The Auricle Vol 3 Edn 1

VOLUME 3 EDITION 1

TABLE OF CONTENTS

// VOLUME 3 EDITION 1 //

LETTER FROM THE EDITORS

WHAT ARE YOUR PLANS THIS YEAR?.........................................................................6

GIRL IN HARVARD

LISA TESCHER TALKS FINAL YEAR AT AN IVY LEAGUE................................................7

WHERE IN THE WORLD?

STORIES AND ADVICE FROM ELECTIVES OVERSEAS....................................................13

THE INTERN CRISIS

ASHRAY RAJAGOPOLAN ON PROGRESS AND THE FUTURE...........................................17

welcome to the transition issue!

THE YEAR IS 2014.

Everywhere you turn, it seems like people are making ‘big plans’.

These range from scoring in the top quartle of the end-of-year exam to smashing internship interviews to planning the much anticipated backpacking trip through Europe that follows shortly afterward.

Maybe there’s a part in Med Revue that you want to land.

Or there’s a fitness best you want to beat. We’ve heard of attending interstate festivals, surviving Tough Mudder, doing the Great Ocean Road with friends, working on research projects, getting through first patient encounter jitters and taking advantage of social events on campus (hint: anything SAS, MESS or MUMUS).

One guy wants to deliver his first baby without fainting.

The point being: there’s always something that we want to do.

In this edition, we’ve given you a selection of some seriously great reads.

Learn what it’s like to spend a rotation at an Ivy League medical school (its name rhymes with Schmarvard).

Find out where you can go for final year electives overseas, how others found it and what advice they have for you.

And lastly, get informed. Even if you’re only in first year, the internship crisis is very real for all of us. No matter how long we spend at Sir John’s, it’s going to effect us eventually... and it may even become worse if we don’t take action.

As always, we’d love to hear from you— all submissions and queries to publications@mumus.org.

Your Publications Reps, Michelle Li (Clinical) Elizabeth Low (Pre-Clinical) 7

GIRL IN HAR VARD. REPRINT: 2011 EDITION

ARRIVING AT HARVARD MEDICAL SCHOOL, LISA TESCHER WAS ARMED WITH MORE THAN JUST A PEN AND A STETHOSCOPE. SHE HAD SELF-MEDICATED ON NERVOUS EXCITEMENT.

I had more than a healthy dose of expectations. For the next rotation I would not only be studying at the oldest university in America, but also the top medical school in the world. I would be working in a health system that I knew little about, other than the glamorised perspective I had gleamed from American medical television drama’s such as Grey’s Anatomy. I was worried that I would drown. That the standard would prove to challenging. Instead, I flew back to Australia with not only a refined work ethic, heightened organisational skills but also an intricate appreciation for internal medicine.

From my first day it was evident that the differences between the role of an Australian medical student and that of my American counterparts extended beyond the mandatory white coat medical student ‘uniform’. At age 21, they were on average eight years my senior. Their nametags boasted of impressive qualifications, such as MD/PhD or MD/MBA students. The role of a medical student at Massachusetts General Hospital would be comparable to that of a resident in Australia. The students work e d p h e n o m e n a l l y l ong hours, were at the mercy of unpredictable pagers and played an active role in patient management. At first this responsibility seemed an intimidating start to final year, but it proved an incredible challenge and excellent foundation from which I look forward to building my 5th year education.

My days started with the traditional routine of a 6am morning arrival to review the blood tests and imaging from the previous day. This was followed by a ward round with the renal fellow in which we would scuttle between the 24 hospital floors to review each of our patients. It provided me with the ideal opportunity to observe an expert in action. I was lucky enough to receive oneon-one mini tutorials during these ward rounds about how to detect subtle clinical signs, such as a faint pericardial rub. I also learnt ways to structure progress notes so that they conveyed the core information in a concise manner that could be easily interpreted by other members of the patients treating team. Often we would wind up in the dialysis unit towards the end of ward round, managing acutely unwell patients whose bodies were struggling to cope with the strain of daily dialysis treatments.

It was not unusual to see patients blood pressure dropping dangerously low or spiking high fevers as they contended with both the burden of Renal Replacement Therapy as well as all the other co-morbidities that had led them to require the dialysis initially.

9

‘The role of a medical student... would be comparable to that of a resident in Australia.’

The aspect of my day that was vastly different to anything I had experienced before were performing consult services independently. Each day my renal fellow would receive at least one page from a hospital physician alerting him to an inpatient that had fallen into acute renal failure or developed a significant electrolyte disturbance. These were referrals from internal medicine physicians, most of which had trained at Ivy league universities and were now working at one of America’s most prestigious hospitals. These patients were being referred for a renal consult service because their treating team were struggling to identify a cause for their renal condition or couldn’t adequately manage the patient. These patients were being referred to me.

The renal fellow would not call up the referring clinician, he would not go to the patient and do an extensive history and examination, he would not file through all of the patients past history. Instead, it was my role on the renal team to perform this initial consult, and within a few hours be confidently presenting my admission, findings, investigations performed and management plan to the consultant.

Given that prior to arriving at Mass. General Hospital I had spent less than 1 week of my clinical years learning about kidney conditions, it was quite a daunting task. The majority of the patients I reviewed were those with acute renal failure. Generally my approach to a consult would involve an initial preparatory hour in which I would sift through all of the patients’ investigation findings and medical reports to develop a thorough awareness of the patients background level of health.

10

It was only after I had extensively scoured through the depths of their medical records, would I finally attend to the patient’s bedside. I would take a full history of not only their recent renal/electrolyte decline, but also all the events in the preceding hours/days/weeks that had culminated to this outcome. I would then examine the patient and collect a urine sample and ensure all of the appropriate blood tests had been performed. From here I would correlate my clinical suspicions with the evidence in front of me. I would precisely time when the patient developed uraemic symptoms to when their medications were adjusted, and then correspond this with blood tests for drug toxicity. I was also fortunate that the hospital’s light microscope had multiple eyepieces, so that as the consultant viewed the urine sample under different magnifications, he was able to explain to me the various structures seen. By the end of the rotation I felt confident differentiating between bland sediments, hyaline casts, granular casts, crystals and the list goes on. More importantly I fully appreciated the diagnostic significance of detecting each of these in a patient’s urine. From here I would present my full patient admission, including investigation results, to the nephrology consultant.

In Australia specialty consult services typically write less than a page on handwritten notes upon admitting a new patient to their service, and dot-points are perceived as the ideal for concise information sharing. I quickly learnt that this was not the norm in the USA. I would type at least 4 pages of notes for each patient under my care. Instead of just writing the likely differential diagnosis down, as is often the practice in Australian hospitals, I was expected to devote a page of discussion as to why certain conditions were excluded as the cause of the patient’s renal failure, and why others were considered more likely. From a clinical education perspective it gave me a much more thorough grasp of the pathophysiology inherent to many conditions of the kidney. It also gave me the opportunity to use evidence based medicine to sculpt my clinical impression of a patient, and then to use the latest research to guide my suggested management plan.

11

Massachusetts General Hospital, as the largest teaching hospital of Harvard Medical school, prided itself on running an extensive array of educational sessions for medical students, residents, registrars and consultants. Every day of the week there were lunchtime teaching sessions available to all medical students and residents. The topics were diverse and allowed me to learn about infectious diseases, obesity patterns, oncology developments, renal stone prevention and the list goes on. Additionally each afternoon there were case presentation sessions for medical students and interns, in which interesting patients from different inpatient units were discussed among the junior medical staff.

The speakers were often Harvard professors relating their latest research developments, or visiting professors from nearby Yale University. The topics varied from Monday’s kidney genetics session, to Tuesday’s renal case discussions, to Wednesday’s acid-base interactive tutorials, to Thursday’s dialysis classes and then culminating in the renal transplant meetings on Friday.

Upon returning to Australia, it has been interesting to spend time in the Emergency Department at the Royal Melbourne Hospital and learn about how renal conditions are managed in this acute care context. I was impressed to see that most patients have their electrolyte levels investigated so that baseline data will be available if they were to ever develop a electrolyte disturbance or renal dysfunction. It has also been a nice relief to work in a hospital that places a greater emphasis on work-life balance and doctor wellbeing, with the 8 hours ED shift days at RMH being much more realistic than the 12 hour days I would often have in America.

The emergency department component of this elective has also allowed me exposure to many renal conditions that often would not warrant a referral to renal specialists. These include developing an appreciation of the antibiotic guidelines for managing urinary tract infections, and what imaging would be indicated for working up a patient with suspected kidney stones.

Six weeks later I am extremely happy I undertook the challenge. My placement has definitely nurtured my passion for internal medicine, particularly renal disease. It has allowed me to learn not only how the health systems vary between Australia and America, but also develop my skills in admitting patients and using evidence based management to guide my clinical decisions.

‘The speakers were often Harvard professors relating their latest research developments’ 12

RECENT GRADUATES SHARE THEIR FINAL YEAR ELECTIVE EXPERIENCES

Where was your overseas placement?

We (I travelled with another 5th year) were placed at the Central Clinical University Paediatric Hospital, Sarajevo, Bosnia and Herzegovina (BiH).

Where was your overseas placement?

I went to Queenstown, NZ, and did my placement in the medical clinics at The Remarkables and Coronet Peak ski fields.

What did you do?

I spent six weeks in the ski field medical clinic on the mountain, seeing lots of musculoskeletal injuries and a few head injuries. It’s very similar to being in an ED, except that The Remarks are a 45 minute drive (or 5 minute helicopter ride!) from town and any imaging.

What did you do?

Quickly became a novelty. We rotated approximately every two to three days between hospital departments and were consistently greeted by confused smiles and the question, “Why Bosnia?”

What was the best part of the experience?

In regards to medicine, we saw every bizarre childhood illness from across BiH. Whilst we were there a team of Swedish cardiothoracic surgeons flew in to operate; cue one day in which we heard every paediatric murmur.

What was the best part of the experience?

Ski breaks! When it’s quiet you can get out for a ski and just return when a patient comes in. The clinic was very hands on as there’s a doctor, a nurse and yourself on the mountain.

Working closely with ski patrol was a great experience too, they’re highly skilled and really friendly.

What was the worst?

BiH is in dire economic straits with an employment level approaching 66% (down to as low as 50%) employment in its youngest demographic. Its medical resources are limited. In the gastroenterology department we watched an orphaned two month old boy with biliary atresia slowly dying for want of a liver transplant which Bosnia’s economy was unable to procure.

What was the worst?

Accommodation in Queenstown during the ski season is expensive, as is a season lift pass, but it’s worth it for the experience. The clinic can be a bit slow sometimes, but that’s just a good excuse to head out skiing!

Best thing you did in your spare time?

Being taken by a local to the Sarajevo grudge match. Typical Eastern European football: crowds surrounded by riot police, chanting masses and so many flares the ground become invisible.

Best thing you did in your spare time?

I spent most of my free time skiing or enjoying the nightlife.

Advice for someone who wants to do the same thing?

The medical centre in town were fantastic to deal with to organise my placement, drop them an email early and they will try their best to help.

Advice for someone who wants to do the same thing?

Apply early, have at least a bit of the language down and live like and with the locals.

14

I spent my 6 week elective in Pokhara, Nepal, spending time in obstetrics and gynae, a village health outpost, and ophthalmology.

Best: Short hours (10-2, if that) with plenty to do afterwards and on weekends (boat on the lake, short hikes and longer treks, paragliding, hire scooters, swim in the river/lake, rafting, sunsets, safaris, cheap shopping and food and drink at the restaurants in town... not sure if I can pick a favourite!)

Interesting: Seeing how they deliver medical care in a low resource setting, how to be efficient and economical (400 patients in a single antenatal clinic).

Worst: Hard to learn on the wards—patients don’t speak English and there wont always be someone to explain things to you. You don’t get to do anything and they don’t really know who you are (which is good when you want to take a day off or visit other wards of the hospital)!

Advice: Consider going through a company, especially if you’re going by yourself. We went through Work the World—expensive; but easy, safe, peace of mind, local staff to help you, and other students to share your experiences with). Would be great to do during years 3-5.

I was doing neonatology at the Charite hospital in Berlin, Germany. The best part was that my German improved a lot! Berlin is an incredible, vibrant, bustling city and you will be spoilt with things to do for your 6 weeks here. World-class museums, clubs, parks, and activities to keep you occupied. Easy to do day-trips on weekends. Also very affordable for a European capital.

The worst? I probably didn’t get as much medicine out of it as I might have had I done an elective in English (my German is somewhat proficient but certainly not fluent).

Learn as much German as you can before you go and be prepared for the language barrier to be difficult. If you want to get a strong medical rotation out of it, best to do it somewhere English speaking; if you want to go somewhere with lots to do in the city, Berlin is perfect.

• Queen Elizabeth Hospital in Bridgetown, Barbados • Anaesthesia • Favourite things: I saw Rihanna! I also had the best supervisor (Dr. Philip Gaskin) who let me do everything (including spinals yay). We found that the medicine in Barbados was similar to Australia and very teaching orientated. The teams understand that you’re on ‘holiday’ and let you off early which was nice.

• I was really lucky and didn’t experience this—but most of the other elective students we met mentioned that they had more of a ‘3rd year standby’ role (which was really boring). Although the elective itself is cheap ($250USD + ~$100 USD application fee), food is very very expensive (...though rum and beer is cheap).

• Barbados is a tropical island (the beaches are breathtaking) + tons of elective students from all around the world + cheap alcohol. Catamaraning (including snorkelling with turtles), was awesome—do it. Surfing was pretty cool too.

• Best time to go: Cropover (rotation 5) and join the parade! Organise your elective early. We organised ours roughly a year in advance and found that most of the elective options were already taken. Most of the electives have supervisors already assigned to them, but because of the nature of anaesthetics I got to move around and ‘choose’ my supervisor which worked in my advantage because I got to do lots. Definitely go with someone, most of the elective students came in pairs and it’s good to have someone to explore the island with. Person to contact: colleen.king@cavehill.uwi.edu.

• Johns Hopkins, Baltimore, USA • Critical care rotation in the Neuro Critical Care Unit, Surgical ICU, Weinberg ICU, Medical ICU and Coronary Care Unit.

• Fantastic facilities, teaching and simulation workshops. A highlight was a workshop doing kidney transplants on live anesthetised pigs.

• Often a lot of downtime in the afternoons; the hospital is pretty overstaffed.

• $15 lobster at Ebitt Bar and Grill, Washington DC. • Email the director of the unit you want to work in directly rather than applying through the registrars office.

THE INTERN

CRISIS

WHERE DO WE STAND NOW? ASKS ASHRAY RAJAGOPALAN

what’s the intern crisis?

Most of us will already be aware of the internship crisis—essentially, that every medical school has significantly increased its student intake, meaning that the number of medical graduates each year has begun to exceed the number of internship positions available. In 2013, there were 3326 applicants for 3080 jobs.

Internship is an essential next-step for graduates to be qualified to practise in Australia as medical professionals, and not having an internship means that you cannot work as a doctor—rendering your degree essentially useless.

Last year, the intern crisis was partly resolved when then Federal Health Minister Tanya Plibersek and five State and Territory Governments funded 116 additional internships – 90 in private hospitals and 26 more in public hospitals. The remaining graduates are thought to have taken internships overseas.

Despite Government action to reduce this, there remains a predicted shortfall of over 100 internships in 2014.

what’s the Government doing about it?

In August last year, then Health Minister Tanya Plibersek announced an $8 million package to fund 60 additional intern places for 2014 in rural areas.

Coalition Health Spokesman (now Health Minister) Peter Dutton went much further during the election campaign, announcing 100 new intern places for the next four years at cost of $40 million.

These were to be placed in private hospitals and other settings, particularly again in rural and regional areas.

The Greens also made an election commitment to ensure that internships are provided for all graduates of Australian medical schools, and to support funding necessary to achieve this.

This additional funding was a significant win for both graduating medical students and the community, as it supports the development of our health workforce.

These commitments make a significant contribution towards rectifying this, and the Coalition commitment is particularly beneficial as it extends over the whole forward estimates period (four years), which provides more certainty in the supply of internships and reduces the need for last minute negotiations and funding decisions to try and reduce a shortfall. However, it is still predicted that there will be a shortage of internships in 2014 and beyond, and none of the $10mil comitted to places went to Victoria as we’ve almost maxed out our capacity for interns.

new medical schools potentially worsening the shortfall Another pertinent problem for the provision of internship places is a number of proposed new medical schools, including a new medical school at Curtin University and a Murray-Darling Medical School joint venture by Charles Sturt and La Trobe Universities. These have been opposed by the AMA and AMSA, given the existing internship crisis and the number of students from Melbourne and Monash Universities already at surrounding hospitals.

The proposal is ba c k e d b y The Nationals, but is controversial amongst their Coalition partners in the Liberal Party, and was already rejected by Labor Health Minister Tanya Plibersek before the election.

postgraduate training positions shortage The shortage of internship positions isn’t the only problem at hand—there’s also a shortage of postgraduate positions, both in specialty training and residency (known as the training pipeline), and both issues need to be addressed so that medical graduates can progress to complete specialist training and enter the workforce.

Last year, up to 500 junior doctors working for Queensland Health were not selected to be re-employed the following year.

Similar shortages of postgraduate positions are predicted in other states.

The internship crisis is gradually being addressed, thanks to the energetic campaign over the past two years, but it doesn’t stop there—it’s essential for the future of our health workforce to ensure that medical graduates can access training positions right up until Fellowship.

what have med students been doing about it?

As more details of allocation procedure become clear, the Medical Student Action on Training (MSAT) campaign has been working to establish the facts on internship numbers next year. Doubtless this will become more public as information emerges, as we already saw in last year’s very successful #interncrisis campaign on Twitter and social media.

Other action being taken by AMSA includes an a telephone campaign in August to contact all the MPs in Victoria, distribution of factsheets to state and federal MPs, and other lobbying to raise awareness and promote action on the internship crisis from the State and Federal Governments.

what else can be done?

As I wrote in The Auricle last year, a potential idea to address the internship crisis could be for overseas rotations to be accredited, where interns would spend three months in the year. This would serve many purposes, to allow interns access to a more diverse and unique experience of medicine, as well as to provide care to communities where medical care is inaccessible or inadequate, while simultaneously effectively reducing the number of interns requiring supervision in Australian hospitals.

Internship systems in other countries could also provide avenues to explore to resolve our present shortage of positions – for example, India employs a system whereby interns are automatically allocated to hospitals that are attached to the university from which they graduated. This works similar to hospital rotations being allocated for medical students, except extended to internship as well.

conclusion Given the time and money that goes into medical training and the importance of maintaining a health workforce that is capable of meeting the needs of the community, it is senseless to not do everything possible to be able to ensure postgraduate training is available to all medical graduates to eventually be able to work as medical practitioners in fields of medicine that Australia most needs.

This cannot be addressed from year-to-year in last minute negotiations – what is needed is a consistent, long term approach to provide more training positions.

The shortage of internship positions has previously impacted primarily international students, but with an extended shortfall, this could affect domestic students as well. In addition, the more general shortage of postgraduate training positions means that this should be of concern for all medical students, and indeed, the entire community.

Certainty and stability in medical training is essential not just for medical students and doctors in training, but also for the medical workforce going into the future. Approaches to solving this problem include opening up more training positions in private hospitals and general practice, as well as in rural and regional areas, and these hold great potential, provided that funding can be secured to make this a reality.

This is where the action of medical students can make a big difference, to advocate and make sure that this issue receives the full attention of State and Federal Governments, to reach a long-term, sustainable solution to this training crisis.

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