important aspect. When students learn, they commonly wish to know how their learning is progressing, and this is often done by form of assessment [3]. Awarding students marks or grades, such as 7/10 or 56%, does not give the learner any indication of what they actually need to do to improve their score if they were to do the assessment again. This is the basis of the newer paradigms of assessment such as programmatic assessment [4], which many medical schools are developing and implementing into their new curriculums. This narrative feedback encourages students to not simply settle for a ‘pass mark’, but develop a desire to reflect on performance and improve. Therefore, the ability of a learner to move through this matrix requires an ability to recognise which part of the matrix they are situated currently. Stages 2 and 3 are usually very obvious to learners, however stages 1 and 4 are not. Furthermore, having two distinct ends to learning suggests that there is a very obvious beginning and end, which is far too simple.

Figure 1. The conscious competency learning matrix – the four stages of learning [2].

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Consider this model with a person learning to drive a car. Before learning to drive, many people have been in a car and sense that driving might be relatively easy to do. This is stage 1, where they are not aware of how difficult it can be for the person who has never done it before. When they actually have their first lessons, they realise how difficult it is and become aware of how unskilled they are, realising that they have a lot to learn. This is stage 2. As they continue to learn to drive, every step is very deliberate and thought out; however, they begin to gain competency and recognise the things that they are doing right. This is stage 3. Finally, they get to a point where driving is no longer deliberately thought-out; they can change gear and brake automatically without thinking. They are at stage 4, and no longer aware of their own competence. However, if the person ages and loses reflexes and abilities, this level of skill will change, or even if they simply change cars and become unfamiliar with their environment.

Figure 2. Level of learning and the competency matrix

Learning can also be displayed in a time cycle, with time spent learning on the x-axis, and level of learning on the y-axis, as seen below in Figure 2. This model displays the ‘dip’ that people describe as they attempt to acquire a new skill. The ‘dip’ actually reflects a person’s appreciation of what they know, and therefore relates to their confidence rather than their knowledge. The lack of focus on reflection and ongoing learning in this early model of the competency matrix is one of the significant flaws. Stage 4 ‘unconscious competence’ has also been described as ‘mastery’ [5]. This phrase suggests that the learner can learn no more: they have mastered their skill. This has obvious risks in the field of medicine, where disease concepts and knowledge, investigations, and management are continually changing.

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If a practitioner does not maintain their level of skill, they will no longer have ‘mastery’ of their subject. This can easily occur if apathy or complacency start to creep into a doctor’s practice [6]. This suggests that reflective practice is required if a practitioner is to maintain their mastery. However, as stated in the previous paragraph, the practitioner needs to reflect at both ends of the matrix (stage 1 and 4), as well as throughout the middle stages of 2 and 3. Reflective practice needs to be an ongoing process throughout a practitioner’s career; always present in the background or even the forefront of their thinking. This idea led to the development of a more recent version of the matrix, displayed in figure 3.

Figure 3. Reflective competence as a fifth level of the competency matrix. (Courtesy of Will Taylor, Chair, Department of Homeopathic Medicine, National College of Natural Medicine, Portland, Oregon, USA, March 2007 [6])

Regarding teaching and learning, this fifth stage of competence has been described as ‘conscious competence of unconscious competence’, which is a person’s ability to recognise and develop unconscious incompetence in others and themselves [6]. More simply, it is described as reflective competence, as seen in Figure 3. The ability to recognise one’s ongoing learning needs, and the accumulation of one’s knowledge and application of said knowledge is a major aspect of emotional intelligence, and to recognise it in others is an even greater level of emotional intelligence.


The link between this article and my two previous articles can be seen here, where emotional intelligence for personal learning and the learning of others is intertwined with situational awareness (within the learning environment) and intellectual humility (in your rate of acquisition of knowledge versus what there is still to learn). Having learned a skill, many learners will forget what they went through to learn it, and how they mastered it – they have forgotten the theory and application and have become simply functional. This has a major impact if they try to teach the skill to somebody, as they will struggle to impart the knowledge if they can’t recall how they amassed it. Therefore, they can make worse teachers than someone who has good ability at the conscious competence stage [7]. There are three other key aspects of learning that are neither demonstrated nor explained by this framework. Firstly, whilst the diagram demonstrates an overlap between each of the stages of the competency model, as stated earlier, reflective competence should occur at all stages. In some circumstances learners are not always ‘unconsciously incompetent’ from the beginning, and accept that they don’t know what they are attempting to learn, so they are ‘consciously incompetent’ from the beginning. However, in other clinical circumstances they are ‘unconsciously incompetent’, suggesting that their place on the competency matrix has to be related to the context of what they are learning. Therefore, the diagram relates to a specific person learning a specific task. This problem has commonly been related to younger learners, which can be derogatory as they may well be more willing to accept that they have a lot to learn, compared with a more experienced learner who might believe they can’t be taught anything new. Secondly, in some cases where the learner is at a level of being ‘consciously competent’, they become ‘unconsciously incompetent’ as further learning is attempted. This is related to the previously mentioned intellectual humility, and aligns with overconfidence as somebody acquires a new skill. Reflective competence should not be considered a fifth stage that occurs once a leaner has attained ‘unconscious competence’, but rather a background quality that is always present.

Thirdly, whilst the initial diagram talks about learners going back from stage 4 to stage 3 and then stage 2, this only occurs if the person possesses reflective competence. If they do not possess this quality, they can regress from stage 4 of ‘unconscious competence’ directly to stage 1 of ‘unconscious incompetence’ without even realising. The current diagram does not show a link between unconscious competence and unconscious incompetence for when reflective competence is lost, and this process may occur. The point at which the transition from unconscious incompetence to conscious competence occurs has often been called the ‘light-bulb moment’ [8], but the light-bulb might not flash in the opposite direction, going from unconscious competence to unconscious incompetence if the learner doesn’t possess reflective competence. What this learning model demonstrates is that whether or not a learner is actually ready to learn may not be so straightforward. The ability to possess the correct mindset to learn links with the previous discussion regarding intellectual humility and situational awareness. Whereas a growth mindset is about how you apply oneself to the learning environment once you are immersed in it, the competency matrix, and especially the beginning of the matrix, influences your ability to learn before you have even entered the learning environment. Since mentors and educators are not always present in a learner’s development, it is imperative that they impart the ability and the desire for the learner to develop and sustain reflective competence throughout their learning. If learners have the intellectual ability, a desire to learn, and also possesses reflective competence, then they should eventually develop unconscious competence – mastery. If learners start to learn, but become overconfident in their learning and their abilities, they have lost the ability of reflective competence and will once again be unconsciously incompetent. If learners develop ‘mastery’ of the process and they maintain reflective competence, they will recognise when they are beginning to lose or have lost their ‘mastery’, meaning they can choose to reharness their skills or not to. Therefore, the important aspect for learners and educators is not just ensuring how learners negotiate the competency framework, but how they are cognitively situated before they commence the learning process, and how they will remain cognitively situated throughout their ongoing learning.

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Conclusion This is the final instalment in the series of discussions around your professional identity and the development of your learning and professional practice. What I hope I have demonstrated is that a huge amount of responsibility for ongoing learning and development rests with the learner themselves, and not with assessment organisations and accreditation bodies. It is useful to know about theory and concepts such as the competency matrix, intellectual humility, growth mindset, and situational awareness, however the most important aspect is how you personally utilise these theories and develop them within your own learning and professional practice. Your medical career can be long, and within that time your ability to learn and perform will inevitably change, and not always for the better. Therefore, it is vital that you recognise that your learning is there to help others – your patients. Your patients are the ultimate beneficiary of your learning and development, which is why it is paramount that you start to ensure it develops optimally as early as you can in your career. This requires reflecting with the right people at the right time in the right manner, including yourself.

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References [1] Conger DS, Mullen D. Life skills. Int J Adv Counsell. 1981;4(4):305-319. [2] Peck M. Blog of an Auckland Magician [Internet]. Auckland, New Zealand: Peck M. 2011 - . The Four Stages of Learning; 2013 Aug 22. Available from: http://aucklandmagicianblog. com/the-four-stages-of-learning/ [3] Wormald BW, Schoeman S, Somasunderam A, Penn M. Assessment drives learning: an unavoidable truth? Anat Sci Educ. 2009;2(5):199-204. [4] van der Vleuten CP, Schuwirth LW, Driessen EW, Dijkstra J, et al. A model for programmatic assessment fit for purpose. Med Teach. 2012;34(3):205-214. [5] Barrett LF, Russell JA. The structure of current affect: controversies and emerging consensus. Curr Directions Psychol Sci. 1999;8(1):10-14. [6] Businessballs [Internet]. England: Businessballs; 2019. Conscious Competence Learning Model; [cited 2019 Oct]. Available from: https://www.businessballs.com/ self-awareness/conscious-competence-learning-model/ [7] Nonaka I. A Dynamic Theory of Organizational Knowledge Creation. Organization Sci. 1994;5(1):14-37. [8] Oxford Dictionaries [Internet]. England: Oxford University Press; c2019. Light-Bulb Moment. Available from: http://www. oxforddictionaries.com/definition/english/light-bulb-moment


An Interview with Professor Alicia Jenkins – Endocrinologist, Researcher and President of Insulin for Life David Chen Bachelor of Medicine/Bachelor of Surgery (Honours) 5th year medical student (5-year degree) at Monash University David is a final year medical student at Monash University and an Associate Editor of the Australian Medical Student Journal. He has undertaken research projects in diabetes, which he has greatly enjoyed. Prof. Alicia Jenkins MBBS, MD, FRACP, FRCP Director of Diabetes and Vascular Medicine at NHMRC Clinical Trials Centre Prof. Jenkins is a clinician-scientist with interests in diabetes and vascular medicine working at NHMRC Clinical Trials Centre and St Vincent’s Hospital Melbourne. She is also the President of Insulin for Life. In this issue of the Australian Medical Student Journal, we are fortunate to interview Professor Alicia Jenkins, a Clinical Endocrinologist at St Vincent’s Hospital Melbourne, Director of Diabetes and Vascular Medicine at NHMRC Clinical Trials Centre and President of Insulin for Life. She was also recently awarded the prestigious ADS Kellion Award, which acknowledges an outstanding contribution to diabetes research, clinical or service areas. Prof. Jenkins provides us with an insight into the field of diabetes and endocrinology, the benefits of undertaking research, as well as her charity work for Insulin for Life. Prof. Alicia Jenkins

Q: Why did you become a doctor? A: “To help people”. This is the answer I gave as a 17 year old, who grew up in a farming community when asked after having been offered a place in medicine at the University of Melbourne. It’s still the same reason I continue long hours as a clinician, medical researcher, educator and advocate. It’s a diverse, challenging, rewarding, achievable and incredibly important goal. Q: Why did you choose a career in endocrinology? A: My mother was diagnosed with Type 1 diabetes in 1939 (and lived until age 92), so I knew the challenges that people with diabetes face, and the importance of excellent and accessible care and of research. I was interested in all aspects of medicine during medical school and residency, and as diabetes is common and impacts every system in the body endocrinology was a great fit for me. An added bonus was the strong laboratory and research options that can improve patient outcomes. Q: How would you describe the typical day of an endocrinologist? A: The typical day for most endocrinologists is providing specialist care to people with diabetes, or other conditions affecting other hormone systems, such as the thyroid, pituitary, adrenal, bone or reproductive organs. Most of this is done on an outpatient basis, with some inpatient work for some. The endocrinologist will interact with patients and often with their family, other general and specialist clinicians and allied healthcare providers. Some time should be spent in ongoing education, such as reading medical journals, as treatment options for endocrine conditions are advancing rapidly and it’s important to be up to date so as to provide the best care. An endocrinologist involved in research and teaching will also need to spend time writing research grants, conducting funded research, which may be people and/or laboratory based, and in training activities. Q: What do you find most rewarding about your work? A: Making a positive impact in the lives of many people, including patients and their families, other healthcare professionals, trainees and researchers. The diverse range of skillsets and work-place options (clinic, university, research laboratory, national and international work places) add to it. Australian Medical Student Journal

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Q: What advice would you give to medical students and doctors interested in a career in endocrinology? A: Endocrinology has so many career options within: subspecialties, a mixture of clinical, research and teaching; part-time or full-time and diverse (urban, rural, remote or overseas) work locations. And with the diabetes epidemic there is certainly job security! It’s great if you like caring for individuals long-term, being part of a multi-disciplinary team, and are interested in evidence-based medicine with new drugs and devices. Q: How did you become interested in research and what is the current focus of your research? A: As a registrar I was exposed to a research active endocrinology unit at the University of Melbourne (St. Vincent’s Hospital) and realised that existent treatments and care delivery could be expanded so as to improve health outcomes for people with or at risk of diabetes. My research focus is the prediction and prevention of diabetes complications via the optimal use of technology (e.g. pumps, sensors, telemedicine), and (clinical, biochemical and molecular) biomarkers. This involves conducting clinical trials of new and repurposed drugs and devices. Q: What are the benefits of being exposed to research as a medical student? A: There are many benefits, and of course some challenges. Research trains one in analytical thinking, in accessing and assessing evidence and in communicating ‘science’ and the gaps in medical science and care to others (including medical, scientific and lay groups). Every good doctor, even if they don’t do any research or continue in research, will utilise research results in their daily clinical practice. Q: Could you tell us about your charity, Insulin for Life (IFL)? A: IFL (www.insulinforlife.org) collects in-date unopened diabetes supplies in (so far nine) affluent countries and provides them at no cost to clinics for the poor in over 40 disadvantaged countries. We help run (overseas) diabetes camps, community screening days, with advocacy and global health research. Seventy-five percent of the people with diabetes in the world today live in disad vantaged regions, and I believe it is important that those of us who have the capacity to help others should do so. Health is wealth and as medical students and doctors with expertise in health, we have much to share. Q: How can medical students and doctors contribute to this excellent cause? A: There are many options. Diverse skill-sets and time commitments are welcome. Volunteers can help raise awareness, fundraise, help with camps, prepare diabetes supply shipments (going from Ballarat), help with social media, website monitoring and research projects. Check out www.insulinforlife.org or contact me (alicia.jenkins@ctc.usyd.edu.au).

Correspondence David Chen dchen092@gmail.com

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Change in the Cardiopulmonary Exercise Testing Response in Patients with Coronary Artery Disease who do not choose to Participate in Cardiac Rehabilitation Nikhil Kumar Fourth year MBBS student, University of Queensland Nikhil completed a Bachelor of Arts (Psychology) at York University, Canada where he completed his honour thesis on spatial memory in three-month-old infants. He has since completed a PostBaccalaureate at California State, East Bay, USA and is currently residing in Brisbane, Australia undertaking the MBBS program at The University of Queensland. Nikhil will start his internship in 2019 with Greenslopes Private Hospital. Andrew Victor MD Andrew earned his Bachelor of Sciences in Cell and Molecular Biology from Concordia University in his hometown of Montreal, Quebec, Canada before completing his medical degree at the University of Medicine and Health Sciences, with placements across the USA and Canada. He is currently awaiting residency and works as a Physician Assistant and Cardiac Technician at Whitby Cardiovascular Institute and a Physician Navigator in the ED at Michael Garron Hospital in Toronto, Canada. Abstract: Background: The purpose of the present study is to track changes in the cardiopulmonary exercise testing (CPET) response in a coronary artery disease (CAD) cohort who underwent a revascularisation intervention or optimisation of medical management. Materials and Methods: A retrospective, observational study of 138 patients with CAD (20% female, mean age 65±9 years) who underwent percutaneous intervention (PCI), coronary artery bypass graph (CABG), or medical management.. CPET was completed after treatment for CAD and during a follow-up visit, with a mean study length of 13±5 months. Peak oxygen consumption (VO2), VO2 at the ventilatory threshold (VT), peak O2 pulse, the minute ventilation/carbon dioxide production (VE/VCO2) slope, the oxygen uptake efficiency slope (OUES) and the VO2 /WR slope were determined at baseline and during the follow-up CPET. Results: A significant reduction (p<0.001) in: 1) peak VO2 (19.2±4.3 vs. 18.2±4.3 mlO2·kg-1·min-1) and 2) VO2 at VT (11.9±2.4 vs. 11.4±2.4 mlO2·kg-1·min-1) was observed. There were no significant changes (p≥0.25) in the following variables between CPETs: 1) peak O2 pulse (12.4±3.2 vs. 12.3±3.2 ml/beat); 2) VE/VCO2 slope (27.9±4.8 vs. 28.1±4.4); 3)OUES (1.9±0.5 vs. 1.9±0.50); and 4) VO2/ WR slope (9.0±0.98 vs. 8.9±1.2 ml·min-1·Watt-1). Conclusion: The current study indicates that several key CPET markers of physiologic integrity remain stable in patients with CAD. Functional capacity and sub-maximal aerobic exercise tolerance parameters indicated signs of decline at follow-up.

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Introduction Cardiac rehabilitation (CR) is considered a gold standard of care for those diagnosed with coronary artery disease (CAD) and has received a Class 1 Recommendation from the European Society of Cardiology and American College of Cardiology [1-2]. The goals of CR are to improve cardiovascular work efficiency, increase exercise tolerance to reduce physical decline, and maintain physical capacity [3-7]. These goals can be met through a combination of cardiovascular training, weight training, and regular adherence to dietary and caloric planning. These goals were supported by a Cochrane systematic review in 2016 by Anderson et al [7], where CR was shown to reduce cardiovascular mortality, the risk of hospital admissions, and provide improvements in quality of life. This review included 63 studies with 14,486 participants in total, and a median follow-up of 12 months and a minimum of six months follow-up. Following myocardial infarction or revascularization, comparisons were made between patients who participated in CR and those who did not. Despite the strong evidence in support of CR, up to 70% of eligible patients did not participate in CR [8]. In another study by Fried et al [9], many older patients with multiple co-morbidities had reported their struggle with understanding the relationship between their diseases and treatment, which may lead to poor uptake and attendance in CR. Functional exercise capacity (FC) is defined using a calculated peak oxygen consumption (VO2) determined by age, weight, and gender. VO2 is measured by multiplying the cardiac output with the arteriovenous oxygen difference. In other words, FC is the maximal capacity of the body to transport oxygen during exercise. There are multiple methods to determine FC. Cardiologists have primarily relied on treadmill stress testing, but more recently, the utilization of CPET has shown an advantage in allowing for a more comprehensive panel of cardiorespiratory fitness markers, which are further discussed in the methods section of this article. FCÂ changes following CR are well documented [10-15]. However, in patients who do not participate in CR, changes in cardiac biomarkers obtained from CPET remain unclear.

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Aim To document the changes in FC in patients who do not participate in post-intervention CR. Hypothesis A decrease in functional capacity is correlated with not participating in CR and a sedentary lifestyle. Furthermore, patients who participate in CR following revascularisation have an improved FC. Materials and Methods: Study design This study is a retrospective, observational study. The study was considered completed when participants had finished both aspects of the study. Participant selection and recruitment This study included patients who were diagnosed with CAD via an angiogram. These patients underwent revascularisation or optimisation of medical management, such as percutaneous coronary intervention (PCI), coronary artery bypass (CABG), or medication modification. All patients were recruited from a single community cardiology practice in Whitby, Ontario Canada between January 2014 and June 2017. It is standard practice in this clinic to refer all patients to cardiac rehabilitation and this is provided free of charge to the patient. All participants were clinically stable. During consultation with the physician, eligible patients revealed that they exercised no more than once per week, and did not want to participate in CR, even when medically advised to do so. Patients were excluded if they were clinically unstable, exercised regularly, had any interest in CR, or refused to repeat CPET after a year for reassessment of their status. Clinically unstable patients included those with chronic heart failure, respiratory disease, anaemia, uncontrolled hypertension, and inability to exercise due to lower extremity or joint issues. All participants signed two written informed consent forms, one for the procedure and another for their data and outcomes to be used for research purposes only. These consent forms were approved by the Canadian Association of Research Ethics Board.


Outcome and measures Diagnostic and prognostic markers derived from CPET were used to measure the improvement of cardiac efficiency post-intervention and after one year. CPET was completed as part of routine management and the patients consented to have their data recorded for retrospective study purposes. Routine management included a post-intervention assessment of patients to assess functional capacity. The CPET cardiorespiratory fitness markers used in this study were VO2, VO2 at ventilatory threshold (VT), peak O2 pulse, the minute ventilation/carbon dioxide production (VE/VCO2) slope, the oxygen uptake efficiency slope (OUES) and the VO2/WR slope. As previously described [10-15], VT is calculated using the slope of VO2/VCO2 and represents the point at which CO2 production becomes greater than the increase in VO2, thus causing the slope to steadily decrease. The VE/VCO2 slope is the minute carbon dioxide production. The OUES is the relationship between ventilation and oxygen uptake. The VO2/WR slope is the relationship between oxygen uptake and work rate. CPET Procedure CPET was performed 4-6 weeks post-intervention and follow-up was scheduled for 12 months after this first session. CPET was performed on an electromagnetically-braked cycle ergometer using a customized linear-ramp protocol designed to elicit fatigue within 8-12 minutes of exercise. CPET was completed as per guidelines [16]. Medications were not withheld prior to testing. CPET was used with three minutes of unloaded cycling that progressively increased 10-15 watt/min until optimal test duration was completed. There was no change in ramp intensity. Completion of the test was patient-dependent; requiring maximum exertion (ME), as defined by the respiration exchange ratio (RER). CPET sessions were completed by one of two qualified exercise physiologists and a medical student under physician supervision. Patient history and exercise status were not provided to the conductors of the test prior to patient investigation. Technicians who were operating the test session were blinded to the recruitment for the study. Standard 12-lead electrocardiograms (ECG) were obtained at rest and throughout the procedure. Reasons for stopping a session were based on symptoms, designated criteria, or completion of the timed test. Symptoms included pre-syncope, exercise fatigue, dyspnoea, or stable angina.

The designated criteria included achieving a respiratory exchange ratio ≥ 1.1, blood pressure ≥230/130 mmHg or drop in systolic pressure ≥20 mmHg. Stress ECGs were analyzed for ST changes at peak exercise. A normal response was defined as a lack of significant ST-segment changes. A positive response was defined as ST-segment depression of 1 mm or greater (upsloping or flat) in two or more leads. Studies were considered indeterminate if they had significant artifact or other abnormalities such as left bundle branch block or ST-segment change <1 mm [17]. Spirometry and CPET machines are owned, operated and maintained by MET-TEST (USA), using the Metabolic Cart made by Cosmed (Italy). The equipment was calibrated to the manufacturer’s specifications prior to each test. Analysis VO2 and VCO2 were measured at every breath and the averages over 10 seconds and 30 seconds were displayed on the device monitor, numerically and graphically respectively. Peak VO2 was expressed as the highest averaged interval during the final 20 seconds of testing. VE and VCO2 values were acquired from the beginning of exercise to the time of peak exertion. These values were placed into the spreadsheet software Microsoft Excel (Microsoft Corp., Bellevue, WA) to calculate the slope of VE/VCO2. Statistical testing All data is presented as the mean ± standard error (SE) and was analysed by a one-way ANOVA and Bonferroni post-hoc testing. A confidence interval of 95% was used and p-values <0.05 were considered statistically significant. Results Participant Characteristics Every patient of the clinic who underwent CPET as routine investigation, was approached to take part in research. In total, 250 patients were eligible for this study, with 138 consenting for post-corrective intervention and follow-up appointment. The mean age of patients was 65±9 years and a total of 20% were female. All participants had CAD and received some sort of cardiac intervention – 53 participants underwent PCI, 68 participants underwent CABG, and 17 received pharmacological intervention. Data containing co-morbidities to cardiac disease, such as hypertension, diabetes, dyslipidaemia were not stored. In terms of patient management, the only data recorded was whether the patient exercised regularly or not and was used for exclusion criteria.

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Table 1. Changes in functional exercise capacity over time following intervention (n=138) Post-Intervention

1 Year Follow-Up

p-value

Peak O2

19.2±4.3 mlO2·kg−1·min−1

18.2±4.3 mlO2·kg−1·min−1

p<0.001

VO2 at VT

11.9±2.4 mlO2·kg−1·min−1

11.4±2.4 mlO2·kg−1·min−1

p<0.001

Peak O2 Pulse

12.4±3.2 ml/beat

12.3±3.2 ml/beat

p>0.05

VE/VC O2 Slope

27.9±4.8

28.1±4.4

p>0.05

VO2/WR Slope

9.0±0.98 mlO2·kg−1·min−1

8.9±1.2 mlO2·kg−1·min−

p>0.05

OUES

1.9±0.5

1.9±0.5

p>0.05

Outcome data Data from the one-year follow-up was variable as repeat testing was dependent on the patient returning to clinic and re-consenting for their testing data being used for research purposes. Patients returned on average 13 months after corrective intervention (± 5 months). There was a significant decline in peak VO2 and VO2 at VT, which demonstrates a decline in FC and sub-maximal aerobic exercise over time (see Table 1). Peak VO2 declined from 19.2±4.3 to 18.2±4.3 mlO2·kg-1·min-1 and VO2 at VT declined from 11.9±2.4 to 11.4±2.4 mlO2·kg-1·min-1. Both were significantly reduced, with a p<0.001. However, there was no significant difference in peak O2 pulse, VE/VCO2 slope, OUES, and VO2 /WR slope (p>0.05). Discussion Cardiac rehabilitation The importance of CR is well-documented and well-understood. Patients who have undergone CR have shown significant improvements in CPET markers [15]. Hence, CR is recommended by multiple national and international agencies [1-2]. This study demonstrates that most of the traditional CPET markers (peak oxygen consumption, VO2 at ventilatory threshold, peak O2 pulse, the minute ventilation/carbon dioxide production slope, the oxygen uptake efficiency slope and VO2/WR slope) did not improve in patients with CAD who did not participate in CR. Previous studies have not singularly examined patients who do not participate in CR. These findings are expected as intervention for patients with CAD do not provide symptomatic benefit to the extent that one would assume when using the intervention alone. There is evidence thay medical and therapeutic lifestyle changes and appropriate cardiac rehabilitation are more beneficial [18]. Furthermore, the FC and sub-maximal aerobic exercise tolerance markers showed significant decline on follow-up testing.

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Possible explanations for this decline may include a sedentary lifestyle and lack of compliance with medical advice and management [19]. These findings all support the necessity of cardiac rehabilitation to include education on maintaining a therapeutic lifestyle in patients post-intervention CAD patients. Further research would be necessary to determine the impact of a lack of cardiac rehabilitation on the occurrence of cardiac events. The wealth of data provided by the CPET in cardiac stress testing provides an interesting new modality for future research and overall patient care. Limitations A limitation of the study is that data on patient demographics, such as co-morbidities to cardiac disease and history of previous cardiac disease was not stored. Other data that should have been stored included smoking status, family history of cardiac disease, and medications, but these details were unavailable. This study also contains a measurement bias, in which the variation of follow-up had a difference of 10 months. This was dependent on each patient scheduling and then attending their follow-up appointment. Including an additional longitudinal measure, such as five-year follow-up would further strengthen the findings.


Conclusion It can be inferred that an absence of appropriate cardiac rehabilitation can increase the risk of deterioration in FC. This is supported by the decrease or lack of significant change in CPET parameters, such as peak VO2 and VO2 at VT, when assessing patients post-intervention. These data suggests that PCI or CABG alone may not translate to an improvement in cardiac function. However, participation in appropriate CR has been shown to measurably improve FC and exercise tolerance [1-7]. These studies serve as evidence that a therapeutic lifestyle with aerobic physical activity needs to be re-emphasised to patients alongside aggressive risk factor control measures, such as blood pressure and lipid management. These changes further support the importance of CR referral and maintaining patient compliance to regularly scheduled rehabilitation sessions. CPET is a valuable addition to the armamentarium in combating mortality and morbidities of patients with CAD. Acknowledgements The authors would like to thank the Whitby Cardiovascular Institute for financial and material support.

Correspondence Nikhil Kumar nik.kumar.ismc@gmail.com

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2016;92(1088):328-32. [13] Pinkstaff S, Peberdy MA, Kontos MC, Fabiato A, Finucane S, Arena R. Usefulness of decrease in oxygen uptake efficiency slope to identify myocardial perfusion defects in men undergoing myocardial ischemic evaluation. Am J Cardiol. 2010;106(11):1534-9. [14] Lavie CJ, Arena R, Swift DL, et al. Exercise and the cardiovascular system: clinical science and cardiovascular outcomes. Circ Res. 2015;117(2):207-19. [15] Kumar N, Behbahani H, Shamim A, et al. Rehabilitation

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[3] Lazzeroni D, Castiglioni P, Bini M, et al. Improvement in aerobic capacity during cardiac rehabilitation in coronary artery disease patients: is there a role for autonomic adaptations? Eur J Prev Cardiol. 2017;24(4):357-64. [4] Yang X, Li Y, Ren X, et al. Effects of exercise-based cardiac

disease. Eur Heart J. 2016;37 (Abstract Suppl):1122. [16] American Thoracic Society; American College of Chest Physicians. ATS/ACCP Statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med. 2003;167(2):211-77. [17] Chaudhry S, Kumar N, Behbahani H, et al. Abnormal

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[5] Liou K, Ho S, Fildes J, Ooi SY. High intensity interval versus moderate intensity continuous training in patients with coronary artery disease: a meta-analysis of physiological and clinical parameters. Heart Lung Circ. 2016;25(2):166-74. [6] Pattyn N, Coeckelberghs E, Buys R, Cornelissen VA, Vanhees L. Aerobic interval training vs. moderate continuous training in coronary artery disease patients: a systematic review and meta-analysis. Sports Med. 2014;44(5):687-700. [7] Heran BS, Chen JM, Ebrahim S, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2011;(7):CD001800. [8] Doll JA, Hellkamp A, Ho PM, et al. Participation in cardiac rehabilitation programs among older patients after acute myocardial infarction. JAMA Int Med. 2015;175(10):1700-2. [9] Fried TR, McGraw S, Agostini JV, Tinetti ME. Views of older persons with multiple morbidities on competing outcomes and clinical decision-making. J Am Geriatr Soc. 2008;56(10):1839-44.

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2017;228:114-21. [18] Chatterjee S, Sengupta S, Nag M, Kumar P, Goswami S, Rudra A. Cardiopulmonary exercise testing: a review of techniques and applications. J Anesth Clin Res. 2013;4:340. [19] Booth FW, Roberts CK, Laye MJ. Lack of exercise is a major cause of chronic diseases. Compr Physiol. 2011;2(2):1143-211.


Organisational process and patient factors contributing to hospital outpatient clinic non-attendance Irushi Ratnayake Fifth year Medicine Monash University Irushi has enjoyed her first experience with clinical research and will continue to foster her experience in the future.

Dr. Lyn- Li Lim MBBS, GradDipClinEpi, MPH, FRACP Eastern Health Dr. Lim is an infectious diseases and general physician at Eastern Health who is involved in teaching medical students and basic physician trainees.

Abstract Background: Missed outpatient clinic appointments result in inefficient use of staff time, prolong waiting lists, limit clinic accessibility for other patients, and may be detrimental to patient health. This study examines organisational and patient factors which may lead to hospital clinic non-attendance at outpatient clinics in two metropolitan hospitals in Victoria, Australia. Methods: We conducted a review of organisational process by interviewing staff on clinic triaging, booking, and cancellation processes. An audit of patients booked into the two clinics was undertaken with baseline demographic data on patients who missed appointments. Electronic databases were reviewed to identify staff follow-up action and the documented reasons for failure to attend (FTA). Results: Of 207 appointments, 25% (n=51) were not attended during the study period. In 14% (n=7) of patient FTAs, there was no electronic documentation trail on follow-up contact by staff or outcome. Organisational factors including lack of integration between electronic systems and inconsistent electronic documentation by clinic staff were found to contribute to FTA. Of contacted patients, the most common reasons for non-attendance were hospital or emergency department admission (13%, n=4), not interested in treatment (13%, n=4), and forgetting (9%, n=3). Conclusion: This study demonstrated a high rate of patient FTAs in two Victorian metropolitan outpatient clinics. Robust data on capturing reasons for non-attendance will be valuable when identifying measures to reduce patient FTAs. Organisational factors including inconsistent electronic documentation by staff and disjointed electronic systems contributed to FTAs. Integrating data from multiple electronic systems and developing consistent clinician processes to clearly document FTA and attempts to contact patients following FTA will reduce the reasons for non-attendance found in this study and enhance co-ordination of care.

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Introduction As Australia’s population continues to age and the burden of chronic disease increases, ensuring opportunity to access outpatient clinics becomes increasingly important. Hospital outpatient clinics have a role in consolidating care between community practitioners and tertiary services and ensuring discharged medically complex patients receive timely specialist follow-up [1]. Patients who fail to attend (FTA) clinic appointments (that is, non-attending patients who neither use nor cancel their appointment) represent a major source of inefficiency in global healthcare systems. In the UK in 2012, 5.8 million outpatient appointments were missed, causing an estimated £585 million of revenue to be wasted due to non-attendance [2] . Missed appointments result in ineffective use of staff time, prevent access to clinics by prolonging waiting times, and are detrimental to patient health outcomes as continuity of care is lost [2]. Patients with advanced disease who fail to attend are found to have an increased likelihood of emergency department admissions and increased mortality in comparison to patients who have not missed appointments [3,4]. Determining the reasons behind patients failing to attend may identify solutions that improve adherence and reduce inefficiencies in the healthcare system. The aim of this study is to examine organisational and patient factors which may lead to non-attendance in two outpatient clinics in two metropolitan hospitals in Victoria, Australia. Methods This project was approved as a quality assurance project through the Eastern Health Office of Research and Ethics (QA102-2017). The project was conducted at an Australian health service at the infectious diseases (ID) clinics at two metropolitan hospital sites. These sites shared common organisational processes and medical staff, while administrative staff were site specific. Brief semi-structured interviews were conducted with administrative staff members exploring the process of triaging, booking, and cancelling patient appointments. Data from these interviews were then compared to hospital guidelines.

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Figure 1. Process of booking and rebooking appointments by clinic administrative staff.

Figure 1 outlines hospital guidelines for triaging, booking, and rebooking patient appointments. For both sites, medical staff triaged internal and external clinic referrals uploaded onto a centralised electronic triage system by administrative staff. All patients were routinely sent postal reminders at minimum three days prior to the appointment and a text message reminder two days prior, detailing preparation for the appointment and instructions for cancellation [5]. If a patient fails to attend, hospital guidelines recommend calling the patient to enquire the reason for non-attendance and rescheduling the appointment if required [5]. Following two consecutive FTAs, guidelines recommend removing patients from the clinic list with clinician approval. Patients are informed of the FTA policy via the postal and text message reminders [5]. In addition, an audit of non-attending patients over a four-week period was conducted by one author, reviewing patients booked into ID clinics at both sites. For patients who failed to attend clinic appointments, baseline demographic data was collected including age, gender, and reason for appointment. In addition, reason for non-attendance, prior history of failure to attend, attempts to cancel, and action undertaken by doctors or administrative staff was gathered. This information was extracted by searching three electronic databases where patient information on outpatient appointments was captured in both hospital sites: Clinical Patient Folder (CPF®), Electronic Medical Record (EMR®), and HOMER,© in addition to a hardcopy documentation used by clerical and medical staff. Basic computations using the data were performed using Microsoft Excel 2016.


Results Semi-structured interviews Interviews with medical and clerical staff identified that a paper FTA document is used by doctors, clinic nurses, and clerical staff to capture a follow-up plan after patient non-attendance. After clerical staff have used this document to either rebook, discharge, or contact patients, this document is destroyed with no electronic trail. Three electronic databases are used by both hospitals for the documentation of FTA data. Two databases (HOMER© and EMR©) can be completed by clerical staff with administration rights capturing information on FTA. These databases do not include free text sections on FTA. The third database (CPF©) has a section that can be completed only by clinical staff (medical or nursing) on FTA, including free text sections on reasons for FTA and actions. Interviews identified that there was no consistent process followed by medical staff in capturing data electronically on reasons for and actions following FTA, although all were comfortable with documenting the plan on the paper FTA document. Administrative staff reported routinely entering FTA data in one database in real-time (HOMER©), however due to lack of integration between databases, this information may be incomplete or inconsistent across all databases, resulting in difficulty for staff to access comprehensive data on FTAs. The EMR© database codes for all patient missed appointments, including FTAs, as “cancelled.”

Patient audit Of 207 appointments booked into ID outpatient clinics at two sites over a four-week period, 25% (n=51) appointments were missed and 7% (n=14) were cancelled. Three patients missed two or three appointments during the study period, accounting for seven missed appointments. These patients were included multiple times on FTA data. Of FTA patients, 77% (n=36) were attending the clinic for follow-up appointments. Of these 36 patients, 67% had previously failed to attend ID clinic appointments, 42% had missed two or more previous ID appointments and 39% had previously failed to attend outpatient clinic appointments for other specialities. The median age of patients who failed to attend was 43 years (range: 19-89 years) and 55% (n=26) were male. Eight patients indicated requiring an interpreter on registration. A greater number of FTA patients were follow-up (77%, n=36) than new (23%, n=11) (Table 1).

Table 1. Characteristics of FTA patients.

Variable

Category

No. Participants

% Participants

Gender

Male

26

55%

Female

21

45%

New

11

23%

Follow-up

36

77%

Prior FTA

24

51%

No Prior FTA

23

49%

Non-English Speaking

8

17%

Patient Type

Prior FTA*

Language

*Prior FTA at either ID or non-ID clinic

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a) Documented reasons for patient FTA Electronic documentation by medical and nursing staff of attempts to contact FTA patients was inconsistent, with evidence of real-time electronic entries by medical staff in 86% (n=44) of missed appointments on CPF© and no entries by clinic nursing staff. Lack of documentation of attempts to contact the patient by clinic nursing or administration staff could be explained by lack of electronic documentation despite attempts having been made. Where there were entries, we identified 63% (n=32) of patients had been contacted by the clinic doctor following FTA and the remaining patients could not be contacted. Of contacted patients, a specific reason for non-attendance was not documented in 41% (n=13) of cases. Documented reasons for failing to attend in 32 contacted patients were admission to hospital or Emergency Department of the health service (13%, n=4), not wanting treatment (13%, n=4), forgetting (9%, n=3), feeling better (6%, n=2), and clerical error (4%, n=1), which involved being booked into two appointments by staff. Reasons for FTA are summarised in Table 2. Table 2. Patients booked for ID clinic appointments, by reasons for FTA.

Contacted Patient Specific reason not documented Hospital or ED admission Not interested in treatment Forgot Feeling better Clerical error

Other Death Transfer care to other hospital Unable to get investigations Change of address Cannot afford to attend Unable to contact Not documented

Total

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13 13 4 4 3 2 1 5 1 1 1 1 1

b) Documented actions following patient FTA Most FTA appointments (71%, n=36) were rebooked, with the remaining 25% (n=13) of patients discharged, excluding one death and one admission to hospital. Of the 36 rebooked patients, 50% (n=18) were directly contacted, attempted to be contacted, or the patient’s primary care doctor was contacted. Patients who were discharged from clinic were routinely notified of discharge by mail to patient’s nominated address and 30% (n=4) were additionally contacted by the doctor. Table 3 illustrates actions following patient FTA. Altogether 55% (n=28) of all patients who failed to attend were followed up. 18 patients had failed to attend two consecutive appointments and 67% (n=12) of these were rebooked, with the remainder being discharged. Of the patients who had missed two consecutive appointments and were rebooked, 42% (n=5) were directly contacted, attempted to be contacted, or the primary care doctor contacted. Table 3. Documented actions following patient FTA.

Rebooked Contacted Not Contacted Discharged Contacted Not Contacted Admission to hospital Death

Total

12 7

51

36 18 18 13 4 9 1 1

51

Discussion Missed appointments have damaging medical consequences for patients due to delayed diagnosis, lack of follow up, and inability to renew scripts. Our audit demonstrated that one in four patients missed their appointments; this is comparable to hospital clinic data nationally [6] and internationally, with rates ranging from 6% to 33% [4,7-9]. The high rate of non-attending patients in this Victorian outpatient clinic setting demonstrates the relevance of this issue and the necessity of identifying solutions to combat non-attendance. Organisational factors including lack of integration between electronic systems, unreliable coding for FTAs, and inconsistent electronic documentation by clinical staff were found to contribute to FTAs in this study. Common reasons for non-attendance included hospital or ED admission, not wanting treatment, and forgetting. Patient factors which were associated with FTA included prior FTA in the same or different outpatient clinics.


Examination of organisational processes and staff semi-structured interviews identified inconsistencies in data capture across all three electronic systems for data entered on FTAs. The first inconsistency was lack of integration across the three systems. Electronic integration would flag real-time data on patients unable to attend due to current readmission to our health service, deceased status, or new contact details, which constituted 12% (n=6) of non-attendances in this audit. Another inconsistency was coding terms for FTA and patient cancellations being used interchangeably in one of the electronic systems, which made it difficult for staff to track how often a patient missed appointments. Reviewing these processes would be useful in establishing baseline FTA rates and providing more reliable trended data on patient non-attendance. Our review found that clinical staff had inconsistent practice in electronically documenting actions and reasons for patient FTA, including whether the patient was directly contacted. Actions following FTA by clinical staff (for example, rebooking or discharge) was consistently captured on a paper document that was destroyed after actions were carried out by administrative or nursing staff. Administrative staff were able to document follow-up actions by either flagging whether the patient was rebooked (sending the patient an appointment by mail) or discharged electronically but had no access to free-text documentation. Organisational factors such as inefficient scheduling systems and administrative error have previously been found to cause FTA [10]. Identifying these inefficiencies and enacting changes such as duplicating paper data capture and improving consistency of coding for patient FTAs will allow for more robust data on capturing reasons for non-attendance, which would be valuable in developing service delivery improvements. The most common documented reason for non-attendance in our audit was admission to hospital or an emergency department, which accounted for 13% of FTAs. This demonstrates that consolidation of electronic systems to automatically cancel appointments when patients are admitted to hospital may substantially reduce FTAs. In addition, patients not wanting treatment (9%) or feeling better (6%) were common reasons for non-attendance. Other studies have also reported that healthier disease status and patient perception that the appointment

was not required are characteristic of those who missed appointments [7], while symptomatic disease was associated with greater adherence [4] . This demonstrates the potential value of contacting patients following non-attendance to remove them from the waiting list. Another practice to consider is contacting patients before their appointment to enquire whether they are still interested in treatment. This measure has been shown to be effective in other Australian health services [6]. Previous studies have found other reasons for non-attendance are patients feeling better or unhappy with treatment [2], being unaware of the appointment [7], having conflicting appointments, being an inpatient in hospital or in the emergency department, or clerical error [3], which includes requests to reschedule or cancel appointments not followed through by staff, as reasons for FTA. In our audit there were a higher number of non-attendances in males and young adults. While this may reflect the baseline demographics of the clinic patients, other studies have also reported variation in attendance based on patient demographics including gender and age group with male gender and younger age between 16-30 more likely to FTA [11-13]. 16% of FTA patients indicated a preferred language other than English on registration data, which has been associated with lower health literacy [14] and a reduced understanding and utilisation of healthcare services [15]. Observational studies have also identified other significant factors associated with FTA: living far away from the clinic [16], being an ethnic minority, having a perceived lack of social support [17], or being from a low socio-economic status [12,13]. Identifying patient groups at higher risk of non-attendance should enable the creation of interventions targeted toward these groups [17]. Studies have identified that individuals who had previously missed appointments in the same or different outpatient clinics are more likely to fail to attend future appointments [7,12]. This is similar to our findings showing two thirds of non-attendees had previously missed an appointment. For patients who miss appointments over multiple specialist clinics within the health service, clear documentation of reasons for FTA will improve co-ordination of care.

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Our study also showed that despite documented efforts by the doctor to directly contact over half the FTA patients, subsequent FTA likelihood remained high. This suggests that patients who previously fail to attend are at risk of doing so again. We postulate that this patient group may lack a personal connection with their doctor or the clinic and indicates the need for opportunistic counselling and reinforcement with these patients where possible when initially booking or rebooking the appointment. At the time of discharge from hospital, accurate electronic capture of previous multiple FTAs should flag with the discharging team the need to discuss with the patient the reasons for clinic follow-up. Accurate capture of FTA and reasons for FTA may also offer the opportunity for staff to rebook the appointment using a live call to the patient rather than letter and text message. While more time-consuming, a phone call is more effective than automated appointment reminders [18]. Limitations and Future Research It was beyond the scope of this study to compare the baseline characteristics of patients who attended versus non-attendees. A comparison of these two groups would enable the identification of groups at higher risk of failing to attend. The patient audit was restricted by a lack of documentation of reasons for and actions following FTA, which may have been due to a delay in uploading scanned notes. A study with larger patient numbers or a retrospective analysis may be necessary to give a more accurate understanding of how organisational process influences FTA. Including more patients registered as non-English speaking would be useful to determine if current follow-up processes following clinic non-attendance support this group. Future research investigating time and extra resources dedicated to following up FTA patients would also be important in streamlining approach and resource allocation.

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Conclusion Hospital outpatient clinics have an important role in consolidating care between community practitioners and tertiary services and ensuring discharged medically complex patients receive timely specialist follow-up. Ensuring consistency of coding for patient FTAs is useful in establishing baseline FTA rates and providing trended data on patient non-attendance. Duplicating paper data capture and integrating data capture on patient non-attendance across electronic systems are other potential areas of improvement identified in our study. Patients with previous FTAs are at risk of doing so again, therefore accurate capture of FTA and reasons for FTA is needed to allow more accurate identification of this patient group and offer the opportunity for staff to rebook the appointment using a live call to the patient rather than letter and text message, and to initiate close patient counselling as part of hospital discharge planning. Patients may have multiple clinic non-attendance across multiple public hospital outpatient services; clear documentation of attempts to contact and outcomes would support patient co-ordination of care. Acknowledgements We wish to thank the Eastern Health Infectious Diseases medical and outpatient staff for their support.

Correspondence Irushi Ratnayake irat2@student.monash.edu


References [1] Department of Health. Specialist clinics in Victorian public hospitals access policy [Internet]. Melbourne; 2013 [cited 2017 Dec 14]. Available from: https://www2.health.vic.gov.au/getfile/?sc_itemid=%7BE6447CD4-2AD8-48B3-8760-08A028FC788E%7D [2] Murdock AC, Lindsay H, Tham TC. Why do patients not keep their appointments? Prospective study in a gastroenterology outpatient clinic. J R Soc Med. 2002; 95:284-6. [3] Delgado Guay MO, Tanzi S, San Miguel Arreugi, MT, Chisholm G, De la Cruz MG, Bruera E. Characteristics and outcomes of advanced cancer patients who miss oupatients supportive care consult appointments. Support Care Cancer. 2014;22:2869-74. [4] Nielsen KM, Faergeman O, Foldspang A, Larsen ML. Cardiac rehabilitation: health characteristics and socio-economic status among those who do not attend. Eur J Public Health. 2008;18:479-83. [5] Objectify Database. Specialist Clinics: Appointment Scheduling and Booking (including FTAs and cancellations) [Internet]. 2015. [cited 2017 Dec 1]. [6] Department of Health. Specialist clinic service improvement guide. Melbourne: Health service Programs Branch; 2013 [cited 2017 Dec 14]. Availabe from: https://www2.health.vic.gov.au/about/publications/formsandtemplates/Specialist-clinics-improvement-guide [7] Collins J, Santamaria N, Clayton L. Why outpatients fail to attend their scheduled appointments: a prospective comparison of differences between attenders and non-attenders. Aust Health Rev. 2003;26(1):52-63. [8] Secondary Care Analysis Team. Hospital Outpatient Activity 2015-16. National Health Service; 2016 [cited 2017 Nov 24]. Available from: http://digital.nhs.uk/catalogue/PUB22596 [9] Cumming A. A guide to good practice: elective services. Wales: National Leadership and Innovation Agency for Healthcare; 2005 [cited 2017 Nov 24]. Available from: http://www.wales.nhs.uk/sitesplus/documents/829/guidetogoodpracticeelective.pdf [10] Roberts K, Callanan I, Tubridy N. Failure to attend out patient clinics: is it in our DNA. Int J Health Care Qual Assur. 2011;2(5):406 - 12. doi: 10.1108/09526861111139214 [11] Ellis DA, McQueenie R, McConnachie A, DPhil PW, Williamson AE. Demographic and practice factors predicting repeated non-attendance in primary care: a national retrospective cohort analysis. Lancet Public Health. 2017;2(12):551-9. [12] Campbell K, Millard A, McCartney G, McCullough S. Who is least likely to attend? An analysis of outpatient appointment ‘Did Not Attend’ (DNA) data in Scotland [Internet]. Edinburgh: NHS Health Scotland; 2015 [cited 2018 Mar 19]. Available from: http://www.scotpho.org.uk/ downloads/scotphoreports/scotpho150319-DNA-analysis-in-Scotland.pdf [13] Milne V, Kearns R, Harrison A. Patient age, ethnicity and waiting times determine the likelihood of non-attendance at a first specialist rheumatology assessment. Int J Rheum Dis. 2014;17(1):19-25. [14] McLean SM, Booth A, Gee M, Salway S, Cobb M, Bhanbhro S et al. Appointment reminder systems are effective but not optimal: results of systemiatic review and evidence synthesis employing realist principles. Patient Prefer Adherence. 2016;10:479-99. [15] Henderson S, Kendall E. Culturally and linguistically diverse people’s knowledge of accessibility and utilisation of health services: exploring the need for improvement in health service delivery. Aust J Prim Health. 2011;17(2):195-201. [16] Car J, Gurol-Urganci I, de Jongh T, Vodopivec-Jamsek V, Atun R. Mobile Phone messaging reminders for attendance at heathcare appointments Cochrane Database Syst Rev. 2013;(7):CD007458. [17] Catz SL, McClure JB, Jones GN, Brantley PJ. Predictors of outpatient medical appointment attendance among persons with HIV. AIDS Care. 1999;11(3):361-73. [18] Scott H, Lyon P. No easy solutions: lesson learned from an intervention to reduce clinic non-attendance rates in a Scottish hosptial. Int J Consum Stud. 2005;29(5):458-67.

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Intravenous Magnesium Therapy Treatment of Severe Asthma in Adults Jackson W Newport MBBS Queensland Health, Rockhampton Hospital JHO, Rockhampton Hospital Jackson graduated from James Cook University in 2016. He has an interest in anaesthesia and intensive care. The Lan Bui MBBS (Hons) BPharm (Hons) Queensland Health The Bui is currently a surgical registrar at the Sunshine Coast Hospital. He has an interest in surgery and critical care medicine. Abstract Background: Acute exacerbations of asthma may present as severe life-threatening illness that accounts for as many as 37,500 hospitalisations and 394 deaths each year in Australia. The current cornerstone of therapy in acute asthma includes short acting beta-2 agonists, short acting anti-muscarinic agents and corticosteroids. This systematic review aims to assess the current evidence for the use of intravenous magnesium and its efficacy in acute severe asthma. Materials and Methods: An online literature review of databases including OVID Medline, The Cochrane Database of Systematic Reviews, and PubMed was undertaken, including articles published between 1980 and 2017. Articles were analysed based on evidence regarding respiratory function, hospital admissions, biochemical effects, and adverse effects. Results: Although IV magnesium sulphate did not show statistically significant benefits in all asthma groups, there appeared to be some evidence of its efficacy in a subset of patients with severe asthma that had failed other first-line therapies. The treatment can reduce hospital admission rates with little evidence of adverse effects. Conclusion: The role of IV magnesium sulphate in asthma remains unclear; however, IV magnesium sulphate appears to be efficacious in severe asthma exacerbations when used synergistically with standard therapy. Introduction Asthma is a serious medical condition with potentially life-threatening consequences for all age groups. In Australia, acute asthma attacks account for some 37,500 hospitalisations and 394 deaths per year [1]. Although not completely understood, airway hyper-responsiveness is caused by acute and chronic inflammation in the lungs. The sum of these inflammatory reactions causes bronchoconstriction, bronchial oedema, and increased mucus production. Subsequently, patients suffer from recurrent episodic wheezing, dyspnoea, chest tightness, and persistent cough [1,2]. Table 1. Classification system for asthma severity based on Forced Expiratory Volume in one second (FEV1) predicted or personal best. Adapted from Albertson et al. [6]

Classification

Signs and Symptoms

FEV1

Mild

Dyspnoea only with activity, wheezing

>70%

Moderate

Dyspnoea interferes with or limits usual activity, wheezing

Severe

Dyspnoea at rest, interferes with speaking full sentences, decreased breath sounds, reduced wheezing

<40%

Too dyspnoeic to speak, perspiring, may lack air movement and wheezing (silent chest), cyanosed, lethargic

<25%

Life-threatening

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40-69%


Asthma can be categorised into mild, moderate, severe, or life-threatening (Table 1). A feared complication is status asthmaticus (SA). This is a severe subset of acute asthma that is unresponsive to first line therapies [3]. SA carries a mortality of 10-25% in patients intubated in Intensive Care Units (ICU). During SA, hypoxaemia develops due to lung hyperinflation, alveolar hypoventilation, and regional ventilation/perfusion (V/Q) mismatch, leading to acute type II (hypercapnic) respiratory failure. Death results from cardiopulmonary arrest [4,5]. Current Australian guidelines highlight three fundamental medication classes to treat moderate-to-severe acute exacerbations: short-acting beta-2 agonists (SABA), short-acting muscarinic antagonists (SAMA), and corticosteroids [7]. The dilemma arises when a patient with SA responds poorly to these established measures. Thus, research into novel or alternative approaches is important. Methylxanthine derivatives, such as theophylline, were initially promising but later failed to show additional benefit over established therapies [8]. One proposed alternative is intravenous magnesium sulphate (IVMS). Use of magnesium for the treatment of asthma exacerbations was first proposed by Rosello et al. in 1936 [9]. While its exact mechanism of action remains unknown, magnesium is hypothesised to mediate bronchodilation via three mechanisms. Firstly, magnesium competes with calcium for entry into cells through voltage- and receptor-operated calcium channels. This causes inhibition of intracellular calcium release from the sarcoplasmic reticulum and inhibits smooth muscle contraction [10]. Secondly, it inhibits acetylcholine release and prevents mast cells from releasing histamine [11]. Thirdly, it has antiinflammatory properties against T-lymphocytes, neutrophils, and pro-inflammatory cytokines [12]. Worldwide, there are discrepancies in the adoption of IVMS into clinical practice. In the United Kingdom (UK), utilisation of IVMS is extensive, with up to 93% of severe asthma presentations to the emergency department given IVMS [13]. In contrast, IVMS for severe asthma is used sparingly in the United States, given only in 2.5% of emergency department presentations [14] . This disparity is likely due to conflicting data concerning the effects of magnesium on bronchial hyperreactivity [15].

This article aims to examine the effect of IVMS in severe asthma and SA in the emergency department in the three main areas of respiratory function, hospital admissions, and its biochemical and adverse effects. Methods A literature search was conducted in 2016 and 2017. Online databases that were used to evaluate the evidence surrounding the use of intravenous magnesium sulphate include: OVID Medline, The Cochrane Database of Systematic Reviews, and PubMed. Articles were found using the following terms: intravenous, magnesium, adult, exacerbation, asthma, and critical care. Manual reference searching was also employed during this research period. The literature search was limited to trials from 1980 to 2017 (totalling 37 years). Initially, articles were screened for relevant search terms in their title and abstract, and the availability of full-text original research. Included in the analysis were full text papers of randomised control trials of intravenous magnesium sulphate compared with placebo in asthma exacerbations in adults. Only papers published in English were included. Studies were excluded if the focus was nebulised magnesium sulphate, the studies involved child subjects (less than 18 years of age), the language of publication was not English, or if the research was unpublished. A total of 504 articles were found using the search terms ‘magnesium’ and ‘asthma’. 113 search results were found using ‘intravenous magnesium AND Asthma’, and these articles were subsequently screened for relevance. Meta-analyses were included if they addressed the key research question and were applicable to adults. Randomised control trials were included if they met the above criteria. A total of 18 randomised control trials and three meta-analyses were included for review. Results: Table 2 lists the articles meeting inclusion criteria in this review, the type of study and the summarised findings of each.

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Table 2. Studies included in the literature review.

Study

Design

N

Objectives

Outcomes

Statistics

Okayama et al. [12] 1987, USA

Crossover

10

IVMS in acute and severe asthma exacerbations

Improved respiratory resistance, FEV1, and FVC

IVMS improvement Respiratory resistance: 71%±3%, FVC: 117%±5%, FEV: 118%±1% compared to baseline p ≤0.05

Noppen et al. [13] 1990, USA

Drug response

10

IVMS vs. albuterol on FEV1

Significant improvement FEV1 with IVMS

FEV1 following IVMS administration 0.94±0.39 L to 1.3±0.44 L p<0.05

Skobeloff et al. [14] 1990, USA

RCT Double blind

38

IVMS in poor responders to first-line therapy

IVMS improved FEV1 vs. placebo

225-297 L/min IVMS group vs. 208-216 L/min placebo (p-value not stated)

Tiffany et al. [23] 1993, USA

RCT Double blind

48

IVMS 2 g loading + infusion vs. loading only vs. placebo on FEV1 or PEFR

No significant changes in FEV1 or PEFR

FEV1=0.036, p=0.96 PEFR=0.51, p= 0.61

Sharma et al. [17] 1994, England

Single blind Crossover

18

IVMS vs. normal saline in known asthmatics without exacerbation

IVMS significantly increased FEV1, FEF 25-75% and V50

FVC pre-treatment 2.75±0.88, after IVMS 2.86±0.87 FEV1 pre-treatment 1.60±0.63, after IVMS 1.74±0.67 p<0.05

Bloch et al. [16] 1995, USA

RCT Double blind

135

IVMS + standard therapy effects on pulmonary function test and admission rates

No statistically significant changes in cohort overall, but there were statistically significant improvements in FEV1 and admissions rates in a subgroup of patients with severe exacerbations

Overall cohort: Hospital admission: 35.3% placebo, 25.4% IVMS (p=0.21) Subgroup with severe exacerbations: admission rates 78.6% placebo, 33.3% IVMS (p=0.009) FEV1 (p<0.05)

Hill and Britton [31] 1996, England

RCT Double blind

20

Histamine provocation test IVMS vs. placebo on AUC for change in FEV1

Weak bronchodilator effect. AUC significantly higher in the magnesium group. No significant difference between IVMS vs. placebo on histamine provocation

AUC, p=0.049 Histamine provocation p=0.7

Alter et al. [25] 2000, USA

Metaanalysis of 9 trials

859

IVMS bolus in acute asthma exacerbations

Adjuvant bolus IVMS statistically beneficial in improving spirometric airway function by 16% of a standard deviation

95%CI (0.028-0.297); p=0.02

Boonyavorakul et al. [21] 2000, Australia

RCT Double blind

33

2 g IVMS vs. standard therapy on severity score and admissions

No statistically significant improvement

Admission: 95%CI (0.19-2.67) Severity score: p=0.366

Rowe et al. [26] 2000, England

Meta-analysis of 5 adult and 2 paediatric trials

665

Adjuvant IVMS in acute asthma in the emergency department in terms of FEV1, PEFR, and hospital admissions

Not for routine use in all severities of asthma exacerbations. Severe exacerbations improved FEV1 and PEFR

Respiratory function: SMD, 0.30; 95% CI (0.050.55); p=0.02; Hospital Admission: RR 0.86; 95%CI (0.73-1.01); p=0.06

Schenk et al. [15] 2001, USA

RCT Double blind

30

IVMS bronchodilation post-methacholine provocation

Significantly increased FEV1 approximately 20% vs. placebo

The time to decrease FEV1 by 20% following dosing of methacholine was 0.83±0.54 mg/mL to 1.31±0.66 mg/mL, p=0.0001 in IVMS, compared to no change in the placebo group (0.86±0.52 mg/mL to 0.91±0.54 mg/mL, p=0.83)

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Silverman et al. [18] 2002, USA

RCT Double blind

248

IVMS vs. placebo in severe asthma (FEV1 <30%)

Improved FEV1

IVMS group mean FEV1 of 48.2% predicted, compared to 43.5% predicted placebo group p=0.045

Singh et al. [19] 2008, Iran

RCT Double blind

10

IVMS vs. placebo

Statistically significant improvement FEV1 6.07%

IVMS: 40.77+9.2% improvement from baseline, Control: 34.7+7.3% improvement

Bradshaw et al. [22] 2008, England

RCT Double blind

129

1.2 g IVMS vs. placebo in patients with PEF<75%

No benefit with regards to hospital admission rates or % predicted PEF at 60 min for the whole group, or for subgroups of life-threatening, severe and moderate acute asthma

Hospital admission rate: IVMS 79%, placebo 78% p=0.98 Predicted PEF at endpoint IVMS 63.7%, placebo 61.6 p=0.63

Goodacre et al. [20] 2013, England

RCT Double blind

1109

IVMS and nebulised magnesium vs. placebo on admissions and breathlessness

No statistically significant improvement in hospital admissions or breathlessness

Shan et al. [27] 2013, England

Meta-analysis of 11 adult trials

1754

IVMS and nebulised magnesium in adults and children with acute asthma

Significant improvement in respiratory function but weak evidence on admission rates

Kew et al. [28] 2014, USA

Meta-analysis of 14 adult trials

2313

Most studies were double-blinded trials comparing a single infusion of 1.2 g or 2 g IV MgSO4 over 15 to 30 minutes versus a matching placebo.

Single infusion of 1.2 g or 2 g IV MgSO4 over 15 to 30 minutes reduces hospital admissions and improves lung function in adults with acute asthma who have not responded sufficiently to oxygen, beta2-agonists and IV corticosteroids.

Admissions at 4 hours: IVMS 279, placebo 278 (p=0.083) Change in % predicted PEFR at 1 hour: IVMS 11.4%, placebo 10.2% Respiratory function: SMD, 0.30; 95%CI (0.050.55); p=0.02 Admission: RR 0.86; 95%CI (0.73-1.01); p=0.06 Hospital admission: 0.75; 95%CI (0.60-0.92) favours magnesium PEF: 4.78 95%CI (2.14- 7.430 favours magnesium

Table 2. Continued. N = sample size; RCT = Randomised Controlled Trial; CI = Confidence Interval; AUC = area under curve; PEFR = Peak Expiratory Flow Rate; FVC = Forced Vital Capacity; FEV1 = Forced Vital Capacity in 1 second; SMD = Standardized mean differences.

Discussion: Respiratory function Several studies have demonstrated IVMS to have positive bronchodilatory effects, showing improvements in spirometry values such as forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and peak expiratory flow rate (PEFR) after IVMS administration [12-19]. Okayama and Aikawa [12] noted dose-dependent improvements in FVC (117±3%) and FEV1 (118±1%) after administration of IVMS infusion, which persisted for up to ten minutes after conclusion of the infusion. Although this study was of patients with mild asthma, Okayama and Aikawa [12] noted improved dyspnoea and piping rales in three of these patients who had severe attacks. Noppen and Vanmaele [13] and Skobeloff and Spivey [14] both investigated IVMS in severe asthma and found improvements in FEV1 (0.94±0.39 L to 1.3±0.44 L) and PEFR (208-216 L/min to 225297 L/min) respectively that persisted up to 20

minutes after infusion cessation. In both studies, however, there was concomitant administration of SABAs, methylprednisolone, and methylxanthines, which may have had adjunct effects on the IVMS therapy and increased the duration of its efficacy [14]. Additionally, the limited power of these three studies may have contributed to the pronounced pulmonary effects.

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Silverman and Osborn [18] conducted a multi-centre randomised double-blinded controlled trial of 248 patients with severe asthma (FEV1 ≤30% predicted). With administration of IVMS therapy, there was a statistically significant improvement in FEV1 compared to placebo (48.2% versus 43.5%; p<0.05). Bloch and Silverman [16] conducted a similar trial with 135 subjects. 35 patients were classified as severe asthmatics, compared to 94 who were classified as moderately-ill based on initial PEFR measurements. Although this study found no benefit in the moderately-ill group, there were improvements in the severely-ill group. The authors hypothesised that patients in the severely asthmatic group were relatively refractory to SABA medication, and that magnesium mediated bronchodilation through alternate pathways [16]. The 3Mg Trial, perhaps the largest trial, enrolled 1109 patients [20]. The authors concluded that there was weak evidence of improvement in patients with severe asthma exacerbations but, interestingly, placed more emphasis on a visual analogue scale (VAS) for assessment of dyspnoea. They showed an improvement in PEFR at 1 hour with IVMS (11.4% in IVMS compared to 10.2% in the control group) and no differences between groups at 2 hours post-therapy (14.4% in both groups). However, the authors did not comment on these findings [20]. Some studies found that IVMS had no benefit in acute severe asthma [21-24]. Although most of these studies were randomised trials, they failed to reach statistical significance in their findings, and also excluded certain subsets of severe acute asthma such intubated patients, which may underrepresent patients with life-threatening asthma [21,23]. Furthermore, one study administered 1.2 g IVMS compared to other studies that used 2 g IVMS. Noting the earlier finding of the dose-dependent effect of IVMS, this may have contributed to the negative findings in this study [22]. Furthermore, a large trial by Hirashima and Yamana [24] found IVMS had no beneficial impact on 28-day mortality compared to placebo. Here, 619 patients received IVMS and 14,122 received a placebo. However, the authors concluded that further studies are required to clarify the effects of IVMS on severe asthma-related mortality [24].

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Overall, three meta-analyses of a total of 21 studies suggested that pooled results failed to demonstrate statistically significant evidence for benefit across all asthma severity groups [25-27]. Kew et al. [28] examined 14 studies with 2313 patients who were randomised to receive 1.2-2 g IVMS or placebo. Patients that were given a beta-2 agonist, corticosteroids, and oxygen were included in the study. The authors concluded that the evidence supported use of magnesium, in combination with standard therapy, to reduce hospital admissions and improve spirometric indices of lung function. However, the authors commented that differences in the trial designs of the reviewed papers — whether the concomitant use of medications or asthma severity — altered the treatment effect of IVMS. Moreover, the research suggests that IVMS should be used as adjunct therapy or reserved for patients who fail to respond to initial therapies [25,27]. Hospital admissions There are conflicting results regarding the effects of IVMS on hospital admissions in the setting of acute asthma. Many studies have noted reduced admission rates [14,16,19,20]. The 3Mg Trial highlighted that 72% of patients given IVMS were admitted to hospital within seven days from presentation compared to 78% of controls [20]. However, other studies found little to no differences in admission rates [18,21]. In the study by Silverman and Osborn [18], admissions were counted at four hours post-presentation to the emergency department. This may not be representative of admissions since, for instance, some patients may require a longer emergency department stay to be stabilised before being admitted. Boonyavorakul and Thakkinstian [21] found a lower hospital admission rate in the magnesium group but this failed to achieve statistical significance. Furthermore, the authors noted that the lower study power may have contributed to the non-significant findings. Nevertheless, a meta-analysis reported that, whilst overall there was no difference in hospital admissions, admissions in the subgroup of patients with severe asthma tended to be lower in those treated with IVMS compared with placebo (OR 0.10; 95% CI 0.04-0.27) [26]. Currently, the evidence favours reduced admissions but further robust research is required to elucidate this point, and to see if there have been reductions in length of hospital stay.


Biochemical effects Research highlights that magnesium is a predominantly intracellular ion, and therefore serum levels may not reflect intracellular concentrations [13]. It is possible to have normal serum levels of magnesium with intracellular depletion [29]. Studies have shown that in asthmatic patients, intracellular magnesium levels are depleted in comparison to their non-asthmatic counterparts. Furthermore, the use of adrenergic stimulation and sympathomimetic medication during an acute asthma exacerbation can decrease magnesium levels through urinary loss and intracellular shift [30] . Noppen and Vanmaele [13] examined serum and intracellular concentrations of magnesium following IVMS infusion and found that the magnesium concentrations in red blood cells did not significantly differ after the magnesium infusion [13]. Dominguez and Barbagallo [31] analysed magnesium levels in erythrocytes and found that intracellular magnesium concentrations were significantly lower in asthmatic patients. Intracellular magnesium levels appear to correlate with bronchial reactivity to methacholine in atopic subjects with and without asthma, and with and without bronchial hyper-reactivity [31]. In a 2001 study conducted by Schenk and Vonbank [15], 30 patients with known bronchial hyper-reactivity were trialled on either intravenous magnesium or a placebo. Patients who demonstrated bronchoconstriction went on to have a subsequent bronchial provocation test with methacholine. The study concluded that the use of magnesium significantly improved bronchial hyperreactivity. In the magnesium infusion group, 30% of subjects regained their baseline FEV1, compared to just 10% in the placebo group. The authors recommended using magnesium as an adjunct to standard therapy [15]. This study did not measure intracellular magnesium levels but hypothesised that subjects may have had some intracellular depletion. While Schenk and Vonbank [15] used methacholine as a source of bronchial provocation, Hill and Britton [32] found that IVMS did not alter airway reactivity when using inhaled histamine for bronchial provocation [32]. This discrepancy remains unclear given that magnesium has antiinflammatory properties [11].

Adverse effects Concerns have been raised over the potential side effects of hypermagnesaemia, including arrhythmia, hypotension, and loss of deep tendon reflexes [17]. None of the studies in this review found patients who experienced or demonstrated symptoms of hypermagnesemia after 2 g of magnesium infused over 20 minutes. However, some patients experienced palpitations, tremors, anxiety, dry mouth, and nausea, which authors attributed to salbutamol or other SABA agents [18]. The most commonly recognised symptom of magnesium administration is a cutaneous warmth which is well-tolerated by most patients [28]. The use of magnesium in severe asthma exacerbations has been demonstrated to counteract the tachycardia of sympathomimetic medications. This occurs by inhibiting calcium influx and blocking outward movement of potassium through ion channels in myocytes [33]. Sydow and Crozier [29] utilised high-dose IVMS (10-20 g over 1 hour) in ventilated patients with status asthmaticus, noting that two patients had arterial hypotension as a side effect of the treatment [29]. Nevertheless, this hypotension could be treated with vasopressors [34]. Thus, it appears IVMS administered acutely is safe and well-tolerated with minor adverse effects. Australian Guidelines Currently, the Australian guidelines recommend a graduated therapy for treatment of severe asthma. This starts with intermittent or continuous nebulisation of bronchodilators. The guidelines recommend repeat nebulisation in patients that respond poorly to initial therapy. After subsequent nebulisation, the guidelines recommend use of 10 mmol magnesium sulphate (equivalent of 2.5 g) over 20 minutes [7]. Despite lack of Australian-specific data involving the therapeutic use of IVMS, the current literature available would support the use of magnesium routinely in adult patients with severe or life-threatening exacerbations of asthma. IVMS would be best utilised in combination with standard therapy including oxygen, inhaled beta-2 agonists, inhaled antimuscarinic agents, and corticosteroids in severe exacerbations.

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Limitations This paper did not include unpublished research or research that is not published in English, raising the potential for selection bias. Conclusion Evidence for the role of IVMS in the treatment of acute exacerbations of asthma remains conflicting. The literature appears to support the use of magnesium in severe exacerbations of asthma, defined as a FEV1 ≤ 30% of predicted. In reviewing the literature, magnesium has the greatest effect when given with standard therapy to treat exacerbations of asthma. In some studies, IVMS appears to be beneficial in reducing hospital admission rates in severe asthma exacerbations. Current literature suggests that IVMS may be considered as a first-line therapy in conjunction with current standard therapy in Australia.

Correspondence Jackson Newport Jackson.newport@my.jcu.edu.au

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AHPRA, Mistrust, and Medical Culture in Australia Dr David Arroyo MD (University of Queensland David Arroyo is a recent medical school graduate from the University of Queensland. He was born in the United States where he earned a Master of Biomedical Science and worked as an Emergency Medical Technician for six years which included four years as a supervisor. He continues to perform research across a number of fields. This article is a brief excerpt from an essay which won the Catherine Thorp-Cramb Prize in Doctors’ Mental Health. Abstract From nearly the moment that medical students take their oaths, the assault on one’s mental health begins. Students understand that they will make sacrifices to study medicine, but the understanding that the medical field may take a significant mental health toll is generally overlooked and underappreciated. Many factors leading to this demise have been well-described in the literature, yet, a doctor’s mental health is often not discussed, silenced by both professional and societal stigma. This is a worldwide issue with some disastrous consequences. For example, in the United States alone, an estimated 300-400 doctors commit suicide each year, more than doubling the rate of the general population. This is equivalent to an entire cohort of medical students, making the profession among the most dangerous in the country. In Australia, doctors experience significantly high levels of psychiatric morbidity, which typically manifest as depression, anxiety, burnout, and suicidal ideation, eroding both their personal and professional lives. Many doctors do not seek help for mental health conditions, largely due to stigma as well as an unfounded fear of a notification to the Australian Health Practitioner Regulation Agency (AHPRA). This essay will outline issues surrounding concerns that doctors with mental health issues may have regarding AHPRA and discuss the mistrust that persists in contemporary medical culture in Australia. Introduction The notion that all individuals are predisposed to mental illness was well chronicled by the philosopher Plato in Timaeus, where he became among the first of his colleagues to demonstrate a primitive, yet pragmatic, understanding of the complex dynamics of mental health resulting in a modern truth: we are all susceptible. While contemporary conceptualisations of mental illness have evolved considerably from the times of unbalanced humours, diseases of the psychē (soul), and “cold bile” as underlying aetiologies, there still persists a fundamental, yet pervasively false impression (or perhaps belief) that, as modern-day healers, doctors are somehow exempt from the stressors that lead to mental health deterioration. Doctors are subject to a multitude of biological, psychological, and social stressors which is capable of destabilising one’s mental health. Indeed, the medical field is distinct from other professions, unapologetically offering an overwhelming workload, immense pressure, unrelenting competitiveness, and unrealistic expectations. These factors significantly increase the risk of depression, anxiety, stress, emotional exhaustion, depersonalisation, and suicide [1-4], and are significant contributors to the extraordinarily high incidence of burnout that has plagued doctors across continents and cultures for decades [5,6]. This essay will outline issues surrounding concerns of an AHPRA notification and discuss the mistrust among colleagues that persists in contemporary Australian medical culture.

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The AHPRA myth: A justified fear? There is a pervasive concern culminating in a harmful, yet widespread myth that must be addressed: the fear of a report to Australian Health Practitioner Regulation Agency (AHPRA). The prevailing belief is that doctors cannot disclose mental illness to another healthcare professional without risking punishments such as significant practice restrictions, public shaming, and even loss of registration. Are any of these assumptions accurate? The practical answer is, in short, no. Prior to debunking this myth, one must first acknowledge the shortcomings of AHPRA and Australian law. The mission of AHPRA is to support the health practitioner boards including the Medical Board of Australia to protect the public through the regulation of health practitioners to ensure safe healthcare throughout Australia [7]. AHPRA investigates formal complaints and addresses concerns over the impairment of doctors following reports by other healthcare practitioners or organisations. Recently, the Queensland parliament passed a new law titled, Health Practitioner Regulation National Law and Other Legislation Amendment Act 2018 which, in addition to increasing penalties for offences under Australian law, intends to “support registered practitioners to seek help for a health issue (including mental health issues)” [8]. The legislation is designed to provide treating doctors guidance when making the determination of impairment [9]. However, a number of medical organisations representing over 53,000 Australian practitioners opposed the bill arguing that it is ambiguous and discourages doctors from seeking help for a mental health condition (Table 1) [10]. Table 1. Australian medical organisations opposing Health Practitioner Regulation National Law and Other Legislation Amendment Bill 2018 in its current form49

Australian Medical Association (AMA) Queensland The Royal Australian and New Zealand and College of Psychiatrists, Queensland Branch (RANZCP QLD Branch) The Royal Australian College of General Practitioners (RACGP)

Proposed amendments to the law advocated by these organisations were denied [9]. The new law is applicable to every state but Western Australia which over a decade ago had implemented laws reflective of the proposed amendments. This indeed has the potential of eroding a trust that doctors give to their patients yet feel that they are not entitled to receiving themselves. With this in mind, feelings that AHPRA has created a structural stigma is not unjustified. Under the pretext of patient safety, doctors may understandably feel that they are being unfairly, and perhaps unethically, targeted for seeking help for a mental health issue. Additionally, the AHPRA investigation process may in itself raise concerns. In 2017-18, 35.5% of notifications took more than six months to resolve [11], and the potential for a prolonged fight over a doctor’s profession may trigger or worsen issues such as depression and anxiety. For the doctor who is already suffering from a mental health issue, this process is detrimental and may feel like a punishment for experiencing something that is commonly found in the general population. As a result, it is not uncommon to find that doctors seek treatment far away, use pseudonyms, and pay cash for mental health services (See Appendix 1 for alternatives). Importantly, under the AHPRA investigation process, practitioners are considered competent until proven otherwise. The myth that APHRA is a reasonable threat to medical practitioners will be dispelled here. Under mandatory reporting laws to AHPRA, there is a significantly high threshold for the mandatory reporting of a healthcare provider for mental impairment that detrimentally impacts their ability to practice. The practitioner making the report must first have a reasonable belief that the treating doctor is a threat to patient safety, based on specific events, and ideally, the decision to report should be free of bias. Action taken against a practitioner for mental health impairment is exceedingly rare. For example, in 2017-18, of the 63 mandatory notifications made against doctors throughout all of Australia for impairment, only 13 had resulted in a suspended or cancelled registration [11]. Of relevance, a 2013 study showed that the distribution of all complaints filed against doctors over the previous 11 years was significantly skewed [12].

Australian College of Rural and Remote Medicine (ACRRM) Australasian College for Emergency Medicine (ACEM)

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The study showed that 3% of Australian practitioners accounted for 49% of total complaints with 1% accounting for 25% [12]. This indicates that those cases where sanctions were imposed were exceedingly rare outliers and these practitioners likely posed a realistic danger to the public. The specific circumstances of these cases were unknown and may have overlapped with other APHRA-related issues of misconduct. Significantly, a doctor who has sought help voluntarily for a mental health condition is highly unlikely to go through the process of an AHPRA investigation, let alone experience any consequences; with the vast majority of those forced to undergo any investigation absolved. Additionally, in 2020, mandatory notification requirements will change from a practitioner being “at risk of harm” to the public to “substantial risk of harm” to the public which is designed to support practitioners in seeking help [13]. The evidence demonstrates that despite flaws, AHPRA is not the enemy of medical practitioners. Given the low probability of sanction, why do doctors often feel AHPRA is a realistic threat? Doctors do not trust their own Perceived social condemnation among both the public and peers may be the most important driving factor behind the fear of an AHPRA notification. There are several important factors behind a doctor’s reasons for not seeking treatment, supported by an abundance of high-quality evidence. The fear of stigmatisation is the most commonly cited reason doctors refuse professional help, both in Australia and worldwide [1,14,-17]. This is evidenced by a shocking finding from Beyond Blue’s 2013 National Mental Health Survey regarding how doctors feel about their depressed colleagues. An astounding 31% of female doctors and 45% of male doctors in Australia did not believe that doctors with a mental health history would be as reliable as the ‘average’ doctor [1]. This sentiment has already been passed to the next generation as evidenced by an Australian study of younger, mostly depressed, physician trainees who did not seek help. The vast majority (88%) believed that doctors should portray an image of good health [18]. A recent meta-analysis found that depressive symptoms in doctors was associated with medical errors [19]. Despite these sentiments, there is no evidence to suggest that a doctor that has been treated for a mental health condition is at an increased

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risk to their patients. Surprisingly, stigmatisation among doctors in Australia might very well be worse than the general Australian population [20] . Other factors for not seeking help include embarrassment (59%), lack of confidentiality (52.2%), and the impact on their right to practice (34.3%) [1]. Doctors fear a report might increase the risk for lawsuits, affect employment, and salary negotiations, all representing a threat to one’s finances and personal life. Not unlike the Australian general population [21], there was also a generalised preference to self-manage (30.5%) [1] , which may be seen as a reportable violation depending on the choice of self-management. Those who voluntarily seek treatment despite these concerns, are likely to keep their condition a secret which can lead to feelings of isolation and loneliness, exacerbating mental health decline. Where does the mistrust begin? Perhaps the most influential experiences arise during the medical school years. A 2015 study found that students were negatively judged by supervisors for seeking help for burnout and that their colleagues openly revealed mental health problems of other colleagues [22]. Witnessing this behaviour at an early level may lead to the fear of stigma ultimately resulting silence and prevent doctors from seeking help. These factors are among the reasons that only a third seek help for their own mental health conditions [21], and these types of experiences are likely reasons that doctors reaching even the highest level of their training do not seek help. It is well-established that students become more empathetic after completing rotations in psychiatry [23-25]. Since these studies are performed on a student population that have completed their psychiatry rotations in recent years, perhaps doctors need regular mental health education to help prevent empathy dissipation. Education about how to appropriately address a colleague in distress, coupled with available support is key.


The first encounter Despite the issue of doctor’s mental health being a current concern, with an evidence-base that has never been better, both doctors and medical students fail to support each other. Doctors tend to internalise the perceived negative views of their colleagues resulting in an unhealthy refusal to seek treatment for issues that are unlikely to fade over time. They must also be aware that a colleague who discloses a mental health issue could be doing so for the first time. The first experience of disclosing a mental health condition has the power to alter how one will approach any future issues. A negative experience could mean that they never seek help again. Therefore, it is the responsibility of all doctors to demonstrate a supportive response and handle mental health disclosures appropriately. The principles of beneficence and non-maleficence (expected for any patient) must be consciously applied to fellow doctors without judgement, in the forms of dignity and empathy, and arguably most important of all, with complete confidentiality. The importance of appropriate handling cannot be understated, and these personal and professional responsibilities cannot be abdicated. Doctors fear stigma. It is not surprising the current environment leads to a reluctance to seek help and a tendency to leave mental health issues unaddressed. It is a brave decision when a doctor does disclose a mental health issue. Should it have to be a brave decision? Or, can it be the norm? The prevalence of mental health conditions, affecting those who take on the task of healing others, means disclosure to colleagues and seeking professional help should not seem difficult. Nor should it come with any fear of sanction. The unfortunate reality is the medical field has not come close to reaching this point. The pace of change is slow, meaning it is possible it will take many more generations of doctors who will who suffer, learn, witness, and speak out in order to create a culture that is mentally healthy for doctors. Through promotion, education, and open discussion, both medical students and doctors can change attitudes and nurture a new culture. The idea that a doctor is susceptible to suffering and still be competent is one that needs to be made commonplace. This sentiment must become the norm from the first day of medical school, especially since this is when the stigma and silence begin. This will help create a much needed change in culture.

Conclusion Medicine is among the most challenging fields in existence, psychiatric morbidity is endemic and suicide an occupational hazard. Evidence continues to demonstrate the magnitude of the problem. The medical field has historically overlooked the mental health and wellbeing of its own. This is beginning to change. It is important that doctors with a mental health condition seek treatment without fear of APHRA. The privilege to practice medicine must not be jeopardised unnecessarily. Changes needed in the culture of medicine are long overdue. This must begin from day one of medical school. It may prove to be challenging or meet with resistance, but it is time for a significant change. This is not simply a human resources issue, but is indeed a human rights issue. Acknowledgements The author would like to thank Jessica Arentz, Kate Holzlein, and Thomas Rowe for their comments on this piece as well as Lars Eriksson for assistance with the search strategy. The author also wishes to thank author and physician, Dr Pamela Wible, MD who has dedicated much of her career towards helping doctors in distress and has helped shed a light on an important issue of much relevance to the author. She was a great inspiration throughout the development of this paper. Correspondence Dr David Arroyo david.arroyo@uq.net.au

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Appendix 1 Resources for help If you or someone you know is in crisis, there is help. Please contact any of the following: Beyond Blue Lifeline: 13 11 14 Beyond Blue Suicide Call Back Service 1300 659 467 https://www.beyondblue.org.au/get-support/ get-immediate-support For confidential support for issues affecting doctors such as work-related stress, bullying, harassment, discrimination, sexual harassment, substance use, personal stress, mental health, trauma counselling, self-harm, suicide, violence, grief and bereavement: RACP Support Program: 24/7 Support 1300 687 327 (Australia) 0800 666 367 (New Zealand) https://www.racp.edu.au/fellows/physicianhealth-and-wellbeing/i-need-support/ racp-support-program Queensland Doctors’ Health Programme 24/7 Support 07 3833 4352 https://dhasq.org.au/

References [1] Beyond Blue. National mental health survey of doctors and medical students. Melbourne, Australia; 2013. [2] Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. JAMA. 2016;316(21):2214-36. [3] Andrew LB. Physician suicide. In: Brenner BE, editor. Medscape. [Internet]. WebMD; 2018. [updated 2018 Aug 1; cited 2019 June 30]. Available from: https://emedicine.medscape. com/article/806779-overview#a1 [4] American Foundation for Suicide Prevention. Healthcare professional burnout, depression and suicide prevention. [Internet]. 2019. [updated 2019; cited 2019 June 30]. Available from: https://afsp.org/our-work/education/healthcare-professional-burnout-depression-suicide-prevention/ [5] Kumar S. Burnout and doctors: prevalence, prevention and intervention. Healthcare. 2016;4(3):37. [6] Rotenstein LS, Torre M, Ramos MA, Rosales RC, Guille C, Sen S, et al. Prevalence of burnout among physicians: a systematic review. JAMA. 2018;320(11):1131-50. [7] Australian Health Practitioner Regulation Agency. National Registration and Accreditation Scheme Strategy 2015-2020. [Internet]. 2017 [updated 2017 October 17; cited 2019 June 30]. Available from: https://www.ahpra.gov.au/documents/default. aspx?record=WD15%2f18461&dbid=AP&chksum=Y%2f9CwoiBPMuzHa1dje1DLw%3d%3d [8] Australian Health Practitioner Regulation Agency. Legislative amendments on mandatory reporting and fake practitioners. [Internet]. 2019 [updated 2019 February 26; cited 2019 June 30]. Available from: https://www.ahpra.gov.au/News/2019-0226-legislative-amendments-on-mandatory-reporting-and-fakepractitioners.aspx [9] Hayes P. Mandatory reporting laws pass without profession-recommended changes RACGP. newsGP [Internet]. 2019 Feb 27 [cited 30 June 2019]. Available from: https://www1.racgp.org.au/newsgp/professional/ mandatory-reporting-laws-pass-without-profession-r [10] Royal Australian College of General Practitioners. Queensland doctors call on state government to save lives. [Internet]. 2018 [updated 2018 December; cited 2010 June 30]. Available from: https://www.racgp.org.au/gp-news/ media-releases/2018-media-releases/december-2018/ queensland-doctors-call-on-state-government-to-sav [11] Australian Health Practitioner Regulation Agency. Annual Report 2017/18. 2018 [cited 2019 June 30]. Available from: https://www.ahpra.gov.au/annualreport/2018/notifications.html [12] Bismark MM, Spittal MJ, Gurrin LC, Ward M, Studdert DM. Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia. BMJ Qual Saf. 2013;22(7):532-40.

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[13] Australian Health Practitioner Regulation Agency. Mandatory notifications: What you need to know. [Internet]. 2019 [updated 2019 December 3; cited 2019 December 9]. Available from: https://www.ahpra.gov.au/Notifications/mandatorynotifications. aspx [14] Lyons Z, Laugharne J, Laugharne R, Appiah-Poku J. Stigma towards mental illness among medical students in Australia and Ghana. Acad Psychiatry. 2015;39(3):305-8. [15] Adams EF, Lee AJ, Pritchard CW, White RJ. What stops us from healing the healers: a survey of help-seeking behaviour, stigmatisation and depression within the medical profession. Int J Soc Psychiatry. 2010;56(4):359-70. [16] Hassan TM, Ahmed SO, White AC, Galbraith N. A postal survey of doctors’ attitudes to becoming mentally ill. Clin Med. 2009;9(4):327-32. [17] Gold KJ, Andrew LB, Goldman EB, Schwenk TL. “I would never want to have a mental health diagnosis on my record”: A survey of female physicians on mental health diagnosis, treatment, and reporting. Gen Hosp Psychiatry. 2016;43:51-7. [18] Axisa C, Nash L, Kelly P, Willcock S. Psychiatric morbidity, burnout and distress in Australian physician trainees. Aust Health Rev. 2020;44(1):31-8. [19] Pereira-Lima K, Mata DA, Loureiro SR, Crippa JA, Bolsoni LM, Sen A. Association between physician depressive symptoms and medical errors: a systematic review and meta-analysis. 2019;2(11):e1916097. [20] beyondblue information paper: stigma and discrimination associated with depression and anxiety. [Internet]. 2015 [updated 2015 August; cited 2019 June 30]. Available from: https://www. beyondblue.org.au/docs/default-source/policy-submissions/stigma-and-discrimination-associated-with-depression-and-anxiety. pdf?sfvrsn=0 [21] Brijnath B, Antoniades J. “I’m running my depression:” Selfmanagement of depression in neoliberal Australia. Soc Sci Med. 2016;152:1-8. [22] Dyrbye LN, Eacker A, Durning SJ, Brazeau C, Moutier C, Massie FS, et al. The impact of stigma and personal experiences on the help-seeking behaviors of medical students with burnout. Acad med. 2015;90(7):961-9. [23] Janoušková M, Weissová A, Formánek T, Pasz J, Bankovská Motlová L. Mental illness stigma among medical students and teachers. Int J Soc Psychiatry. 2017;63(8):744-51. [24] Pascucci M, Ventriglio A, Stella E, Di Sabatino D, La Montagna M, Nicastro R, et al. Empathy and attitudes towards mental illness among Italian medical students. Int J Cult Ment Health. 2017;10(2):174-84. [25] Lyons Z, Janca A. Impact of a psychiatry clerkship on stigma, attitudes towards psychiatry, and psychiatry as a career choice. BMC Med Educ. 2015;15(1):34.

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Biopsy of the Skin Linda Chan MBBS (2014), James Cook University Resident Medical Officer, Concord Repatriation General Hospital I am passionate about dermatology and medical education. As a combination of my two passions, I am particularly interested in increasing the amount of practical, high-quality dermatological resources pitched at medical students.

Abstract Obtaining a skin biopsy is a relatively simple but important tool in the diagnosis and management of both skin neoplasms and inflammatory skin conditions. Many students are cautious about performing a skin biopsy. This may reflect a lack of proficiency or uncertainty regarding where to sample the skin, how to choose the biopsy method, and how to handle the sample. This article explores all the practical aspects of taking a skin biopsy, and explores how to choose the most appropriate site and technique for a biopsy. Introduction A skin biopsy is one of the most important tools in the diagnosis and management of skin diseases [1-7]. In principle, it involves removing a specimen of skin from the disease site for further evaluation under a microscope by a pathologist. It is a simple procedure that provides valuable additional evidence for the confirmation of skin malignancies and assists in confirming or excluding disease processes that share similar clinical presentations [1-7]. Skin biopsies aid clinicians in arriving at an accurate diagnosis of cutaneous malignancies and in obtaining features for prognostication [1,7]. They are also helpful in understanding the zone of pathology in blistering skin conditions [1] and differentiating atypical presentations of inflammatory dermatosis [7]. Histological features that are obtained from skin biopsies allow clinicians to exclude specific diagnoses that exhibit overlapping clinical features [7].

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Elizabeth Dawes-Higgs MBBS, MSc(Med), BE(Mech), DPD, PhD, FACD Dr Liz Dawes-Higgs is a highly educated and passionate dermatologist. She currently teaches and mentors students through the Australian College of Dermatologists and Concord Hospital. She is a state and national examiner for the Australasian College of Dermatologists. Dr Dawes-Higgs received the Schering-Plough Award for her laboratory-based research. She was awarded her Doctor of Philosophy from The University of Sydney for research on the biomechanical properties of skin. What does having a skin biopsy involve? Skin biopsies are usually performed in a medical practitioner’s office under local anaesthesia. The skin at the biopsy site is marked and cleaned [6]. Injection of the local anaesthetic produces transient stinging. After the skin specimen is collected, the clinician may close the wound with a suture if needed and a dressing may be applied. Do patients have to stop any of their usual medications? Warfarin does not need to be stopped for skin biopsies, but patients must inform his or her doctor so that an appropriate plan for the surgical technique and equipment for haemostasis is available. An international normalised ratio between 2.5–3.0 is generally accepted for simple skin surgery [2]. Less is known about the use of antiplatelet therapy. It appears that the use of clopidogrel and aspirin increases the risk of complications during Moh’s surgery [2]. The cessation of dual antiplatelet is generally not necessary [2]. Preparing the skin for biopsy The chosen biopsy site will be marked with a surgical marker to avoid obliteration after the injection of local anaesthesia [1]. The area is then cleaned with a disinfectant. Choosing a disinfectant Alcohol reduces skin flora by 75% within one minute of application, but is mainly effective against Gram-positive microorganisms [2]. Povidone-iodine solution and chlorhexidine have a broader antibacterial spectrum, including some Gram-negative microorganisms, and are commonly used in skin surgery [2].


It is recommended to make a note of the direction of Langer’s lines (skin tension lines), which are generally parallel to the direction of collagen in the dermis [1]. Incisions made parallel to the Langer’s lines will close more easily and with better cosmetic results than those made perpendicularly [1,3,4]. Local anaesthesia administration Local anaesthesia is injected using a 29-gauge or 30-gauge needle. The needle is drawn back to check for blood, in order to ensure there is no risk of injecting the anaesthetic into the systemic circulation [4]. The initial injection is made perpendicular to the skin to minimise the sting. Deeper injections are less painful but do take longer to achieve anaesthesia [1]. Usually, 1–2% lignocaine with 1:100 000 adrenaline is used. Other options include mepivacaine and bupivacaine [2]. Topical agents such as EMLA cream (a mixture of prilocaine and lidocaine) or 4% lidocaine cream can be combined with injected local anaesthesia. Two hours of occlusion with EMLA will anaesthetise skin up to 5 mm deep [2,4]. This depth is sufficient for the chest, abdomen, face, and genitals but not for the palms, soles, and back, which have a thicker epidermis [4]. Different types of skin biopsies commonly performed Choosing the best form of biopsy technique requires knowledge of the level of the lesion in the skin [2]. Figure 1 illustrates the levels of skin architecture reached by the common techniques.

Punch biopsy This is ideal for diagnostic purposes as it produces full thickness skin specimens [3]. Advantages: It has a high ease of performance and produces uniformly shaped tissue [4]. Disadvantages: The material can be inadequate and not include deeper tissue [4]. Technique: It is performed using a circular blade attached to a pencil-like handle (Figure 2). The blade size ranges from 2–8 mm in diameter. A punch of 3–4 mm is enough for most conditions [3,8]. Small diameter biopsies, such as 2 mm, are rarely used and reserved for cosmetically sensitive sites such as the face.

Figure 2. Punch biopsy blades.

After choosing the appropriate size of punch biopsy, the skin is stretched with the thumb and second finger perpendicular to the normal skin tension lines. The punch blade is placed perpendicular to the skin, with constant downward pressure in a circular motion. When the blade reaches the subcutaneous adipose tissue, there is a sensation of “give”, indicating that a full thickness cut has been made. The blade is then removed and the specimen carefully extracted to avoid crushing. If necessary, the wound is closed with a single layer of interrupted sutures. Generally, 4-0 or 5-0 monofilament nylon is used for the body and scalp and 6-0 nylon is used for the face [1,3]. Sutures on the face can be removed in 3–5 days. Sutures on the chest, abdomen, arms, or scalp can be removed in 7–10 days. Sutures in the back and legs can be removed in 12–20 days [1].

Figure 1. Levels of skin architecture.

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Shave biopsy Shave biopsies are quick to perform and do not require suturing for closure. It is most suited for lesions elevated above the skin, such as seborrheic or actinic keratosis, skin tags, wards, superficial basal cell carcinomas, and squamous cell carcinomas [1]. Advantages: They are quick to perform and provide large epidermal specimens [1,2]. Disadvantages: This technique is not suitable for pigmented lesions and will usually leave a depressed scar at least the size of the initial lesion [1]. Technique: The portion of the lesion that is above the level of the skin is shaved off using a blade [9]. The skin is left to heal via secondary intention with a dressing applied over the top. Saucerisation biopsy This is similar to a shave biopsy and ideal for vesiculobullous disorders and larger seborrheic keratoses. Its advantages and disadvantages are similar to those of the shave biopsy technique [1,2]. Technique: The biopsy blade is held between the thumb and index finger and bends to form an arc, which allows its intersection into the dermis (Figure 3). The plane of cleavage passes through the reticular dermis. It is performed using a shaving blade [4]. The wound is not sutured and is allowed to heal by secondary intention [4].

Figure 3. Saucerisation biopsy blades.

Incisional biopsy The main indication for an incisional biopsy is to obtain a sizable quantity of tissue to avoid diagnostic error.

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Advantages: This is highly useful in diagnosing panniculitis, scarring alopecia, non-pigmented skin cancers with central necrosis, and larger vessel vasculitis as it provides a sizeable specimen that will allow the pathologist to review all features [2]. Disadvantages: This is a time-consuming process and requires expertise [5,6]. Technique: The technique is identical to that of an excisional biopsy [5,6]. The incision should also follow the skin tension lines [2]. Excisional biopsy This is used for lesions that cannot be removed with a punch biopsy due to size, depth, or location, pigmented lesions suspicious for melanoma, and keratoacanthomas [5,6,10]. Advantages: Excisional biopsy allows for the greatest diagnostic accuracy as the pathologist can examine the entire lesion [1]. Disadvantages: This technique requires the greatest amount of expertise, training, and time to perform [1]. Technique: A surgical scalpel is used. The entire lesion is completely removed up to the subcutaneous tissue plane. The wound is closed using two layers of sutures [4]. How do you choose the site and type of skin biopsy? Skin cancers A small punch biopsy from the centre of the lesion is recommended for suspected basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) [6]. The area with the best diagnostic yield is the centre of the lesion, as it avoids confounding reactive changes around the periphery. If, however, there is central necrosis, an incisional biopsy that includes both the central portion and peripheral tissue is preferred [6]. For SCCs, sufficient tissue needs to be biopsied for the pathologist to visualise the junction between the epidermis and dermis. One study found invasive SCCs in 20% of cases of actinic keratosis which were found by shave biopsy. The patients in these cases subsequently underwent re-excisions [6]. BCCs often contain a mixture of growth patterns. Therefore, a single punch biopsy may not identify an aggressive component in 50% of cases. Suspected melanomas should be excised with a 2 mm clinical margin and not partially biopsied [5].


Inflammatory skin conditions Lesions with the most advanced inflammatory changes are preferred in most cases, but those that show secondary changes, such as excoriation, should be avoided [1,7,8]. The sample should include maximal lesion area and minimal normal skin [1]. Areas to be sampled should preferably be free from topical treatment for one month prior to the biopsy [7]. If there is suspected vasculitis, lesions 48–72 hours old are ideal for histological analysis. For direct immunofluorescence, lesions less than 24 hours old should be sampled. The incisional biopsy technique should be used for panniculitis, larger vessel vasculitis, and annular lesions, for example, granuloma annulare [7]. Ulcers, erosion, and blistering conditions A lesion formed within 48 hours is preferred as it provides the most specific histology features [1,7]. Whenever possible, remove the vesicles intact during the biopsy. Bullae should be biopsied at the edge, keeping the blister roof attached [1]. Immediate and long-term complications of skin biopsies Anaphylaxis True anaphylaxis to local anaesthetic agents is very rare. However, reactions to additives may masquerade as a true allergy. In patients at risk of type I hypersensitivity, an intra-dermal test can be performed for local anaesthetics or a patch test for EMLA [4]. Bleeding This is the most common complication, especially on the scalp, face, genitals, and in elderly patients with atrophic skin [4]. Other risk factors are a low platelet count, coagulopathy, haemophilia, and von Willebrand disease. It can also be drug-induced by substances such as aspirin, clopidogrel, heparin, and over-the-counter use of fish oil, garlic, and ginseng supplements [9]. Majority of bleeding is due to the rupture of small venules. The application of pressure for 2-3 minutes stops the oozing. Swabs that are soaked with hydrogen peroxide, 20–40% aluminium chloride, or Monsel’s solution can also be helpful. If there is an identifiable bleeding vessel, this can be cauterised or ligated [4,9].

Damage to other structures Damage to nerves and vessels is rare. A biopsy in the pre-auricular areas can occasionally damage the facial nerve, as the branches are superficial [9]. Infection In one study, 22 out of 100 diagnostic biopsies showed signs of clinical infection. In the same study, two biopsy lesions had wound dehiscence alone and five showed signs of both infection and dehiscence. The most common bacterium on wound swab was Staphylococcus aureus [9]. The incidence of secondary infection in the groin and axillae is higher, therefore biopsy in these areas should be avoided if possible [1]. If the wound is frankly purulent or associated with cellulitis, oral antibiotics should be prescribed. Infected wounds in the hands, feet and, intertriginous areas are often infected with Candida and can respond to topical antifungal ointments [1]. Systemic risk factors for infection include an immunosuppressed state, particularly diabetes mellitus [9]. Scarring Scarring with or without pigmentary changes is not uncommon after the biopsy site heals. Hypopigmentation is common after removing lesions from hyperpigmented lesions. Hypertrophic scarring tends to occur over the deltoid and chest areas. It is best to avoid these areas if possible [1]. The incision should be made along the relaxed skin tension lines to provide a good cosmetic scar [9]. Delayed healing Problematic healing tends to occur over the tibia, especially in diabetic patients or those with arterial and venous insufficiency [1]. This should be explained during the consenting process.

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Sending the specimen to the pathologist The skin specimen is placed in a jar containing the fixative formalin (Figure 4). It generally takes between one to two weeks for the final pathology report to be released. The report may be inconclusive, therefore correlation with the clinical findings is important. In certain conditions, repeated biopsies may be required. There are several ancillary tests that can be used by the pathologist to aid in the diagnosis of skin diseases. The most common are direct immunofluorescence (DIF), microbiological culture, flow cytometry, and polymerase chain reaction analysis Figure 4. Specimen jar. such as lymphocyte clonality. Many of these additional tests will require non-formalin fixed specimens [7].

References [1] Alguire PC, Mathes BM. Skin biopsy techniques for the internist. J Gen Intern Med. 1998;13(1):46-54. [2] Llamas-Velasco M, Paredes BE. Basic concepts in skin biopsy. Part I. Actas Dermosifiliogr. 2012;103(1):12-20. [3] Zuber TJ. Punch biopsy of the skin. Am Fam Physician. 2002;65(6):1155-8. [4] Nischal U, Nischal K, Khopkar U. Techniques of skin biopsy and practical considerations. J Cutan Aesthet Surg. 2008;1(2):107-11. [5] Luk PP, Vilain R, Crainic O, McCarthy SW, Thompson JF, Scolyer RA. Punch biopsy of melanoma causing tumour cell implantation: another peril of utilising partial biopsies for melanocytic tumours. Australas J Dermatol. 2015;56(3):227-31. [6] Harvey NT, Chan J, Wood BA. Skin biopsy in the diagnosis of neoplastic skin disease. Aust Fam Physician. 2017;46(5):289-94. [7] Harvey NT, Chan J, Wood BA. Skin biopsy in the diagnosis of inflammatory skin disease. Aust Fam Physician. 2017;46(5):283-8. [8] Keeling BH, Gavino AC, Gavino AC. Skin Biopsy, the allergists’ tool: how to interpret a report. Curr Allergy Asthma Rep. 2015;15(10):62. [9] Abhishek K, Khunger N. Complications of skin biopsy. J Cutan Aesthet Surg. 2015;8(4):239-41. [10] Llamas-Velasco M, Paredes BE. Basic concepts in skin biopsy.

Conclusion Obtaining an appropriate skin biopsy remains one of the most fundamental clinical skills in the diagnosis and management of both inflammatory skin conditions and skin malignancies [1-7]. It is, therefore, crucial to understand the considerations involved in choosing an optimal biopsy site and a suitable biopsy technique to maximise the histological diagnostic features and minimise adverse clinical events.

Correspondence Linda Chan linda.chan@my.jcu.edu.au

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Part II. Actas Dermosifiliogr. 2012;103(2):100-10.


BT shunts, Berlin Hearts and Brave Decisions Nicole Da Cruz, MBBS (Year 5), Western Sydney University, student and casual academic. Nicole is a final year medical student with an interest in medical education and ethics. She is a keen writer, runner and painter. She enjoys combining her talents to improve the capacity of her peers and patients. Abstract An elective in paediatric cardiac surgery provides a unique insight into a niche specialty. The high-level care requires multiple systems to align. Within the patient lies the heart, a mechanical and biological system. Any intervention performed on the heart impacts the wider clinical context, requiring the treating team to balance technical feasibility with the functional needs of the patient. Risk stratification, collaboration, and prioritising quality of life are the basis of modern day paediatric cardiac surgery. However, the execution of these goals is dependent upon the evolution of knowledge, technology, and communication. In drawing upon historical milestones in the field and current management strategies, the author highlights the complexity and innovation involved in paediatric cardiac surgery. Introduction The Hospital for Sick Children in Toronto, Canada is a centre rich in innovation, where I was fortunate enough to spend my medical elective observing paediatric cardiac surgery. To be present for such life-changing procedures provided many opportunities to consider what is required for high-level care. Upon reflection, many systems are at play. The biological heart as a mechanical system is influenced by surgical intervention, which impacts upon the patient as a functioning being, in the context of future capacity, quality of life, and family. Another critical element is information transfer. Communication is needed for the treating team and patient’s family to reach a shared understanding of care intent and management. Shared understanding also moves beyond the therapeutic process of the current patient to consider future patients. The evolution of knowledge is ongoing. At any one time, the procedures performed are governed and defined by knowledge, and technology developed and refined overtime from historical practice and research. Indeed, high-level care is multi-faceted and dynamic.

In order for a unified outcome to be achieved, such intricate inter-related networks must synchronise in a syncytium, much like the intrinsic cardiac muscle fibres. While the technical aspects of paediatric cardiac surgery as a discipline are beyond the scope of this paper, the applied approach of systems thinking form the foundation of this reflection. This discussion will focus firstly on how previous scientific inquiry forms the basis for our current understanding in paediatric cardiac surgery. The lens of history will describe how discovery and innovation has influenced practice. To highlight the progress in our understanding as a medical community, two paediatric cardiology milestones will be discussed; specifically, the post-mortem description of an atrial septal defect (ASD) and the development of the Blalock-Taussig (BT) shunt in response to Tetralogy of Fallot. Secondly, the ‘present-day’ context will be considered. My elective at the Hospital for Sick Children provided a framework to observe and consider current technologies at our disposal to improve quality of life. Hypoplastic left heart syndrome, while not a ‘modern’ pathology, still presents a challenge to surgical practice and will be discussed. Furthermore, the left-ventricular assistance device (LVAD) will be noted as a recent innovation. Finally, the universal demand of high-level communication will be emphasised. The need for a systematic engrained approach to multi-disciplinary team meetings, the ability to prioritise function over technical feasibility, and the aim to ensure a global standard to paediatric cardiac surgery will be discussed. Evidently, this piece has the luxury of painting with broad brushstrokes, elaborating only on a few key cases in limited detail. The purpose is to offer insight and feed the insatiable curiosity that the medical student elective experience affords.

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The Lens of History Our understanding of the biological human system and our capacity to modify the human heart will always be evolving, building upon the observations of our predecessors. A historical understanding of anatomy informs us that form influences function - “simplicity is the ultimate form of sophistication” [1]. While, as a medical student in the twenty-first century, I can conceive of the anatomy involved in an atrial septal defect, this was not always the case. During the period between 1485 and 1515, Leonardo Da Vinci described in his postmortem work Quarderni d’Anatomica how he had “found from … left auricle to … right auricle, a perforating channel” and questioned “whether this occurs in other auricles of other hearts” [2]. Through repeated observations, borne on the backs of many individuals over time, evidence was formed and knowledge established. With knowledge and the ability to predict and pre-empt, one paves the way for therapeutic intervention. Emblematic of historical scientific pursuit revolutionising clinical practice is the BT shunt, a key development in the field of paediatric cardiac surgery [2]. The revolutionary paper was published in 1954, entitled “The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia” [3]. At the time, the challenge and clinical manifestation was known as the “blue baby,” the term conveying the sense of a fate beyond medical and surgical aid [2]. The cyanosis was observed by paediatrician Dr. Helen Taussig, who collaborated with Drs. Alfred Blalock and Vivien Thomas (originally a carpenter and the grandson of a slave in Louisana). This was an unusual collaboration at a time when women were rarely considered faculty, and when there were racially segregated wards at Johns Hopkins [3,4]. From the bedside to the laboratory (where the disease was modelled on animals) to the final development of surgical techniques, their systematic approach demonstrates the evolution of knowledge for practical application [3] . Today, we know that Tetralogy of Fallot is one cause of a blue baby. In Tetralogy of Fallot, blood flow to the lungs is reduced by a stenosed or atretic pulmonary valve [3]. The BT shunt provides a critical route for blood from the heart to bypass the lesion and effectively reach the lungs for oxygenation to occur [3,5].

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The infants “were turned from blue to pink” [2]. This advancement won Blalock and Taussig the Nobel Prize, while Thomas, who helped design the instruments and anastomosis, received no formal recognition at the time, a reminder that the greater social context is an overarching system at play [3,6]. Today, social values have changed and the work by all three contributors lives on in a modified BT shunt used to treat congenital lesions. Present-Day Technology and Capability As we move our discussion to the present-day, the same treadmill system of knowledge rearing innovation applies. Within the last few decades, an area of development and surgical advancement is in procedures performed on single-ventricle patients [7]. Previously, children who presented with underdeveloped ‘hypoplastic’ heart chambers did not have a chance at ex utero life [7]. The disease pathogenesis is based on the embryological need of blood flow for developing cells to grow. For instance, severe congenital aortic stenosis may be the catalyst for a case of a hypoplastic left heart [8] . This affords the opportunity for minimally invasive ultrasound-guided intervention to alter the natural history and mitigate morbidity and mortality [8]. Nevertheless, there are risks associated with fetal intervention requiring both short and long-term consideration in selected patient groups [8]. Risk stratification is required in order to determine which patients will receive the optimal benefit from this evolving technology. The system of care can provide biventricular circulation and reassurance to families that their child will live through to adulthood [7]. However, single ventricle physiology persists in the population, as not all cases are diagnosed prenatally, a consequence of the system of care and the tools we employ not always identifying the anatomy of the heart [7]. Given the rarity of the condition, it would not be economically feasible in our social context to screen each patient without risk stratification. Unfortunately for the treating team and families of children born with hypoplastic hearts, the post-natal surgical strategy (while offering some time and functionality) is a palliative pathway [7]. We must remember the simplicity of the heart as a service to other organ systems; biologically, a single-ventricle physiology with a decrease in cardiac output cannot sustain adequate growth and function [7].


Despite poor outcomes in some patients with congenital heart defects, decompensation does not preclude hope, with modern day technology improving outcomes. There are ongoing efforts and advances in surgical strategy to optimise the system of the heart, the body, and the patient. Indeed, previously palliated patients with progressive ventricular failure and hypoxia have been put on mechanical assistance devices as an alternative therapy [9]. LVAD, also known as the “Berlin heart”, is a means of circulatory support for the failing native heart [9]. As a paracorporeal system, it is cannulated into the internal heart but rests external to the body [9]. It functions like a bike pump with a pneumatic driver and a movable membrane. Suction allows filling of the device during diastole and positive pressure facilitates ejection into the systemic circulation during systole [10]. The ingenious invention provides destination therapy as a reliable bridge to transplant or definitive treatment [10,11] . However, it is not successful in all cases. Recent multicenter data has shown the rate of survival to heart transplant or recovery with use of the LVAD to be 75% [11]. Moreover, despite reports of successful bridging to transplantation, there is limited use of ventricular assistance devices in single-ventricular patients with higher rates of mortality compared to patients with biventricular physiology [11]. Furthermore, there are complications including embolic stroke, which requires anticoagulation in all settings [9] . Another consideration is that immunological consequences of ventricular assistance devices may limit the capacity for later organ transplantation due to an increased incidence of rejection and graft loss following transplant [9] . Regardless, the LVAD has improved standard best practice care. Prior to the early 2000s, the predominant mode of circulatory support was extracorporeal membrane oxygenation which required intensive care provision [10,11]. The advent of the LVAD, which does not require intensive care, provides a more reliable alternative with improved survival, patient function, and satisfaction [10,11]. The noteworthy difference is the capacity for ambulatory care, affording the potential for an improved quality of life - the ability to mobilise, go to the ward, and play [10,11].

Moreover, there is also some consideration of a safe transition to community outpatient care [12]. In the adult population, patients on LVADs are discharged safely from hospital, however in the paediatric population there remains some trepidation because primary caregivers and schoolteachers need to be educated and adequately supported to manage risk in a more vulnerable patient group [12]. The LVAD is a testament to how we can optimise the mechanical system to support the psychosocial system within which a patient functions. The need for high-level communication in high-level care The treating team requires high-level communication because, despite technological advances, survival does not always correspond to quality of life. While the majority of babies with congenital heart disease survive, many have impaired neurodevelopment [13]. For a hospital that has a plethora of resources and expertise, knowing when to withdraw treatment is a difficult choice. As a clinical case, a patient on extra-corporeal membrane oxygenation (ECMO) did not continue to undergo active treatment, despite the technically feasible option of having an LVAD. When CT brain findings, showing multiple cortical infarcts, were discussed at a multi-disciplinary team (MDT) meeting, palliation was considered to be in the best interest of the patient and their family. Raising the concern highlighted the culture of the unit, which promoted open communication to balance and contrast the different system outcomes: biological, technical, and functional. The team cohesion highlighted was fostered by the hospital system’s implemented strategy. As a commitment to the ongoing improvement of the unit, weekly performance rounds made the point of retrospective analysis for each patient’s clinical course. Behind the impetus to go through every patient was the recognition that these were high-risk cases with inherent potential for error and identifiable threats to patient outcomes [14]. This process of identifying and managing error and risk through effective utilisation of all resources available is central to a concept known as “crew resource management” (CRM) [14].

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CRM, conceived by NASA and aviation experts, is an integral part of systems thinking and is practically applied and mandated in commercial cockpit training [14]. In the hospital context, each post-operative course was considered a patient “flight,” with their preoperative management strategy or “flight-plan” juxtaposed and examined with the actual clinical trajectory (plotted from the arrival in the operating room until point of discharge or death) [14]. The strategy acknowledges and learns from other high-stake industries that high-level care transcends the profession, requiring inter-disciplinary dialogue and conversation. While there is a systemic vigilance engrained, the NASA approach promotes blame-free error assessment [14]. This highlights how high-level care rests not only on technical pillars, but also on non-technical skills and system policy. More broadly, the communication between treating centres also contributes to the promotion of high-level care. In 2017, a world database for paediatric and congenital heart surgery was established [15]. Institutions from Japan to Mexico and Colombia to Italy are communicating their practice details including demographics, pre-operative patient history, surgical data, and 1-year post-operative outcomes [15]. By confidentially comparing centre-specific data to regional, national, and international aggregated data, quality improvement strategies can be identified and implemented with guidance from international experts in the field [15]. Aligned with our societal value of universal health care, the aim is to improve outcomes on a global front [15]. This encompassing system of a worldwide standard, regardless of societal or economic status, forms the concluding sentiment of this discussion. While this paper has considered many variables in high-level paediatric care, the constant will always be the universal applicability of the human heart which can be found in any hospital, nation, or human time period.

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Conclusion This paper has discussed many interconnected systems, telescoping through the perspectives of history, technology, and communication strategies. Ultimately, high-level care in the context of paediatric heart surgery requires a firm grasp of each system. Whether it be risk-stratification, technological innovation, or the interpretation of a worldwide surgical database, an array of connected interventions are required to optimize patient outcomes. Acknowledgements I would like to thank the University of Toronto and the cardiovascular surgery staff at the Hospital for Sick Children especially Dr Edward Hickey for the opportunity, as well as Dr Osami Honjo, Dr John Coles, Dr Christoph Haller, Helen Trifunovski, and the amazing nursing and critical care teams.

Correspondence Nicole da cruz 17748764@student.westernsydney.edu.au


References [1] De Luca L. Percutaneous treatment of coronary bifurcation lesions: is simplicity the ultimate sophistication? Circ Cardiovasc Interv. 2016;9:e004328, [2] Neill CA, Clark EB. The Developing Heart: A ‘History’of Pediatric Cardiology. Springer Science & Business Media; 1995 [3] Murphy AM, Cameron DE. The Blalock-Taussig-Thomas Collaboration. JAMA. 2008;300(3):328-30. [4] Soylu E, Athanasiou T, Jarral OA. Vivien Theodore Thomas (1910-1985): An African-American laboratory technician who went on to become an innovator in cardiac surgery. J Med Biogr. 2017;25:106-13. [5] Kiess M. History and evolution of the treatment of adult congenital heart disease. BC Med J. 2016;58(7):368-72. [6] Cooley DA. The first Blalock-Taussig shunt. J Thorac Cardiovasc Surg. 2010;140(4):750-1. [7] Rychik J. The relentless effects of the Fontan paradox. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2016;19(1):37-43 [8] Freud LR, Tworetzky W. Fetal interventions for congenital heart disease. Curr Opin Pediatr. 2016;28:156-62. [9] Chu MW, Sharma K, Tchervenkov CI, et al. Berlin Heart ventricular assist device in a child with hypoplastic left heart syndrome. Ann Thorac Surg. 2007;83:1179-81. [10] O’Connor MJ, Rossano JW. Ventricular assist devices in children. Curr Opin Cardiol. 2014;29:113-21.Halaweish I, Ohye [11] RG, Si MS. Berlin heart ventricular assist device as a long-term bridge to transplantation in a Fontan patient with failing single ventricle. Pediatr Transplant. 2015;19:193-5. [12] Conway J, VanderPluym C, Jeewa A, Sinnadurai S, Schubert A, Lorts A. Now how do we get them home? Outpatient care of pediatric patients on mechanical circulatory support. Pediatr Transplant. 2016;20:194-202. [13] Donofrio MT, Limperopoulos C. Impact of congenital heart disease on fetal brain development and injury. Curr Opin Pediatr. 2011;23:502-11. [14] Hickey EJ, Nosikova Y, Pham-Hung E, et al. National Aeronautics and Space Administration “threat and error” model applied to pediatric cardiac surgery: error cycles precede ~85% of patient deaths. J Thorac Cardiovasc Surg. 2015;149:496-507. [15] St. Louis JD, Kurosawa H, Jonas RA, et al. The World Database for Pediatric and Congenital Heart Surgery: the dawn of a new era of global communication and quality improvement in congenital heart disease. World J Pediatr Congenit Heart Surg. 2017;8:597-9.

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Collaboration between doctors and veterinarians for the greater good of all species Subhashaan Sreedharan BSc(Hons) Medical Student (Year 4), University of Melbourne Subha is a final year medical student at the University of Melbourne. Before commencing medical school, he completed a Bachelor of Science (Honours) at the University of Melbourne, majoring in Animal Health and Disease and specialising in Veterinary Bioscience. Dr. Silverio Nanni BSc DVM(Distinction) Veterinarian Dr. Nanni is a small animal veterinarian working in British Columbia, Canada. He graduated with a Bachelor of Science majoring in Biology from the University of British Columbia prior to completing his veterinary medicine studies at the University of Melbourne. Abstract The One Health Initiative was founded to improve collaborative clinical and research efforts between medical, veterinary and environmental experts. Human and veterinary medicine share common issues and challenges, such as zoonotic diseases and antimicrobial resistance. However, the fields of human and veterinary medicine are largely divided and collaboration is limited. An interdisciplinary approach may be effective in overcoming the challenges common to both human and animal health. To improve communication and teamwork between the two fields, interdisciplinary education could be introduced into both veterinary and medical school curricula. Medical and veterinary students should consider how collaboration could benefit their education and their future patients. Introduction “Between animal and human medicine there is no dividing line – nor should there be” —Rudolf Virchow [1]. The One Health Initiative is an international movement encouraging interdisciplinary collaboration between human, animal and environmental experts in order to improve the lives of all species [2]. While there are clear differences between human and animal medicine, both disciplines share a common body of knowledge in anatomy, physiology, pharmacology and pathology. More importantly, doctors and veterinarians share the common goal of improving the quality of life of their patients. Increasing collaboration between these two professions may allow doctors and veterinarians to better achieve this goal.

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History and Development of One Health The concept of One Health was first described as early as the late 19th century. Rudolf Virchow was the first to propose a close link between human and animal health. Virchow coined the term “zoonosis” to describe infectious diseases that are transmissible from animals to humans, and suggested that there should be no distinction between human and veterinary medicine [3]. William Osler, Virchow’s student, continued this theme. Osler taught both veterinary and medical students, published on comparative pathology, and was a promoter of the “One Medicine” concept [4]. Unfortunately, with the expansion of both fields in the 20th century, the divide between veterinary and human medicine grew [4]. In order to rebuild and strengthen the relationship between doctors and veterinarians, the American Medical Association (AMA) and American Veterinary Medical Association (AVMA) endorsed the concept of One Health in 2008 [2]. The AMA and AVMA have pledged to improve communication between the two professions, develop joint educational programs, and build cross-species research collaborations [2]. In Australia, the Australian Veterinary Association (AVA) is working to increase awareness of the One Health Initiative [5]. However, the Australian Medical Association is yet to publicly endorse this concept. The Australian Medical Association and AVA should consider implementing a joint One Health taskforce similar to that of their counterparts in the United States.


Importance of One Health A One Health approach is particularly relevant to the major health issues of zoonotic diseases and antibiotic resistance. It has been estimated that 60-75% of emerging infectious diseases are zoonotic [6, 7]. These diseases are a significant health and economic burden [6, 7]. Five of the top six ‘category A’ disease agents identified as a potential bioterror threat by the Centers for Disease Control and Prevention (CDC) are zoonoses [8]. Given the critical role of animals in the epidemiology of these diseases, the effective control of zoonoses requires research in both human and animal populations conducted by multidisciplinary teams. This integrated research is currently lacking [9]. Antimicrobial resistance (AMR) is another major health issue with significant consequences. The sub-therapeutic doses and long exposure periods used in animal production systems may create the ideal circumstances for microbes to develop resistance to antibiotics [10, 11]. This resistance can be transmitted to human pathogens or to human microbiota [10, 11]. The World Health Organisation suggests that a multidisciplinary effort is required to effectively halt antimicrobial resistance [12-14]. In 2002, Canada became one of the first countries to develop a joint programme for the surveillance of antibiotic resistance in humans and animals [15]. In 2015, all WHO Member States committed to developing a multidisciplinary national action plan to tackle AMR. Seventy-nine countries had a finalised plan by 2017 [13, 14]. The Australian Government has published the National Antimicrobial Resistance Strategy, outlining their response to the threats of antibiotic misuse and resistance. The Australian AMR Steering Group is co-chaired by the Australian Chief Medical and Chief Veterinary Officers. One of the goals of the AMR Strategy is to establish and maintain linkages between the medical, veterinary and environmental sectors. The Steering Group recognises that collaboration between medical and veterinary boards, and professional colleges and societies, is vital to ensure the AMR Strategy is executed effectively [16].

One Health in Action There are several examples of scientific breakthroughs made from research collaborations between doctors and veterinarians. One such example goes back to as early as 1893, when Theobald Smith, a doctor, and F. L. Kilbourne, a veterinarian, discovered that ticks were responsible for the transmission of babesiosis [17]. In the late 20th century, Hendra virus was first described in Australia following an outbreak of fatal equine and human cases in Queensland [18]. In response to the outbreak, the Queensland Government quickly established an expert taskforce to identify the natural host of the virus [18]. The successful taskforce included animal and human clinicians and scientists, as well as a number of other experts from a range of disciplines. Some of the key people from this taskforce attribute the advances in knowledge they made to the diversity of the group and the mutual respect they shared [18]. These are just two historical examples of human and veterinary medical professionals collaborating to discover new scientific knowledge that can be applied across species. More recently, the Duke Comparative Oncology Group, made up of veterinarians, doctors and scientists, was created with the goal of using a cross-species approach to improve the treatment of soft tissue and bone sarcomas [19]. The genetic profiles of canine and human osteosarcomas have been shown to be very similar, providing a unique opportunity for cross-species research [20]. Companion dogs develop osteosarcoma in similar sites to humans, with similar histology, response to traditional therapies, and risk of metastasis [20]. However, over 10,000 new cases are diagnosed in dogs every year while only 800 new cases of osteosarcoma are diagnosed in humans annually [20]. Given the greater number of cases and the accelerated biology of osteosarcoma in dogs, there is an opportunity to increase the rate of research into this disease by using both canine and human populations compared to research conducted in humans alone [20]. Collaborative research between medical and veterinary professionals has the potential to discover novel treatments for osteosarcoma for the benefit of human and animal patients.

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In addition to combined research groups, interdisciplinary clinical teams are becoming increasingly common. Human and animal conditions have historically been treated as separate entities. However, some interdisciplinary teams are working to rectify this divide. In Los Angeles, specialist physicians from the University of California-Los Angeles (UCLA) Medical Centre consult on veterinary cases at the Los Angeles Zoo and sit on the zoo’s Medical Advisory Board [21]. In several American academic hospitals, doctors invite veterinarians to their ward rounds and vice versa [21]. In 2011, the Zoobiquity Conference was launched with the aim of bringing doctors and veterinarians together to discuss clinical cases and solve the shared challenges facing human and veterinary medicine. These examples highlight the steady progression of interdisciplinary collaboration under the One Health Initiative. Introducing One Health to Students One possible strategy for improving the level of collaboration between doctors and veterinarians is to introduce interdisciplinary group projects into the curricula of medical and veterinary schools. This would foster teamwork and early networking between veterinary and medical students. Similar projects are already being implemented in the United States. The Zoobiquity Research Initiative pairs UC-Davis veterinary students with UCLA medical students to work collaboratively on projects affecting animal and human health [21]. Encouragingly, Edwards et al. [22] reported that medical student attitudes towards collaborative learning were more positive after an interdisciplinary surgical skills session with veterinary students. It is important to note that there are logistical challenges in implementing such a system in Australia. In particular, there are a disproportionate number of medical students compared to veterinary students. There are 21 medical schools compared to only seven veterinary schools nationwide. In Victoria alone, there are more than 3000 medical students compared to only 500 veterinary students [23, 24]. However, five of the seven Australian institutions with veterinary schools also have a medical school. These are James Cook University, University of Adelaide, University of Melbourne, University of Queensland, and University of Sydney. It may be more feasible for these institutions with co-located veterinary and medical schools to introduce collaborative learning.

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A pilot study trialing collaborative learning between medical and veterinary students in Australia would provide insight into the feasibility and potential benefits of such a program. Rabies and tuberculosis are two potential project topics that would emphasise the importance of collaborative work in achieving successful outcomes for human and animal populations. Projects exploring the similarities and differences between the pathogenesis and treatments for common diseases affecting both animals and humans, such as cancer or heart disease, would help medical and veterinary students appreciate the clinical challenges shared by both fields. These learning exercises will encourage medical and veterinary students to consider how a collaborative approach might benefit their future patients, while also providing an early networking opportunity. Conclusion The current lack of collaboration between doctors and veterinarians represents a missed opportunity to benefit from interdisciplinary research and clinical practice. To seize this missed opportunity, Australian medical and veterinary schools should consider incorporating the One Health Initiative into their curricula. Medical and veterinary students should be encouraged at this early stage of their careers to consider how their future patients could benefit from interdisciplinary collaboration. Given the complex challenges facing humans and animals today, it is critical to recognise the connection between human and animal medicine. Improving communication between the two currently divided disciplines would be a good starting point in fostering the collaboration required to tackle our shared challenges.

Correspondence Subhashaan Sreedharan subhashaan.sreedharan@gmail.com


References [1] Klauder JV. Interrelations of human and veterinary medicine. N Engl J Med. 1958;258(4):170-7. [2] King LJ, Anderson LR, Blackmore CG, et al. Executive summary of the AVMA One Health Initiative Task Force report. J Am Vet Med Assoc. 2008;233(2):259-61. [3] Schultz M. Rudolf Virchow. J Emerg Infect Dis. 2008;14(9):1480-1. [4] Gyles C. One medicine, one health, one world. Can Vet J. 2016;57(4):345-6. [5] Australian Veterinary Association. One Health. 2018. Available from: http://www.ava.com.au/news/media-centre/hot-topics-6. [6] Jones KE, Patel NG, Levy MA, et al. Global trends in emerging infectious diseases. Nature. 2008;451(7181):990-3. [7] Coker R, Rushton J, Mounier-Jack S, et al. Towards a conceptual framework to support one-health research for policy on emerging zoonoses. Lancet Infect Dis. 2011;11(4):326-31. [8] Kahn LH, Kaplan B, Steele JH. Confronting zoonoses through closer collaboration between medicine and veterinary medicine (as ‘one medicine’). Vet Ital. 2007;43(1):5-19. [9] Shaffer L. Role of surveillance in disease prevention and control: cross-species surveillance contribution to one medicine. Proceedings of the 145th American Veterinary Medicine Association Annual Convention. 2008 July 19-22; New Orleans, LA; 2008. [10] Holmes A, Moore LSP, Sundsfjord A, et al. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet. 2016;387(10014):176-87. [11] Robinson TP, Wertheim HF, Kakkar M, Kariuki S, Bu D, Price LB. Animal production and antimicrobial resistance in the clinic. Lancet. 2016;387(10014):e1-3. [12] Robinson TP, Bu DP, Carrique-Mas J, et al. Antibiotic resistance is the quintessential One Health issue. Trans R Soc Trop Med Hyg. 2016;110(7):377-80. [13] Food and Agriculture Organisation, World Organisation for Animal Health, World Health Organisation. Monitoring global progress on addressive antimicrobial resistance: analysis report of the second round of results of AMR country self-assessment survey. Geneva, Switzerland; 2018. [14] World Health Organisation. Antimicrobial resistance: report by the secretariat. Geneva, Switzerland; 2017. [15] Zinsstag J, Schelling E, Waltner-Toews D, Tanner M. From “one medicine” to “one health” and systemic approaches to health and well-being. Prev Vet Med. 2011;101(3):148-56. [16] Australian Government. Responding to the threat of antimicrobial resistance: Australia’s First National Antimicrobial Resistance Strategy 2015-2019. Canberra: Department of Health and Department of Agriculture; 2015. [17] Kahn LH, Kaplan B, Monath TP, Steele JH. Teaching “one medicine, one health”. Am J Med. 2008;121(3):169-70. [18] Black P, Douglas I, Field H. This could be the start of something big—20 years since the identification of bats as the natural host of Hendra virus. One Health. 2015;1:14-6. [19] Duke University and Duke University Health System. Comparative Oncology (Duke Cancer Institute). 2016. Available from: http://www. cancer.duke.edu/comparativeoncology/home [20] Paoloni M, Davis S, Lana S, Withrow S, Sangiorgi L, Picci P, et al. Canine tumor cross-species genomics uncovers targets linked to osteosarcoma progression. BMC Genomics. 2009;10(1):625. [21] Horowitz BN, Bowers K. Zoobiquity: What Animals Can Teach Us About Being Human. Random House; 2012. [22] Edwards JC, Walsum KV, Sanders CW, et al. Attitudes of veterinary medical students and medical students toward collaborative learning: An experiment. J Vet Med Educ. 2004;31(1):77-9. [23] University of Melbourne. Doctor of Veterinary Medicine: FAQs. 2018. Available from: https://study.unimelb.edu.au/how-to-apply/dvm-faq Medical Deans Australia and New Zealand. Student Statistics Tables. 2018. Available from: https://medicaldeans.org.au/data

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Could drinking tea cure acne? Courtney Haller 4th Year Medicine, University of Queensland Courtney is a student interested in dermatology who dreams of becoming an expert on acne treatments. The use of spearmint tea for acne is a topic heavily featured on internet forums and in popular magazines [1,2]. Spearmint, or Mentha spicata, is rooted in Europe and Asia, as it grows best in temperate climates. Spearmint is commonly used to flavor foods and gum and as an aromatic oil. Some examples of its reported medical benefits include its use in bacterial and fungal infections, bronchitis, halitosis, and sinusitis. Side effects include contact dermatitis and, in animal studies, impaired absorption of iron supplements as well as renal and liver toxicity. In addition, animal studies have found that spearmint may cause sedative and antidepressant effects [3], while spearmint extract can act as an anti-inflammatory, analgesic, and antipyretic in mice [4]. I would like to report the case of a 24-year-old Caucasian woman with a six-year history of severe facial nodulocystic acne. Her past medical history included a five-year history of severe migraines with auras, well-controlled with nortriptyline. Her family history was significant for maternal nodulocystic acne. The patient’s dermatologists prescribed intermittent oral tetracycline and topical benzoyl peroxide and clindamycin. This helped eliminate most open and closed comedones, however, the cystic lesions were only slightly improved. Intermittent intralesional corticosteroids helped reduce larger cystic lesions persisting for longer periods. At 22-years-old, she was treated with oral isotretinoin, which completely cleared her acne after six months of treatment. Due to side effects, including severe mood changes, she had to discontinue isotretinoin. This resulted in the return of her baseline acne. The patient continued the regimen of daily topical benzoyl peroxide and clindamycin. The addition of topical metronidazole and salicylic acid did not help. Oral hormonal contraceptives were contraindicated due to her history of migraines with auras. She continued to have nodulocystic lesions. Then, having read testimonials in the media, the now 24-year-old patient made the decision to start drinking two cups of spearmint tea daily, in addition to continuing her usual routine of benzoyl peroxide and clindamycin. After six months of drinking spearmint tea, the patient subjectively stated she believed her acne had decreased by 50%, in both the size and number of nodulocystic lesions on her face. This case is interesting, as there is no scientific evidence to support spearmint’s use in acne treatment. Although there is no evidence in the literature on spearmint’s role in acne treatment, there are two studies on its effect on androgen levels, a key player in the development and persistence of acne. The first, a randomised controlled trial, found that women with polycystic ovarian syndrome (PCOS) and hirsutism were supplemented with spearmint tea had significant decreases in free and total testosterone, increases in luteinizing hormone (LH) and follicle-stimulating hormone (FSH), and decreased subjective patient ratings of hirsutism. Conversely, this study found no difference in objective hirsutism ratings [5]. The second study also looked at spearmint tea supplementation in females with hirsutism. After spearmint consumption, there were significant decreases in free testosterone, while LH, FSH, and estradiol levels increased [6]. There were no reported side effects in either study. Although spearmint was compared to a placebo, there are no studies on spearmint in comparison to current antiandrogenic medications. Spearmint may be able to treat acne due to its possible antiandrogenic properties demonstrated in the studies above. Antiandrogens are commonly used in acne treatment as androgens play a significant role in sebum production, a major contributor to acne breakouts [7]. Androgens, including testosterone and the more potent dihydrotestosterone (DHT), increase sebum secretion. Antiandrogen agents include spironolactone, cyproterone acetate, flutamide, gonadotropin-releasing hormone agonists, insulin sensitizers, and combined oral contraceptives. Spearmint may have a role in the treatment of acne through an antiandrogenic effect, although there is little scientific evidence to date. Prospective research needs to be conducted to evaluate the efficacy of spearmint as an adjuvant to standard acne treatment. Informed consent was obtained from the patient for publication.

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References [1] Allure. Reddit Users Claim Drinking Spearmint Tea Can Cure Acne [Internet]. 2017 [cited 2019 Jul 30]. Available from: https://www.allure. com/story/can-drinking-spearmint-tea-cure-acne-reddit [2] Stylecaster. The Internet is Freaking Out that Spearmint Tea Cures Acne [Internet]. 2017 [cited 29 Jul 30]. Available from: https://stylecaster.com/beauty/spearmint-tea-acne-cure/ [3] Ulbricht C, Costa D, Serrano J, Guilford J, Isaac R, Seamon E et al. An evidence-based systematic review of spearmint by the natural standard research collaboration. J Diet Suppl. 2010;7(2):179-215. [4] Yousuf P, Noba N, Shohel M, Bhattacherjee R, Das B. Analgesic, anti-inflammatory and antipyretic effect of Menta spicata (spearmint). Br J Pharmacol. 2013; 3(4):854-64. [5] Grant P. Spearmint herbal tea has significant anti-androgen effects in polycystic ovarian syndrome. A randomized controlled trial. Phytother Res. 2010 Feb;24(2):186-8. [6] Akdoğan M, Tamer M, Cüre E, Cüre M, Köroğlu B, Delibas N. Effect of spearmint (Mentha spicata labiatae) teas on androgen levels in women with hirsutism. Phytotherapy Res. 2007;21(5):444-7. [7] Zouboulis C, Rabe T. Hormonal antiandrogens in acne treatment. J Dtsch Dermatol Ges. 2010;8 Suppl 1:S60-74.

Correspondence Courtney Haller courtney.haller@uq.net.au

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A Compendium of Histology: A Book Review Sue Sritharan Bachelor of Medicine/Bachelor of Surgery, Monash University Year 4 of 4 years Student Sue is a fourth-year medical student with a keen interest in medical management and training of doctors. Delving into the intricate world of histology can be a daunting endeavour. Histology (or microanatomy) is a component of medical school training that is frequently assessed. Medical students can undeniably appreciate its usefulness in determining a pathological diagnosis of disease; however, its realm of work may be perceived as esoteric. However, as pathology is the basis of disease, an elementary understanding of histology is broadly applicable to all medical specialties. With the exception of pre-clinical laboratory hours, the average medical student has remarkably limited exposure to histology. This compendium provides an excellent overview and summary of the essence of histological study. It details the normal histological structures of the major organ systems and a practical means to study slides. The trio of textbook [1] authors are Danish trained medical doctors with experience in histological teaching and an interest in engaging the medical student cohort. Dr Anders Rehfeld, Dr Malin Nylander Figure 1: A Compendium of Histology. and Dr Kirstine Karnov are all medical graduates of the University of Reproduced with permission. Copenhagen and commenced teaching histology to students early during their university years. Following on, the authors have pursued higher research in varying specialties of male reproductive biology, gynaecological endocrinology and oral cancer. The trio have combined their passion for cell biology with teaching to produce a histology reference book purpose built for medical students. While some students may utilise a rote-learning based approach, the compendium renders histology as a largely manageable study using a straightforward category system. Major organ systems are further subdivided into classes based on their constituent tissues. As such, each category hosts further partitioned high-yield information. The compendium is divided into four main parts: Introduction (Part I), Cytology (Part II), Histology of Tissues (Part III) and Histology of Organs (Part IV). Part I describes the properties and the basic organisational structure of cells and tissues. It also includes a practical guide to analysing fresh or frozen specimens and common staining principles. Part II discusses the framework of organelles and their elemental compositions. Part III comprises of the main types of tissue types such as epithelial, connective, muscular and nervous tissues with illustrations and photomicrographs of typical sliced sections. Part IV studies the major organ systems and components including the musculoskeletal system, nervous system, cardiovascular, respiratory, immune and lymphatic system, integumentary system, digestive system, urinary system, endocrine system, male and female reproductive systems, the eye and the ear.

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Figure 2. Memo-Box describing the memory aid acronym “AMI”. Reproduced with permission.

The book systematically utilises a dot-point format to relay pertinent information. Distributed throughout the book are “Memo-boxes” which detail a unique or interesting acronym as a memory aide to recall key concepts. For example as shown in Figure 2, when describing the layers of the blood vessel wall, the acronym AMI or Acute Myocardial Infarct would be beneficial: “Tunica Adventitia, Tunica Media: The Middle Layer → the smooth Muscle cell is the only cell type here, Tunica Intima: The “Intimate” Layer, closer to lumen.” The book also includes both stylised illustrations of key structures and selected photographs of the specimens presented as a comparison to aide comprehension. Furthermore, the authors should be commended for their consistent minimalistic page design and clear graphics. At each chapter’s conclusion, the authors have provided appropriate references from a number of accredited expert sources. This serves a dual purpose of providing assurance for the material and also directing the reader to further resources. Most importantly, students with no prior knowledge of the basics of histology or self-visualisations of tissue specimens will find this book most informative. This is principally due to the scrupulously crafted summary of the crux of histology in a categorised shorthand format. As the compendium follows a rudimentary approach of the tissues of the human body, this basis can be an aide to understanding pathological changes when students transition to clinical years. This book is an ideal companion for medical students learning histology and for revision prior to examinations. With an excellent and concise overview of the main organ systems and with no extraneous material, the book perfectly achieves its set purpose. Furthermore, it may also prove of value to junior doctors, pharmacists or academics wanting to re-establish their grounding in the fundamentals of the human body. In comparison to other histology texts or guidebooks, the compendium by its very definition, cannot include the rare or extraordinary. Individuals seeking further information should utilise this book as a supplementary tool as they progress further into their medical education. Wider reading will benefit medical students that would like to note conditions commonly encountered with particular pathological processes. The English-version of this Danish histology reference book is a perfect addition to a medical students’ personal library and a highly recommended core textbook to prepare for final examinations. Most Australian medical university libraries routinely have subscriptions to academic e-books such as SpringerLink, hence this book would be an expense-free venture for students. It would be invaluable to those wishing to establish a foundation in histology and those individuals who have a special interest in pathology.

Correspondence Sue Sritharan sue.sritharan@gmail.com

References [1] Rehfeld A, Nylander M, Karnov K. A Compendium of Histology. Switzerland: Springer International Publishing; 2017.

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Clinical Cases in Obstetrics, Gynaecology and Women’s Health: A Book Review Chinelo Aghanwa Bachelor of Medicine, Bachelor of Surgery, James Cook University Chinelo is a final year medical student. Throughout her medical schooling she has developed an avid interest in women’s health and intends to pursue a career in obstetrics and gynaecology. Introduction In any standard five to ten-week long rotation in obstetrics and gynaecology experienced by a medical student or junior doctor, it is unlikely that they will encounter every single presenting complaint pertinent to the specialty. Nor will they always have the opportunity to reflect on the scenario and process important learning points as they occur in real-time. For many medical students who find themselves time-poor on such rotations, a good review book can aid their understanding of the topic at hand. With a wide range of textbooks on obstetrics and gynaecology, the selection of high-yield resources can be difficult. Clinical Scenarios in Obstetrics, Gynaecology and Women’s Health by De Costa, Robson and Lim is a textbook that describes 50 cases commonly encountered in obstetrics, gynaecology, and women’s health in general practice [1]. The textbook is divided into four parts, with guidelines for history-taking and physical examination in part one. The case-scenarios are divided into three separate sections representing the breadth of obstetrics, gynaecology, and women’s health. Summary of argument A good review textbook is concise, contains already familiar content, and serves as a learning tool for preparation for exams or the wards. These are features of the pocket-sized case-based textbook Clinical Scenarios in Obstetrics, Gynaecology and Women’s Health by De Costa, Robson and Lim. Figure 1. Clinical Cases in Obstetrics, Gynaecology and Women’s Health. Reproduced with permission.

About the authors The textbook combines years of experience in obstetrics and gynaecology from Professor Caroline de Costa, Professor Stephen Robson, and clinical Associate Professor Boon Lim, all of whom share an interest in teaching. As an academic currently staffed at James Cook University, Professor de Costa teaches medical students and supervises Honours and PhD research. Professor Stephen Robson has an area of interest in assisted reproduction. Associate Professor Boon Lim is an editor for the British Journal of Obstetrics and Gynaecology.

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Summary of contents A diverse range of scenarios are represented in this textbook with a particular focus on clinical management. This resource also provides perspective on social determinants that impact women’s health, which need to be considered by health professionals for the provision of holistic patient-centred care. Strengths Through the case scenarios, the textbook illustrates and simplifies concepts in obstetrics and gynaecology for time-poor medical students. Each case covers the patient’s presenting complaint, pertinent history, physical examination, and management in a stepwise fashion. The textbook further broadens the reader’s understanding of obstetrics and gynaecology by building upon the case scenarios, considering potential complications, and proposing subsequent management. Through this method, the reader is able to gain understanding of the complications commonly associated with certain conditions in women’s health and how to manage them accordingly. In addition, cases are interspersed with references to literature and guidelines from the time of the textbook’s publication. Medical students will most likely benefit from reading this textbook for a number of reasons. The style in which the textbook is written helps to develop clinical reasoning. The textbook frames each case scenario with a vignette on the patient’s presentation, followed by a series of questions and potential solutions for the reader to work through. This style of questioning also encourages the reader to develop a framework to facilitate critical-thinking and decision-making, drawn from the experience of the authors. The cases also include questions commonly asked by patients in those scenarios and explains how to approach giving advice. The closing of each case scenario has a subsection called ‘clinical pearls’, which are important revision points for the reader, and reminders to ‘always check the whole woman’. Conclusion: This pocket-sized textbook is suitable for any student whose learning style is compatible with casebased evaluation. It is a valuable resource for any medical student or junior doctor on a rotation in obstetrics and gynaecology.

Correspondence Chinelo Aghanwa Chinelo.aghanwa@gmail.com

References [1] De Costa C, Lim BH and Robson S. Clinical cases in Obstetrics, Gynaecology, and Women’s health. Second Ed. North Ryde, NSW: McGraw-Hill Pty Ltd; 2013.

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Staff Internal Director Rose Brazilek (2019) Sara Kim (2020) Internal Deputy Director Sara Kim (2019) Sean Mangion (2020) External Director Zak Doherty External Deputy Director John Ward (2019) Teresa To (2020) Editor-in-Chief Robert Ellis Secretary Suranutha (Sue) Sritharan (2019) Nic Savage (2020) Financial Officer Cathy King Sponsorship Officer Gayathri Bimal (2019) Sinali Seneviratne (2020) Online Publications Officer Ashly Liu (2020) Siobhan Manners (2019) Social Media Officer Sarah Loria Publicity Officer Kaela Armitage (2020) Samuel Geraghty (2019) Print & Graphic Design Officer Isabel Lee

Senior Proof Readers Emily Feng-Gu Rosalind O’Neill Section Editors Linda Alexander Aidan Tan Mabel Leow Warwick Cann Lucy Hanlon Associate Editors Subhashaan Sreedharan Danielle Aliano David Chen Cameron Wright Daniel Wong Aloysius Ng Jacob Ross Shahzma Merani Sharon Del Vecchio Naomi Cohen Justin Smith Shourye Dwivedi Nikhil Dwivedi Esther Johns Simran Dahiya Andy Lu Arunan Jeyakumar Proof Readers Matthew Riggs Vannessa Leung Stephanie Dimitrov Hannah Gordon Ivy Jiang Madeleine Spicer Margaret Hezkial Marisse Sonido Ke Sun Louise Goodwin


University Representatives Bond University Nikhil Dwivedi Danial Bahudin

University of Notre Dame (Fremantle) Leila Heidarvand Teresa To

Curtin University Angel Thomas Katie Croston

University of Notre Dame (Sydney) Tim Outhred Daniel Mastroianni

Deakin University James Gaston Hayley Cron

University of Notre Dame (Melbourne) Elena Harty

Griffith University Megan Sandeman

University of Queensland Kaela Armitage

James Cook University Ahthavan Narendren

University of Sydney Thuvarahan Jegathees Shemani Jagoda

Macquarie University Alexandra Stesin

University of Tasmania Natasha Abeysekera

Monash University Edmund Khong Jaidyn Muhandiramge

University of Western Australia Melissa Daniels

University of Adelaide Tu-An Ma Medhir Kumawat University of Melbourne Christine Min-Kyung Jun Yonis Abukar University of New South Wales Danica Xie Grace Wong Michelle Wu

University of Wollongong Bevan Dong Western Sydney University Kaitlyn Hockey


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