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.

Can we skill and activate children through primary school physical education lessons? "Move it Groove it" - a collaborative health promotion intervention

Background: Physical education (PE) lessons are an ideal setting to improve child fundamental movement skills (FMSs) and increase physical activity (PA) for optimal health. Despite this, few studies have assessed the potential to do both simultaneously. The “Move It Groove It” primary school intervention in New South Wales, Australia, had this opportunity.

Methods: A whole school approach to implementation included establishment of school project teams, a teacher “buddy” system, project Web site, teacher training workshops, and small grants for equipment. The quasi-experimental evaluation involved 1,045 year 3 and 4 children (aged 7 to 10 years) in nine intervention and nine control rural primary schools (53% boys/47% girls). It utilised pre- and postobservational surveys of (1) mastery or near mastery levels for each of eight FMSs, (2) proportion of PE lesson time spent in moderate to vigorous PA (MVPA) and vigorous PA (VPA), and (3) teacher- and lesson-related contextual covariates. Data were analysed by hierarchical logistic multiple regression.

Results: For FMSs, overall mastery or near mastery level at baseline was 47% ranging from 22.7% for the overarm throw among girls to 75.4% for the static balance among boys. The intervention delivered substantial improvements in every FMS for both genders ranging from 7.2% to 25.7% (13 of 16 comparisons were significant). For PA level, mean MVPA at baseline was 34.7%. Baseline MVPA for boys was 38.7% and for girls was 33.2%. The intervention was associated with a nonsignificant 4.5% increase in MVPA and a significant 3.0% increase in VPA. This translates to a gain of <1 minute of MVPA per average 21-minute lesson.

Conclusions: This is the first study to show that by modifying existing PE lessons, significant improvements in FMS mastery can be gained without adversely affecting children’s MVPA and VPA. To increase PA levels, we recommend increasing the number of PE lessons per week.

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.

The process evaluation of it's your move!, an Australian adolescent community-based obesity prevention project

Background
Evidence on interventions for preventing unhealthy weight gain in adolescents is urgently needed. The aim of this paper is to describe the process evaluation for a three-year (2005-2008) project conducted in five secondary schools in the East Geelong/Bellarine region of Victoria, Australia. The project, 'It's Your Move!' aimed to reduce unhealthy weight gain by promoting healthy eating patterns, regular physical activity, healthy body weight, and body size perception amongst youth; and improve the capacity of families, schools, and community organisations to sustain the promotion of healthy eating and physical activity in the region.

Methods
The project was supported by Deakin University (training and evaluation), a Reference Committee (strategic direction, budgetary approval and monitoring) and a Project Management Committee (project delivery). A workshop of students, teachers and other stakeholders formulated a 10-point action plan, which was then translated into strategies and initiatives specific to each school by the School Project Officers (staff members released from teaching duties one day per week) and trained Student Ambassadors. Baseline surveys informed intervention development. Process data were collected on all intervention activities and these were collated and enumerated, where possible, into a set of mutually exclusive tables to demonstrate the types of strategies and the dose, frequency and reach of intervention activities.

Results
The action plan included three guiding objectives, four on nutrition, two on physical activity and one on body image. The process evaluation data showed that a mix of intervention strategies were implemented, including social marketing, one-off events, lunch time and curriculum programs, improvements in infrastructure, and healthy school food policies. The majority of the interventions were implemented in schools and focused on capacity building and healthy eating strategies as physical activity practices were seen by the teachers as already meeting students' needs.

Conclusions
While substantial health-promoting activities were conducted (especially related to healthy eating), there remain further opportunities for secondary schools to use a whole-of-school approach through the school curriculum, environment, policies and ethos to improve healthy eating, physical activity and healthy body perceptions in youth. To achieve this, significant, sustained leadership will be required within the education sector generally and within schools specifically.

Fostering intercultural understanding through secondary school experiences of cultural immersion

In parallel with many nations’ education policies, national education policies in Australia seek to foster students’ intercultural understanding. Due to Australia’s location in the Asia-Pacific region, the Australian government has focused on students becoming “Asia literate” to support Australia’s economic and cultural engagement with Asian countries. Drawing on Allport’s optimal contact principles and key factors supporting intercultural understanding, this study examines two “sister school” cultural immersion trips in Indonesia and East Timor to explore ways in which their different approaches supported positive intergroup contact and helped foster intercultural understanding among students. Focus groups and interviews with school project teams and analysis of both researcher and teacher project field notes and documents suggested that these schools’ programmes could be mapped onto Allport’s contact principles in different ways. The paper concludes with promising approaches that can help to inform sister school programmes.

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.

Reason for hope : primary students' mathematics learning environment

This paper reports the results of a student survey of perceptions of classroom learning environment conducted as part of a major investigation into effective pedagogical practices in mathematics and science. All primary school project participants were surveyed, The 36 Likert-type items were subjected to a Partial Credit Model analysis, and response categories subjected to statistical requirements. The results are presented graphically, their meanings examined, and the implications of the findings for both researchers and practitioners are discussed.

Cost-effectiveness of whole-of-community obesity prevention programs: an overview of the evidence

Whole-of-community obesity prevention programs that impact on multiple players and promote community capacity show promise as an important strategy in the fight against global obesity. This paper reviews the economic evaluation literature of multifaceted, community based obesity prevention programs. There are few cost effectiveness studies. Whilst results to date are encouraging, there is considerable uncertainty surrounding the long term results given the lack of evidence regarding sustainability of program effect and a consequent reliance on economic modeling to fill the gaps. More empirical studies of longer duration are needed to demonstrate the longer term effectiveness and cost effectiveness of these programs, and to facilitate identification of the elements necessary for their sustainability.

Clinical reasoning sessions: back to the patient

BACKGROUND: Problem-based learning (PBL) was developed as a facilitated small group learning process based around a clinical problem. Originally designed for pre-clinical years of medical education, its application across all years poses a number of difficulties, including the risk of reducing patient contact, providing a learning process that is skewed towards an understanding of pathophysiological processes, which may not be well understood in all areas of medicine, and failing to provide exposure to clinically relevant reasoning skills. CONTEXT: Curriculum review identified dissatisfaction with PBLs in the clinical years of the Sydney Medical School's Graduate Medical Program, from both staff and students. A new model was designed and implemented in the Psychiatry and Addiction Medicine rotation, and is currently being evaluated. INNOVATION: We describe an innovative model of small-group, student-generated, case-based learning in psychiatry - clinical reasoning sessions (CRS) - led by expert facilitators. IMPLICATIONS: The CRS format returns the student to the patient, emphasises clinical assessment skills and considers treatment in the real-world context of the patient. Students practise a more sophisticated reasoning process with real patients modelled upon that of their expert tutor. This has increased student engagement compared with the previous PBL programme.