Lack of integration of medical education in Australia: the need for change

The lack of cohesion across health and education sections and national and state jurisdictions is counterproductive to effective national policies in medical education and training. Existing systems in Australia for medical education and training lack coordination, and are under resourced and under pressure. There is a need for a coordinated national approach to assessment of international medical graduates, and for meeting their education and training needs. The links between prevocational and vocational training must be improved. Tensions between workforce planning, education and training can only be resolved if workforce and training agencies work collaboratively. All prevocational positions should be designed and structured to ensure that service, training, teaching and research are appropriately balanced. There is a need for more health education research in Australia.

An urgent challenge: new training opportunities for junior medical officers

There will be a massive increase in the number of medical school graduates over the next 5–10 years — there were 1287 Australian resident graduates in 2004, and there will be more than 3000 by the middle of the next decade.

A workshop held during the 11th National Prevocational Medical Education Forum explored ways to provide the additional prevocational training posts that will be required.

Four possible sites for additional training posts were discussed:
         • expansion of public hospital training posts;
         • general practice;
         • private hospitals; and
         • other sites, including private rooms and community placements.

Current accreditation procedures will need to be amended to accommodate more interns.

There will be limited access to prevocational training posts for non-resident (full-fee-paying) graduates and international medical graduates.

There is an urgent need for postgraduate medical councils, state health departments, the federal government, and medical boards to work together to identify, develop and accredit new training posts.

Vitamins D and A can be successfully measured by LC-MS/MS in cord blood diluted plasma

OBJECTIVES: In widely used protocols for the collection and isolation of cord blood mononuclear cells, investigators are left with substantial volumes of diluted plasma which could be used for other measurements. The aim of this study was to ascertain the validity of umbilical cord blood (UCB) diluted plasma samples for vitamin D, A and E analysis compared to UCB serum samples. DESIGN & METHODS: Twenty UCB matched samples of diluted plasma and serum were collected. The samples were analysed by two liquid chromatography-tandem mass spectrometry (LC-MS/MS) methods on two separate occasions. RESULTS: The results of 25(OH)D3 obtained by the two laboratories demonstrated close agreement with a mean difference of 0.14nmol/L [95% confidence interval (95% CI), -6.8 to 7.1]. Both methods demonstrate close agreement for 25(OH)D3 in UCB serum versus diluted UCB plasma; mean difference 2.2nmol/L [95% CI, -9.5 to 13.9] and 4.1nmol/L [95% CI, -14.5 to 6.1] for the results from Lab A and Lab B, respectively. Vitamin A was quantified by Lab A in UCB serum and diluted UCB plasma; mean difference 0.07μmol/L [95% CI, -0.41 to 0.28]. Results of 25(OH)D3 epimer and vitamin E in the diluted UCB plasma were below the limit of quantification, and could not be compared with UCB serum. CONCLUSIONS: Diluted UCB plasma can be used for the quantification of retinol and 25(OH)D3 by LC-MS/MS. By contrast, quantification of 25(OH)D3 epimer and vitamin E in diluted UCB plasma is not supported by this study due to limitations in analytical sensitivity.

Medical student exposure to general practice in Australian medical courses

BackgroundThere is a wide variation in how much general practice exposure, medical students get in Australian medical courses.AimsThis study is designed to identify the time spent in GP specific formal education and in clinical attachments to general practices in each Australian Medical School.MethodSurvey sent to the Head of Discipline for general practice at each Australian Medical School.ResultsGP specific formal education, GP attachment time and timings in the course will be presented.ConclusionAttracting high calibre applicants to GP vocational training requires more emphasis on GP medical student exposure.

Equity-focused health impact assessment framework

Background to the Development of the Equity-Focused HIA Framework
The equity focused health impact assessment (EFHIA) framework arises out of a two year research project funded for the most part by the Australian Government’s Public Health Education Research Program (PHERP) Innovations Grants (Round 2) scheme. This project had as its primary objective the development of a framework for health inequalities impact assessment, subsequently renamed equity focused health impact assessment. A partnership between the University of Newcastle, Deakin University and the University of New South Wales (the Project Management Steering Committee) received the funding and the Australasian Collaboration for Health Equity Impact Assessment (ACHEIA) was formed to undertake appropriate background research and to develop, pilot test, modify and disseminate the framework. The work commenced in September 2002 and concluded in October 2004. Part of the funding included a capacity building workshop in August 2004. ACT Health and the Division of Medicine at the John Hunter Hospital, Newcastle, also provided financial support for the project. The August 2004 Workshop was supported by NSW Health. All participants and organisations involved in the project gave extensive in-kind support.
The aims of the workshop were to bring together an international collaboration of multidisciplinary investigators, public health experts, and key senior health managers working in national, state and local settings, to inform the further development of the framework and to provide training in its application. The initial goals of the project were to work collaboratively to develop a strategic framework to assess the health inequalities of public health-related policies, plans, strategies, decisions, programs and services. The EFHIA framework as presented at the August workshop was developed through:
1. an extensive review of the relevant literature
2. formal and informal consultation with members of ACHEIA (the international
reference group), members of the Project Management Steering Committee and
other relevant experts; and
3. testing of the draft EFHIA framework with the 5 case study partners – who applied the draft framework in a range of health settings (see
Acknowledgements).
The result of this work has been the development of an equity focused health impact assessment framework that can be used to determine the unanticipated and systemic health inequities that may exist within the decision making processes or activities of a range of organisations and sectors. The EFHIA framework provides one approach that can be used to assist decision makers to put equity and health on their agenda in a more obvious and systematic way. The framework represents a ‘moment in time’ rather than a definitive statement or ‘toolkit’ on the best way to proceed. Further practice, refinement and adjustment will be needed over many years to consolidate both HIA and EFHIA. As well as this guide to the framework, additional outputs from the project team include:
- A literature review
- A position paper
- A report on the five case studies
- An evaluation report.
With the consent of the Australian Government, a monograph will be made available to workshop participants at the end of October which contains the framework and the appropriate background papers.

Implementing FATF standards in developing countries and financial inclusion : findings and guidelines

This report, emanating from a project commissioned by the FIRST Initiative, considers the impact of the implementation of Anti-Money Laundering (AML) and Combating the Financing of Terrorism (CFT) controls on financial inclusion in five countries (Indonesia, Kenya, Mexico, Pakistan and South Africa). Based on these findings, it develops a set of guidelines to assist the authorities in developing countries to design effective AML/CFT regimes that are compliant with Financial Action Task Force (FATF) standards and supports financial inclusion.
The report and guidelines will be of benefit to countries striving towards the dual goals of protecting their institutions against money laundering and the financing of terrorism as well as extending financial inclusion, irrespective of whether protective measures are being considered in the process of implementing or amending AML/CFT controls to meet the Forty Nine Recommendations of the FATF or in order to meet other, related international requirements, such as those set out in the 2000 United Nations Convention on Transnational Organised Crime or the 2003 United Nations Convention Against Corruption.
The project was supervised and guided by a steering committee consisting of representatives from the FIRST Management Unit, World Bank, International Monetary Fund (IMF), the UK’s Department for International Development (DFID), the Consultative Group to Assist the Poor (CGAP), the South African National Treasury, the FinMark Trust and Professor Nikos Passas, an acknowledged world expert on AML/CFT standards and implementation.

Cystic fibrosis in children of the eastern Arabian peninsula : a clinical, spatial and genetic study

Aim: The aim of this thesis is to describe the process by which the inherited disease, cystic fibrosis, (CF) was recognised as an important clinical entity in the United Arab Emirates (UAE) and the Sultanate of Oman (Oman). It examines the clinical presentation of the first patients and assesses their degree of severity. Further, it describes the first studies carried out to determine the underlying CF mutations associated with the disease in the UAE and Oman. An estimate is offered of the birth frequency of the condition. Overall, the cultural, geographical and historical aspect of the societies in which the disease occurs is stressed. Methods: An initial literature search was carried out using Medline of any literature pertaining to the Arab World and CF. this was read and classified into the relevance to Arabs in general, the Middle East and then specifically the Arab (Persian) Gulf societies. Thereafter, a clinic was established at Tawam Hospital, Al Ain, UAE, for children presenting With chronic respiratory disease that could serve as a national referral centre. It was run by the Author as a service of the Paediatric Department of the UAE University Medical School. I sent a letter to every Paediatrician working in the UAE informing them of our clinic and offering our services for the diagnosis and management of chronic respiratory disease in children. This was based on the author's experience as a respiratory paediatrician in Australia and New Zealand and as the Professor of Paediatrics in the UAE. No such service then existed in the UAE. Funding was sought to establish a research programme and develop a molecular genetics laboratory in the UAE Medical School. A series of successful research applications provided the grants to commence the investigations. Once a small number of children had been identified as having CF from those referred to the respiratory clinic, the initial project was to assess and report their clinical presentation. Following this an early start was made on the identification of the mutations responsible. Once these were established an attempt was made to estimate the frequency of the condition at birth. Additional clinical studies revolved around assessing the severity of the condition that was associated with the main mutations that were identified. A clinical comparison was made with those with the mutation AF508 and the other main mutation, despite the obvious limitation of small numbers then available. Radiological assessment was made to evaluate the progression of the disease. The final aspect of the study was to assess patients from Oman and compare their findings and mutations with the neighbouring UAE. Based on information gained hypotheses are proposed regarding the spread of the gene mutation by population drift. Thesis outline: A literature review is presented in the form of a critique on the disease and a resume of the relevant aspects of the genetics of CF. Additionally, facts about the two countries' geography and history are presented. Finally, knowledge about CF mutations and population origins from other areas is presented. The second main section deals with the clinical features of the disorder as it presents in the UAE. Molecular findings are then presented and details of the common mutation found in Bedouin Arabs. Hypotheses are then presented based on the information gathered. Results: CF is not a rare disease in the Arab children of the UAE and Oman. These findings refute previous reports of CF being a rare or non-existent disease in Arabs. The condition presents with a severe clinical picture, with early colonisation of the respiratory tract with staphylococcus, haemophilus and pseudomonas organisms, even with conventional CF management practices in place. The CF mutation S549R is prevalent in Arabs of Bedouin stock, while AF508 is found in those of Baluch origin. The former may be descendants of Arabs who left southern Arabia and travelled to the Trucial Coast at the time of the destruction of the great dam at Marib. The origins of this mutation may lie in the area that corresponds to the modern Republic of Yemen. The latter groups are descendants of those who came originally from Baluchistan. It is hypothesised also that the ancestral home of the AF508 mutation may be in the geographical area now known as Baluchistan, that spans three separate modern political territories. The evidence presented supports the concept that the S549R mutation may be associated with a severe, if not the severest, clinical pattern recognised. It equates with that seen with the homozygous AF508 genotype. The absence of an additional mutation in the promoter region accounts for the different clinical pattern seen in previously described patients. Conclusions: There needs to be a major awareness of the presence of CF as a severe clinical disease in the children of the Gulf States. The clinical presentation and findings support the concept of under recognition of the disease. Climatic conditions put the children at special risk of hyponatraemia and electrolyte imbalance. The absence of surviving adults with the disease suggests premature deaths have occurred, but the high fertility rates have maintained the gene pool for this recessive disorder.

Implementing a suitable jobs register in the construction industry : preliminary evidence

This pilot study investigated the efficacy of a job register index to support return to work (RTW) for injured workers in the construction industry. Participants included injured workers (n = 22), supervisors/managers (n = 23), treating practitioners (n = 5), occupational rehabilitation consultants (n = 5), union representatives/occupational health and safety representatives (n = 5), RTW coordinators (n = 2), steering committee members (n = 4) and the designated project officer (n = 1). A pre–post test intact group design was used to evaluate the perceived utility of the job register. A partial set of the sample including injured workers and supervisors/managers participated in the pretrial phase (n = 28) while the trial phase included more numerous stakeholder groups to assess the perceived utility of the register (n = 39). Participants completed surveys that incorporated a number of differing sections including injury description and circumstances, communication and collaboration with others, their overall opinion of the return to work process in general and suggestions for future improvements. Additional questions were designed for those participating in the trial with regards to the efficacy of the register. Data were analysed using analysis of variance procedures with pairwise comparisons of pre–post intervention test means. Alternative job options were seen to be offered more frequently. Communication and cooperation improved post implementation. Supervisors perceived the job register a useful innovation to facilitate RTW. The register represents a new resource to the construction industry with potential for wider application following further study.