Rob Mitchell

Antibody that blocks stimulation of cortisol secretion by adrenocorticotrophic hormone in Addison's disease

To investigate whether Addisons disease may in some cases be due to the blocking of adrenocorticotrophic hormones action at the adrenal cortex by antibodies IgG isolated from a woman with Addisons disease associated with the autoimmune polyglandular syndrome type I was studied. Its effects on guinea pig adrenal cells in vitro were investigated and compared with those of IgG from three normal subjects and IgG obtained commercially. IgG from the patient inhibited the stimulation of cortisol secretion by adrenocorticotrophic hormone by 77 (SD 2)% and 57 (12)% at concentrations of 0·5 and 0·05 g/l, respectively; IgG prepared five months after she had started treatment with replacement steroids inhibited cortisol secretion by 74 (1)% (0·5 g/l) and 51 (15)% (0·05 g/l). The other IgGs had no inhibitory effects. The IgG from the patient and that obtained commercially did not inhibit the stimulation of cortisol secretion by dibutyryl cyclic adenosine monophosphate or precursors of cortisol. None of the IgGs bound to adrenocorticotrophic hormone. These results suggest that the IgG from the patient acted against the receptor for adrenocorticotrophic hormone, and its presence may explain the patients raised concentrations of adrenocorticotrophic hormone, failure to respond to exogenous adrenocorticotrophic hormone, and normal basal cortisol concentrations. Addisons disease may thus in some instances be a receptor antibody disease.

Perspectives on the working hours of Australian junior doctors

The working hours of junior doctors have been a focus of discussion in Australia since the mid-1990s. Several national organizations, including the Australian Medical Association (AMA), have been prominent in advancing this agenda and have collected data (most of which is self-reported) on the working hours of junior doctors over the last 15 years. Overall, the available data indicate that working hours have fallen in a step-wise fashion, and AMA data suggest that the proportion of doctors at high risk of fatigue may be declining. It is likely that these changes reflect significant growth in the number of medical graduates, more detailed specifications regarding working hours in industrial agreements, and a greater focus on achieving a healthy work–life balance. It is notable that reductions in junior doctors’ working hours have occurred despite the absence of a national regulatory framework for working hours. Informed by a growing international literature on working hours and their relation to patient and practitioner safety, accreditation bodies such as the Australian Commission on Safety and Quality in Health Care (ACSQHC) and the Australian Medical Council (AMC) are adjusting their standards to encourage improved work and training practices.

A vertical study programme for medical students: peer-assisted learning in practice.

Background: Monash University employs a vertically-integrated curriculum with cumulative knowledge testing throughout the course. To facilitate cross-year level revision, a vertical study programme (VESPA) was established using the principles of peer-assisted learning (PAL). Aim: To implement and evaluate VESPA in relation to defined objectives. Methods: Following from a successful pilot, a working group organised five 2 h VESPA sessions over the course of 2009. Each was case-based and study materials were provided. Participants were allocated to a group of 10–15 students of all year levels, and pre-interns acted as facilitators. Sessions were evaluated using a 10-question survey. Results: A total of 647 evaluation surveys were completed overall and participant numbers ranged from 79 to 182 per session. Of these, 624 (96%) agreed the case materials were easy to follow and 562 (87%) believed they allowed students from all year levels to contribute; 552 (85%) felt VESPA helped them understand curriculum content. There were no significant differences between sessions. Conclusions: VESPA represents an innovative application of PAL that has been well received by students. Potential benefits to participants include academic revision, the development of mentoring relationships and enhanced teaching and facilitation skills. This model of a structured revision programme would suit other settings with vertically-integrated curricula and assessment.

Portfolio careers for medical graduates: implications for postgraduate training and workforce planning

Portfolio careers in medicine can be defined as significant involvement in one or more portfolios of activity beyond a practitioners primary clinical role, either concurrently or in sequence. Portfolio occupations may include medical education, research, administration, legal medicine, the arts, engineering, business and consulting, leadership, politics and entrepreneurship. Despite significant interest among junior doctors, portfolios are poorly integrated with prevocational and speciality training programs in Australia. The present paper seeks to explore this issue. More formal systems for portfolio careers in Australia have the potential to increase job satisfaction, flexibility and retention, as well as diversify trainee skill sets. Although there are numerous benefits from involvement in portfolio careers, there are also risks to the trainee, employing health service and workforce modelling. Formalising pathways to portfolio careers relies on assessing stakeholder interest, enhancing flexibility in training programs, developing support programs, mentorship and coaching schemes and improving support structures in health services.

Balancing quantity and quality in emergency medicine training for interns

The introduction of a national registration standard for internship at a time of marked growth in graduate numbers provides an opportunity to review the value and cost of emergency medicine (EM) terms for interns. Given that new graduates are no longer mandated to complete an ED-based rotation, would quality be enhanced by providing a smaller number with a more comprehensive experience? EM terms during internship are greatly valued by junior doctors. They provide an important experience in generalist medicine as they expose interns to a broad range of undifferentiated acute illness not often encountered in other rotations. In addition, EDs can facilitate the acquisition of core competencies listed in the clinical management, communication and professionalism domains of the Australian Curriculum Framework for Junior Doctors. A recent study has demonstrated that EM terms also have a crucial role in assessing junior doctor performance and detecting interns who are not ready for more independent practice. The requirement for interns to take primary responsibility for undifferentiated patients, along with proximity and depth of supervision, contribute to the EM rotation being an important ‘acid test’. Assessments undertaken in the EM term might also be more valid because multiple supervisors are involved. Despite these educational benefits, workforce and clinical service reforms are making it more difficult for EDs to deliver quality training for interns. Medical graduate numbers have increased by approximately 10% per annum since 2007, resulting in significant capacity issues at the prevocational level. Providing a sufficient number of ED placements has proved challenging, and the EM term now represents a major ‘bottleneck’ in intern training. The increasing requirement for intern placements comes at a time of growing demand for emergency medical services, and intensifying pressure on EDs to achieve time-based targets. Concerns that the National Emergency Access Target will impact on training quality have previously been published in this journal. Despite these challenges, the availability of senior ED staff to provide effective supervision represents the most significant constraint in expanding capacity. Coinciding with the increase in graduate numbers, the Medical Board of Australia has released a national standard for achieving general registration, which will apply for all Australian and New Zealand medical graduates commencing their internship in 2014. The new arrangements have been introduced to achieve national consistency in intern training and will be supported by an accreditation framework that is currently being developed by the Australian Medical Council. In addition to 10-week terms in medicine and surgery, interns will need to obtain at least 8 weeks experience in ‘emergency medical care’ (EMC). This rotation does not need to be in a medium or large ED, as has previously been required by most states and territories. As a consequence, the EMC term will increase flexibility for health services by allowing some general practices and smaller hospitals to substitute for EDs. Primary care settings can provide junior doctors with valuable training; however, the equivalence of this experience – in clinical, supervisory, assessment and other aspects – to an ED term is questionable. Unfortunately the lack of metrics for internship outcomes makes evidence-based decision making impossible in this regard, leaving policy makers with a combination of expert opinion and pragmatism on which to base decisions.

Four-hour access targets for emergency departments: Potential negative implications for the work practices and clinical training of junior doctors

Dear Editor, The Council of Australian Governments has recently agreed to adopt a four-hour access target for Australian EDs. The target’s potential to lessen the impact of ED overcrowding and hospital access block has made it a key component of national health reform, and it has been the focus of much discussion in Australasian medical journals. In advance of its implementation, potential adverse implications for medical education and training have been identified. In Western Australia (WA), a four-hour target has been operating since April 2009. Compliance objectives have been met to varying extents across hospital sites, with emerging evidence of a positive impact on access block. However, junior doctors have also reported negative impacts on clinical training, patient safety and professional morale. In response to this anecdotal evidence, and in the absence of any published data, the Australian Medical Association of WA (AMA [WA]) undertook a scoping survey to assess the extent of junior doctor concerns, and to identify relevant issues in advance of more substantive research. The scoping survey was a confidential, online questionnaire with 13 items. On 15 July 2011, a direct link was emailed to an established AMA (WA) database of 1482 junior doctors (i.e. 857 AMA [WA] members and 625 non-members) representing the vast majority of permanent domestic-graduate trainees working in the WA public hospital system. Within 72 h, there were 162 respondents; of these, 48.77% were registrars, 42.59% were interns/resident medical officers and 8.64% were senior registrars. Based on a total reported WA junior doctor population of 1618 persons, the sample provided sufficient power for the results to be statistically significant (with population values within 5% of survey estimates) at a confidence level of 95%. The scoping survey identified significant concerns relating to the four-hour target. Eighty-one per cent felt this rule compromised their capacity to deliver proper patient care, and 48.4% thought it negatively impacted on training opportunities. Only 2.6% agreed that current mechanisms for providing feedback on the fourhour target were working, and 88.6% said they were subject to pressure from other staff to move patients out of the ED. Respondents also provided extensive freetext comments about other issues, including bullying, inadequate supervision and fatigue. A recurring complaint was the lack of support for junior doctors working ward-based cover shifts. Several suggested that, as a consequence of the time-based access target, they were required to assume greater responsibility for the care of patients recently arrived from the ED. Notwithstanding the limitations of its methodology, the results of this scoping survey suggest that the four-hour target could have significant implications for the work practices and clinical training of junior doctors. These results provide a strong case for more substantive research in this area, with a particular focus on prevocational doctors and emergency medicine trainees. Although the target’s potential to mitigate the effects of access block is acknowledged, the unintended consequences identified in WA will need to be addressed before the roll-out of the national programme.

Impact of a structured intern education programme on clinical documentation in the emergency department

To evaluate the impact of More Learning for Interns in Emergency (MoLIE) on clinical documentation in the ED of a large regional hospital.

Fit for the future? The relevance of Emergency Medicine Australasia to current and prospective emergency medicine trainees.

Emergency Medicine Australasia (EMA) is to be congratulated on its 25th anniversary. For a quarter of a century, the Journal has fulfilled an important role in publishing original research and facilitating discussion in academic emergency medicine (EM). At this milestone, it is timely to review the value of EMA to current and future Australasian College for Emergency Medicine (ACEM) trainees. This article reflects on trends in EM training, medical publishing and Web 2.0, and makes suggestions for further modernisation of the Journal.

Unaccredited registrar positions in Australian public hospitals: is it time for a rethink?

Unaccredited registrar positions are a significant source of inefficiency in postgraduate medical training. Their educational value is debated due to a lack formal supervision, appraisal or assessment requirements. In the context of increasing numbers of trainees and escalating demand for public hospital services, the extent to which unaccredited registrar positions can be converted to accredited training posts warrants urgent examination. The major obstacle is meeting college standards, particularly with respect to caseload and supervision requirements. Notwithstanding the barriers to reform, this article describes how a coordinated process to accredit these posts would increase training capacity and enhance vertical integration in postgraduate medical education.

Health professionals as politicians

[Extract] In the Australian Parliament, business executives, managers, self-employed business people, company directors, political consultants, advisors and lobbyists are over-represented. We reviewed the profiles of all 226 individuals who are members of the House of Representatives and Senate. Approximately 25% of our current politicians hold law degrees, but less than 2% hold medical degrees. The four doctors in the current Parliament are Dr David Gillespie (Nationals), Dr Andrew Laming (Liberal Party), Dr Andrew Southcott (Liberal Party) and Dr Richard Di Natale (Australian Greens). There are only three members of Parliament who have degrees in social work or psychology and none with a nursing background. This division of occupations is similar in the US Congress and UK House of Commons, as well as in a large number of other democracies.