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LETTER
CONTENTS
From the Editor Welcome to the last edition of Panacea for 2016. Our 50th volume is here to end the year with a bang and hopefully some real reflection. There are op-eds, poems and photo series from your peers, as well as articles from activism group No FGM Australia, and AMSA alumni Dr Nicky Betts. I can’t begin to describe the experience I’ve had this year, but this edition is my thank-you letter to everyone I have worked with under my capacity as Publications Officer. To the AMSA Representatives who work so hard, to the events and committee teams who put on amazing conferences and campaigns, and to the Executive team I have been with this year, I am incredibly grateful. I’ve included a little yearbook-esque section at the end of this magazine which showcases the amazing people who have worked all year as part of your AMSA. I’m incredibly proud of what we have created and I hope you guys enjoy it too. Thanks for an amazing year, Jessica Yang Publications & Design Officer National Executive 2016
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Female Genital Mutilation in Australia by No FGM Australia
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GHC: social challenges by Nicole Da Cruz
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Young One by Deepthy Koshy
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The First Amendment by Dr Nicky Betts
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Crystal Eye by Henness Wong
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Stopping Sugar by Daniel D’Hotman & Edward Cliff
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Music in the Operating Theatre by Lila Convery-Chan
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Wednesday by Justine Binny
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Scar Stories by Nikhil Autar
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The International Medical Student by Latha Deva
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Letter to First-Year Me by Sophie Collins
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Humans of Mental Health by Rob Thomas
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AMSA Yearbook
female genital mutilation (fgm) in australia: it’s everyone’s problem.
Khadija Gbla, Paula Ferrari & Sybil Williams No FGM Australia
WHY FGM?
FGM: THE NUMBERS
FGM is a threat to Australian girls. FGM is a cultural practice which has been deeply embedded within some cultures for hundreds – if not thousands – of years. Evidence shows that these communities do not abandon these practices when they settle in new countries, despite the laws and practices of the receiving country. Elsewhere in the world, studies have shown that migrants from countries where FGM is prevalent continue the practice once settled in new countries.
Female genital mutilation (FGM) is a secret crime and difficult to detect, and to date, the actual prevalence of FGM in Australia has been unknown. There is no central reporting in Australia of data about FGM where it is detected within medical or community settings.
No FGM Australia has received many accounts of Australian girls who are either being cut in the country, or being removed and taken overseas for the purpose of FGM. Recently there has been the first successful prosecution in NSW of an FGM case. In addition, professionals are aware of girls being taken for FGM, and doctors have been asked to perform female genital mutilation. It is wrong to assume that if girls do not present with acute genital injuries, that FGM is not happening in Australia. It is wrong to assume that because someone comes from an FGM affected community that they will subject their daughter to FGM, however these girls are still considered in the highest risk group. At this point there is no government data collected about female genital mutilation.
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No FGM Australia considers FGM to be child abuse, sexual abuse and an extreme form of violence against women.
No FGM Australia recognise that not all mothers who have had FGM themselves will continue the practice once they reach Australia. However, statistics indicate daughters of women who have survived FGM are at elevated risk. No FGM Australia commissioned a report to identify the number of women and girls living in Australia who are likely to be either survivors of FGM or at risk of FGM. Additionally, using Australian birth statistics, No FGM Australia has estimated how many girls are born to women who are likely to be FGM survivors. This report uses the best data available and makes estimates based on this data. Nothing will replace actual data, but until this information is available, this report gives an indication of the scope of the problem in Australia in 2014. This report uses census data from the ABS and UNICEF prevalence data which shows all types of FGM in most of the countries where all types of FGM are known to be prevalent.
The report showed: 1. Women born outside Australia Australia has over 83,000 women and girls who have migrated to the country and who are likely to be survivors of FGM or be at risk of FGM. This includes: • 5,640 girls under the age of 15 – this group are at high risk of FGM • 36,236 women of childbearing age (between the ages of 15 – 49) 2. Girls born in Australia Women born outside Australia who are likely to be survivors of FGM are estimated to give birth to around 1100 girls every year – that’s around 3 per day. These girls are at high risk of FGM. This report will be reviewed when the next census results are released – however, since its publication, worldwide estimates of the number of women and girls with FGM have risen to 200 million worldwide, partially due to the discovery of new cultures which practice FGM. Separately, Dr Elizabeth Elliot and the Paediatric Research Society of Australia and New Zealand, has also completed some primary research with paediatricians across ANZ, asking about their experiences with FGM. The results confirmed No FGM Australia’s anecdotal findings that there is significant FGM activity in Australia, both medical and non-medical.
TERMINOLOGY: FGM OR CUTTING / CIRCUMCISION?
ous sexual abuse, grievous bodily harm and a violation of human rights. There is no excuse, whether religious or cultural, for violence against children. There are 4 main types of FGM as categorised by WHO. Each form can result in severe problems physically, psychologically and sexually. Type 1: Clitorodectomy: partial or total removal of the clitoris and clitoral hood Type 2: Excision: partial or total removal of the clitoris, clitoral hood and the labia minora and / or majora Type 3: Infibulation: partial or total removal of the clitoris, clitoral hood, labia minora and majora. Complete stitching of the remaining opening such that a small hole remains the size of a grain of rice for urination, menstruation, sex and childbirth. Type 4: All other forms of interference with the genitals for non-medical reasons including pricking, cutting, burning.
MEDICAL EFFECTS OF FGM
There is a long list of harmful effects of FGM including short and long term effects. Within a western cultural context where FGM is considered as a form of mutilation, and where sexual function is celebrated, there can be additional psychological effects.
The legal term for this practice is FGM: Female Genital Mutilation. However, in a clinical setting, we advise use of the word ‘cutting’ or ‘circumcision’, which may be more familiar and less confronting than FGM.
Some of the immediate harm includes: • haemorrhagic shock and neurogenic shock from severe pain • bleeding to death • infection
ABOUT FGM
Longer term harm includes: • chronic pain • chronic pelvic infections • development of cysts, abscesses and genital ulcers • excessive scar tissue formation • infection of the reproductive system • decreased sexual enjoyment and psy-
Female genital mutilation comprises “all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons”. Female genital mutilation is a form of violence, predominantly committed against children. It is not only child abuse, but seri-
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chological consequences, such post-traumatic stress disorder
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terpret • be aware of your own responses and reactions the first time you examine a woman or girl who has undergone FGM to ensure she does not feel uncomfortable or different.
Additional risks for complications from infibulations include: • urinary and menstrual problems • infertility • later surgery (defibulation and reinfibu- Some barriers to asking about FGM which have lation) and painful sexual intercourse. been raised by doctors include: • Lack of time to ask about FGM Sexual intercourse can only take place after • Concern that FGM is not relevant to the opening the infibulation, through surgery or reason for presenting at the clinic penetrative sexual intercourse. Consequently, • Fears that the patient may be triggered sexual intercourse is frequently painful during for emotional or psychological issues if the first weeks after sexual initiation and the asked about FGM. male partner can also experience pain and complications. However please view asking about FGM as increasing understanding about the patient and Within a western context like Australia where how a range of health issues may be affected female genital mutilation is not an acceptable by FGM. practice, women and girls who immigrate to Australia who have been mutilated can feel IMPORTANTLY: asking about FGM highlights socially isolated, and experience psychologi- any child protection issues which may be prescal trauma because they are not like the other ent for daughters of patients with FGM. women in their new home who have not been mutilated. They may even feel trauma that their FGM should be treated like any “inherited” conbodies are now considered to be mutilated in dition, where a child can be in danger due to the a Western context, where in their country of presence of FGM in the mother. Therefore, like origin it may have been a celebrated or highly other inherited or infectious conditions, famivalued status. ly members must be considered as part of a treatment of the parent.
MANAGEMENT OF FGM
For women or girls suspected or known to have It is important to ask whether the woman or girl had FGM, management falls into 3 broad cat- has been circumcised or cut to: • raise a topic the woman or girl may be egories: reluctant to discuss 1. Management of physical symptoms • ensure the she receives the best possible 2. Management of psychological sympcare toms • determine and document FGM status for 3. Safeguarding assisting with care and follow up • enable the woman or girl to receive inforTalking about FGM with women and girls can mation about changes she may experibe uncomfortable for both the individual and ence after de-infibulation. the professional. • discuss de-infibulation and re-infibulation with her before labour It is important to include a question about the • ensure she has access to appropriate FGM status of the woman or girl in your asservices, including psychological and sessment or first contact meeting. sexual health counselling. • use a female interpreter where possible and avoid using family members to in-
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When discussing FGM with the woman or girl, it is important to: • avoid making assumptions and judgements, however be aware that there may be problems associated with FGM nonetheless that you need to be aware of, including psychological and emotional problems. • be sensitive to the intimate nature of FGM • use simple language and ask straightforward questions • be direct when assessing its impact by asking questions such as, ‘do you experience any pain or difficulties during intercourse?’, ‘do you have any problems urinating?’ or, ‘have you had any difficulties in childbirth?’ • make the woman or girl feel comfortable and ensure she knows she can come back if she wishes
some jurisdictions up to 21 years’ imprisonment in others. The Attorney General’s 2013 Review report notes that although FGM has been extensively criminalised in Australia, there an issue with lack of prosecutions for the crime. There is an inconsistency between the number of women reported as having sought care for FGM and the number of reports to law agencies. Therefore, the recommendation is to increase the information sharing between health and community services and law enforcement agencies.
YOUR RESPONSIBILITY UNDER THE LAW Every state has laws which mean that some professionals are legally required to report if they are concerned about a child in danger of physical and sexual abuse.
When talking with a survivor of FGM, use language which will be appropriate to the clinical setting. • You could ask: “have you been cut down there?”, “have you had traditional cutting?” or “have you been circumcised?” and point to your lap area. • Then you could ask: “what term do you use to refer to traditional cutting or circumcision?”. • Then you can use the term that that person feels most comfortable using.
Who is mandated to make a notification? The legislation in each state generally contains lists of particular occupations that are mandated to report. The groups of people mandated to notify cases of suspected child abuse and neglect range from persons in a limited number of occupations (e.g., Qld), a very extensive list (ACT, NSW, SA, Tas.), through to every adult (NT, Vic). The occupations most commonly named as mandated reporters are those who deal frequently with children in the course of their work: teachers, doctors, nurses, and police.
FGM AND THE LAW
In any case you are morally and ethically bound to report a child in danger of serious abuse.
In Australia, FGM is a criminal offence in all states and territories. It is also illegal to remove a child from Australia for the purposes of FGM. In 2013, the Federal Attorney-General carried out a review of the legislation in each state with recommendations for consistent penalties across the country. A report was published which was noted by the Standing Council on Law and Justice on 5 April 2013. At that meeting, ministers agreed to recommendations aimed at ensuring Australian women and girls are protected to the greatest extent possible from this practice. Penalties at present vary greatly, ranging from 7 years’ imprisonment in
“We have mandatory reporting in every Australian state and territory. Up until now people have not looked at FGM as child abuse, they’ve looked at it as some sort of traditional/ cultural practice that we don’t have to think about, but it’s child abuse just the same as any other form of child abuse. If you were cutting up any other bit of a child, bits that could be seen, you’d soon report it.” - Felicity Gerry QC
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A FINAL WORD FROM KHADIJA
This is not about culture. This has been a big misconception. This is not about race. It transcends that. This is about human rights. This is about the human rights abuse of little girls. Little girls who go to school with your daughters, your nieces, your cousins. They just want to be happy. They deserve to be happy. They deserve to feel pleasure. Damn it, they deserve to one day have an orgasm if they want one. Nobody has the right to take that away from them. And nobody has the right to mess with their bodies. The shame, stigma and silence that surrounds female genital mutilation is what has allowed it to survive to this day. I want to break the silence. Silence has done nothing for us. Silence hasn’t done anything for the little girls who have been put through this horrible practice. Silence hasn’t protected them – in fact silence has ensured that to this day, as we speak, there is a girl somewhere in the world who is crying, bleeding and asking for somebody to stop what is happening to her. Silence did that. When we as a people are silent, in the face of such a profound abuse of human rights, the practice continues. We’re silent in the face of such a profound abuse of a woman’s right to her body. Her right to safety. But most of all her right to a goddamn clitoris.
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about the authors KHADIJA GBLA - Executive Director
Khadija Gbla was born in Sierra Leone, her family sought refuge in Australia in 2001 after enduring a thirteen-year civil war within her homeland. Now a proud Australian citizen, Khadija has won multiple awards and has represented Australia in the international arena at the Harvard National Model United Nations, Commonwealth Youth Forum and Australian and Africa Dialogue. Khadija has supported many multicultural initiatives and in most recent times, has been a vocal campaigner to protect young girls from female genital mutilation (FGM) and to get support for women who are survivors of the practice. Khadija is a survivor of Female Genital Mutilation (FGM) and has been actively working to help protect young girls and support survivors for the past 15 years. Khadija Gbla is the Executive Director of No FGM Australia. Khadija has a vision of a world where her generation is the last to suffer FGM.
PAULA FERRARI - Managing Director
Paula is a health professional, educator and independent scholar. She first became aware of FGM after reading Alice Walker’s book “Possessing the Secret of Joy”. She became an activist after she had two daughters of her own. She became outraged following the discovery that Australian girls, little girls like her own daughters, were being subjected to FGM, and yet there was a huge silence around this within schools, hospitals, universities where she had taught or practised as a teacher and health professional at grassroots and academic levels. As FGM is a primarily a form of violence against children, therefore a child protection issue, she would like to see all frontline professionals trained in how to identify girls in danger of FGM, and for FGM to be included in all mandatory reporting and university training. She believes that all girls should be safe from abuse regardless of their colour or background. Paula is based in Melbourne.
SYBIL WILLIAMS - Director
Sybil Williams was born in Barbados. Her father worked for UNICEF, so she then lived in Nigeria, Burma, Nepal, Egypt, Lebanon, Bahrain and Wales before arriving in Australia in 1988, aged fifteen. She is a communications specialist and founder of marketing consultancy, Atomic Tangerine. Sybil first learnt about FGM from her father, who told her this story. Whilst working for UNICEF (when she was in her early teens) he took a three month consultancy back in the Sudan. After finishing a day’s workshop with a governmental body, one of the participants approached him: “Do you remember me, Doctor Williams?” the man asked. Dad replied – “Of course. You were sitting at the back of the room…” “Ah! You don’t remember me…” he said, as Dad began frantically trying to work out how he could have forgotten this man. “You, Doctor Williams” continued the man, “have been the greatest source of trouble in my marriage. “You gave a session on human reproduction to my class. And during that class you banged your fist on the table and said ‘You are not a man if you allow your daughters to be cut! You are not a man!’ “And, Doctor Williams, my wife, my sister, my mother, my mother-in-law, my aunties and all my female relatives have not stopped giving me hell for it. But I wanted to tell you, my daughters are not cut, and neither are the daughters of anyone else in that room.” That story made a huge impression on her and always gives her goose-bumps. That’s how she learnt about female genital mutilation, and now why she continues to fight the practice here in Australia. Sybil is based in Sydney.
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global health conference: social challenges a medical student’s perspective Nicole Da Cruz Western Sydney University As medical students we are selected, screened by the process of application and multi-mini interviews to ascertain whether we can do the critical aspect of medicine well. The ability to communicate, have strong interpersonal skills and convey ideas, is a must. While we all enter day 1 with a baseline, the medical curriculum brimming with flowcharts and didactic procedures to learn, tends to fill our brain with jargon that becomes habituated and one forgets how to communicate simply and clearly. Having attended the Global Health Conference in Newcastle in August 2016 as a delegate of Western Sydney University, I am reminded how important it is to cultivate and foster communication skills. The academic speakers shared a plethora of ideas and narratives; nevertheless those that were well received were those that spoke directly and in a language that was accessible. Personally, I believe Julian Burnside exemplified this. His public portfolio as a barrister and commercial litigator goes beyond my understanding, and is rather intimidating. Nevertheless, speaking via videoconference from Melbourne was a man who wanted to have a conversation. A conservative, speaking passionately about the treatment of refugees shifted my understanding. The content was largely unsettlingly familiar, yet his manner, speaking frankly that he would ‘take up any case of medical professionals being prosecuted by the Government for speaking up about the state of refugee and asylum seeker health,’ created a bond between two largely different professions. Such banding together for the common
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good is often spoken with superlative tones of idealism, yet having a reputed individual coming forth from his living room as an advocate puts a human face to the action. In a following workshop, centred on medical students and professionals speaking up about pertinent issues; we were challenged to speak to our local MPs. Again, not something the medical curriculum grapples with, yet logistically this is how productive change can come about in our diplomatic society. It was bizarre, in the ‘mock-activity’ we had to “sell” our “spiel” in a few sentences to gauge interest. Often not an easy task; what I believe takes hours to months (to years) of reasoning logically in perplexed discussion over often morally ambiguous topical policies – to distil it down to capture the audience. Not only words, but also tone fit for a member of parliament or a journalist. Taking the time to prepare in order to reach out to the public, what I may fancifully envision a coloniser’s journey to be, the arduous task of crossing an ocean, for the final joy of finding fertile land. Evidently I brought my own thoughts to the table, and in keeping with the spirit of a conference raised my hand to give feedback that whatever action is taken in policy must be backed by a team, any undertaking of a common vision will be stronger with more minds and hands invested. Personally, this was a moment of building confidence, seeing my voice as important in the discussion. I was encouraged later to know that the speaker who led that break-out session happened to be an alumni of our university, making his narrative
and practical administration of change more tangible given that he sat in the same classrooms in which I sit and completed the same coursework which I face. It is intriguing how it made me confront my own possibility. Another memorable speaker who captured my attention was Khadija Gbla. Her use of humour in the context female genital mutiliation - such a horrid and violent practice, made her message reachable. She was a survivor, she told her story and it had a happy ending, being able to conceive and have a healthy baby. Nevertheless, the practical outcome to her talk was explicit: as medical professionals it is your duty to ask. She told us to ask in three different ways, with both verbal and non-verbal cues. With much gesticulation she tore down cultural walls, to reach a point of understanding among us all, making us laugh but also making us realise it is possible to express the message succinctly. We as future doctors need to get comfortable with the uncomfortable in order to treat our patients effectively, not symptomatically but get to the root of the problem. Further, she raised the issue of prevention. The need to recognise high risk groups and intervene if necessary. Being told that this is not a cultural issue but a human rights issue, and having someone speak directly - not tiptoe around notions of sensitivity helped us to realise the prevalence of the issue. I am no not only better aware of the problem but am willing to address the issue in my practice. Finally, a common theme addressed throughout the conference was that surrounding a paradigm shift. The workshop taken by Engineers without Borders was emblematic of critical change in interventional strategy to aid. It was clear that in order for projects to be sustainable efforts are being made to move away from the “charity model” of top-down donations without considering the thoughts of the community and without entering into discussion with relevant groups. The World Vision Ad of an African child with Kwashiorkor was most successful in bringing in financial funds, but failed in that it
put into the public’s mind a schema of helplessness. Endeavours with this mindset are bound to fail; the example provided was of the slum communities in India. Despite “flying toilets” a polite way of phrasing the complete lack of facilities (hence the need to throw human faeces as far from the home as possible) when a new set of apartment complexes were built, those living in slums chose to continue to live as they had done so and demonstrated an entrepreneurship flair in renting their new properties, rendering the whole aim of the project null. Rather, it may be as simple as asking what are the community objectives (i.e. better sanitation) before ploughing through with money and resources that may be better distributed elsewhere. Further it is not just material goods, but an understanding of human skills and expertise to be shared among the partnership. There is an almost child-like simplicity to the notion that each community has something to give, and moving forward in my professional development this has taught me that the ability to listen is a critical aspect in the ability to lead. AMSA’s Global Health Conference widened my perspective. Healthcare not only to the individual but to communities, a concept that is taught as an idea, yet practical implementation has eluded me until now. I believed that great individuals with motivation, networks and bravery would tackle this vital link bridging philosophy with reality, until I realised I was one of them sitting in an auditorium of bright talented medical students. In one key talk entitled ‘how to be a media tart’ the speaker told us blatantly, there is never a time when someone taps you on the shoulder to say that you have reached a level of expertise to make your opinion legitimate in public. That there will be no structured formal time to begin engaging with issues that you believe in, rather it is up to us to be confident to speak from our platform. This I believe comes hand in hand, not only with competence, but also with clarity.
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young one Deepthy Koshy, University of Western Australia
This is the story of a young girl, I met in rural Western Australia. Oh young one, where did we fail you? I first meet you, in a rural emergency department. I see your unkempt hair, your brilliant dark eyes, your scruffy clothes. I study you. I see how your story was written before you were born. I observe your thin upper lip, your smooth philtrim. The way your cheeks are flat moons that frame your face. I see the stain of fetal alcohol syndrome on your features. You grew in womb that was flooded with poison And this poison has written its code into your genes. This is where we failed you first. As I talk to you, I realise that you’re here. Alone, at the age of 13, in an emergency department. I ask why no one came with you. You say, “where I live, there are no parents” This is where we have failed you twice. I ask you why you’ve come in. You tell me your tummy hurts, as clutch your lower abdomen. I ask if it hurts when you pee. You nod furiously. It stings like knives. I read your medical file. I see that you’ve been admitted for pelvic inflammatory disease, testing positive for chlamydia, gonorrhoea and trichomoniasis. Last year. At the age of 12. This is where we have failed your three times. As we talk, each word brings us closer together. I see that you begin to trust me and my heart is about to burst for all that I feel. You do not deserve this. I ask you if you’ve had any discharge from ‘down below’. You ask me what I mean. I say, “have you had any funny smells or discharge from your vagina”. You ask me what a vagina is. I point to a diagram. I show you where your urethra is, I show you your anus. I point to the vagina. I finally say, “you know, it is where the penis goes inside during sex” As I say this, you stare at me. I see the vacancy behind your eyes. This is where we have failed you four times.
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I tell you that we think you have a serious infection down below. We need you to stay over night, put a drip in, give you strong medications to help you feel better. I tell you that we need an adult to stay with you because you are a minor. You say, “I don’t know who to call.”
This is where we have failed you five times. I come back to see you the next day. You ask me about what you have. I explain you have a serious infection that comes from having unprotected sex. You say, “what’s that.” I feel scared for you, because no one has taken the time to make sure you understood. I pull up a chair and walk you through your mysterious infection down below. I walk you through the anatomy of sex. I walk you through periods. I walk you through pregnancy. I walk you through condoms. I walk you through consent. This is where we have failed you on six, seven, eight, nine, ten accounts. I wrote this creative piece as a cathartic response to three young women I met in a rural community up in the Kimberley, in Western Australia. All three were adolescents who had recurrent presentations for clinically fulminant pelvic inflammatory disease (PID). Due to varying reasons, all three had not completed a full course of treatment. My heart hurt as I learnt about these young women, and their stories that had led to this situation. The first pertinent point I learnt from this experience was the importance of opportunistic sexual health education. There are gaps in access to and knowledge of sexual health, particularly for young people in rural areas. It is important that we, as future health care professionals, take that extra time to provide education. As a medical student in these settings, we often have more time. The second was the reality of the sequelae that arise from PID; chronic pain and infertility are serious complications, and are avoided with timely delivery of antibiotics. In patients so
young, this must be the focus of treatment. The third was the importance of tailoring your care to a patient. One particular young women was terrified of the hospital at night; every time she was admitted as an inpatient for a course of intravenous antibiotics, she would abscond before the treatment could be completed. After discussion with the treating team, and a thorough literature review on treatment for pelvic inflammatory disease, the decision was made to treat her as an out patient. The relief on her face was palpable. This led to fostering a positive relationship between this young lady and the local health care system. Much to everyone’s delight, she came back for an education session with the community health care nurse and a test of cure. My heart hurts when I think of the young ones just like these women I met. I hope that we, as the future generation of clinicians, can actively work to help remove the barriers that stand between these young people accessing appropriate health care they need.
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the first amendment Dr Nicky Betts is a junior medical officer at Concord Hospital and was previously the Crossing Borders National Project Manager. The controversial Border Force Act, announced in July 2015, included provisions to imprison immigration staff for “making a record of or disclosing” information pertaining to the working or living conditions in immigration detention centres. Essentially, doctors or other staff could be sent to jail for up to two years for speaking out against inhumane conditions in places such as Nauru and Manus Island, which have been described by the United Nations as in violation of international anti-torture conventions. There was a substantial outcry when it was initially instituted, but the pushback lost a lot of steam after a couple of months as the protests of the opposition to the BFA were steadfastly ignored. An amendment was announced today, exempting healthcare professionals - including doctors, nurses, mental health workers, midwives, pharmacists and dentists - from responsibility to obey the secrecy provisions of the Act. The amendment was actually made in secret on October 1st, and only today has news made its way to mainstream media. This is a key breakthrough that a variety of organisations have been working towards since the fateful day the Act first came into being. Congratulations are in order for the many organisations who have been tirelessly campaigning against this act, including Doctors for Refugees and other medical and advocacy bodies. This small victory notwithstanding, there remains a long road ahead. The exemption granted to healthcare professionals does not extend various other professions - lawyers, social workers and teachers - despite their exposure to the same issues. Rather than exempting certain groups from aspects of the Border Force Act, it would be better to have the entire act repealed. On a more fundamental level, the broader issues with Australia’s refugee policy remain all too present. Our indefinite, mandatory detention of all asylum seekers, including children, continues to make a mockery of basic human rights and our 14 so-called Australian value of “giving everyone a
fair go”. Offshore detention centres such as Nauru and Manus Island are breeding grounds for mental illness, in a population already fraught with post-traumatic stress disorder, anxiety disorders and depressive disorders. If asylum seekers somehow managed to avoid all these from the time they fled persecution in their home country, they still have to face the tortuous uncertainty of indefinite detention, often for years on end. As a medical student, there are number of ways you can get involved. Every medical school has a global health group, which runs a Crossing Borders branch. Crossing Borders in turn consists of three chief areas. The first is direct assistance; that is working directly with refugees in the community/detention, or fundraising for organisations that do so. Consider holding a bake sale, or an auction night, for the Asylum Seeker Resource Centre or the Water Well Project. Equally important is the education of ourselves and our colleagues; most medical schools do not spend much time on refugee health issues, but understanding them will make us better doctors. Advocacy is the final arm of Crossing Borders, and it’s the best way to try and go about creating policy change from the top down, rather than the bottom up. Consider giving your local Member of Parliament a call to arrange a meeting - they’re not as scary as you think, and an essential part of their job is meeting with constituents. Most of the time, advocacy campaigns ultimately do not achieve what they set out to achieve. Working in this space can at times be extremely demoralising, as it is easy to feel like nothing that we do makes a difference. However, these events are a reminder that although it may take time, and setbacks may occur, positive change is indeed possible. It’s also a potent example that these issues can be highly unpredictable, and the Government may unexpectedly give ground at any time, and as such take courage to keep fighting the good fight.
crystal eye Henness Wong University of Wollongong
Henness Wong is a first year student at the University of Wollongong. Crystal Eye is a sentimental photo series he began after finding a pair of crystal orbs on his late brother’s desk. Henness takes photos through one crystal to show Hing Yue beauty around the world, and his sister keeps the other. You can see more at his Instagram: @henn.penn.
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stopping sugar in its tracks Daniel D’Hotman & Edward Cliff Monash University
Daniel D’Hotman and Edward Cliff are medical students from Melbourne and lead policy authors at the Australian Medical Students’ Association. They completed research at the University of Oxford in 2015 – Daniel in health policy and Edward in diabetes physiology. This article was originally published in The Sydney Morning Herald. Australians are addicted to an insidious white powder that is endemic in our schoolyards and destroying the lives of young people. Processed sugar, particularly the high concentrations found in soft drinks with no nutritional value, is causing significant harm to the health of young people and putting strain on our health system. The shocking reality is that more than one in five Australian children are now overweight or obese, along with over 60% of Australian adults. We must stop blaming individuals for poor nutritional ‘choices’ and fix the food system that has turned us into the second fattest nation in the OECD. A tax on sugary drinks is one evidence-based policy measure that could make a dent in this supersized problem. The Australian Medical Students’ Association this week added its voice to the growing tide of support for an Australian tax on sugary drinks, with representatives of Australia’s 17,000 medical students voting unanimously for the initiative.
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Support for sugar drink taxation is gaining steam across the globe. The World Health Organization this year recommended a tax on sugar-sweetened beverages as an effective means to reduce childhood obesity. The UK’s Conservative government answered this call, recently passing legislation for a soft drink tax to be implemented next year. It joins countries such as Mexico, France, Hungary, Norway and parts of the USA in taxing this harmful substance. Closer to home, Victorian Liberal MP Russell Broadbent risked the scorn
of his Coalition counterparts when he publicly called for a 10% tax on sugar to combat obesity and diabetes. Australia has led the charge against tobacco, with progressive taxation bringing about world-leading reductions in smoking rates. Proceeds from the tobacco excise raise more than $7 billion every year, reducing the financial burden of smoking on the health system. The time has come to implement a similar strategy for sugary drinks. Opponents suggest a sugar-sweetened drink tax has a fat chance of being effective. But evidence both from Mexico and a local trial at Melbourne’s Alfred Hospital is clear: a tax on sugary drinks significantly reduces consumption of these harmful beverages with direct benefits to health. Modelling studies suggest a 20% volumetric tax on sugary drinks in Australia could prevent 800 cases of diabetes every year, significantly reduce the impact of heart disease and stroke, and result in a saving of 112,000 and 56,000 Disability Adjusted Life Years (a fancy measure of an intervention’s impact on quality of life) for men and women respectively And what about the money? Studies indicate that implementation of this tax in Australia would deliver over $400 million in revenue each year. This estimate doesn’t even take into account the drastic savings for the health system down the line, which is already struggling from a lack of funding and an ageing population. It is important to emphasise that this is not a cash grab. While the finer details of the policy must be nutted out, there are many exciting opportunities to invest the proceeds of a sugar tax – on the health system, fresh fruit and vegetable subsidies, or nutritional education for children.
These measures would directly benefit the health of all Australians, particularly those who suffer from obesity and its associated effects. The companies behind soft drinks - collectively known as Big Soda – employ many of the same tactics used by Big Tobacco to devastating effect; they manipulate scientific evidence, implement diversion campaigns and meddle with health
education in schools. We have the opportunity to hit these organisations where it hurts, and in the process save billions of dollars by reducing the devastating health impacts of their sugary drinks. With widespread support from politicians, economists and health practitioners, the time has come for Australia to adopt a sensible, evidence-based measure to combat the harrowing scourge of childhood obesity.
newghc2016: in the green
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music in the operating theatre: help or hindrance for quality and safety? Lila Convery-Chan University of Western Australia Case vignettes Imagine surgically-minded medical student nirvana: I was scrubbed in, retractor in hand, exchanging banter with the team, and had even earned myself a nickname with the surgeon. ‘Plug in my iPod will you?’ the surgeon called out to the nurse. Beaming at me over the operating table, he declared ‘music makes us happy’, as jovial rock music began to snake its way through the theatre. Spirits were high. The routine and straightforward procedure went by in a flash. Fast forward one week. Same theatre, different surgeon. No music was playing but raucous noise emanated from drills, suckers, and multiple conversations. A more complex patient lay before us. Barely five minutes had elapsed when the nurse first misheard one of the surgeon’s requests. She asked him to repeat himself. She misheard again, this time handing him the wrong tool. Communication continued to falter as the surgery progressed. Flustered, the surgeon began grabbing and replacing the tools from the sterile tray himself. Tensions were high. I stood there silently clutching two retractors, too scared to ask questions or even breathe too loudly. My mind drifted back to the fond and fun memory from the week prior and I wondered whether switching on some music would help or hinder the present situation. The Pros of Music for Quality and Safety I imagined music as the metaphorical olive branch that could have quelled the frustrations and lifted the mood in the second case, but I needed to see the evidence. Surgical staff and patients alike believe that playing music in the operating theatre (OT) has positive effects1 and there is good evidence backing these views. In Conrad et al’s random¬ised control study, surgeons assigned¬ to perform laparoscopic tasks under varying noise conditions demonstrated greater accuracy with classical music compared to either silence, dichaotic music (auditory stress), or mental loading in the form of arithmetic. The effect of music versus no music was also examined in a prospective randomised study with fifteen plastic surgery residents completing a layered suturing task. Lis20tening to self-selected music improved both the
speed and quality of wound closure2. Repair time was reduced by 8% across all participants (P = 0.009), an effect more pronounced among senior residents who demonstrated an improvement of 10% (P= 0.006). Music improved suturing quality by 6%, as assessed by a blinded panel of senior plastic surgeons2. Music is thought to provide a motivational effect that can improve surgical efficiency2, 3, 4 and maintain the mental arousal needed to overcome the effects of fatigue or monotony5. Surgical staff report music in the OT to be calming, noting its ability to mask distracting sounds like drills, diathermy, pagers, phones, and conversations1, 6, 7 , thereby aiding concentration and task performance8, 9, 10. Plus, it can positively influence teamwork6 and create a more pleasant work environment10, which are known to boost technical performance11 and speed in surgical procedures12. Music offers direct benefits to patients as well. Reductions in stress, anxiety, pain perception, and demand for analgesic and anaesthetic drugs have all been reported in patients exposed to intraoperative music12. A randomised control study of 84 adults undergoing spinal anaesthesia for urological procedures found that patients who listened to intraoperative music self-administered less propofol than patients who listened to white noise or OT noise (music=0.004mg/kg, white noise=0.014mg/kg, OT noise=0.012mg/kg, P=0.001)13. The advantages of music for patients are well evidenced12, 14, 15, 16, 17, 18, 19, 20, and patient satisfaction is reportedly higher when music is played18. In fact, music was originally introduced to OTs as an anxiety-reducing measure for patients back in 19146. Played for patients’ benefit, soothing harmonious tunes were strictly adhered to6. Just as technology has evolved from gramophones, through to cassettes, CDs, and now to iPods and smartphones, the purpose of music in the OT has evolved from patient to surgeon benefit. While surgeon benefit can translate into quality and safety for the patient, it is important to maintain
the patient focus of care. Decisions about playing music in the OT17 should be made with therapeutic intent and align with the relevant National Safety and Quality Health Service Standards. The Cons of Music for Quality and Safety Noise can be defined as a sound that is unwanted or that interferes with normal hearing18, 21. Adding music might further contribute to an already noisy surgical situation. The World Health Organisation (WHO) recommends that noise in hospitals should not exceed 40 decibels (dB)22, while Western Australian regulations acknowledge workplace noise levels as excessive and potentially damaging at 75dB23. The nonlinear relationship between sound pressure and loudness dictate that a 10dB increase equates to an approximate doubling in perceived loudness. The average OT noise is 65dB24, but can reach 110dB in many procedures7, 24, 25, and rise transiently to 140dB in surgeries employing drills and other power tools24. To put these figures in perspective, 110dB is comparable to a power saw, pain begins at 125dB, and 140dB is akin to a jet engine26. Exposure to such high noise levels can impair staff concentration, cause stress, breed communication breakdowns and subsequent surgical errors, while long term exposure may contribute to noise induced hearing loss21, 27. These factors alone or in combination can be detrimental to patient safety in the OT, for example mishearing drug names or doses21, or causing lapses in attention at critical moments. Individuals with hearing difficulties may be even more affected. The OT is a demanding environment requiring high cognitive loads and complex auditory processing21. Excessive noise levels can mask speech, impair the auditory processing of surgeons21, increase the need to repeat verbal requests, and lengthen operating time6. Weldon et al utilised video recordings of laparoscopic procedures to further delineate the effect of music on communication. The need for a surgeon to repeat a request to a nurse in order for it to be heard or understood occurred five times more frequently when music was played (music=63 repeated requests; no music=6 repeated requests, P<0.0001). Needing to repeat requests roused staff frustration and added as much as 68 seconds to the operating time6. In light of these findings, it is no surprise that communication in the OT is thought of as difficult and error prone28. To understand speech with 90% accuracy, speech must be 10-15dB higher than the background noise. Surgical team members
therefore need to speak at 80dB if they are to be heard above the average 65dB noise level21. Distraction due to noise and communication errors are the two of the most commonly cited causes of surgical errors. For cardiac patients, time in the OT represents 4% of their length of hospital stay, yet 21% of medical errors occur during their time in theatre29. The high risk and serious nature of surgical errors beg the question of whether 90% accuracy in communication is even acceptable21. The OT is in a constant state of flux, demanding rapid changes in response to unexpected or novel events. Consider iPods, where tunes can vary markedly in volume from track to track. Volume adjustment takes time, for example the nurse trying to find the volume control, may cause delays when clear communication is vital6. Sudden change in volume or unexpected sounds can also cause a startle response, disrupting concentration and inducing technical error9. Errors and delays in communication can rapidly become critical to patient safety; it takes only a split second to severe an artery, or desterilise the operating environment. In addition, music can mask or conflict with monitoring signals and alarms12, 21, 30, 31 . High noise levels during surgery has adverse physical and psychological effects on patients as well. While sedation seeks to achieve patient comfort and cardiovascular stability, playing music that compounds distressing noise levels may undermine these goals18. Patients are at increased risk of noise induced hearing loss because of anaesthesia-induced paralysis of the stapedius muscle reflex that normally acts to attenuate loud sounds,27 and at increased risk of surgical site infections when OT noise is high32, 33. The presence of devices in theatre such as iPods and smartphones from which music is played raises additional concerns. Namely, their misuse is implicated in causing distraction, interfering with medical equipment, transmitting nosocomial infections, and compromising patient confidentiality34. Help or Hindrance â&#x20AC;&#x201C; What, Why and When? Minimising noise and distraction in the OT is cited as important for quality and safety5, 31. Still, the power of music to improve surgical performance and to foster a happier, more productive workforce12, 16 cannot be ignored. Given that 63% of surgical staff regularly listen to music in the OT1 and that no policy guidelines currently exist, the factors which tip the balance from helpful to hindrance need careful assessment to ensure
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that quality and safety are optimised, not compromised. Factors such as music type, vocals, volume, preference and familiarity, surgical experience, and critical operation phases influence the effect of music. Certain genres are associated with enhanced surgical performance4, 35. Classical music, easy listening and chart classics are popular choices associated with positive outcomes1, 16. Music with vocals seems to impair attention, whereas non-vocal compositions such as classical and jazz exhibit no such effect3, 10, 36. The volume ought to be low enough to not impair communication, concentration or monitoring systems, yet audible enough to mask noise and confer the performance benefits. Intuitively, we know that different people experience music differently. What some consider pleasant, another may find an annoyance. Familiarity with and preference for the music being played is key to its favourable effects10, 37, particularly when it comes to surgical accuracy8, quality, and time to task completion2. Considering the senior surgeon typically chooses the music, it may not be the favoured choice by everyone present. OT staff who prefer working without music or dislike the selected tunes can feel that it is being imposed on them30, a phenomenon likely to be exacerbated by cultural differences17. Special consideration should be given to nurses as they tend to be on the receiving end of communication errors6, and to anaesthetists who are tasked with vigilant audio-visual monitoring of the patient status3. Ascertaining and respecting individual preferences can help to safeguard high performance in critical care situations17. Familiarity with the task being performed influences a surgeons ability to simultaneously process auditory input21. The positive effects of music are roughly proportional to experience, whereby more experienced surgeons yield more benefit than less experienced trainees, whose concentration may be impaired on the same task with the same music9, 32. Noise levels tend to increase towards the end of surgical procedures, which coincides with final tasks like wound closure often being delegated to trainees32. It is reasonable to suggest that music be abstained from during training, and in novel, extended or complicated procedures, as well as emergency situations1, 38. Selective use of music during non-critical phases of the procedure does not to pose a major hazard5, but senior surgeons need to be cognizant of the potential effects on their
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team and on their patient and that these effects are more pronounced under certain conditions. A patientâ&#x20AC;&#x2122;s vulnerability and dependence on others during surgery creates an ethical duty for the quality and safety of care to not be knowingly put in jeopardy. Engagement with clinical governance structures may aid a systematic process for music in the OT, but surgeon leadership ultimately lies at the heart of a positive safety culture5. While formal processes may not be accepted or appropriate in all theatres, informal yet open discussions may be all that are needed to achieve a harmonious consensus. Weldon et al advocates the â&#x20AC;&#x2DC;team time outâ&#x20AC;&#x2122; undertaken as part of the WHO Surgical Safety Checklist as an opportunity to converse about the playing of music6. Thought could also be given to noise level monitoring in theatres and to documentation of music or noise conditions for the purpose of incident reporting and investigation. It is important to note that most research presented in this essay considered either self-selected music or pre-selected music believed to be calming13, 18, 20. Surgical performance was assessed in simulated conditions, while many patient studies utilised headphones, neither of which portray the true effects of music in the operating environment17. More research into the impact of music in non-simulated OT environments need to be conducted in concert with rigorous cost-benefit analyses to further clarify how the pros stack up against the cons. Conclusion Rewind to the opening case vignettes: My fleeting question about the effect of adding music to the second case remains unresolved. Subjectively, the jovial rock music enhanced the operating environment in the first case, while noise levels impeded communication in the latter. Perhaps a non-vocal melody in the latter situation played at an appropriate volume that was agreeable to the team might have lifted the mood, masked equipment noise, and enhanced quality and efficiency. Conversely, it may have simply added to the calamity. Perhaps the surgeon had made a conscious decision not to play music for this reason. Based on the literature examined, my verdict is that music has the potential to help or hinder quality and safety in the OT. Accordingly, determining the net effect relies on the judgement of the senior surgeon, whose accountability for the quality of care delivered calls for an evidence-driven assessment on a case by case basis.
REFERENCES 1.Ullmann Y, Fodor L, Schwarzberg I, Carmi N, Ullmann A, Ramon Y. The sounds of music in the operating room. Injury. 2008;39(5):592-7. 2.Lies SR, Zhang AY. Prospective randomized study of the effect of music on the efficiency of surgical closures. Aesthetic Surgery Journal. 2015:sju161. 3.Yamasaki A, Mise Y, Mise Y, Lee JE, Aloia TA, Katz MH, Chang GJ, Lillemoe KD, Raut CP, Conrad C. Musical preference correlates closely to professional roles and specialties in operating room: A multicenter cross-sectional cohort study with 672 participants. Surgery. 2016;159(5):1260-8. 4.Siu K-C, Suh IH, Mukherjee M, Oleynikov D, Stergiou N. The effect of music on robot-assisted laparoscopic surgical performance. Surgical innovation. 2010;17(4):306-11. 5.ElBardissi AW, Sundt TM. Human factors and operating room safety. Surgical Clinics of North America. 2012;92(1):21-35. 6.Weldon SM, Korkiakangas T, Bezemer J, Kneebone R. Music and communication in the operating theatre. Journal of Advanced Nursing. 2015;71(12):2763-74. 7.Hodge B, Thompson J. Noise pollution in the operating theatre. The Lancet. 1990;335(8694):891-4. 8.Conrad C, Konuk Y, Werner P, Cao CG, Warshaw A, Rattner D, Jones DB, Gee D. The effect of defined auditory conditions versus mental loading on the laparoscopic motor skill performance of experts. Surgical endoscopy. 2010;24(6):1347-52. 9.Wong SW, Smith R, Crowe P. Optimizing the operating theatre environment. ANZ journal of surgery. 2010;80(12):917-24. 10.Makama J, Ameh E, Eguma S. Music in the operating theatre: opinions of staff and patients of a Nigerian teaching hospital. African health sciences. 2010;10(4). 11.McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K. The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Quality and Safety in Health Care. 2009;18(2):109-15. 12.Moris DN, Linos D. Music meets surgery: two sides to the art of “healing”. Surgical endoscopy. 2013;27(3):719-23. 13.Ayoub CM, Rizk LB, Yaacoub CI, Gaal D, Kain ZN. Music and ambient operating room noise in patients undergoing spinal anesthesia. Anesthesia & Analgesia. 2005;100(5):1316-9. 14.Arai YC, Sakakibara S, Ito A, Ohshima K, Sakakibara T, Nishi T, Hibino S, Niwa S, Kuniyoshi K. Intraoperative natural sound decreases salivary amylase activity of patients undergoing inguinal hernia repair under epidural anesthesia. Acta Anaesthesiologica Scandinavica. 2008;52(7):987-90. 15.Newman A, Boyd C, Meyers D, Bonanno L. Implementation of music as an anesthetic adjunct during monitored anesthesia care. Journal of PeriAnesthesia Nursing. 2010;25(6):387-91. 16.Sadideen H, Parikh A, Dobbs T, Pay A, Critchley P. Is there a role for music in reducing anxiety in plastic surgery minor operations? The Annals of The Royal College of Surgeons of England. 2015. 17.Han L, Li JP, Sit JW, Chung L, Jiao ZY, Ma WG. Effects of music intervention on physiological stress response and anxiety level of mechanically ventilated patients in China: a randomised controlled trial. Journal of clinical nursing. 2010;19:978-87. 18.Ilkkaya NK, Ustun FE, Sener EB, Kaya C, Ustun YB, Koksal E, Kocamanoglu IS, Ozkan F. The effects of music, white noise, and ambient noise on sedation and anxiety in patients under spinal anesthesia during surgery. Journal of PeriAnesthesia Nursing. 2014;29(5):418-26. 19.Sarkar D, Chakrab K, Ghosh D, Chakrabarty K, Bhadra B, Singh R. Effects of music on patients caesarean section under spi. 2015.
20.Zhang X, Fan Y, Manyande A, Tian Y, Yin P. Effects of music on targetcontrolled infusion of propofol requirements during combined spinalepidural anaesthesia. Anaesthesia. 2005;60(10):990-4. 21.Way TJ, Long A, Weihing J, Ritchie R, Jones R, Bush M, Shinn JB. Effect of noise on auditory processing in the operating room. Journal of the American College of Surgeons. 2013;216(5):933-8. 22.Berglund B LT, Schwela DH. Guidelines for Community Noise. Geneva: World Health Organisation, 1999. 23.Government of Western Australia. Code of Practice: Managing Noise at Workplaces. WorkSafe Western Australia Commission 2002. 24.Love H. Noise exposure in the orthopaedic operating theatre: A significant health hazard. ANZ journal of surgery. 2003;73(10):836-8. 25.Engelmann CR, Neis JP, Kirschbaum C, Grote G, Ure BM. A noise-reduction program in a pediatric operation theatre is associated with surgeon’s benefits and a reduced rate of complications: a prospective controlled clinical trial. Annals of surgery. 2014;259(5):1025-33. 26.Chasin M. Decibel (Loudness) Comparison Chart. Retrieved January. 1997;14:2004. 27.Siverdeen Z, Ali A, Lakdawala A, McKay C. Exposure to noise in orthopaedic theatres–do we need protection? International journal of clinical practice. 2008;62(11):1720-2. 28.Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ, Gawande AA. Patterns of communication breakdowns resulting in injury to surgical patients. Journal of the American College of Surgeons. 2007;204(4):533-40. 29.Gurses AP, Martinez EA, Bauer L, Kim G, Lubomski LH, Marsteller JA, Pennathur PR, Goeschel C, Pronovost PJ, Thompson D. Using human factors engineering to improve patient safety in the cardiovascular operating room. Work. 2012;41(Supplement 1):1801-4. 30.Hawksworth C, Asbury A, Millar K. Music in theatre: not so harmonious. Anaesthesia. 1997;52(1):79-83. 31.Hasfeldt D, Maindal HT, Toft P, Birkelund R. Patients’ Perception of Noise in the Operating Room—A Descriptive and Analytic Cross-Sectional Study. Journal of PeriAnesthesia Nursing. 2014;29(5):410-7. 32.Dholakia S, Jeans JP, Khalid U, Dholakia S, D’Souza C, Nemeth K. The association of noise and surgical-site infection in day-case hernia repairs. Surgery. 2015;157(6):1153-6. 33.Kurmann A, Peter M, Tschan F, Mühlemann K, Candinas D, Beldi G. Adverse effect of noise in the operating theatre on surgicalsite infection. British journal of surgery. 2011;98(7):1021-5. 34.Attri J, Khetarpal R, Chatrath V, Kaur J. Concerns about usage of smartphones in operating room and critical care scenario. Saudi journal of anaesthesia. 2016;10(1):87. 35.Mentis HM, Chellali A, Manser K, Cao CG, Schwaitzberg SD. A systematic review of the effect of distraction on surgeon performance: directions for operating room policy and surgical training. Surgical endoscopy. 2016;:1713-24. 36.Shih Y-N, Huang R-H, Chiang H-Y. Background music: Effects on attention performance. Work. 2012;42(4):573-8. 37.Kim Y-K, Kim S-M, Myoung H. Musical intervention reduces patients’ anxiety in surgical extraction of an impacted mandibular third molar. Journal of Oral and Maxillofacial Surgery. 2011;69(4):1036-45. 38.Bosanquet DC, Glasbey J, Chavez R. Making music in the operating theatre. BMJ. 2014;349:g7436.
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wednesday Justine Binny Western Sydney University
It’s Wednesday. The end day. Today is not my friend. I missed the whole morning ‘Cause I sleep-walked again. And last week? Last Wednesday? I was balanced on the edge and some hands hauled me back and for that I am grateful But I dredge up all the Wednesdays that preceded these recent horrors And my headaches and my migraines correspond to times when I was trying to escape the banality and the mundane non-Monday So this is the final Wednesday in which I will share in the pain
First I need to hold it and hate it for holding me back and thank it for showing me the truly evil knack people have of strangling you when life’s already knocked you out. So I’ll come back but only if it’s Thursday and I win the next bout. If you can’t tell me why Then I won’t understand And I won’t do it your way
This isn’t lyrics, this ain’t a poem, this is soliloquy. This is Me standing alone on the stage. Only Me. This isn’t lyrics, this ain’t a poem, this is soliloquy. This is Me standing alone on the stage. If you can’t tell me why Only Me. Then I won’t understand This isn’t lyrics, this ain’t a poem, this is soliloquy. And I won’t do it your way This is Me standing alone on the stage. Only Me. I guess if I was grateful I’d appreciate the creative This isn’t lyrics, this ain’t a poem, this is spark soliloquy. but this Wednesday I wish I had nothing to say This is Me standing alone on the stage. rather than play in this dark. Only Me. The reality, I realise, is that my Wednesday wasn’t the worst If you can’t tell me why but something inside needs to end it before it can Then I won’t understand And I won’t do it your way end me
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newghc2016: creative team
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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scar stories
nikhil, leukaemia by analia paino Nikhil Autar Western Sydney University Jasmine Gailer scarstories.org Analia Paino analiaphotography.com
Scar Stories Inc. has been running as a creative project since 2011, showcasing photographic images of young cancer patients who have been scarred by their treatment. The charity has a specific mission: to raise awareness about young adult cancer; raise funds for specialty care for this age group; and help these young people come to terms with what most people keep hidden following cancer treatment - the physical scars that remind them of a grim, painful experience. Jasmine Gailer started Scar Stories as a fundraising project for CanTeen in 2011 after her own experience with cancer. After taking a photo of her cancer scar in an effort to overcome the negative body image associated with it, then 22-year-old, Jasmine, felt better for it! Jasmine grew Scar Stories from a project into a self-sustaining charity and over the last five years the organisation has exhibited more than 50 scar portraits, with 16 professional photographers, exhibited around Australia and embarked on a number of exciting projects and support services for patients and survivors. Coming to terms with life post-cancer is challenging, but being involved in advocacy projects helped Jasmine and she believes it can help other young people as well. Any 18 - 35 year old cancer patient or survivor can access Scar Storiesâ&#x20AC;&#x2122; services, whether that is posing for a photographic portrait, attending a free art, music or photography class, going along to one of Scar Storiesâ&#x20AC;&#x2122; social events, or volunteering for the organisation.
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I was diagnosed with leukaemia at 17 and given a 10, maybe 20% chance of living. This was 4 years ago... I was devastated...as any human being would be. But after a while, I started to hate that feeling. The constant depression. The tears. The gut clenching dread. I wanted this to all be over. I wanted a way out of the hole I’d dug myself. But there wasn’t much to really look forward to. In the end, what ended up helping me most was a simple thought exercise I did one day. I took a step back and looked at what had happened to me, as if it had happened to someone else. From there I guess I saw everything that had happened to me objectively. So I could question everything that was going on and more importantly, what I was doing. And I did that through asking WHY. Why was I feeling that way? There was no answer. In the end I realised I had what I had. Though it may suck, I couldn’t go back in time and change what had happened. I couldn’t take away my cancer. What was my anger and frustration accomplishing? Nothing. Other than making me feel WORSE about everything. Why was I feeling that way then? I didn’t have an answer for that. But that question alone made me realise one thing that stays with me to this day. Because in the end all those feelings; the anger, fear and depression – all of it was coming from ME. My brain. My mind. If I was making myself feel that way, that meant I could take that away too. In the end, We Will ALWAYS have the final say of what’s going on with us. But we’re only human, right? And with months to years of chemo, pain, treatment; all of which is likely leading to me dying anyway, there wasn’t much to look forward to, right?
So I questioned those fears and doubts too. Again, one question got me through that. ‘Why?’ Why was I thinking I was cursed for being diagnosed so young? My doctor’s words as this happened rang through my head as I heard this. When I was diagnosed he told me, “The good news is, you’re 17 and you have leukaemia, but the bad news is, you’re 17 and you have leukaemia”. Good news? GOOD NEWS? REALLY? I remember thinking for a while after that. But when I thought about it, being diagnosed young meant I could get the optimal treatment, I could recover faster. I didn’t have a job or a family or kids to worry about. Indeed, I had one right there beside me the whole way! What I once thought was a curse turned out to be a blessing… Why was I so afraid? I was looking at chemo as a thing that brings pain, misery and suffering. And it would. But wasn’t it also a medicine? The very thing that could get me out of this? Indeed, my doctors wouldn’t be putting me through this if they didn’t think it could work. Why was I so pissed off, afraid and depressed? In the end, I was worrying about all these things I couldn’t control. And that worry and stress was only hurting me more. From stepping back and looking at my situation27
objectively I could see that the only logical thing to do was to focus on the things I could control! My health. My actions. And my happiness. Because what this has taught me is that you will always have a second, better way, of looking at things. ALWAYS. It’s not easy to see that straight away. Definitely not if you’re overwhelmed and in the midst of it. But if you can take a step back, talk about it with someone, and just ask ‘WHY?’ You can get yourself through just about anything and become the happiest, most successful version of yourself.
It doesn’t take courage. I wasn’t brave or inspiring or crazy in my ‘battle’ (in truth, it was a beating) with cancer. I cried, I wailed for it to be over. I still do sometimes (beating cancer isn’t always the end of suffering for many survivors). But I kept in mind these things; what it was all for, and by doing that I saw something good in the darkest days of my life. You don’t need some crazy willpower or positivity either. Because in the end… if you can take that step back, and ask why.. If you can help your friends and family do the same… then it becomes only logical, it only makes sense to take the path that leaves you most well off. And I hope what I’ve said can help you do this.
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Nikhil writes a blog about his journey, hoping to inspire the medical profession (he’s studying medicine now!) to care more for their patients, educate people on worthy causes and ultimately, to help others out in all kinds of circumstances (he truly believes this mentality can help with anything, from the mundane struggles we have in day to day life, to the epic journeys we take in life). He’s also doing many exciting things, including research, and growing his own charity! You can find him at nikhilthegrizzlybear.blogspot.com.au
“the international medical student” Latha Deva, University of Melbourne
Latha Deva is a third year international medical student at the University of Melbourne and is the National Projects Officer on the AMSA Executive. The views expressed in this article are the author’s own and do not reflect the views of affiliated organisations. At AMSA’s Third Council last month, student representatives from all around Australia met in Sydney to discuss AMSA’s policies and raise pertinent issues experienced by medical students around the country. The 2016 National Survey results were discussed in part, to inform representatives of the views of medical students and to guide future policy. The survey had 1300 respondents, with varying response rates across universities which did not proportionally reflect their enrolment numbers. Over 75% of the respondents were domestic medical students. One section of the survey required students to rank groups of applicants according to how they believed internships in Australia should be allocated. I was eager to read these results, to learn what my colleagues across the country thought about this widely discussed issue, in lieu of the looming internship crisis. The results revealed the following priority ranking: 1. Domestic students applying in the state in which they have graduated medical school 2. Domestic students applying in a state in which they completed year 12 but did not graduate from medical school 3. International students applying in the state in which they have graduated medical school 4. Domestic students applying in a state in which they neither completed year 12 nor graduated from medical school 5. International students applying in a state other than that in which they completed medicine
6. Graduates of medical schools outside of Australia As I read these results, the only thing that I took away was this – “my friends believe I am taking away their jobs”. The thing that most medical students, including some of my closest friends, don’t often realise, or perhaps even consciously remember in their interactions with me, is that I am an international student. The number of times my colleagues have been surprised to learn that I am on a student visa is countless. “I never picked that you weren’t from here” “You’re from Singapore? How do you not have an accent?” These seemingly innocuous statements disguise the deeper reality that most students have a certain face associated with “The International Medical Student”. In a country that is home to many diasporas with residents coming from over 200 countries, we pride ourselves in our diversity and inclusivity. This empathy and respect for those who have varied social, cultural, linguistic, and religious backgrounds, is generally heightened amongst medical professionals. However, this priority ranking suggests that perhaps we are not as accepting as we would like to believe. When faced with a threat, we are naturally compelled to guard our territory. The looming internship crisis, fuelled by insufficient federal and state investment in medical internship positions despite workforce shortages, makes us all want to defend our jobs. While this cloud of uncertainty hangs over us, we must remember that state governments continue to guarantee every single domestic student an internship in the state in which they have graduated medical school. This is the most statistically reasonable way to ensure that most of Australia’s medical graduates
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get registered, while ensuring that they are able to pay off their HECS and FEE-HELP debts. However, our international colleagues often do not have this job certainty in their home countries. Many have no prospect of being registered as a medical practitioner without an internship position in Australia. A large majority have forged deep roots here, having called Australia home for anywhere between 4-8 years, and have far too much to lose professionally and personally without an internship. But this harsh reality doesn’t come to the forefront when one contemplates “The International Medical Student”. As evidenced by the National Survey results, most of my colleagues believe that they should be considered for jobs in the state they completed Year 12, and prioritised over their international colleagues who are graduating from that very state. When push comes to shove, we aren’t afraid to exert this idea of “otherness”. Some of our med-
council 3, 2016: latha deva & chris simpson
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ical schools do not have any international students enrolled. So when we have discussions about who deserves jobs and where people should go, stories of “The International Medical Student” can get mistold by eyes holding images of stereotypes and untruths. Naturally, our own experiences and perceptions govern our beliefs. But please, do recognise that the jobs your international colleagues are asking for are not yours. They are not trying to take away your jobs; they are just asking for jobs too. Lend your voice to this discussion so that your domestic colleagues can develop well-informed views. Do not be afraid to challenge the status quo and demand for more funding for training positions to address the workforce shortages in regional, rural and remote Australia in a sustainable manner. Help your international colleagues who are outnumbered, and show leadership by defending those without a strong voice. Collectively, let us change this narrative so that every Australian medical graduate is guaranteed the training opportunity they deserve.
VAMPIRE CUP RESULTS amsaâ&#x20AC;&#x2122;s national blood drive
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a letter to first-year me Sophie Collins University of Newcastle Dear 17-Year-Old Sophie, On that fateful night in January when uni offers are released, you’re crying in your grandma’s house as you’re struck with the reality of moving away from home for the first time. You’ve made it into medical school – in Newcastle. As a girl who’s lived in the same Sydney suburb for roughly 14 years, “far away” to you means the 25-minute commute into the city. You can’t even picture what it would be like to move 2 hours away to a regional centre you’ve visited maybe twice in your life. But, spoiler alert: you do it, and it’s the best decision you’ve ever made. You make lifelong friends, learn how to do your own laundry, and apparently even get to be a doctor at the end of it all. But it’s not all sunshine and roses. In between laughing yourself stupid at 1am with friends, you are going to cry harder than you have ever cried in your life. You are going to meet doctors whom you want to be when you grow up, and doctors who make you want to leave the profession forever. You’re going to take naps like you haven’t since preschool and stay up on night shift until you are nauseous. And you’re going to almost faint in surgery. A lot.
• DO: something interesting for your elective in first year. It’s the one chance you get to study something non-medical at uni! Music. Poetry. French. Or if not something creative: anatomy. You’re going to need it. (See point #1.)
sane here, and browsing tumblr until midnight does not count. (Actually, quit that website for good. It will make you a much happier person.)
• DO: find a way of studying that works for you. When you get to second semester fourth year and you still haven’t figured out whether listening to music makes you more or less productive, you’ve really missed the boat.
• DO: put a bra on before leaving the house every day. You would think it would be difficult to forget to do this. It is not. If you ever needed proof that medical school will make you crazy, there it is.
• DO: a rural year! Your time in a regional hospital will absolutely be the best thing for your medical • DON’T: be fooled into think- education. Plus it makes Newcastle ing you can get away with doing just look way closer to home. one learning target for PBL each • DON’T: mix vodka and week. You learn nothing by doing slushies. Trust me. This does not this. Your first semester tutor is ly- end well. ing. • DO: go to ALL the medsoc • DO: audition for MedRevue, events! While college parties (and every year, until they let you in. It will non-med friends) are special, it’s become the highlight of your time in important to get to know everyone medical school. in your cohort too. • DON’T: squander your • DON’T: ask your patients pre-clinical years. It’s pretty much for permission to watch their op the last free time you’ll ever have. when they’re already tripping on You won’t understand the mean- midazolam. You will carry the look ing of “full-time uni” until you have the anaesthetic registrar gives you to get up before dawn for surgical to your grave. (Also it’s very unethrounds. ical.)
• DON’T: develop a crush on one of your housemates. It just makes things awkward. (This rule also applies to directors of MedRevue and law students.)
• DON’T: fret about moving away from home. In Newcastle – and beyond – you are going to befriend some of the most wonderful people you’ve ever met in your life: people who are kind, intelligent, hilarious, loving, and absolutely make you into the best version of yourself that you can be. You will go on road trips and camping trips and move in together and stay up until 3 in the morning discussing the meaning of life. And it will be wonderful.
So, how to survive the next five tumultuous, challenging, sleep-deprived, chocolate-fuelled years? Well, I haven’t made it through all of them yet, but here are some handy dos and • DO: be prepared to have don’ts for the first few (some I did, your mind blown by the humble Mcand some I wish I didn’t)... Flurry. As a girl who’s never tasted • DO: memorise the difference a McDonald’s dessert in her life, between the left and right sides of the you are gonna be spending way too heart early on. This will make your life much money on these bad boys. See also: Yogurtland, waffle fries, and way easier. • DO: call your family often. • DON’T: buy expensive text- trips to Kmart. DON’T: give up running or You’ll miss them. books. The library is a wonderful • music. You need hobbies to stay thing.
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council 3, 2016: sydvention convener scott ashby
humans of mental health Rob Thomas University of Queensland
If you’ve met me before, I was probably in pain that day. They say around 90% of mechanical back pain self-resolves in less than 6 months. For my low back pain, it’s coming up on 36 months and I’ve given up hope of being completely pain-free. It has dashed my lofty hopes of being a sportsman, or being a surgeon. The link between chronic pain and depression is well-established, but this year I felt it myself. Faced with a 7-week flare, culminating in 3 weeks of constant 8/10 pain I was desperate for help. I went to a GP on the Coast where I was on placement, not my regular one. I know as a med student that chronic pain is near impossible to fix – it’s a “management dilemma”. What I really wanted that day was some validation that my pain was real – what I got was an offer for strong opioids, something that I refuse. Future doctors, understand this: you can never know the pain that the people around you endure. Do not disregard pain because it’s hard to fix, and don’t ignore the alternative medicine route when it comes to patients finding comfort. I can last days or weeks with a smile on my face, in 6/10 pain sometimes. Pain goes hand in hand with suffering, and sometimes all a patient really needs is for you to acknowledge that you care.
This year, the AMSA Mental Health team focused on three key goals, a bulk-billing database of medical professionals, a “Wellbeing Toolkit” for mental health student bodies and representatives, and a month long campaign, “Humans of Medicine”. In October, we began a daily campaign to reach out to medical students across Australia, releasing articles, advice, tips and talking points, along with links to stories about real medical students. These submissions allowed medical students to boldly disclose physical and mental health problems and issues they had encountered during their time studying, as well as strategies and techniques used by them to help make it through the other side. Stories came from students of many different universities, both clinical and pre-clinical, discussing diverse topics including the mental health effects of chronic pain and other physical illnesses, anxiety, depression, exhaustion and interpersonal struggles. We closed out our campaign, with additional study tips, exam stress-management ideas and where to turn if deferrals or special consideration was needed. With nearly 300 new likes, daily posts, and nearly 20 new Humans of Medicine stories, we hope this year’s campaign is just the first step towards de-stigmatising mental illness amongst medical students and starting a conversation about how we can all be healthier, happier and able to assist colleagues in need. Raymond Chester-Wallis Mental Health Campaign Coordinator mentalhealth.amsa.org.au
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team
A collection of photos of AMSA’s Executive, e to showcase all our amazing volunteers and
National Executive First row L-R: Tabish Aleemullah (UNSW), Latha Deva (UniMelb), Elise Buisson (WSU), Bradley McIntyre (USyd), Ciaran O’Brien (USyd) Second row L-R: Millie Garg (UNSW), Jaffly Chen (UNE), Matthew Lennon (UNSW), Chloe Boateng (WSU), Sunela Pathirana (UNSW), Jessica Yang (WSU)
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photos
events teams, committees and project teams d the work they put into our organisation.
AMSA Representatives First row L-R: Rob Thomas (UQ), Tarren Zimsen (JCU), George Martin (UNDF), Jack Lego (UTAS) Second row L-R: Blaire Brewerton (Flinders), Merredith Cully (UWA), Haydn Dodds (Bond), Melanie Stevenson (USyd) Third row L-R: Oliver Hovav (UoW), Monica Chen (Adelaide), Douglas Roche (Griffith), Josh Monester (Monash) Fourth row L-R: Joshua Darlow (UoN), Pedro Pau (UNDS), Kate Penfold (UNE), Ali Cimen (WSU), Cecile Pham (UNSW) Fifth row: Tom Harvey (ANU) Not pictured: Rosey Chen (UNE), Basheer Alshiwanna (UoN), Dale Jobson (Deakin), Matt Bright (UniMelb)
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event
National Leadership Development Seminar L-R: Jeremy Abetz (Monash), Hannah Rayner (USyd), Michael Zhang (Monash), Tayla Tatzenko (UQ), Steph Baddock (ANU), Pip Dosseter (ANU), Maria Rimsha (UoN), Ian McConnell-Whalan (ANU)
National Convention, Townsville First row L-R: Vrushank Bakshi, Lisa Fernandez, Sophie Manoy Timothy Mettam, Katherine Rimmer, Satyen Hargoven, Brendon Loh, Reece Tso, Isabel Guthridge, Annabelle Chalk, Muditha Nanayakkara, Holly Sexton Second row L-R: Kari Ludvigsen, Krisnel Chang, Orla Barry, Angelica Traint, Sajid Chowdhury, Honor Magon, Zac King
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teams
Global Health Conference, Newcastle L-R: Jaz Daniells, Jana Kobras, Allisa Robertson, Bhavi Ravindran, Caroline Powers, Imogen Andrews, Abbi Linghanathan, Jack Mackenzie, Brett Scott, Jessey Blake, Jim Fann, Laura Dryburgh, Adelaide Pratt, Ming Yong, Nas M Abdul
Rural Health Colloquium, Melbourne First row L-R: Samantha Donaldson, Julie Graham, Mitch Simpson, Yindi Sutton, Jasper Lin Second row L-R: Isabelle Anne, Ella Warboys, Ryan Horn, Ashley Wang
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comm
AMSA Global Health In pairs L-R: Alice Mizrahi (Monash), Charlotte Oâ&#x20AC;&#x2122;Leary (Monash), Tom Pearson (UQ), nick mannering (UMelb), Olivia Anderson (Flinders), Gowri Shivabesan (Monash), Bethany Holt (UQ), George Martin (UNDF) , Alma Corker (UWA), Erin Clarke (UNDF), Idy Deng (UoN), Tash Abeysekera (UTAS), Tahlia Gadowski (UQ), Alyssa Pradhan (Adelaide), Anju Roy (UNSW), Stormie de Groot (UNE) Bottom: Jordan Budgen (UQ) Not pictured: Nadia Perera (UNSW), Julie Graham (JCU), Carolyn Reimann (JCU), Laalithya Konduru (Flinders), Bec Kelly (UTAS), Katie Burkitt (ANU), Matt Paltridge (JCU)
AMSA Rural Health L-R: Morgan Jones, Skye Kinder, Emily McLeod, Ryan Horn, Soph Alpen, Ellie Isom, Jenna Mewburn, Mitch Simpson, Brad Wittmer Not pictured: Zhengjie Lim, Bhagya Mudunna, Jiwanjot Kau
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mittees
AMSA Mental Health
Vampire Cup
Raymond Chester-Wallis
Top: Dale Jobson (Deakin), Bottom: Christopher Simpson (UQ)
Medical Education Committee
International Studentsâ&#x20AC;&#x2122; Network Top: Reuben George, Bottom: Amanda Ciozda Not pictured: Caleb Lin
First row L-R: Vanessa Wong (Monash), Aidan Allen-Hall (UWA), Rob Thomas (UQ), Anuj Krishna (Monash Second row L-R: Grace Kim (UNSW), Jeffery Wang (Monash), Konrad Pisarski (UQ), Georgia Bertram (UNDF)
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