Panacea Vol 50 Issue 1 (August 2016) by The Australian Medical Students' Association

CONTENTS

What I Wish I Knew As A Medical Student contents

Breaking Bad News Badly

Bone Marrow Donation: A ref lection

Halsted: A surgeon, pioneer and addict

On Letting Go: a photo series

The Simple Things:

On burnout & rediscovering the joy in medicine

No Jab, No Pay No Fair

Cultural Diversity in Psychiatry

Why the Search Engine Uprising Must Be Crushed

25 4 Image credit: Jessica Yang

16 22

Pokemon Go Pandemic Stuns Rural GPs

Coming Through the Front Door: Asylum Seekers & Australia

CREDIT A special thanks our contributors: Joshua Druery, USYD Nathan Lenehan, WSU Ashleigh Ray, WSU Dr Danielle McMullen Benjamin Paul, Deakin Brittany Sheed, UNDF Thomas de Vries, Monash Dominic Walpole, Deakin Andrew Wang, Monash Samantha White, UWA

no•stal•gia

It’s been a crazy year leading up to this edition - NLDS, Convention, GHC and two Councils are now under the belt for the 2016 Executive. After my last major project - the Internship & Residency Guide, it’s a welcome contrast to work on such a different publication - especially one that showcases the amazing talents of my fellow medical students. I’ve had an amazing time so far working with the rest of my team and I hope I can give back a little with Panacea. This year marks our 50th volume of Panacea - that’s 50 years of med students writing articles and submitting creative pieces for their peers to enjoy. On Panacea’s 50th birthday, It only seems appropriate that this edition’s theme be NOSTALGIA. So keep reading and you will find ref lections on medical student life, examinations of health policy ,and even some visual and satirical pieces for your perusal. If you want to be featured in the next edition of Panacea, don’t hesitate to contact me at publications@amsa.org.au Jessica Yang, WSU Publications & Design Officer AMSA National Executive, 2016

And to our Sponsorship Officers: Jaff ly Chen, UNE Sunela Pathirana, UNSW Sam Roberts, UNSW And to the National Executive who helped proofread and produce this edition: Chloe Boateng, WSU Latha Deva, UniMelb Matt Lennon UNSW National Convention 2016 photography by: Anna Hoy, Monash Helen Quach, UNSW Mikaela Kelly-Irvin, JCU Naomi Kelly, TSV Creative Paige Barnard, TSV Creative Kari Ludvigsen, TSV16 This edition of Panacea is proudly sponsored by The Royal College of General Practitioners (RACGP). Thanks also to our major sponsors: The Australian Medical Association BOQ Specialist

Studying medicine will open many doors, including ours Not everyone is eligible to be a client of BOQ Specialist. But you are. As a medical student, you can join the numerous doctors who have chosen to trust us with their finances throughout their careers. Weâ&#x20AC;&#x2122;ve worked with the medical profession for over twenty years and because weâ&#x20AC;&#x2122;ve taken the time to know more about you, we can do more for you. Visit boqspecialist.com.au/students to find out more.

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WHAT I WISH I KNEW AS A MEDICAL STUDENT

I recently polled the AMA/ASMOF NSW Doctors in Training Committee for their top tips to medical students. And here’s the wisdom they chose to impart.

It’s good to be different – most people will follow one of four paths: med, surg, ED, GP. But think outside the box! There is so much more to medicine… pathology, radiology, psychiatry, medical admin, sexual health to name a few! Go to all your tutes – yes, physiology, biochem, anatomy etc may seem a bit irrelevant now. And endless communications tutorials may seem silly. But it really all does become relevant! Worry less about the destination and just enjoy the ride. Medical training is LONG and full of twists and turns. Medical school is just the beginning, so learn to enjoy constantly moving, exams, study etc. It doesn’t matter where you train, the experience is what you make it. Rural terms are full of great medicine, great mentors, great colleagues and great pub food. Enjoy it! Don’t make up your mind too soon. You may just find that term you’ve tried desperately to swap out of is the one you fall in love with. Use the opportunities of medical school and your early hospital years to “try before you buy”.

Care for your colleagues – you are all on the same team! Your peers are your colleagues, not your competition. So, play fair, and look out for signs your mates might be struggling. If they are, give them a hand Know when and where to get help – medical school and your career as a doctor will be stressful at times. You will see things no one should have to see, be confronted with great responsibility, and be under huge pressure. Surround yourself with good friends and colleagues. Know resources such as mentalhealth.amsa.org. au/ and jmohealth.org.au/ to get support if times get tough Have a hobby – the last point was about getting help when times are rough, but let’s try to prevent getting there. Make sure you build a work/life balance. Enjoy your job. Enjoy your playtime Learn to bake! You will be on the right side of all the nurses with a good muffin, or a cheesy scroll (or to be honest even a bag of chips on night shift). And believe me – you want to be on the good side of the nurses. Those guys and gals will save you over and over again. They know the patients. They know the system. Work with them, not against them, and you’ll sail through Don’t study too hard! Yes, passing exams is essential. But you will be studying for the next decade. Never again will you have as much free time as you do in medical school. So enjoy it!!

This article first appeared in 2015 Edition of RUBIX, the publication of the NSW Medical Students’ Council (NSWMSC).

SAMANTHA WHITE

university of western Australia

BREAKING BAD

NEWS BADLY

Breaking bad news is a complex communication task that many health professionals try to avoid for various reasons, however it is a core skill required by clinicians and a task that many will need to complete regularly. Communication skills and frameworks around breaking bad news are taught in medical school and have become a key competency for doctors. Thanks to this teaching, I have become acutely aware of the necessity of effective and empathetic communication of bad news to patients. Therefore, I was shocked when I was sitting in on a surgical outpatients clinic and observed a registrar bluntly tell a patient and his daughter during a routine post-operational follow up appointment that he had “liver mets” that “showed up on the CT scan”, that he was “too unwell to treat them with chemotherapy”, with no other information. When he told them this, the patient looked blank and the daughter looked confused, and asked “Sorry, what are you telling us… that he’s going to die from this?” followed by, “but we thought the operation had gone well and the cancer was removed”. At this point, the registrar repeated the same information, using a lot of medical jargon, not explaining the diagnosis and prognosis any clearer than he had the first time. There was then a knock on the door, and he got up to see who needed him, murmured something at the door, and proceeded to leave the room without saying a word to the patient. I was left in the clinic room with an elderly patient who was just told he has cancer again and will eventually die from it, and his daughter who was clearly distressed and was crying. This devastated me; this patient and his family had just received a complete disservice of our medical system and the expectations of

the doctors who serve it. After slightly recovering from my shocked state, I reached out and passed a box of tissues to the daughter, making eye contact with her in an attempt to silently show her my sympathies for what had just occurred. She thanked me, and proceeded to restate what she had said to the doctor about them thinking the cancer was gone. I merely offered reassurance by listening to her, nodding and acknowledging what she was saying. It was not my place, or responsibility, to begin explaining to her how or why the liver metastases had occurred and so I simply sat in silence waiting for the registrar to return. When he finally did return, he closed the consult hurriedly and clumsily, giving the patient and his daughter some more information and saying that the surgical team would see him in the clinic again in some weeks and that he would also refer him to the oncology clinic. The patient and his daughter left, without saying much more to the doctor, but still visibly upset. Whether they knew how poorly delivered the news they’d just received was, I do not know, but either way they should not have been leaving with such a lack of information and planning for the subsequent management, and in such an emotional state with no offer of support. Buckman [1] defines bad news as “any information [that] adversely and seriously affects and individual’s view of his or her future”. It is important information, that gives the patient autonomy in decision-making, facilitates patient-centred care, and allows collaboration and informed consent for management and care planning. In this scenario, bad news was delivered to both the patient and his daughter as it affects both of their lives. Therefore, the doctor in this scenario should have demon-

strated the behaviours we expect from modern day physicians, and ideally used an accepted framework for delivering bad news, such as the well-known SPIKES model [2]; Setup, Perceptions, Invitation, Knowledge, Empathy, Strategy and Summary. A study by Bendapudi et al. [3] found the qualities that patients value in physicians include being confident, empathetic, humane, personal, forthright, respectful and thorough. These qualities are particularly important for doctors to embody when delivering bad news. »» Confidence encourages trust, important for building rapport and a connection with patients. »» When a doctor tries to understand what the patient is feeling and experiencing, and communicates this understanding to the patient and their family, this is empathy. »» Showing humanity; being caring, compassionate, and kind; should be aligned with being a doctor and providing care for people. »» Being personal, interested in the patient and treating them as an individual person, taking them seriously and working with them, confers respect. »» Providing information and explanation in plain language in a straightforward manner, is a forthright approach. »» Being thorough is ensuring the patient understands the information, has their questions answered, knows what the next step is, and knows their emotional response to the situation is validated. The ‘7 ideal physician behaviours’ fits in well with the ‘SPIKES framework’ to provide a model for all doctors to follow when delivering bad news to a patient and their family, so that they are best informed and respected. These qualities lead to a collaborative partnership between the doctor and the patient, and foster ethical patient-centred care. So, why is it that not all doctors can deliver bad news well? There are many possibilities, but there are some that stand out for me in the con-

text of this scenario: »» Don’t like doing it; »» Not sure what to say; »» Don’t have the skills and are not prepared; »» Don’t know how to respond when patients are emotional; »» Feel sad, awkward or uncomfortable; »» Have compassion fatigue (burnout); »» Don’t think it’s their job/responsibility to deliver bad news; »» Have a fear of being blamed; »» Fear expressing emotion in front of patients; »» Fear of not knowing the answers; »» Have a personal fear of illness and death. Patient-centred care and communication skills have become a focus of medical education in Australia. We should all have an appreciation of why apt communication skills not only improve the day-to-day medical services doctors deliver, but can drastically improve the emotional experience patients and their families have when receiving bad news. Through both negative and positive clinical experiences, ref lecting on the ideal physician behaviours, and reviewing the SPIKES model for delivering bad news, we realise the impact these interactions can have on the patient experience of both their illness and of our health system. As future doctors, we can all endeavour to embody the ideal behaviours of a physician to try ease the pain that comes with communicating bad news to patients and their families. As I’ve now seen for myself, failure to do this can lead to a negative, even unjust, patient experience and representation of the health service we should provide. References: 1. Buckman R. Breaking Bad News: A Guide for Health Care Professionals. Baltimore: Johns Hopkins University Press; 1992. 2. Baile W, Buckman R, Lenzi R, Glober G, Beale E, Kudelka A. SPIKES – A six-step protocol for delivering bad news: application to the patient with cancer. The Oncologist. 2000;5:302-11. 3. Bendapudi N, Berry L, Frey K, Parish J, Rayburn W. Patients’ perspectives on ideal physician behaviours. Mayo Clin Proc. 2006;81(3):338-44.

BRITTANY SHEED

university of Notre dame, fremantle

BONE MARROW DONATION: A REFLECTION

This article first appeared in Issue 1, 2016 of Notre Damus, the publication of the University of Notre Dame, Fremantle’s medical society (MSAND).

On the 30th of November 2015, I received a phone call from the Australian Bone Marrow Registry (ABMR) informing me I could possibly be a match for a 6 year old girl from Melbourne with leukaemia. I didn’t expect to ever get this phone call so, naturally I was shocked, but also very excited at the opportunity to give this young girl a fighting chance at beating her disease. When I was asked to come in for additional blood tests to confirm the match, I didn’t have to think twice about saying yes. So, how did I get to this point? I have been donating blood for the last 6 years after feeling like it was time I should do something that helps others. Donating blood has always been a quick, painless and convenient experience for me, so I’ve continued ever since. There are a few perks to donating blood as well – free food and drinks, a free blood test with every donation and most of all you get to feel like you’ve done something good for someone else. After one of my first donations, I was asked if I wanted to tick a box saying I would like to be on the bone marrow registry. I ticked that box, not really thinking much of it, because I knew it was very unlikely I’d ever match with someone. Fast forward 6 years and I can now say that ticking that box was probably one of the best decisions I’ve ever made. What was the process of donating bone marrow? After my initial phone call with Sue from the ABMR, I went in for a meeting and additional blood tests. These tests were taken at the Aus-

tralian Red Cross Blood Service in Perth City, however at the time I was informed that Sue (my case worker) could meet me at my most convenient donor centre in Perth. I had approximately 10 vials of blood taken for extensive testing, not only for typing but also standard infectious disease tests. It was also at this appointment that Sue outlined the whole process to me and we filled out some paperwork and consent forms. The blood test results were given to the haematologist who would be performing my surgery at Fiona Stanley Hospital. I had an appointment with him where he ran through my tests to ensure I was healthy enough to donate. I also had a general check-up at this appointment and a run down on what the surgery would be like for me. Because I was donating to a child they would take the bone marrow from the posterior superior iliac spine of both of my hips. Many donors these days are able to donate marrow using peripheral stem cells harvested from the peripheral blood. The process for this is entirely different and somewhat less invasive than the procedure I underwent. When the results indicated that I was a good match, I was taken off the ABMR and ‘held’ as a donor for the patient until a decision was made about whether or not the donation was going to proceed. This means that nobody else seeking bone marrow can use me as a donor until the first patient has made their decision. The recipient can ‘hold’ a donor for three months until they decide whether or not they want to undergo a bone marrow transplant. One thing I have learnt is that a bone marrow transplant is a very risky procedure for the recipient, but a relatively minor procedure for the donor. It wasn’t long after the testing that I was in-

formed that the family wanted to go ahead with the donation process. At this point, I was required to fill out some more paperwork, consent forms and standard donor questionnaires. I was also given a lot of information about what the donation procedure would be like for me and how my recovery would be. The date was set for the 22nd of February. Usually bone marrow donation is done first on the surgeon’s list in the morning and then marrow is transplanted later that day. However, the child I was donating to was too unwell to undergo her preparation to receive bone marrow on the 22nd so my marrow was frozen and transplanted a week later. On the day of the procedure, I would undergo infectious disease testing again for the safety of the recipient. Did it hurt? Donating bone marrow is done under general anaesthetic, so the procedure was essentially painless for me. I woke up with two puncture wounds on my lower back covered with a basic waterproof dressing and some padding to reduce by discomfort when sitting and lying. These dressings would stay on for about a week. The pain after the procedure was mild and didn’t require any painkillers. It felt stiff and like I had hurt my back at the gym. The areas around the wounds were bruised, so that was a little uncomfortable for few days. Other than the mild discomfort, I was a little tired for a couple of weeks but was back to my normal activities by the next day. I wasn’t allowed to do any strenuous exercise for four weeks, whilst I was recovering. What happens after the transplant? I had many calls from the AMBR in the month after my donation to check how I was feeling and how my recovery was going. After a year ,I have another appointment with the haematologist to check all my blood tests again and make sure I am still healthy post donation. For

the next year I am not allowed to donate blood or plasma, and in the future will only be able to donate marrow one more time (should it be needed). One month after the transplant, I was informed that the procedure had gone well and now it was just a watch and wait scenario for the young girl I donated to. I will receive an update on her progress one year after the donation, which I am really looking forward to and have my fingers crossed for good news. Should I ever want to meet the girl I donated to (or if she wants to meet me) there has to be written consent from both parties. Bone marrow donation is a completely anonymous process and contact can only be made from a year after the process. Would I do it again? I would donate bone marrow again without thinking twice about it. The procedure was so minor and the pain is minimal despite what most people think about bone marrow donation. I highly recommend everyone who is healthy and eligible to sign up to give blood and put themselves on the ABMR. Imagine if it was your child, sister, mother or friend who needed a life saving transplant. I hope that if someone I care about ever needs a transplant, there will be someone on that registry who is willing to donate for them. I’m sure there are many, many people out there struggling to find a match so the more people we have on the registry the better. Overall, the whole experience has been very rewarding for me and I was supported the whole way through by the staff from ABMR. Sue was there at all of my appointments; tests and follow-ups to ensure everything went smoothly for me and I cannot thank her enough for her time. The nursing staff and doctors at Fiona Stanley were also amazing on the day of my donation and I felt like I was in very good hands.

HALSTED: A SURGEON, PIONEER AND ADDICT This article first appeared in 2016 Edition 1 of The Pulse, the publication of Deakin University’s medical society (MeDUSA).

William Stewart Halsted (1852-1952) was a pioneer of modern surgery in the US. His life was both intriguing and complex, filled with daring surgeries, a meticulous work ethic and hidden addictions. Halsted was born into a wealthy family from New York, and went on to study at Yale, where he was the captain of the football team. He furthered his studies at the College of Physicians and Surgeons Medical School in New York City, where he graduated near top of his class in 1877. By all accounts he was an enthusiastic, charismatic young man whose knowledge of anatomy was second to none. As the House Physician at both Bellevue Hospital and New York Hospital he envisioned and created the very first bedside charts to track and observe vital signs. He then broadened his skills by travelling to Europe to learn from the leaders in academics and the medical profession. This included the likes of Theodor Billroth, Hans Chiari, Richard von Volkmann, Edoardo Bassini and Friedrich von Esmarch, amongst others. Armed with new teachings and a fresh outlook, Halsted returned to the US in 1880 and worked at four different New York hospitals, where he was a bold and original surgeon, as well as a demanding teacher. During this time, he performed two of his more audacious procedures. The first involved his sister, who was having a postpartum haemorrhage following the birth of her first child. Unable to control the bleeding, and with his sister approaching a rapid death, Halsted transfused his own blood directly into her, saving her life and in the process probably performing the first transfusion in America. A year after this incident, Halsted again operated on a member of

BENJAMIN PAUL DEAKIN UNIVERSITY

his family, this time on his mother and her infected gallbladder. Under lamplight at 2am on the kitchen table, he drained pus and removed 7 stones from her gallbladder, again performing one of the first gallbladder surgeries in the US. In 1884, Halsted discovered the use of cocaine as a local anaesthetic, from which a story of addiction began to unfold. He and his colleagues experimented with cocaine, using themselves and their medical students as guinea pigs. Unfortunately, this led to the ultimate demise of most involved, and those that were left, including Halsted, were left with severe cocaine addictions. This hampered his ability to adequately perform his duties, and after the submission of an almost incomprehensible journal article, Halsted admitted himself into Butler Hospital, a rehabilitation centre for drug addiction. He spent the best part of the next two years here, finally relieving himself of his cocaine addiction, only to replace it with a lifelong addiction to morphine. 1889 saw the opening of John Hopkins Hospital, one of the most prestigious and inf luential hospitals in medical history. Halsted was recruited to start up the new hospital as part of the ‘Big Four’; four outstanding physicians including pathologist William Henry Welch, physician William Osler, and gynaecologist Howard Atwood Kelly. Here, Halsted was appointed Surgeon in Chief, and eventually, after gaining the trust of the hospital board following his rehabilitation stint, Professor and Chairman of Surgery. For the next 3 decades, Halsted worked at John Hopkins Hospital, although the audacious surgeon he had once been was now but a vivid memory. During these years, Halsted became more reclusive, started taking ex-

tended holidays and began operating in a more delicate and precise manner than other surgeons of the time. His gentle handling of tissue, vigilant reapproximation of tissue planes and meticulous care for organs led to great advances in surgical technique. Halsted developed new methods for hernia repair, radical breast cancer surgery, bile duct and thyroid surgery, as well as teaching the future generation of exceptional doctors including Harvey Cushing, Walter Dandy and Hugh Hampton Young. His slow and meticulous approach did however draw some criticism, such as from Charles Mayo, who upon visiting John Hopkins and observing one of Halsted’s surgeries noted, “Watching Halsted operate was the first time I ever saw the upper half of an incision heal before the lower end was closed.” Amongst his many achievements, Halsted is also surreptitiously credited with introducing the use of rubber gloves during surgery. Caroline Hampton, head theatre nurse of John Hopkins Hospital and wife of Halsted, developed dermatitis to the mercuric chloride used as disinfectant during surgeries. To avoid this, Halsted wrote to Goodyear Rubber Company and requested a pair of thin rubber gloves for Hampton to wear. These gloves proved popular amongst the other nurses, and eventually the surgeons, though surprisingly, the connection to asepsis was never considered by Halsted. It was not until some 5 years later that Dr Blood-

good, one of Halsted’s residents, suggested that everyone wear them as a matter of aseptic technique. The irony was not lost on Halsted who quipped, “Operating in gloves was an evolution rather than an inspiration or happy thought … it is remarkable that … we could have been so blind as not to have perceived the necessity for wearing them invariably at the operating table.” In 1919, Halsted developed obstructive jaundice and cholecystitis, and underwent a cholecystectomy and choledocholithotomy. He recovered well from this, however, three years later in 1922, he once again became severely unwell with marked jaundice. After travelling to John Hopkins, where his residents successfully operated on him to remove stones in his common bile duct, he developed post-operative bronchopneumonia and consequently died on the 7th of September 1922, leaving behind his wife Caroline and their two dachshunds, ‘Nip’ and ‘Tuck’. William Stewart Halsted’s life and career will be forever remembered for shaping the world of surgery. He has been the feature of many biographies and documentaries, as well as the source of inspiration for the current TV show ‘The Knick’ on Cinemax staring Clive Owen. Through his heroic acts and debilitating addictions, inf luential teachings and changing personality, Halsted certainly remains one of the most interesting and intriguing individuals to ever grace the field of medicine.

National Convention, 2016

ON LET nathan lenehan western sydney university

TING GO This photo series first appeared in the 2016 edition of Blue, the Blue Week publication of Western Sydneyâ&#x20AC;&#x2122;s medical society, WSMS.

THE SIMPLE THINGS:

ON BURNOUT AND REDISCOVERING THE JOY IN MEDICINE This article first appeared in The Auricle, the publication of Monash University’s medical society, MUMUS. You can check it out online at theauricle.org/

The fourth years counted down the days. Braced ourselves for the worst. But nobody could have prepared us for what happened when the day came. They packed, tight, into the common room, still excited about their day’s learning at 5pm in the afternoon. Their endless chatter of cannulas and pneumonia and heart murmurs filled what was, for a week, a space that had been solely ours. The third years had arrived, and the common room was already theirs. It was hard to believe that little over a year ago I was no different. Hopelessly entranced by that first set of lungs I had auscultated. And actually auscultated, free at last of the need to recite that dirty laundry list which becomes the annual mantra of the second year come OSCE season. It is not long before their enthusiasm starts to wane. Because a sleep-in is a beautiful luxury (P<0.05) and because some meetings are better spent sleeping in than sleeping through. Nevertheless, the liveliness of such fresh faced, stethoscope-wearing, notepad-bearing third year medical students on their first day of placement hit me with a pang of nostalgia. Where did our excitement go? Some days roll past in routine monotony. Mo-

Andrew wang monash university

notony, punctuated by the adrenaline of an occasional MCR or mid semester exam, that shifts us into autopilot as we face just what needs to be learnt, memorised and regurgitated. Where the process of study often feels like I’ve hitched a ride on the Prochaska-DiClemente cycle and forgotten just where to hop off. I understand that looking into the past through the rose tinted lenses of nostalgia is a dangerous thing. But there was once a time where some lofty aspiration buoyed us through long solitary nights, straining our eyes to pick the middle of five very subtly different clipart shapes in preparation for the UMAT. Did we ever think it would be like this? That instead of saving lives or removing appendices, we’d sometimes find ourselves trapped in a sequence of bleary eyed mornings, coming to terms with my addiction to caffeine and my propensity for procrastination. Perhaps not. When it comes to the issue of burnout, we’ve already been given the answers. The 7 pillars of wellbeing are our commandments. The recorded lecture run at double speed in first year about stress management and the ‘E-word’ becomes more important than ever. Go for a run, take up life drawing or marathon running; do anything to make sure your study of medicine doesn’t take over your life. A study published in 2013, discovered via a quick Google search (without employing relevant MeSH terms and having not been critically appraised), suggests the importance of ‘intrinsic motivation’, or genuine interest, in

leading to higher achievement and greater creativity in our medical studies. [1] But the perfect student with an endless supply of ‘intrinsic motivation’ is few and far between. There’s a large, grey area between the intrinsically driven Hermione Grainger and those spurred on by extrinsic factors, such as a desire for power or profit. For the rest of us that fall somewhere on this continuum, our interest in medicine can be tarnished following repeated and traumatic exposure to entities such as Turnitin and the generous feedback we’re provided on our exams or OSCEs. Additionally, the emotional and physical pressures of studying medicine may result in us losing focus of our initial goals.

have made suggestions ranging from finding a mentor to witnessing the miracle of childbirth. [2] But sometimes it may be the simple and small things might remind us of the passion for studying medicine when we’re being too busy being medical students. The joy of nailing your first cannula. The emotions of your patients. And even, god forbid, that f leetingly boundless enthusiasm of a bunch of rowdy third year medical students on their first day of clinical rotations. References: [1] http://bmcmededuc.biomedcentral.com/articles/10.1186/1472-6920-13-87 [2] http://www.iier.org.au/iier20/henning.pdf

And there is no easy way out. Articles acknowledging the importance of motivation

The Night Before the Exam by Leonid Pasternak (1935)

Image credit: Department of Health

NO JAB, NO PAY NO FAIR The government’s new vaccination policy raises some important questions around health policy. The issue of child immunization highlights the tension between individual rights and the public good, which exists across many areas of public health. Policy makers should seek to strike the right balance between these two ideals, but they must do so equitably. In this instance, it seems to be a case of ‘No Jab, No Pay – No Fair.’

DOMINIC WALPOLE DEAKIN UNIVERSITY

rare cases serious adverse reactions. Some people may weigh these risks differently and choose not to have their children vaccinated. Others may refuse for entirely different reasons. Who are we to say that they should not have this right? After all, patient autonomy is a key principle of health care.

The benefits of vaccination are undeniable. People who are immunized have a hugely reduced chance of suffering from many harmful diseases. And due to the infectious nature of these diseases, vaccination protects not just the individual, but also the whole community. Vaccines are one of the best public health measures in terms of their safety and cost effectiveness.

Whether or not we choose to respect individual rights or protect the public good has been called the ‘central dilemma’ in public health. Maybe we should mandate certain health requirements for all people, or perhaps individual liberty should always prevail. This tension exists for many health issues and there are valid arguments for both sides. The purpose of this essay is not to argue one way or the other. It is the role of policy makers to determine the right balance on any particular issue.

Yet despite the benefits of vaccination, some people do not wish to have their children immunized. In one sense this poses a challenge for advocacy and patient education for the health profession. In another sense it represents a genuine individual health preference. Vaccination is not entirely without risk, there are in

The use of financial incentives or disincentives, such as taxes, can allow policy makers to take a balanced approach to the central dilemma. These sorts of measures can encourage people to act in the public interest, while allowing obstinate individuals enough latitude to realize their personal preferences.

Obviously, not all health problems can, or should, be addressed in this way, however, incentives or disincentives can be an effective policy tool in some circumstances. They are perhaps a suitable approach for lifting vaccination rates, where the aim is to achieve ‘herd immunity’ not necessarily 100% coverage. The ‘No Jab, No Payment’ policy set to come into effect from 1 January 2016, creates a financial disincentive for parents who do vaccinate their children. The problem with the government’s new policy is not that it will be ineffective, but that it is unfair. To use former Prime Minister Tony Abbott’s language, it is “plainly” unfair. The policy requires parents to vaccinate their children according to the government schedule in order to be eligible for child-care and family tax benefits, unless they can gain an exemption under the policy rules. These welfare payments are means tested, meaning that for a given family make-up the level of payment decreases as household income increases until it is cut off completely. Therefore, withdrawing eligibility for these benefits from a particular group, such as non-vaccinating parents, has a greater impact on low-income families. Non-compliance could cost disadvantaged families up to $15,000 per annum, whereas high-income families face zero disincentive. These are the types of policy failures we should strive to avoid when taking a balanced approach to the central dilemma. Namely, that the disadvantaged face strong financial coercion, while the advantaged go untouched by public policy. This unfairly skews individuals’ rights based on their relative level of advantage. And the same problems arise for any policy that uses welfare restrictions as a policy tool, such as the ‘Healthy Welfare Card’ planned for trials next year. Those who say that the wealthy have earned this greater freedom compared to those on welfare, misunderstand the nature of disadvantage and the purpose of redistributive justice.

are simply targeted policy, as the problems are concentrated within low- socioeconomic groups. However, it may not be so simple with data from the National Health Performance Authority indicating relatively low vaccination rates in aff luent suburbs of Melbourne and Sydney. Rather than being targeted policy, these sorts of measures partly embody the government’s prejudiced and lazy inclination to degrade the rights of the most vulnerable in society whenever there is a problem. Regardless of the distribution of a particular health problem, policy that captures the entire public would be effective. And more importantly this sort of broad policy can ensure that the appropriate balance between individual rights and the public interest is applied fairly to all. The Australian Medical Association (AMA) supports the ‘No Jab, No Payment’ policy with President Brain Owler stating, “Whatever we can do to increase vaccination is important.” The policy will likely lift vaccination rates and, despite its unfairness, may cause little harm. But the government should not continue with health policy in this way. The tension between individual rights and the public good exists for many health issues, especially in the context of a publically funded universal health system. With rising public healthcare costs it may be tempting and perhaps justifiable to shift the balance towards the public good. A range of methods could be used to encourage preventative action and healthy behaviours at the individual level. However, with the burden of disease often concentrated amongst the disadvantaged, policy makers should take care not to unfairly target the vulnerable or further entrench inequality - to do so would be counter-productive. Tony Abbott may have earned two Blues for boxing at university, but the policy he backed to deliver these jabs shows poor form. Let’s hope under new leadership the government aims for fairer health policy, rather than just taking a swing at the easiest target.

Some may argue that such welfare measures

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CULTURAL DIVERSITY samantha white IN PSYCHIATRY

UNIVERISTY OF WESTERN AUSTRALIA

When interviewing, examining and managing patients of different cultural backgrounds, medical professionals are challenged to be culturally aware and safe, taking into consideration cultural factors that impact health, wellbeing and communication. Australia has a highly multicultural society and so it is not possible for medical professionals to be familiar with all cultural practices and beliefs, however it is possible for us to be culturally aware and careful to acknowledge and consider cultural factors that may impact how we manage a patient and inf luence their health outcomes.

Sodium Valproate as she has experienced â&#x20AC;&#x2DC;adverse drug reactionsâ&#x20AC;&#x2122; to these in the past. Ms F was recommenced on 75mg Quetiapine and 300mg Carbamazepine, and engaged with the clinical psychologist, occupational therapist and social worker.

UWA medical students are periodically taught Aboriginal Health from CAMDH, whose teaching makes us aware of Aboriginal culture and practices, how cultural phenomenology and practices can impact health care, and how we can best serve Aboriginal peoples in our Western healthcare system. This year we had a lecture from CAMDH during our psychiatry term, and the information and discussion made me ref lect on the care provided for culturally diverse patients at the mental health facility I was placed in at the time.

Jump forward to day 51 of her admission and Ms F has a stable yet mildly irritable mood, is reactive and interacting well with other patients on the ward, has normal speech and linear thought form, no self-harm or suicide ideation, and is keen to be discharged as she has a young daughter at home whose birthday is approaching. The single symptom fitting of psychosis Ms F demonstrates is that she is communicating with her grandfather and other family members through spirits and the birds. In most patients, these findings would be considered signs of psychosis: hallucinations and delusions. For Ms F however, who is of Maori culture, the spiritual connection to her family members and the ability to communicate through spirits and birds may be normal for her, and be part of cultural phenomenology rather than that of psychosis.

The particular case that came to mind was of a 31-year-old Maori woman who presented with mania and psychosis on a background of bipolar disorder. Ms F initially presented to ED with somatic complaints, but whilst there the medical staff noticed she had tangential speech, was restless, and was smiling to herself at times. Ms F became agitated and aggressive while under observation in ED, and was subsequently admitted as an involuntary patient. The psychiatry team noted her past history of mental health problems and found that her dose of Quetiapine (Seroquel) had recently reduced from 75mg down to 50mg. Ms F was not on a mood stabiliser drug such as Lithium or

Thoughts and beliefs shared by others of a cultural or religious subgroup do not constitute delusions. Evaluating psychiatric patients of different cultural backgrounds is a challenge for all clinicians; differentiating between delusions and hallucinations, and cultural phenomena is a task that can be of particular difficulty as it can mean the difference between an impression of psychosis or one mental wellbeing, altering the requirement for admission, antipsychotic medications and other psychotherapies. The presence or absence of other symptoms of psychosis, such as disorganisation in speech or behaviours, or non-culture-related delusions or hallucinations, should be used to sup-

port a diagnosis of psychosis in individuals of a culturally diverse background. Another point of consideration is that a patient’s delusions and hallucinations could be culturally based, however they are in fact be part of psychosis and not cultural phenomenology. These delusions are usually held with greater certainty by the patient, and are associated with high levels of preoccupation and pervasiveness. Subsequent review of Ms F a week later, on day 57 of admission, found a pleasant and reactive affect woman with a desire to be home with her daughter. She stated that she has never heard ‘voices’ in the same way her friends with schizophrenia describe. This leaves me with two schools of thought: either the experiences she reported last week were cultural phenomena which she continues to hold as important and not part of her mental illness, however she is not sharing these with the team at this point as she wants to be discharged; or the communication with her family through spirits and birds her were in fact hallucinations and delusions of reference, which are associated with cultural phenomena and thus they were more perseverant than her other symptoms of psychosis. The dilemma of accurately identifying clinically

relevant phenomena and respecting the patient’s cultural beliefs exists for all psychiatrists and mental health teams. Health professionals should employ careful consideration of any relevant cultural factors for each patient to ensure the best possible outcome physically, mentally and socially for all psychiatric patients. I will ensure to practice this in the future with all patients on a mental health ward or otherwise, and when reviewing culturally diverse patients ensure I ask questions related to culture to gain a more holistic understanding of their physical, mental and spiritual wellbeing. I will also be conscientious to advocate for culturally diverse patients where appropriate, and help make my colleagues aware of the implications of cultural phenomenology on mental evaluation and psychosis diagnosis. If practicing medicine in a society different to that which I was raised and educated in, I would endeavour to gain an understanding of the local culture as well as cultural and religious subgroups, as it is vital for an accurate assessment of people with symptoms of psychosis, and other mental illnesses. Despite these attempts to be culturally safe, health professionals must always be aware of cultural divides and ensure to take this into consideration when evaluating and managing any patient.

WHY THE SEARCH ENGINE UPRISING MUST BE CRUSHED

ashleigh ray

Western Sydney University

It has long been understood that The Webbed MD is toxic to the medical profession. Such a resource aims to demystify and de-professionalise doctorsâ&#x20AC;&#x2122; expertise, which threatens the elevated social and financial status of us doctors on not only a national, but a world-wide scale (Me, 2016). While clinging to our inf lated incomes is our true motivation for deterring patients from Internet, we must find some more amenable excuse if we doctors are to survive as our medical ancestors did. When exploring this disturbing issue of information sharing, we must first turn to the source that underpins all that we do as doctors - the Hippocratic Oath. As the ever- relevant Oath states:

Take on one apprentice, but donâ&#x20AC;&#x2122;t tell anyone else jack shit about medicine, okay? (National Library of Medicine, 2002) As highlighted in this paraphrased quote, we can see that sharing medical information with the great unwashed is abhorrent and directly contradicts the fundamental basis of medicine. The historical concealment of medical knowledge has proven extremely valuable for doctors, both monetarily and socially. We have enjoyed centuries of great awe, admiration and fear from the general public because of how clever, fancy and rich we are. The following illustration shows that unfortunately, this recent on-the-line distribution of medical information among the lay folk has already lead to shrinkage in the medical pedestal:

(Imperial Woodworks Inc, 2016)

BEFORE

NOW

As the proletariat steal insights into the medical world, they learn that our actual medical knowledge is markedly limited, while our great skill actually lies in our having greatly profited off their medical ignorance for centuries. To elaborate, if everyone knew the tiny but precious bundle of medicine that doctors knew, we’d all be doctors and nobody would be impressed with us and we’d be paid as nurses or some kind of “alliance health” worker. This imperative of maintaining our position in the uppermiddle – or preferably upper – class, and instilling a sense of inferiority in the masses, is the crux of why this search engine uprising must be crushed. I will now draw on a personal experience, which highlights why it is essential for people to be impressed with us. Last Friday I was at a dinner party with several friends but also some people I hadn’t met before. One lady wwas very friendly and we chatted for a few minutes before she asked what I do. I responded smugly that I am training to be a doctor. What happened next was very distressing. The lady pursed her lips, said “hmph”, and started talking to someone else. This ref lects that The Google is cultivating an increasingly dangerous landscape, not just for us doctors but for the wider plebeian population. If people stop being impressed with us at dinner parties, then what are we doing it for? Partygoers becoming less impressed with us is inversely correlated with an increasing medical workforce shortage, as clearly depicted in the graph below:

As shown above, if the great unwashed become savvy in the way of medicine this will diminish our mystique leading to partygoers being less impressed with us. As being impressive is a major reason why medicine appeals, we will look towards other more impressive careers. This will create massive “WWW” or “World Wide Workforce” shortages, leading to poorer health outcomes for our patients. This is the great irony of the tech utopian landscape of internet MD culture. The very scepticism of our profession the internet encourages in people, is also the leading cause for the lack of adequate care available to them. Transparency. Accountability. These are concepts that one may wish to explore in an intimate personal relationship, but they do NOT belong in a health service. To illustrate this point, we will imagine that doctors are fallible. With health illiterate patients of the past, any errors that my forbearers may or may not have committed could easily have been erased from history. The commoners lacked insight to ponder why mummy and daddy may have suffered bizarre and surprising ailments whenever they attended the doctors’ rooms, and thankfully their ignorance allowed the integrity of the medical profession to remain intact for hundreds of years. Fast-forward to 2016 and the town folk all have access to this new webbed system. Any diagnosis, procedure or medical task can now be researched on The Goggle, meaning that if any of us doctors commit a medical error – which we most certainly do not, for we are infallible – the dung munchers will find out! This heightened and involuntary mode of transparency will no doubt lead to doctors being held accountable for their actions. Which is completely unacceptable. While the winning side is clear, for diplomacy the counter argument to this debate must be explored. While the reader may have been reading my words unaware, I am a woman. I apologise for not revealing this sooner.

(Me, 2016) As a female doctor, I have much to gain from this process of degrading and lowering the sta-

tus of medicine as a profession. When doctors are less respected, I will be less threatening to my male counterparts and should have greater chance of finding a mate and bearing children, which is my primary validation. I will also have less male competition within the medical field as they move on to bigger and better (paid) things, and therefore more chance of promotion, as I will only be competing with other silly women. While this is one positive light that we women may glean from the darkness of the digital age, my priority as a woman lays with the pleasure and satisfaction of men, so this WIKIPEDIA development is dangerous indeed. In summary, medical information liberally dispersed among the masses will have devastating impacts not only for us doctors, but also for the wider sub-species. Therefore, while our true motivations are of course cash money and being impressive, we must find some way to National Convention, 2016

convince the sheep to not engage with medical resources online. This should be an area of further research in the coming years. While this research task might prove difficult, we doctors must somehow find a way of sharing large amounts of data across great distances, computer to computer, in order to form self-organising networks of discussion and information sharing to achieve our goals. Some kind of inter-departmental network would be ideal. Some sort of inter-net. REFERENCES: Me (2016). Partygoers Arenâ&#x20AC;&#x2122;t Impressed and Medical Workforce Shortage Graph. I Made it Up. Retrieved from: My Brain Imperial Woodworks Inc. (2016). Church Pulpits. Retrieved from: http:// www.pews. com/pulpit/church_pulpits.aspx National Library of Medicine (2002). Hippocratic Oath. Retrieved from: https:// www. nlm.nih.gov/hmd/greek/greek_oath.html

POKEMON GO PANDEMIC thomas de vries

STUNS RURAL GPs

This satirical article first appeared in FireFront, the newsletter of Monash University’s Rural & Indigenous Health Club (WILDFIRE).

KYNETON, VIC – Pokémon GO has taken the world by storm and our rural hospitals and GP clinics by surprise. The recently released open world, augmented reality smartphone game challenges users to walk around outside to find and catch virtual Pokémon. It has been blamed for the inundation of healthcare providers with patients with trauma from accidents related to inattention. Rural and remote communities have been hit the hardest, with local GPs often having no access to hospitals often being forced to come up with novel ways to deal with emergencies on the f ly. Urban hospitals have also experienced an inf lux of trauma patients due to Pokémon GO use, however, superior resources available to them have meant that they have been able to weather the storm of patients suffering from preoccupation related injuries. Isolated rural health services on the other hand are less fortunate in terms of resources, and the Pokémon GO phenomenon has pushed some health services almost to breaking point. In 2009, Dr. Rob Carson from rural Victorian town Maryborough f loored jaws when he used a maintenance drill to bore a hole into a 12-yearold’s skull to relieve the pressure of a bleed on his brain, caused by a simple pushbike accident, saving his life. However, once extraordinary, it seems that feats like this may end up becoming commonplace if experts’ predictions about the addictive and distracting game are correct.

monash university

Remote Queensland community Black Stump has a population of 685 and is serviced by a single GP practice, with the closest hospital 5 hours’ drive away. It has reported a twenty-fold increase in presentations of people with injuries attributed to the game. “It’s the Pokémon gym by the grain silo that has been causing us the most trouble,” said exhausted local GP Dr. Anthony Weller. “It had got around town that some youngsters had found a high level Charizard there. Before you knew it, we had fifteen people come in who had either fallen off the silo or been hit by the twice-weekly grain transport train while staring at their phones trying to find and catch the bastard.” Dr. Weller hung his head and lamented, “This all could have been prevented if I had told everyone I’d caught the bugger in the first place.” Peculiarly, pain for patients and GPs affected by Pokémon GO has resulted in gain for medical students placed in rural communities. Students of Monash University’s acclaimed NVRMEN program have been asked to assist in managing the inf lux of patients. “I have reattached sixteen fingers, seven legs, three arms and a head on my first week,” says Charlotte Blake, currently in the fourth year of her medical degree and placed in a remote Australian community nobody has ever heard of. “My recent capture of the Pokémon Machamp has really sparked a passion for arms and legs and I’ve been inspired to go on to pursue appendage reattachment surgery.” The Australian Minister for Rural Health, Fiona Nash, was approached to comment on what has been termed a national health crisis, but declined citing a huge post-election workload. Sources say she was overheard soon after attempting to catch “that bloody Snorlax that’s blocking the way to Malcolm’s office.” Deputy leader of the Labor party, Tania Plibersek, was overheard at Parliament House expressing her frustration at the game and the strain it is putting on the relationship between her and Labor leader Bill Shorten, igniting whispers of the sixty-second leadership spill in as many hours.

COMING THROUGH THE FRONT DOOR

Joshua Druery University of Sydney

Asylum Seekers & Australia

It’s the 22nd of August, 2012 and Leigh Sales, her face set in an intimidating glare, is grilling Opposition Leader Tony Abbott and his ears on ABC’s 7:30 program. Leigh: “Do you accept that it’s legal to come to Australia to seek asylum by any means - boat, plane - that it is actually legal to seek asylum?” Tony: “I think that people should come to Australia through the front door, not through the back door. If people want a migration outcome, they should go through the migration channels.” For years now, “coming through the Back Door” has been used as a euphemism for asylum seekers desperately trying to arrive in Australia. It conjures up images of Afghanis and Iraqis deceiving the West by tearing up passports, of people-smugglers sneaking Rohingyas into Australia under the noses of border patrol, of Syrians pouring into our country like a plague. This rhetoric has been used to justify a bipartisan policy to turn back boats and detain refugees in detention centres. But for the life of me, I could not tell you where the Front Door was. So I found out. Under international law, the 1951 Refugee Convention was, and is, the central legal document on which we rely when defining the rights of refugees. It also defines exactly what is meant by a refugee: “[A refugee is defined as an individual who], owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, and is unable to, or owing to such fear, is unwilling to avail himself of the protection of that country.”

It’s key to distinguish a refugee from a migrant or an asylum seeker. While a migrant may move countries to improve the future prospects for themselves and their families, that person is not f leeing for their life or freedom. An asylum seeker is anyone seeking international protection who has not yet been confirmed as a refugee. Asylum seekers have certain rights set out in this convention, the most important being that they may not be penalised based on their mode of entry into a country. Whether they have valid visas, identification documents or nothing at all is completely irrelevant under international law. This means that a country that’s a signatory to the Refugee Convention, such as Australia, cannot ever consider asylum seekers “illegal” in the first place; this language is a misnomer that has surfaced out of confusing and incorrect political soundbites. The Refugee Council of Australia has said that: “It is not a crime to enter Australia without authorisation for the purpose of seeking asylum. Asylum seekers do not break any Australian laws simply by arriving on boats or without authorisation…Australian and international law make these allowances because it is not always safe or even possible for asylum seekers to obtain travel documents or travel through authorised channels.”

Despite this, Australia does have multiple categories of asylum seekers and distinguishes between those arriving in Australia with visas via plane and those arriving without visas via boat. I spoke to a lawyer who has worked with asylum seekers for over 10 years, leading the pro bono refugee practice at his firm. He explained that Australia classifies refugees based on their mode of entry, time of entry and the location in which they arrived and that there are at least a dozen different classifications.

In the eyes of Australian politicians, asylum seekers should ideally be applying for resettlement offshore. This asylum route is through the UNHCR (United Nations High Commissioner for Refugees), a dramatically underfunded UN body that has the daunting task of distinguishing true refugees from would-be migrants. After refugee status is confirmed, these refugees must then live in large camps without the ability to work or build a future while waiting for countries to accept them into resettlement programs. This waiting period can be ten years or more. Considering that there are 21.3 million [1] refugees in the world when compared to the number of places available for resettlement through the UNHCR program (13,750 in Australia [2], 66,200 in America - and these two countries offer the most places of any other in the world), it is very likely that the majority of people living in the UNHCR camps in the current circumstances will never be resettled. No-one can guarantee that these camps are safe places to live and refugees within them have experienced violence in the past. [3] This is the Front Door. In light of this, it’s is no wonder then that refugees risk their lives to sail to Australian soil. Under international law any country that is a signatory to the Refugee Convention must offer protection to asylum seekers that travel to their country. Thus far, Australia has given its very best effort to turn away boats before they reach the country’s territorial waters in order to avoid having to process these people at all. I cannot describe this strategy as anything less than cowardly and heinous. What’s worse is that the overwhelming majority (96-100%) of “boat people” are true refugees entitled to asylum but only 20-30% of those travelling by plane can be considered as such.2 It seems quite clear to me that Australian politicians and the media are focusing their efforts on the wrong group of people. There is, however, another aspect to boat turnbacks. A few years ago the Government had two pathways for refugees: the first the UNHCR Resettlement Program, the second a refugee program composed of any “boat people” or Irregular Maritime Arrivals that arrived through-

out the year. Australia would accept their annual cap of refugees from the UNHCR program and also accepted any asylum seekers that arrived by boat for processing and protection visas [4] (which would require their own article). Recently, though, Australian refugee law has merged the two categories so that any Irregular Maritime Arrivals would be “jumping the queue” and taking the place of a refugee that was “going through the Front Door” by waiting for their entire lives in a UNHCR camp. For this reason Australia has refused to process them onshore and has instead sent these arrivals to Manus Island or Nauru. Offshore detention is the “protection” that the Australian Government, as a signatory of the Refugee Convention, is obliged to give these people. Arriving in this manner is the Back Door, a door that by international law is recognised as the only reasonable way of seeking asylum from any particular country. [2] Turning back boats and restricting asylum seekers to offshore detention is against the spirit of the Refugee Convention. The actions of the Australian Government and the words we’ve been taught to use when discussing this issue dehumanises the most desperate and vulnerable people on our planet, people that are seeking our help. There are still 404 children that live in Australian detention centres both on and offshore4 despite the recent Forgotten Children’s Report stressing that this detention breaches international laws to which Australia is a signatory. An estimated 50% of asylum seekers on Manus Island and Nauru suffer from “significant depression, stress or anxiety”. [4] There are numerous reports of the rape of refugees within Nauru’s detention centre [5], refugees on Manus Island have died in riots and from inadequate medical care, [6] and numerous refugees in detention centres both on and offshore have committed suicide. [7] This cannot possibly be described as “protection”. As a future medical professional, I believe in equality of health, equality of opportunity and the responsibility of health practitioners to give

patients the highest level of care possible. This has been our pledge to humankind since the Hippocratic Oath was first taken over two-thousand years ago. The Australian Government has sought to obviate this obligation with the introduction of the Border Force Act, threatening to imprison any doctors, nurses, teachers or other professionals for two years if they release information about Australian detention centres. That includes information about the health of detained refugees even when a person’s life depends on it. In the coming years doctors will prove to hold a strong place in this discussion. Last year doctors from Melbourne’s Royal Children Hospital refused to discharge children back into detention for fear of conditions that would compromise their health and wellbeing. [8] Those that work in health have the privilege of being considered a voice of moral reason within the wider community and I think we all have a moral imperative to give our strength to that voice. While Prime Ministers have come and gone as through a revolving door, the ideas of the Front Door and the Back Door still remain. Our politicians continue to demonise refugees as an “other”, a threat, fear-mongering for political gain. I hope that this writing might help to dispel some of the myths and legends, rehumanise a stale, semantical debate and demonstrate that Australia makes it very hard for refugees to find any doors into the country at all. References: 1 unhcr.org/figures-at-a-glance.html 2 aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp1415/ AsylumFacts 3 unhcr.org/52bd69f09.html 4 crowdvoice.org/asylum-seekers-in-australia 5 smh.com.au/federal-politics/political-news/naurusmove-to-open-its-detention-centre-makes-it-moredangerous-for-asylum-seekers-20151008-gk4kbt.html 6 smh.com.au/federal-politics/political-news/more-asylum-seekers-have-died-on-manus-island-than-havebeen-resettled-report-shows-20150716-gidi1b.html 7 beyondforeignness.org/fortress-australia-asylum-seeker-and-migrant-death-and-detention-statistics 8 theage.com.au/victoria/royal-childrens-hospital-doctors-refuse-to-return-children-to-detention-20151010gk63xm.html

50 volumes of amsaâ&#x20AC;&#x2122;s panacea Happy birthday to the official magazine of the Australian Medical Studentsâ&#x20AC;&#x2122; Association, and congratulations to all past Editors, Publications Officers and contributors.

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