Towards compassion: statutory powers to regulate impaired doctors in Victoria, 1844-2016.

This article examines the significant changes that parliamentarians have made to the powers of regulators of the Victorian medical profession (regulators) from 1844 to the present day to manage doctors whose ill health has impaired their capacity to practise medicine (impaired doctors). It explores the influences on legislators that altered their conceptions of the best ways of achieving the chief objective that they all shared: to protect the public. The article argues that there was a dramatic progression over this period from parliamentarians confining regulators to responding in a draconian, narrow way to impaired doctors, to empowering them increasingly to adopt a flexible, personalised and empathic regulatory approach. This management style has the potential to support impaired doctors to practise medicine safely, which is beneficial for the practitioners and their patients. Nevertheless, despite legislators’ intentions, in certain circumstances impaired doctors today may still experience regulation that appears punitive and unsupportive. The article therefore recommends that future legislators change regulators’ powers further to encourage them to manage these doctors in particular with greater compassion and thereby improve their chances of practising medicine safely in the future.

Criteria for the systematic review of health promotion and public health interventions

Systematic reviews of public health interventions are fraught with challenges. Complexity is inherent; this may be due to multi-component interventions, diverse study populations, multiple outcomes measured, mixed study designs utilized and the effect of context on intervention design, implementation and effectiveness. For policy makers and practitioners to use systematic reviews to implement effective public health programmes, systematic reviews must include this information, which seeks to answer the questions posed by decision makers, including recipients of programmes. This necessitates expanding the traditional evaluation of evidence to incorporate the assessment of theory, integrity of interventions, context and sustainability of the interventions and outcomes. Unfortunately however, the critical information required for judging both the quality of a public health intervention and whether or not an intervention is worthwhile or replicable is missing from most public health intervention studies. When the raw material is not available in primary studies the systematic review process becomes even more challenging. Systematic reviews, which highlight these critical gaps, may act to encourage better reporting in primary studies. This paper provides recommendations to reviewers on the issues to address within a public health systematic review and, indirectly, provides advice to researchers on the reporting requirements of primary studies for the production of high quality systematic reviews.

Defining dual diagnosis : a qualitative study of the views of health care workers

Background: 'Dual diagnosis' is the term of choice in many countries to describe clients with co-occurring mental health and alcohol and other drug (AOD) issues. However, it is not known if its meaning is consistently represented within and across health care services. This uncertainty has significant implications for referral, consultation and research.
Aim: To obtain information about the way that different health care professionals understand the term 'dual diagnosis'.
Method: Twenty-nine health care workers across five service types (medical, mental health, AOD, dual diagnosis and community health) in Victoria, Australia were interviewed about their understanding of the term 'dual diagnosis'.
Results: The findings indicated that service providers working in AOD and Mental Health had a shared general understanding of what was meant by 'dual diagnosis', despite uncertainties about more specific inclusion criteria. In contrast, medical and community health staff lacked a similar shared understanding, and were more likely to recommend change, but offered no consensus on alternatives.
Conclusion: The results indicate that while the term 'dual diagnosis' has value in efficiently directing attention to the complexity of treatment issues, health practitioners cannot assume it will convey the intended meaning outside mental health or AOD services. Clear articulation of the intended definition may be a necessary requirement in wider health care communication.

Education as a determinant of health and well-being

This chapter is concerned with education as a factor in shaping life opportunities.  Education affects, and is affected by, individual and collective health and well-being.  It is now well established that the health and well-being of students impacts on their educational experience and outcomes, and that those experiences and outcomes impact on students' occupational futures, their future health and well-being and their level of participation as citizens.  Policy makers and practitioners are incresingly attentive to the relationship between education and health because of evidence highlighting the cyclical relationship between the economic and social conttext of schools, poor health and the well-being of students, and educational under-acheivement.

Regulation of insulin signalling by exercise in skeletal muscle

Regular physical activity improves insulin action and is an effective therapy for the treatment and prevention of type 2 diabetes. However, little is known of the mechanisms by which exercise improves insulin action in muscle. These studies investigate the actions of a single bout of exercise and short-term endurance training on insulin signalling. Twenty-four hours following the completion of a single bout of endurance exercise insulin action improved, although greater enhancement of insulin action was demonstrated following the completion of endurance training, implying that cumulative bouts of exercise substantially increase insulin action above that seen from the residual effects of an acute bout of prior exercise. No alteration in the abundance and phosphorylation of proximal members of the insulin-signalling cascade in skeletal muscle, including the insulin receptor and IRS-1 were found. A major finding however, was the significant increase in the serine phosphorylation of a known downstream signalling protein, Akt (1.5 fold, p ≤0.05) following an acute bout of exercise and exercise training. This was matched by the observed increase in protein abundance of SHPTP2 (1.6 fold, p ≤0.05) a protein tyrosine phosphatase, in the cytosolic fraction of skeletal muscle following endurance exercise. These data suggest a small positive role for SHPTP2 on insulin stimulated glucose transport consistent with transgenic mice models. Further studies were aimed at examining the gene expression following a single bout of either resistance or endurance exercise. There were significant transient increases in IRS-2 mRNA concentration in the few hours following a single bout of both endurance and resistance exercise. IRS-2 protein abundance was also observed to significantly increase 24-hours following a single bout of endurance exercise indicating transcriptional regulation of IRS-2 following muscular contraction. One final component of this PhD project was to examine a second novel insulin-signalling pathway via c-Cbl tyrosine phosphorylation that has recently been shown to be essential for insulin stimulated glucose uptake in adipocytes. No evidence was found for the tyrosine phosphorylation of c-Cbl in the skeletal muscle of Zucker rats despite demonstrating significant phosphorylation of the insulin receptor and Akt by insulin treatment and successfully immunoprecipitating c-Cbl protein. Surprisingly, there was a small but significant increase in c-Cbl protein expression following insulin-stimulation, however c-Cbl tyrosine phosphorylation does not appear to be associated with insulin or exercise-mediated glucose transport in skeletal muscle.

Information-based regulation of high-velocity foot-targeting tasks

Judging time-to-contact with a target is an important criterion for avoiding harm in everyday walking and running tasks, and maximizing performance in high-velocity sporting tasks. The information-based regulation of step length and duration during target-directed locomotion was examined in relation to gait mode, approach velocity, target task, expertise, and sporting performance during a series of four experiments. The first three experiments examined novice performers (Each n=12, 6 males, 6 females), whilst the last experiment examined expert gymnasts (n=5). Two reference strips with alternating 50cm black and white intervals were placed on either side of the approach strip for all of the experiments. One 50Hz-panning video camera filmed the approach from an elevated position. In Experiment 4, two stationary 250Hz cameras filmed the post-flight performance of the gymnastic vaults and, in addition, two qualified judges provided a performance score for each vaulting trial. The panning video footage in each experiment was digitized to deduce the gait characteristics. In Experiment 4, the high-speed video footage was analyzed three-dimensionally to obtain the performance measures such as post-flight height. The utilization of visual stimulus in target-directed locomotion is affected by the observer's state of motion as characterized by the mode of locomotion and also often the speed of locomotion. In addition, experience plays an important role in the capacity of the observer to utilize visual stimulus to control the muscular action of locomotion when either maintaining or adjusting the step mechanics. The characteristics of the terrain and the target also affect the observer's movement. Visual regulation of step length decreases at higher approach speeds in novice performers, where as expert performers are capable of increasing visual regulation at higher approach speeds. Conservatism in final foot placement by female participants accounts for the observed increase in distance from the critical boundary of the obstacle relative to toe placement. Behavioural effects of gender thus affect the control of final foot placement in obstacle-directed locomotion. The visual control of braking in target-directed locomotion is described by a tau-dot of-0.54. When tau-dot is below -0.54 a hard collision with the obstacle will occur, however, when tau-dot is above -0.54, a soft collision with the target will occur. It is suggested that the tau-dot margin defining the control of braking reveals the braking capacity of the system. In the target-directed locomotion examined a tau-dot greater than -0.70 would possibly exceed the braking capacity of the system, thus, leading to injury if performed. The approach towards the take-off board and vaulting horse in gymnastics is an example of target-directed locomotion in sport. Increased visual regulation of the timing and length of each step is a requirement for a fast running approach, a fundamental building block for the execution of complex vaults in gymnastics. The successful performance of complex vaults in gymnastics leads towards a higher judge's score. Future research suggestions include an investigation of visual regulation of step length in curved target-directed locomotion.

Adrenergic regulation of carbohydrate metabolism during exercise

1. This series of studies was undertaken to examine the adrenergic regulation of carbohydrate metabolism during exercise. Recreationally active males were tested during moderate to intense exercise on a stationary cycle ergometer. Venous and arterial plasma obtained from indwelling catheters was analysed for hormonal and metabolite responses, and hepatic glucose production and glucose uptake were measured using the tracer-dilution method with stable isotopes. Muscle samples were obtained by the needle biopsy technique to examine muscle glycogen utilisation and the flux of related muscle metabolites using enzymatic, fluorometric and radioisotopic techniques. 2. During moderate exercise adrenaline infusion induced a marked hyperglycemia and this was due to reduced glucose uptake rather than enhanced hepatic glucose production. The reduction in glucose uptake was most likely mediated by a decrease in glucose phosphorylation, as indicated by the accumulation of glucose 6-phosphate with adrenaline infusion. 3. The hyperglycemic response to intense exercise was prevented by the administration of α- and β-adrenergic antagonists. Adrenergic blockade was without effect on hepatic glucose production whereas glucose uptake was enhanced when compared with control subjects. These data support the notion that adrenergic mechanisms are more important in restraining glucose uptake than enhancing hepatic glucose production during intense exercise. Other glucoregulatory factors are responsible for the increase in glucose production during intense exercise. 4. Elevated plasma adrenaline levels during moderate exercise in untrained men increases skeletal muscle glycogen breakdown and PDH activation which results

Regulation of fat oxidative genes in human skeletal muscle

The ability of skeletal muscle to adapt fat oxidation rates is important for human health. Lipid metabolism requires the involvement of many proteins encoded by their corresponding genes. This thesis demonstrates that manipulating plasma free fatty acid levels alters the expression of selected genes involved in regulating fatty acid metabolism.

Regulation of GLUT4 expression in human skeletal muscle

Increasing the number of glucose transporters in muscle ameliorates many of the symptoms associated with type 2 diabetes. This thesis identifies mechanisms regulating glucose transporter gene expression, and therefore glucose transporter number, in human skeletal muscle and provides potential targets for the treatment and management of type 2 diabetes.

Central regulation of energy balance in Psammomys obesus

This body of work focussed on the central regulation of energy balance in a polygenic animal model of obesity and type II diabetes, the Israeli Sand Rat. These studies investigated the role of a number of hypothalamic neuropeptides in the development of obesity, and highlighted the complex nature of this disease.

Is dietary management a responsibility of general practitioners? The views of Victorian general practitioners

Rationale : Australia is experiencing an evolving healthcare system, resulting in an aim of systematic managed care for patients with chronic disease. One outcome has been debate on doctors' dietary management responsibilities.
Aim : To identify general practitioners' perceptions of their dietary management responsibilities for adult cardiac patients.
Methods : A Two phase study was conducted. First, semi-structured interviews with 30 Melbourne general practitioners were conducted to gather preliminary information about dietary management. The results informed a questionnaire for the second phase. This was completed by 248 general practitioners (30%) in Victoria.
Principal findings : Themes arising in interviews, and also supported by cross-sectional survey showed that doctors perceive themselves as filling one or more of three roles. The majority (87.4%) endorsed an 'Influencing' role, 27.4% endorsed 'Dietary Educator' and 44.0% a 'Coordinator' role. The Influencer role was characterised by encouragement of dietary behaviour change, such as discussing benefits and consequences of inaction to dietary change. The Educator role was characterised by the provision of a range of behaviour change strategies- 'how to' achieve change. 'Coordinators' reported the provision of dietary counselling belonged to dietitians alone.
Implications : The results indicate doctors' awareness of need for patients' dietary education should be increased. This could be accomplished by one-on-one education. Patients' access to dietary education should also be facilitated by doctors' referring on. Embedding dietary management protocols in doctors' managed care templates could improve patients' access to dietary education and enhance doctor's collaborative roles.
Presentation type : Paper
Session theme : Getting Evidence into Practice 2