AMSJ Volume 11, Issue 1 2022 by Australian Medical Student Journal

© 2022 Australian Medical Student Journal Australian Medical Student Journal, PO Box 2119, Carlington Court, Carlington NSW 2118 enquiries@amsj.org www.amsj.org Content © 2022, the authors ISSN (Print): 1837-171X ISSN (Online): 1837-1728 Editor-in-chief Mabel Leow Typesetting Faraz Torabi The Australian Medical Student Journal is an independent not-for-profit organisation. The Australian Medical Student Journal can be found on the EBSCOhost databases. Responsibility for article content rests with the respective authors. Any views contained within articles are those of the authors and do not necessarily reflect the views of the Australian Medical Student Journal.

Contents Book Review……………………………………………………………………………….1 Book review – Are you passionate about paediatrics?................................................................................................................1

Case Reports ………………………………………………………………………………3 An Unusual Presentation of Perforated Appendix Mimicking a Liver Abscess in an Aboriginal Male ………….…..3 Skin Rash in a Patient using Antiepileptic Medications, What Could it be? ....................................................................... 6 When Trauma Meets Infection in A Lower Income Country ................................................................................................. 10

COVID-19 Perspectives ................................................................................. 15 COVID-19 as a Valuable Learning Opportunity ......................................................................................................................... 15 COVID-19: Adaptations to Primary Care in Australia ............................................................................................................... 20 Social Distancing and Domestic Violence: An Exploration of the Paradoxical Impact of Our Public Health Response to COVID-19 ……………………………………………………………………………………………………………………………………24

Feature Articles …………………….…………………………………………………..27 Climate Emergency in Australia and the Need for Inclusion of Indigenous Peoples in Solutions ………………….27 Continuity of care; a final year medical students’ professional and personal experience in rural Australia whilst on a longitudinal placement in Broken Hill, New South Wales ………………………………………………………………………32

Literature Review ……………………………………………………………………...35 Simulation Training In Laparoscopic Surgery ………………………………………………………………………………………………...35

Original Articles ………………………………………………………………………..41 Exploring the Reasons for Medical Student Participation in Peer Mentoring Programs ………………………….……41 Enablers and obstacles to medical student satisfaction during obstetrics and gynaecology rotations ………...48

Executive Board ………………………………………………………………………..55 Staff List ………………………………………………………………………………….56

Editor-in-Chief Introduction Dr Mabel Leow, MD PhD Editor-in-Chief, AMSJ

Welcome to Volume 11, Issue 1 of the Australian Medical Student Journal. The COVID-19 pandemic has presented unique challenges to medical students. Whenever we begin to see a glimpse of hope, a new wave of virus comes crashing, and we all return back to status quo. As a result of COVID-19, overseas placements, and some research activities which involves the recruitment of clients have also been suspended. This must have been disappointing. We look forward to returning to the pre-COVID-19 days. This issue consists of two original research papers, one review paper, two featured papers, three case studies, one book review, and three COVID-19 reflections. Readers can look forward to a range of topics in general surgery, dermatology, infectious diseases, and medical education. To increase the readership of our articles, we have also published the papers on AMSJ’s Facebook page. Do like and share the posts if you or your friend’s paper is published! As mentioned in the previous issue, we have started an Understudy team to provide a platform to train pre-clinical medical students with minimal research experience, but aspire to be editors. I am proud to announce that all of them have now become our Associate Editor. Congratulations! If you have an interest in being an editor but have no prior experience, please do not hesitate to reach out to us! Last but not least, I would like to thank everyone who have made this issue possible. First, the AMSJ team is grateful to the authors who have chosen to publish their work in AMSJ. Thank you all for putting in effort for the multiple amendments. We hope that you have learnt from our comments and suggestions. As the Editor-in-Chief, I would also like to thank my entire editorial and proofreading team who have been most supportive. I’m also grateful to the Internal and External team who have been working hard to put the manuscripts together to form this issue. It has been a great challenge for all of us! We hope that you will enjoy reading this issue, as much as we have put this issue together. Correspondence: mabelleowqihe@yahoo.com

Book Review

Book review – Are you passionate about paediatrics? Teresa Sheng En To1 1

University of Notre Dame Australia Teresa Sheng En To completed a Bachelor of Medical Science degree at the University of New South Wales before undertaking an Honours project at Children's Cancer Institute as part of her Honours program. She went on to complete a PhD in cardiovascular health with an in-depth study into the role of myeloperoxidase in endothelial dysfunction and its treatments.

Teresa is now a second-year medical student at the University of Notre Dame Australia and is currently Director of the External Team at the Australian Medical Student Journal.

Introduction Over the last half century, the practice of primary care for children has evolved tremendously. Although paediatrics is a relatively young field compared to other specialties, like a child, it has grown to become an integral part of the health system. The previous international award-winning third edition, Paediatrics and Child Health [1] is succeeded by the latest edition Essential Paediatrics and Child Health [2], which includes twenty-six chapters that are covered in a 520-page textbook. This beautifully presented book combines Prof. Mary Rudolf's four decades of experience as a consultant paediatrician and Professor of Child Health at Leeds University with that of Prof. Anthony Luder and Dr. Kerry Jeavons who both are experts in the field of paediatric medicine.

Summary of Contents The authors carefully combine the core principles and practice of paediatrics into one book, which is perfect for medical students. The textbook begins with an introductory chapter on getting the most out of a paediatric rotation and how to perform well in paediatric assessments, examinations, and objective structured clinical examinations (OSCEs). The book is structured into four main parts. The first part addresses health education and health promotion in children, long-term paediatric conditions, the importance of early years and parenting, and a child’s neurological, emotional, physical, and psychological development. It also discusses how nutrition, physical activity, sleep, and social determinants can play pivotal roles in children's development and health. The second part takes the reader through a thorough paediatric history and performing clinical examinations. For the first time, this fourth edition includes new content on how best to communicate with children, their parents, and colleagues. The authors explore ethical dilemmas that involve children and their parents, taking into consideration the best interest of the child. For example, the principle of autonomy refers to the right of the patient including the child/adolescent to exercise control over his/her body. However, a paediatric patient’s capacity to take part in the medical decision-making process is limited to some extent. This textbook describes how to best manage challenging medical situations that are beyond the doctor's control. The third part includes clinical chapters that are well-structured into systems including respiratory, gastrointestinal, cardiac, neurological, endocrine, musculoskeletal, renal, genitalia, dermatology, and hematological disorders. Each system covers signs and symptoms, history, examinations, investigations, diagnosis, management and treatment, patient education, follow-up, and prognosis. The layout of this textbook is carefully arranged to benefit students’ learning including ‘Diagnosis’ boxes that enable students to understand and differentiate one condition from the other, which is key for making a successful clinical diagnosis. There are ‘Key-points’ boxes that help students remember concepts, ‘At a glance’ boxes that

Book Review

summarise important concepts relating to that condition, and diagrams and flow charts for visual learners who prefer quick facts. There are clear ‘Red flag’ boxes that help depict important signs and symptoms of serious conditions that cannot be ignored. If you are a lover of Murtagh's General Practice [3], then this comprehensive paediatrics textbook is for you, as it takes a simple problem-based approach that is easy to follow and wellorganised. The fourth part contains over two hundred multiple choice questions (MCQs) including two MCQ practice examination papers with answers and cross-references to relevant pages for a more in-depth explanation. Perhaps in the next edition, it would be beneficial to include short explanations with each answer to ensure that students can clinically reason through the answers. Nevertheless, it has often been said that active learning is more effective than passive learning when it comes to exam preparation and revision and, as a medical student, I could not agree more.

notes next to the text, and even share notes with friends. There are icons displayed throughout the textbook that link readers to evidence-based guidelines and videos that show a step-by-step approach on how to examine children with important signs indicated to reach the diagnosis for each system. For the first time in this edition, there are scenarios that allow readers to clinically reason through common problems and diagnoses before managing conditions. This interactive textbook comes with downloadable images that students can copy and paste into their own documents. Whether you are planning, practicing, preparing, or have a passion for paediatrics, this textbook is perfect for medical students who may like to specialise in this field or for readers who need a vital guide for quick referencing during their paediatric rotation in medical school. This textbook provides a comprehensive resource for readers who would like to obtain a deeper understanding of the world of contemporary paediatrics and to keep up to date with the latest technological advances that are available in diagnosing and treating diseases in children.

Review This interactive textbook comes with free access to Wiley E-Text, which allows readers to highlight information, make digital

References 2. 1.

Rudolf M., Lee T., Levene MI. Paediatrics and Child Health. 3rd ed. (UK: John Wiley & Sons); 2011.

Rudolf M., Luder A., Jeavons K. Essential Paediatrics and Child Health. 4th ed. (UK: John Wiley & Sons); 2020. Murtagh H. Murtagh’s General Practice. 7th ed. (AUS: McGrawHill); 2019.

Acknowledgements: The book was provided by John Wiley & Sons. Conflict of interest statement: This is an invited book review by John Wiley & Sons. Funding: None to declare Cite as: Teresa Sheng En To. Book review – Are you passionate about paediatrics? Aust Med Stud J. 2021;1:748–51. Correspondence: Teresa Sheng En To, godbless4eva@hotmail.com Date of submission: 19 December 2020 Date of acceptance: 25 March 2021 Date of online publication: 27 March 2021 Editor: Elizabeth Kaganov Senior Editor: Dhruv Jhunjhnuwala, Mabel Leow Proofreaders: Abhishekh Srinivas, Nadiah Binte Mohamad Shariff Senior Proofreader: Emily Feng-Gu

Case Report

An Unusual Presentation of Perforated Appendix Mimicking a Liver Abscess in an Aboriginal Male Justin Ho-Yin Ng1, Martha Lok-Yung Hui1, Shaveen Kanakaratne1, Justin Ho-Yin Ng1 1

Alice Springs Hospital, NT Justin Ho-Yin Ng is an elective student at Alice Springs Hospital, NT and recent medical graduate at Monash University in Clayton, Victoria. Prior to medical school, he obtained an Honours Bachelosr of Science with Distinction at the University of Toronto-St. George in Canada, majoring in Human Biology and Animal Physiology with a minor in Physiology

Key learning points • Atypical presentations of a perforated appendix • Differential diagnosis of a subphrenic abscess • Challenges for the Aboriginal population predisposing to delayed treatment Abstract Introduction: A perforated appendix presents as an atypical right-sided subphrenic, subcapsular hypodense collection on the computed tomography (CT) scan, mimicking a subcapsular liver abscess. Case: A 26-year-old Aboriginal male presented to Alice Springs Hospital with a one-month history of right-sided abdominal pain, as well as weight loss of 16 kg following treatment with three courses of antibiotics for a suspected sexually transmitted infection. Radiological findings on CT revealed a mild right pleural effusion with right lower lobe partial atelectasis and a right-sided subphrenic, subcapsular hypodense collection with an air-fluid level in the right lobe of the liver. A diagnostic laparoscopy showed a suspected perforated appendix, which was later managed by laparoscopic drainage. This was followed by an open interval appendicectomy with abscess drainage. After one further ultrasound-guided drainage and a 6week course of antibiotics, he was discharged and had a good recovery. Discussion: This case report aims to highlight the importance of a high grade of clinical suspicion for atypical presentations of perforated appendix, as well as the role of exploratory laparoscopy in managing uncertain diagnoses.

Keywords: Aboriginal, perforated appendix, liver abscess Introduction Perforated appendices, one of the complications of acute appendicitis, may present atypically, leading to misdiagnosis and delayed treatment. Furthermore, findings of radiological modalities, such as with computerised tomography (CT), do not always point to the diagnosis of the abscess. In this case, we report an Aboriginal patient in Northern Territory with a perforated appendix presenting with an atypical right-sided

Having had various clinical placements in rural and remote settings across Australia, Justin has developed a keen interest in rural surgery, Indigenous public health administration and health equality Jayantha Senaratne, MBBS, Consultant General Surgeon, Alice Springs Hospital, NT. subphrenic, subcapsular hypodense collection on the CT scan, initially imitating a subcapsular liver abscess. Northern Territory has an estimated population of 245,562 persons, where 30% of the population is Aboriginal [1]. The patient lived in a small community of 199 people in Mount Liebig, locally known as Watiyawanu, a region 325 km west of Alice Springs [2]. In view of the limited local medical facilities, he was transferred to Alice Springs hospital by the Royal Flying Doctor Service. A subcapsular liver abscess was diagnosed on an abdominal CT scan and managed by laparoscopic imaging and drainage due to the unavailability of an interventional radiologist at the time. He needed two further interventions by way of an open appendicectomy with abscess drainage and radiological drainage before being discharged.

Case A 26-year-old Aboriginal male presented to Alice Springs Hospital with a one-month history of right-sided abdominal pain and weight loss of 16 kg. These symptoms occurred following treatment with three courses of antibiotics for a suspected sexually transmitted disease in a community outreach clinic in outback Central Australia. This provisional diagnosis was made given the ongoing abdominal pain and limited investigations available at the outreach health centre. Following treatment, he had unresolved pain, new coughing, and intermittent vomiting. He reported no other significant relevant background medical or surgical history. His vital signs on admission were within normal range. On examination, there was a dull percussion note at the right lung base with decreased air entry. His abdomen was firm, with slight distension and tenderness over the right upper quadrant region and audible bowel sounds. A CT scan of the abdomen with contrast was carried out, showing the presence of a mild right pleural effusion with right lower lobe partial atelectasis. It also showed a right-sided subphrenic, subcapsular hypodense lesion with an air-fluid level in the right lobe of the liver, as shown in Figures 1 and 2. Other than the subcapsular collection (132.7 x 38.7 x 141.3mm), no evidence of hepatobiliary abnormalities, appendicitis, or periappendiceal abscess was reported. Due to the unknown origin and unavailability of interventional drainage during this time, a

Case Report

diagnostic laparoscopy was performed, revealing that the collection had most likely resulted from a suspected perforated appendix. The patient was managed with laparoscopic drainage of the abscess, washout and placement of drain (Figure 3). Further dissection inferiorly towards the caecum was not performed to avoid inadvertent iatrogenic bowel perforation. Following index laparoscopic drainage, the patient was managed with intravenous antibiotics and drain removal on the fourth post-operative day with minimal output. He declined further medical advice upon drain removal, choosing to take own leave, a culturally respectful practice by Aboriginal Australians to return to their community. He represented almost one month later with fevers and recollection of the abscess on repeat CT. Following this, an open interval appendicectomy with abscess drainage was performed via midline laparotomy. A

remnant appendix was found in the right iliac fossa with the caecum intact and no obvious site of perforation. Postoperatively, he required one further ultrasound-guided drainage of an abscess with interventional radiology and a further six-week treatment of intravenous antibiotics under the guidance of the infectious disease team. During his inpatient stay he required regular drain flushes and aspirates into the abscess cavity. The drain was eventually removed in an outpatient setting, once there were minimal aspirates and no further collections on repeat ultrasound imaging. He has since been discharged home and has made a good recovery.

Table 1: Laboratory investigations upon admission to Alice Springs Hospital. Test Result

Reference Range

Indication

Sodium: 123 mmol/L

135-145 mmol/L

Low

White cell count: 18.9 x 109/L

4.0-11.0 x 109/L < 21 umol/L

High High

Alkaline phosphatase: 155 U/L Gamma-glutamyl transpeptidase: 117 U/L

30-110 U/L

High

< 61 U/L

High

Albumin: 32 g/L

39-50 g/L 23-300 U/L

Low High

Bilirubin: 22 umol/L

Plasma lipase: 485 U/L

Discussion Common aetiologies of a subphrenic abscess include amoebic liver abscess, empyema, pylephlebitis, pulmonary collapse, and perforated appendix [3]. A perforated appendix is a potentially fatal complication of appendicitis. If left untreated, it can result in peritonitis, abscess or phlegmon formation and, in some cases, septicaemia [4]. Urgent surgical intervention is often required and is associated with a higher effective rate and lower relapse rate compared to conservative treatment with antibiotics [5]. Given its variable and sometimes atypical clinical presentations, misdiagnosis is not uncommon and occurs in up to 30% of cases [6]. Common misdiagnosed conditions mimicking appendicitis include; Crohn’s disease, urolithiasis, pyelonephritis, ovarian torsion, pelvic inflammatory disease, and ectopic pregnancy [7]. Known risk factors of appendiceal perforation include male sex, advanced age, lower literacy, longer pre-admission period, history of abdominal surgery, immunosuppression, and the presence of atypical presentations (for example, diarrhoea and pain in the epigastric region or right lower quadrant of a longer duration) [6,8]. In this case, the patient was considered at high risk of developing perforation according to the matched risk factors. This case is deemed unusual for a perforated appendix due to its atypical presentation, the absence of distinctive radiological signs of appendiceal inflammation, and the uncommon location of the collection mimicking a liver abscess. While the migration of pain from the periumbilical region to the right iliac fossa presents only in 50% of cases, common signs and symptoms such as abdominal pain and anorexia present in almost all cases [9]. Other signs, including the psoas sign, rebound tenderness, and low-grade fever are less common [9]. This explains why atypical presentations can occur in up to 34% of appendicitis

cases [10]. Further, appendicitis at the subhepatic region accounts for only 0.08% of all appendicitis cases [11]. Nanjaraj et al. reported a similar case where a 19-year-old female with a perforated subhepatic appendix which was first identified by the presence of a peripherally enhancing subcapsular collection via a CT scan of the abdomen [11]. Similarly, a 45-year-old male with perforated retrocecal appendix reported by Nizamani et al. was also shown to have three subcapsular subhepatic abscesses with peripherally enhancing and centrally non-enhancing necrosis on a CT scan [12]. The appendiceal origin of the collection in both cases was confirmed by laparoscopy. Also noteworthy is the presence of pleural effusion in this case. A similar one was also reported by Ku et al. regarding a 14-yearold male who developed a pleural effusion as a rare complication of ruptured appendicitis [13]. While there remains no consensus on the definitive treatment for complicated appendicitis with abscess, it is primarily categorised into surgical interventions, with either immediate or interval appendicectomy, or non-surgical intervention with antibiotics followed by percutaneous drainage. A systematic review by Darwazeh et al. of 21 studies including a total of 1943 patients concludes that nonsurgical treatment is associated with 12.4% higher risks of recurrence, 2.9% of higher morbidity and 4.6 days longer hospital stays than an interval appendicectomy [14]. In contrast, another study by Guida et al. reviewed the cases of six ruptured appendixes with abscesses and supports the management of initial antibiotic therapy followed by interval appendicectomy. This approach is typically reserved for generally well patients with contained perforation, due to a lower chance of developing postoperative abdominal abscess, organ damage, and complicated wound infections [15].

Case Report

Lastly, this case provides some insights into the obstacles Aboriginal Australians encounter which contribute to delayed treatments and unfavourable prognoses. Firstly, Aboriginal Australians may have their own set of cultural beliefs, faiths, and values [16], and may be more reluctant to seek medical attention from mainstream healthcare services [16]. Secondly, within the Northern Territory, there are more than 100 dialects spoken by Aboriginal people and only 2.1% speak only English at home [16]. With interpreters sometimes difficult to obtain, communication barriers between Aboriginal Australians and healthcare workers impose a hardship on trust building, further hampering access to the healthcare system. In this case, the patient’s limited proficiency in English may have contributed to his delayed presentation and suboptimal post-operative care.

Lastly, due to poorer access to education in Aboriginal communities and poorer health literacy [16], compliance issues are not uncommon and may affect a patient’s prognosis. All these factors may have played a role in this case. This case highlights the importance of having a high grade of clinical suspicion for atypical presentations of perforated appendix and how diagnostic laparoscopy plays a role in guiding the management of an uncertain diagnosis.

References 1.

3. 4. 5.

7. 8.

Department of Treasury and Finance. Northern Territory Economy: Population Darwin NT: Department of Treasury and Finance; 2016 [Available from: https://nteconomy.nt.gov.au/population#aboriginal.] Northern Territory Government. Northern Territory Government. BushTel: Mount Liebig. Darwin NT: Northern Territory Government; 2020 [Available from: https://bushtel.nt.gov.au/profile/112?tab=detail.] Bhat SM. SRB's Manual of Surgery. 5th ed. New Delhi: Jaypee Brothers Medical Publishers; 2016. 575-6. Weledji EP, Ngowe MN. The challenge of intra-abdominal sepsis. Int J Surg. 2013;11(4):290-5. Yang Z, Sun F, Ai S, Wang J, Guan W, Liu S. Meta-analysis of studies comparing conservative treatment with antibiotics and appendectomy for acute appendicitis in the adult. BMC Surgery. 2019;19(1). Naderan M, Shahr Babaki AE, Shoar S, Mahmoodzadeh H, Nasiri S, Khorgami Z. Risk factors for the development of complicated appendicitis in adults. Turk J Surg. 2016;32(1):3742. Thompson J, Selvaraj D, Nicola R. Mimickers of acute appendicitis. J Am Osteopath Coll Radiol. 2014;3(4):10-21. Balogun OS, Osinowo A, Afolayan M, Olajide T, Lawal A, Adesanya A. Acute perforated appendicitis in adults: Management and complications in Lagos, Nigeria. Ann Afr Med. 2019;18(1):36.

9. 10.

11.

12.

13.

14.

15.

16.

Hardin Jr DM. Acute appendicitis: review and update. Am Fam Physician. 1999;60(7):2027. Rochlani TD, Shaparia PS, Trivedi HP, Desai TJ. A Retrospective Study on Atypical Presentations of Uncomplicated Appendicitis in a Tertiary Centre with Emphasis on Management Strategy. J Med Sci Clin Res. 2018;06(07):985-9. Nanjaraj C, Rashmi U, Sanjay P, Dennis T, Kavya S, Lal C, et al. Perforated subhepatic appendicitis: Masquerading as a liver abscess. Eurorad Abdominal Imaging. 2017. Nizamani W, Ali M, Ahmed M, Khan A, Ahmed A. A Case of Sub Hepatic Perforated Appendicitis Presented as Multiple Gas Containing Subcapsular Hepatic Abscesses. J Adv Med Med Res. 2016;13(3):1-4. Ku D, Cassey JG, Mejia R. Pericardial effusion as a rare complication of a perforated appendicitis. I J Surg Case Rep. 2017;35:98-100. Darwazeh G, Cunningham SC, Kowdley GC. A systematic review of perforated appendicitis and phlegmon: interval appendectomy or wait-and-see? Am Surgeon. 2016;82(1):115. Guida E, Pederiva F, Grazia MD, Codrich D, Lembo MA, Scarpa MG, et al. Perforated appendix with abscess: Immediate or interval appendectomy? Some examples to explain our choice. Int J Surg Case Rep. 2015;12:15-8. Li J-L. Cultural barriers lead to inequitable healthcare access for aboriginal Australians and Torres Strait Islanders. Chin Nurs Res. 2017;4(4):207-10.

Acknowledgements: None. Conflict of interest statement: The author/s have no conflicts of interest to disclose. Funding: None to declare Author contribution statement: Justin Ng and Martha Hui are the shared primary authors. Dr Shaveen Kanakaratne and Dr Jayantha Senaratne guided and supervised the work. Cite as: Justin HN, Martha LH, Shaveen K, Jayantha S. An unusual presentation of perforated appendix mimicking a liver abscess in an Aboriginal male. Aust Med Stud J. 2020;1:748–51. Correspondence: Justin Ho-Yin Ng, jhng24@student.monash.edu Date of submission: 4 March 2020 Date of acceptance: 24 August 2020 Date of online publication: 29 August 2020 Editor: Marisse Sonido Senior Editor: Shahzma Merani, Mabel Leow Proofreaders: Abhishekh Srinivas, Eleazar Leong Senior Proofreader: Emily Feng-Gu

Case Report

Skin Rash in a Patient using Antiepileptic Medications, What Could it be? Sarah Afram 1, Roy G Beran 1, Sarah Afram1 1

Liverpool hospital, South Western Clinical School, University of NSW Sarah Afram is a Resident Medical Officer at Liverpool hospital. She is planning to start her general practice training next year with an interest in the management and treatment of skin condition and in rural medicine.

Key learning points • Assessment of a rash is not different to other medical assessments. It relies on history and examination and it also rests with pattern

asked to review patients with new rash or skin condition while they are admitted to the hospital for another reason. This case highlights the importance of differentiating between de novo health problems and problems related to chronic health conditions.

recognition. •

We should not assume and consider that a rash, in a patient treated with rash provoking medications, is definitely because of that medication.

•

Systematic approach to a rash should lead to appropriate diagnosis and treatment.

•

Abstract Introduction: Rash is one of the commonest presentations that doctors can be asked to review. Studying this case strengthens the understanding about how to review a patient with rash and how to formalise differential diagnosis based on the clinical condition. This is an educational article that seeks to improve medical students understanding and clinical applications around rashes and to establish an approach that will differentiate between medications evoked rash and rash provoked by other causes. Case overview: This case study will provide a systemic approach when evaluating a skin rash in a patient, especially in a person who cannot communicate and who has been exposed to rash provoking medications. Discussion overview: Antiepileptic medications are known to evoke rash. It is important to take that in consideration when evaluating rashes in patients who are using those medications; however we should keep in mind that there are other conditions that can be the cause.

Keywords: Rash, epilepsy, anti-epileptic medications, genetics Introduction Skin diseases are common in patients presenting to general practice or in patients who are admitted to the hospitals. This case presents a 56 years old gentleman who has a complex neurological condition and and he was found to have skin rash whilst admitted to neurology ward. It is very common to be

Case History GM is a 56-year-old nonverbal and fully dependent man who was admitted to the hospital from a nursing home because of multiple seizures. His comorbidities included: advanced neurodegenerative disease, Hereditary Endotheliopathy, Retinopathy, Nephropathy and Stroke (HERNS) -a rare autosomal dominant condition that affects the vascular endothelium of the brain, retina, and kidneys. This was further complicated by vascular dementia, quadriplegia, epilepsy, diabetes insipidus, hypertension and hyperlipdemia. His regular medications were: dexamethasone 1mg mane, phenytoin 430mg mane and 130mg nocte, thyroxine 50mcg mane, levetiracetam 1g three times daily, lacosamide 150mg twice daily, valproate 1200mg mane, 1000mg mid-day and 1200mg nocte, enoxaparin 40mg daily, metoclopramide 10mg as needed, midazolam 2.5mg as needed. He presented to emergency department following three tonicclonic seizures with reduced level of consciousness. Antiepileptic medications (AEM) levels were checked, valproate level was 26 mg/L (therapeutic level 50-100mg/L) and he was loaded with 1 gram of valproate by emergency department staff. In the emergency department, he received intravenous midazolam 1mg to terminate a further seizure and he had no further seizure activity thereafter. He received ondansetron for vomiting; ampicillin and gentamicin were prescribed for urinary tract infection and then were changed to tazocin as urine culture grew pseudomonas aeruginosa. He was then admitted under the care of neurology team. The following day, nursing staff noticed a rash on his back, between his scapulae, and multiple smaller lesions on the right hip which had not been noticed at the time of admission. As he could not give a history, collateral history was taken from his wife and the registered nurse who looked after him in the nursing home. The registered nurse stated that the rash was not noticed prior to his admission to the hospital.

Case Report

There was no recent change in medications including over-thecounter (OTC) medications; no change in regular bed sheets, clothes, cleaning agents. There was no history of insect bites, no similar presentations in the household and no history of recent travel. He had a localised red rash over the left side of the chest a few weeks prior to this presentation for which he was treated with hydrocortisone 1% w/w and clotrimazole 1% w/w cream by his general practitioner with resolution of the rash. His wife was not aware of the current rash and stated that he does not have a history of allergy, eczema or asthma. A consultation for his rash was sought from the neurology team as he was on numerous antiepileptic medications, known to evoke rash.

Assessment His vital signs were stable. The lesions were well demarcated, annular, advancing centrifugally from a core, leaving a central clearing and mild residual scaling. There was a ~10X10cm erythematous patch with active borders and central clearance on the back, between the scapulae. Multiple similar smaller lesions were noted over the right hip (Figure 1). The rash was not generalised and there was no involvement of mucous membrane. It was unlikely that the rash was pruritic, as the patient was not in distress and there were no scratching marks present.

4.9 mg/L) on presentation, likely secondary to his urinary tract infection, and it was down trending with antibiotic therapy. Skin scraping culture was positive for trichophyton rubrum.

Differential diagnosis One of the differential diagnoses for the rash in this patient was the cutaneous side effects of antiepileptic medications or a reaction to medications that were prescribed on admission. However, the rash appearance favoured fungal infection for which he was treated.

Management Terbinfine hydrochloride 1% twice daily was commenced and the patient was treated as having tinea corporis infection, with skin scraping taken prior to commencing treatment. Figure 1 (Left) Rash between scapulae with involvement of hair follicles. (Right) Rash over the right hip.

Results Full blood counts were normal, including normal eosinophil count. C-reactive protein (CRP) was 312 mg/L (normal range <

Table 1 Comparison between drug evoked rash and rash from tinea corporis

Presentation

Course of presentation

•

Drug evoked rash Urticaria

•

Angioedema

•

Morbilliform rash with no systemic features (commonest presentation) which usually starts on the trunk then spreads all over the body and associated with mild pruritus

•

DRESS

•

SJS/TEN [3]

•

Rash appears immediately after or within few days of beginning of a new medication

•

May take up to 2-6 weeks after medication initiation

•

May occur after second exposure [8]

•

De-challenge: resolution of the rash after stopping the culprit medication [3]

Tinea corporis •

• •

Typically a well-demarcated, sharply circumscribed, oval or circular, mildly erythematous, scaly patch or plaque with a raised leading edge Single or multiple lesions Associated with pruritus [7].

Infection can be acute, chronic, chronic relapsing Risk factors include age, diabetes mellitus, immunocompromised patients, personal hygiene [9].

Case Report

Diagnostic tests

•

Full blood count

•

Skin biopsy: presence of eosinophils, edema and inflammation

•

Drug level to confirm the presence of the drug at the time of the rash[3]

Discussion Patients with skin conditions comprise 17% of general practice consultations in Australia and rash accounts for 2.5% of the total presentation to general practice[1, 2]. Common skin condition presentations to general practice include dermatitis, acne, psoriasis and skin infections[1]. Skin rashes can be induced by certain medications. It is not uncommon to review patients who present with skin rashes along with having other complex comorbidities for which they are taking medications that can cause skin eruption. The diagnosis of drug induced skin eruption can sometimes be very difficult to establish, as a cutaneous drug eruption can closely mimic other common skin diseases[3]. Types of rash can sometimes be difficult to diagnose due to the varying morphological forms that it can present. Many conditions may produce similar rash, some conditions may present with atypical appearance of rashes and some rashes may have altered appearance after starting certain medications or with development of secondary bacterial infections. The patient may be unable to offer adequate history pertaining to the rash. Furthermore, the patients and carers may adopt a trial of medications or herbal remedies before seeking medical advice; especially within the context of uncertainty, that may potentially exacerbate or worsen the appearance of the rash[46]. A comparison between drug evoked rash and tinea corporis rash is listed in table 1. One of the important differential diagnoses of a rash is the possible side effects of medications. Recognising medication side effect is critical as management consists of making as accurate a diagnosis as possible and instituting efficient and effective avoidance measure, except in those situations where the suspect medication is essential and offers the best treatment for the patient's condition. In selected situations, repeated exposure may be the best option to determine sensitivity but should only be considered with expert advice and informed consent[11]. It may require protection against and with potential intervention in the event that anaphylaxis develops, such as adrenaline auto-injector. Antibiotic and Antiepileptic medications are of the most common medications to cause drug eruption and the crosssensitivity rates between certain antiepileptic medications are considered high, especially when involving carbamazepine and phenytoin[12]. Between 1–10% of patients on carbamazepine develop a cutaneous reaction; over 85% of these are mild maculopapular reactions. Stevens-Johnson Syndrome and toxic epidermal necrolysis (SJS/TEN) incidence is estimated to occur in less than 0.06% of adults started on carbamazepine, whilst 0.04% or fewer develop drug reaction with eosinophilia and systemic symptoms (DRESS)[13].

• •

•

Clinical examination Direct microscopic examination of skin scraping taken from the active edges and treated with 10%-20% potassium hydroxide preparation. Fungal culture [10].

The genetic alleles which are potential risk factors for SJS/TEN when using carbamazepine are HLA-B*1502 in the Southeast Asian population particularly those of Han Chinese descent, HLA-A*3101 in Caucasian patients and HLA-B*1511 in Japan, Korea and central China[14, 15]. People of Han Chinese descent should be screened for the presence of HLA-B*1502 prior to initiating carbamazepine therapy especially if being included in clinical trials[15]. It is crucial to consider cross sensitivity between anti-epileptic medications. Patients known to have serious skin reactions to carmazepine need caution when substituting to oxcarbazepine despite the advice to the contrary that claims only 10% crosssensivity[16]. Phenytoin side effects include hirsutism, gum hypertrophy, maculopapular eruptions, generalized exfoliative dermatitis, SJS, TEN, erythema multiforme, vasculitis, follicular or pustular eruptions, fixed drug eruptions (FDE), angioedema, hypersensitivity reactions, purple hand syndrome, cutaneous necrosis, pigmentation changes, porphyria and linear IgA bullous disease[13]. Rash is also a common side effect of lamotrigine treatment, occurring in 8.3% of patients, with half of these withdrawing medications as a consequence[14]. It has been shown that slow introduction of lamotrigine may overcome the risk of a rash[17]. A head- to –head trial comparing lamotrigine with carmazepine showed that carbamazepine has greater propensity to develop a rash than does LTG[18]. HLA-A*2402 was recently confirmed as a shared risk factor for SJS/TEN after exposure to aromatic antiepileptic medications, including lamotrigine[14]. Several studies have indicated that lamotrigine‐induced rashes are more frequent in children than in adults, at least in the case of potentially life‐threatening reactions[19, 20]. A study showed that females were at a higher risk of developing lamotrigine‐ induced rash than were males[21]. The risk of skin reaction is increased when the starting dose of lamotrigine is high, the dose is increased rapidly and when there is a combination with valproate. Valproate side effects also include non-scarring hair loss, petechiae, pruritus, and hypersensitivity syndrome[22, 23].

Conclusion The case of GM arose because the team that was treating him was especially concerned about AEM evoked rashes, although the appearance of the rash favored fungal infection. Because of the basis of the consultation, it was felt to be worth evaluating those factors to be considered when contemplating AEM evoked rashes, together with rashes evoked from other medications. It was considered important to develop a logical approach to the general evaluation of rashes. This should reflect a step wise approach that is crucial to undertake when dealing with any medical condition, and should apply to evaluating rashes. As

Case Report

was the case with GM, rash pattern recognition is an important component of determining the cause of a rash, followed by selective testing and appropriate treatment. This requires

clinicians to expand their appreciation of rashes and their appearance (pattern recognition) and to adapt a systematic approach when evaluating a rash.

References 1. 2. 3. 4. 5. 6.

7. 8.

10.

11. 12.

Blake S, Shumack S. Common and important skin rashes in primary care home. Med. Today. 2019;20(11):18-26. Fahridin S, Miller G C. Presentation of rash. Aust J Gen Pract. 2009;38(7):475-475. Nayak S, Acharjya B. Adverse cutaneous drug reaction. Indian J Dermatol. 2008;53(1):2-8. Ely JW, Stone MS. The generalized rash: part I. Differential diagnosis. Am Fam Physician. 2010;81(6):726-734. Yu Ch, Zhou J, Liu J. Tinea incognito due to microsporum gypseum. J Biomed Res. 2010;24(1):81–83. O’Riordan M, Dahinden A, Akturk Z, Ortiz JM, Dagdeviren N, Elwyn Gm et al. Dealing with uncertainty in general practice: an essential skill for the general practitioner. Qual Prim Care. 2011;19:175-81. Leung AKC, Lam JM, Leong KF, Hon KL. Tinea corporis: an updated review. Drug Context. 2020;9:2020-5-6. National institute for care and health excellence. Drug allergy: diagnosis and management [Internet]. 2014 Sep 04. Available from: https://www.nice.org.uk/guidance/cg183 Singh S, Verma P, Chandra U, Tiwary NK. Risk factors for chronic and chronic-relapsing tinea corporis, tinea cruris and tinea faciei: results of a case–control study. Indian J Dermatol Venereol Leprol. 2019;85:197200. Sahoo AK, Mahajan R. Management of tinea corporis, tinea cruris, and tinea pedis: a comprehensive review. Indian Dermatol Online J. 2016;7(2):77–86. Frew A. General principles of investigating and managing drug allergy. Br J Clin Pharmacol. 2011;71(5):642–646. Hirsch LJ, Arif H, Nahm EA, Buchsbaum R, Resor SR Jr, Bazil CW. Crosssensitivity of skin rashes with antiepileptic drug use. Neurology. 2008;71(19):1527-34.

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Scheinfeld N. Phenytoin in cutaneous medicine: its uses, mechanisms and side effects. Dermatol Online J. 2003;9(3):6. Fowler T, Bansal AS, Lozsadi D. Risks and management of antiepileptic drug induced skin reactions in the adult out-patient setting. Seizure. 2019;72:61-70. Dean L. Carbamazepine Therapy and HLA Genotype. Medical Genetics Summaries [Internet]. 2015 Oct 14 [Updated 2018 Aug 1]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK321445/ Beran RG. Cross reactive skin eruption with both carbamazepine and oxcarbazepine. Epilepsia. 1993;34(1):163-5. Anderson V, Northam E, Hendy J, Wrennall J. Developmental neuropsychology: a clinical approach (Brain, Behavior and Cognition). London: Psychology press; 2001 Alvestad S, Lydersen S, Bridtkorb E. Rash from antiepileptic drug: influence by gender, age and learning disability. Epilepsia. 2007;48(7):1360–1365. Matsuo F. Lamotrigine. Epilepsia. 1999;40(suppl 5):S30–S36. Hirsch LJ, Weintraub DB, Buchsbaum R, Spencer HT, Straka T, Hager M et al. Predictors of lamotrigine-associated rash. Epilepsia. 2006;47:318–322. Wong IC, Mawer GE, Sander JW. Factors influencing the incidence of lamotrigine‐related skin rash. Ann Pharmacother. 1999;33:1037–1042. Ramakrishnappa SK, Belhekar MN. Serum drug level-related sodium valproate-induced hair loss. Indian J Pharmacol. 2013;45(2):187–188. Hebert AA, Ralston JP. Cutaneous reactions to anticonvulsant medications. J Clin Psychiatry. 2001;62(14):22–26.

Consent declaration: Informed consent was obtained from the patient and next-of-kin for publication of this case report. Acknowledgements: None. Conflict of interest statement: The author/s have no conflicts of interest to disclose. Funding: None Author contribution statement: RB and SA conceptualised the manuscript. SA drafted the manuscript. RB supervised SA in writing the manuscript. All authors approved the final manuscript. Cite as: Sarah A, Roy GB. Skin rash in a patient using antiepileptic medications, what it could be? Aust Med Stud J. 2020;1:748–51. Correspondence: Sarah Afram, sara.afram@yahoo.com Date of submission: 19 July 2020 Date of acceptance:: 17 December 2020 Date of publication: 20 December 2020 Editor: Dhruv Jhunjhnuwala Senior Editor: Mabel Leow, Daniel Wong Proofreader: Ivy Jiang, Eleazar Leong Senior Proofreader: Emily Feng-Gu

Case Report

When Trauma Meets Infection in A Lower Income Country Brittany Weir1 1

Sunshine Coast University Hospital Brittany Weir is an intern at Sunshine Coast University Hospital, graduating in 2019 with a Doctor of Medicine from the University of Wollongong. She also previously completed a Bachelor degree in Physiotherapy at the University of Queensland and has worked as a physiotherapist since 2012. Brittany is interested in trauma surgery, orthopaedics, and critical care.

Key learning points • Deficient resources in low- and middle-income countries (LMIC) negatively influence health care and patient related outcomes. • Infection prevention and control (IPC) is crucial in healthcare to slow the spread of antibiotic resistance and reduce patient morbidity and mortality. • Early anatomical reduction of fractures reduces complications and improves long term function. Abstract Introduction: Healthcare-associated infections (HAI) are particularly prevalent in low- and middle-income countries (LMICs). HAIs cause a serious threat to patient wellbeing and have been associated with increased patient morbidity and mortality, longer hospital admission times, increased risk of antibiotic resistance, and higher healthcare costs. Case: A case of a 23-year-old polytrauma patient in Zambia reveals the devastating outcomes of lack of resources, HAIs, and delayed treatment in LMICs. Discussion: Research demonstrates the negative influence of LMIC status on health care and patient related outcomes. This report, in conjunction with the literature, emphasises the importance of prompt trauma management and strict infection control. The critical need for more knowledge around infection prevention and control (IPC) and resources to implement IPC processes in LMICs are highlighted.

Keywords: trauma, healthcare-associated infections, lowand middle-income country Introduction Healthcare-associated infections (HAI) are a major health challenge worldwide, and instances are particularly prevalent in low- and middle-income countries (LMICs) [1-3]. LMICs face many challenges contributing to decreased HAI control including lack of resources, reduced health literacy, and massive

overcrowding [2,3]. HAIs pose a serious threat to patient wellbeing and literature shows that HAIs have been associated with increased patient morbidity and mortality, longer hospital admission times, increased risk of antibiotic resistance, and higher healthcare costs [2,3,6]. Surgical site infections (SSI) are among the most common cause of HAIs, alongside central line-associated infections, catheterrelated infections, and hospital-acquired pneumonia [2,4,5]. Factors such as inadequate hand hygiene, inappropriate antibiotic use, and emergency surgery increase the risk of infection [2,4,5]. Evidence-based practice to prevent SSIs includes preoperative antibiotics and strict perioperative infection control regimes such as hand hygiene and barrier protective equipment [4]. Hand hygiene has been proven to be an effective and critical strategy in reducing all HAIs, in particular the use of alcoholbased hand gel. However, this simple resource is often scarce in LMICs [2,3].

Case A 23-year-old female presented to the emergency department of a local hospital in Zambia, in haemorrhagic shock with polytrauma following a motor vehicle accident (MVA). She was admitted to the hospital with extensive lower limb crush injuries from the MVA. She had no previous medical or surgical history, was single, lived nearby in one of the local villages with her mother, denied alcohol use, and was a non-smoker. Initial management included a primary survey and resuscitation requiring a blood transfusion. Following a secondary survey, she was diagnosed with bilateral closed displaced femoral shaft fractures, a right distal leg traumatic amputation, a left distal fibula fracture, degloving wounds to her left leg and foot, and a deep laceration to her right upper limb, as well as multiple minor skin lacerations. Further management included a guillotine transtibial below knee amputation (BKA) to her right leg, subsequent debridement, and wound dressings. She was commenced on benzylpenicillin, gentamicin, metronidazole, pethidine, and paracetamol.

Case Report

On day six of her admission she was showing signs of residual anaemia (Haemoglobin (Hb) 76 g/L), necrosis of her leg wounds, and sepsis. Following another blood transfusion, she taken to theatre for evaluation under spinal anaesthesia, wound debridement and bilateral Steinmann transtibial pin insertions to assist with distraction of her bilateral femur fractures. There was no air conditioning or HEPA filters in the theatre and exterior windows were open to obtain air flow in the heat. During the procedure, wound cultures were unable to be obtained as the hospital had no supplies of sterile swabs. She was afebrile and haemodynamically stable post-surgery and her Hb levels had improved to 106 g/L. Skeletal traction was commenced for fracture reduction using a rope and pulley system attached to large water bottles which hung off the end of the bed. On day 21, she was taken back to theatre for wound debridement, split-thickness skin graft and stump closure. Daily wound care involved bedside wound dressing removal, normal saline wash, application of gauze soaked in honey, and crepe bandage. She had daily routine bloods as well as chest and limb physiotherapy. Her daily medications included ceftriaxone, analgesia, folic acid and ferrous sulphate. Throughout this patient’s hospital stay she developed multiple wound infections requiring frequent surgeries (Table 1). A major complication was the development of wet gangrene in her right BKA stump wound requiring a transfemoral above knee amputation (AKA). Unfortunately, one week later her AKA stump had also become gangrenous requiring further debridement in theatre. Despite this debridement, four weeks later her AKA stump developed osteomyelitis and she returned to theatre for debridement and sequestrectomy of her AKA stump. Approximately five months’ post injury, the patient was taken to theatre for the tenth time for an open reduction internal fixation of her left femoral shaft fracture. Given the time lapse since injury and unsuccessful attempts at reduction, the fracture had started to heal in the displaced position with callous formation evident on a plain radiograph (Figure 1). The patient was given a spinal anaesthesia with minimal sedation. The procedure was complicated by debridement of extensive fibrous tissue at the fracture site due to a significant overlap of fragments of approximately 10 cm. The fragments were shortened approximately four centimetres, the fracture was reduced, and an interlocking nail was placed in the femoral shaft. She lost a substantial amount of blood during the surgery and was hypotensive (blood pressure 75/40 mmHg) and tachycardic (pulse rate 145 beats per minute). While blood products were necessary for adequate resuscitation, there was only one bag of blood available for transfusion. The patient required tranexamic acid, two litres of normal saline and multiple boluses of adrenaline in addition to the bag of packed red blood cells. Her blood pressure had stabilised to 110/70 mmHg in recovery. The hospital had an inconsistent and limited supply of antibiotics. The common antibiotics available were penicillin, gentamicin, metronidazole, ceftriaxone, and cefotaxime. Occasionally the hospital stocked cefoxitin, ciprofloxacin, linezolid, co-trimoxazole, nitrofurantoin, and piperacillintazobactam. Ceftriaxone was given in this case, justified as the only intravenous antibiotic available at the time, and while the

intention may have been to give this antibiotic preoperatively, it was only administered on completion of the surgery. Sterile equipment such as gowns, gloves and surgical instruments were scarce within the hospital, and the limited supply meant that surgeries were delayed until equipment could be re-sterilised. The wards were overcrowded and hand hygiene throughout this patient’s care was negligible, with finite supply of alcohol-based hand gel, hand washing facilities, and gloves. After five months in hospital, this patient was discharged home in a wheelchair to follow up in outpatient clinics for wound and fracture care. Unfortunately, given the extent of damage caused to surrounding soft tissue during the fracture repair, her functional prognosis was poor with a high risk of fracture nonunion and avascular necrosis. Figure 1 A plain radiograph of the patient’s left hip and femur, demonstrating a displaced femoral fracture with callous formation.

Case Report

Table 1 Timeline of major clinical events since admission.

Day

Major Clinical Event

Resuscitation, guillotine transtibial BKA and wound debridement

Signs of residual anaemia, necrosis of leg wounds and sepsis

Evaluation under spinal anaesthesia, wound debridement, and bilateral Steinmann transtibial pin insertions in theatre

Wound debridement, split-thickness skin graft and BKA stump closure in theatre

Gangrenous right BKA stump wound

Transfemoral AKA in theatre

Gangrenous AKA stump wound and subsequent debridement in theatre

Osteomyelitis in AKA stump and subsequent debridement and sequestrectomy in theatre. Split-thickness skin graft of left leg wounds performed concurrently.

Wound debridement and AKA stump closure in theatre

129

Split-thickness skin graft over AKA stump in theatre

144

Open reduction internal fixation left femoral shaft fracture in theatre

148

Discharged home in a wheelchair

Discussion This case was significant as it combined severe polytrauma, multiple SSIs, and complex fracture management with resourcelimited health care and infection control. Infection control is vital to all aspects of health care, and the devastating outcomes of poor infection control are emphasised by this case. While prevention of infection is key, early recognition of wound infections is crucial to prevent both limb-threatening gangrene and life-threatening sepsis [7,8]. LMIC status negatively influences healthcare and patient-related outcomes [1-3]. This case highlights the lack of resources available in LMICs like Zambia, and the impact on patient outcomes. Basic infection control measures such as hand hygiene and barrier protection proved to be difficult with deficient supplies of alcohol gel, soap, gloves, bacterial swabs, and sterile equipment. Without HEPA filters in theatres, open exterior windows further increased the risk of infection. While hospitals like this in Zambia are extremely resourceful with their equipment, research shows that HAI rates in lower income

countries is at least 2-fold higher than in high income countries [1-3]. Infection prevention and control (IPC) is crucial in healthcare to reduce complications and improve health outcomes. Poor IPC in this case contributed to the complications associated with this patient’s wounds including gangrene, frequent surgeries, limb loss, and prolonged hospital stay, all factors which further increase the risk of additional HAIs [2-5]. Evidence-based practice recommends the use of prophylactic preoperative antibiotics to significantly decrease the risk of SSIs [4-5]. Unfortunately, in this case, antibiotics were only given postoperatively. The presence of infected, necrotic tissue is an indication for extensive debridement which may include lower limb amputation and is necessary to prevent life-threatening sepsis [7-10]. Complications following amputation include medical complications, wound infection, and the need for reamputation, all of which occurred in this case [9,12]. Approximately 10-20% of below-knee amputations entail a reamputation at the transfemoral level, with this rate substantially increased in lower income countries due to poor infection control [9-11].

Case Report

Moreover, evidence suggests a strong relationship between HAIs and antibiotic resistance, a growing global health burden [6]. Drug-resistant organisms cause the majority of HAIs worldwide, placing poor infection control among the drivers of antibiotic resistance [6,12]. Prolonged hospitalisation, recent surgery, and prior antibiotic use – particularly the use of thirdgeneration cephalosporins (e.g. ceftriaxone) – all of which were present in this case, are independent risk factors for a drugresistant infection [12,13]. Therapeutic guidelines [14] recommend a first-generation cephalosporin, for example, cefazolin, as first line antibiotic prophylaxis for open fractures, although these were not available in this Zambian hospital. Zambia is just one of many countries worldwide contributing to the trend of increasing antibacterial drug resistance [15]. Antibiotic resistant microorganisms such as Staphylococcus aureus, Klebsiella pneumonia and Escherichia coli have been isolated in Zambia, and there is a high prevalence of resistance to gentamicin, penicillin, ciprofloxacin, and ceftriaxone [16-18]. The limited supply of sterile swabs, microbiology laboratory equipment, and effective second- and third-line antibiotic

therapies in LMICs further increase the risk of morbidity and mortality associated with antibiotic resistance [6,12,13]. Finally, the importance of early anatomical reduction in the management of displaced fractures was highlighted by this case. The five-month delay to fracture fixation as a result of multiple HAIs lead to a complicated surgical procedure and a poor functional outcome. Early anatomical reduction, surgical repair and functional rehabilitation of femur fractures reduces complications and improves long term function [19,20].

Conclusion The consequences of HAIs can be devastating, with these poor outcomes skyrocketing in a resource-limited LMIC hospital. HAIs are preventable presentations which can lead to significant morbidity and mortality. This case demonstrates the importance of adequate resources on IPC and highlights the vital need for more health awareness and funding in Zambia and, by extension, other LMIC

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Allegranzi B, Nejad SB, Combescure C, Graafmans W, Attar H, Donaldson L, et al. Burden of endemic health-care-associated infection in developing countries: systematic review and metaanalysis. Lancet. 2011;377(9761):228-41. doi:10.1016/S01406736(10)61458-4 Ayed HB, Yaich S, Trigui M, Jemaa MB, Hmida MB, Karray R, et al. Prevalence and risk factors of health care–associated infections in a limited resources country: a cross-sectional study. Am J Infect Control. 2019; 47(8):945-50. doi:10.1016/j.ajic.2019.01.008 Loftus MJ, Guitart C, Tartari E, Stewardson AJ, Amer F, BellissimoRodrigues F, et al. Hand hygiene in low-and middle-income countries: a position paper of the International Society for Infectious Diseases. Int J Infect Dis. 2019;86:25-30. doi:10.1016/j.ijid.2019.06.002 Ban KA, Minei JP, Laronga C, Harbrecht BG, Jensen EH, Fry DE, et al. American College of Surgeons and Surgical Infection Society: surgical site infection guidelines, 2016 update. J Am Coll Surg. 2017;224(1):59-74. doi:10.1016/j.jamcollsurg.2016.10.029 Shafer CW, Allison JR, Hogue AL, Huntington MK. Infectious disease: health care-associated infections. FP Essent. 2019;476:3042. Lakoh S, Li L, Sevalie S, Guo X, Adekanmbi O, Yang G, et al. Antibiotic resistance in patients with clinical features of healthcare-associated infections in an urban tertiary hospital in Sierra Leone: a crosssectional study. Antimicrob Resist Infect Control. 2020;9(1):1-0. doi:10.1186/s13756-020-0701-5 Akinyoola AL, Ojo OD, Oginni LM. Microbiology of amputation wound infection in a Nigerian setting. J Wound Care. 2008;17(5):202-6. doi:10.12968/jowc.2008.17.5.29150 Bonne SL, Kadri SS. Evaluation and management of necrotizing soft tissue infections. Infect Dis Clin North Am. 2017;31(3):497-511. doi:10.1016/j.idc.2017.05.011 Chalya PL, Mabula JB, Dass RM, Ngayomela IH, Chandika AB, Mbelenge N, et al. Major limb amputations: a tertiary hospital experience in northwestern Tanzania. J Orthop Surg Res. 2012;7(1):18. doi:10.1186/1749-799X-7-18 Grudziak J. Etiology of major limb amputations at a tertiary care centre in Malawi Med J. 2019;31(4):244-8. doi:10.4314/mmj.v31i4.5 Belmont Jr PJ, Davey S, Orr JD, Ochoa LM, Bader JO, Schoenfeld AJ. Risk factors for 30-day postoperative complications and mortality

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after below-knee amputation: a study of 2,911 patients from the national surgical quality improvement program. J Am Coll Surg. 2011;213(3):370-8. doi:10.1016/j.jamcollsurg.2011.05.019 Rodrigues R, Fonseca RP, Gomes O, Castro R. Risk factors, length of stay and in-hospital mortality of methicillin-resistant staphylococcus aureus infections: a case-control study. Acta Med Port. 2020;33(3):174-82. doi:10.20344/amp.10952 van Staa TP, Palin V, Li Y, Welfare W, Felton TW, Dark P, et al. The effectiveness of frequent antibiotic use in reducing the risk of infection-related hospital admissions: results from two large population-based cohorts. BMC Med. 2020;18(1):1-1. doi:10.1186/s12916-020-1504-5 Therapeutic Guidelines Limited. eTG complete. [Internet]. 2020. [updated 2020; cited 2020 July 21]. Available from: https://www.tg.org.au World Health Organization. Antimicrobial resistance: global report on surveillance. World Health Organization; 2014. Kabwe M, Tembo J, Chilukutu L, Chilufya M, Ngulube F, Lukwesa C, et al. Etiology, antibiotic resistance and risk factors for neonatal sepsis in a large referral center in Zambia. Pediatr Infect Dis J. 2016;35(7):e191-8. doi:10.1097/INF.0000000000001154 Mwamungule S, Chimana HM, Malama S, Mainda G, Kwenda G, Muma JB. Contamination of health care workers’ coats at the University Teaching Hospital in Lusaka, Zambia: the nosocomial risk. J Occup Med Toxicol. 2015;10(1):34. doi:10.1186/s12995-015-00772 Nagelkerke MM, Sikwewa K, Makowa D, de Vries I, Chisi S, DorigoZetsma JW. Prevalence of antimicrobial drug resistant bacteria carried by in-and outpatients attending a secondary care hospital in Zambia. BMC Res Notes. 2017;10(1):378. doi:10.1186/s13104017-2710-x Blair JA, Kusnezov N, Fisher T, Prabhakar G, Bader JO, Belmont PJ. Early stabilization of femur fractures in the setting of polytrauma is associated with decreased risk of pulmonary complications and mortality. J Surg Orthop Adv. 2019;28(2):137-43. Gangavalli AK, Nwachuku CO. Management of distal femur fractures in adults: an overview of options. Orthop Clin North Am. 2016;47(1):85-96. doi:10.1016/j.ocl.2015.08.011

Case Report

Consent declaration: Written informed consent was obtained from the patient for publication of this case report and accompanying figures. Acknowledgements: The author would like to acknowledge the Research and Critical Analysis team at the University of Wollongong for their invaluable support and guidance, and continual enthusiasm towards research and the education of medical students. Furthermore, a special mention to the orthopaedic doctors at the University Teaching Hospital in Lusaka for their acceptance and enthusiasm towards teaching International medical students. Conflict of interest statement: The author has no conflicts of interest to disclose. Funding: None Author contribution statement: None Cite as: Brittany W. When Trauma Meets Infection In A Lower Income Country Aust Med Stud J. 2020;1:748–51. Correspondence: Brittany Weir, brittany.weir@health.qld.gov.au Date of submission: 20 April 2020 Date of acceptance:: 2 November 2020 Date of publication: 5 November 2020 Associate Editor: Cameron Wright Senior Editor: Shahzma Merani, Mabel Leow Proofreader: Nadiah Binte, Mohamad Shariff Senior Proofreader: Emily Feng-Gu

COVID-19 Article

COVID-19 as a Valuable Learning Opportunity Joel Ern Zher Chan1 1

Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, SA, Australia Joel Ern Zher Chan is a year 6 student at the university of Adelaide where he is studying medicine and surgery.

Key learning points • While COVID-19 led to the interruption of medical education and presented various challenges, medical students can make the most of the pandemic, including public health experience. • Skills in areas like evidence-based medicine, communication and rapport building, interprofessional learning and multidisciplinary collaboration are valuable and transferable. • Medical graduates are expected to advocate for patient health and society as a whole; as such, it is worth pursuing a public health placement at some point during their medical education. Abstract Most medical students do not receive much public health exposure during their medical education, either in the form of theoretical teaching or practical placement experiences. At the University of Adelaide, students can elect to undertake a public health elective during winter school in addition to limited lectures with a public health focus, but there was not much opportunity for such placements prior to COVID-19. Following the interruption of clinical placements during the peak of the pandemic in South Australia, a modified academic structure saw the introduction of a twelve-week public health placement at the Department for Health and Wellbeing for final-year medical students. This article reflects on the author’s immersive experience at the Department for Health and Wellbeing during the COVID-19 pandemic and includes a brief description of the department’s services along with how it fits into the broader COVID-19 response. Public health placements can impact medical graduates’ understanding and passion for health and society and their role as health advocates. Both of these are included in the Australian Medical Council’s Graduate Outcomes statement. Public health placements are therefore worthwhile pursuing.

Keywords: COVID-19, public health, medical education, student placements, health advocate. Introduction I had the opportunity of completing a twelve-week placement at the Department for Health and Wellbeing (SA Health) during the COVID-19 pandemic. SA Health represents the health portfolio of services and agencies responsible to the Minister for Health and Wellbeing. It comprises of multiple functional units that enable smooth delivery of its services. The wider political and legislative systems need to be included in describing how

SA Health and its various functional units fit into the broader COVID-19 response.

South Australia as a member state of the Commonwealth An intergovernmental forum known as the National Cabinet was established to coordinate the national COVID-19 response. Comprised of the Prime Minister and the premiers and chief ministers, the National Cabinet’s decision-making is advised by advisory groups including the Australian Health Protection Principal Committee (AHPPC), the peak decision-making committee for public health emergency management and disease control in Australia. AHPPC is comprised of the Chief Health Officers (and their equivalent roles) of all states and territories and is chaired by the Australian Chief Medical Officer. COVID-19 declarations and determinations made under the Commonwealth’s Biosecurity Act 2015 provide legal support to the decisions made on public health bases.

South Australia as a jurisdiction Several legislations underpin South Australia’s COVID-19 responses, including the Emergency Management Act 2004 and the South Australian Public Health Act 2011. The declaration of a Major Emergency under the Emergency Management Act 2004 gives the State Coordinator and Authorised Officers emergency powers to undertake necessary activities to address the crisis. The State Coordinator is advised by the State Controller from an agency with the knowledge, expertise, and resources to undertake a leadership role, and is supported by other governmental agencies. Together, these form the State Emergency Management Committee, which reports to the Emergency Management Council, a committee of the Cabinet chaired by the Premier. SA Health is the control agency during the COVID-19 pandemic [1]. In addition, a Transition Committee was also set up to guide the lifting of COVID-19 restrictions, with consideration given to the socioeconomic status of the state. It is comprised of the chief executives of the Department of the Premier and Cabinet, Department for Health and Wellbeing, Department of Treasury and Finance, and Department for Trade and Investment, in addition to the Chief Public Health Officer (State Controller Health) and Commissioner of the South Australian Police (State Coordinator during Major Emergency).

Department for Health and Wellbeing as control agency The Chief Public Health Officer is responsible for issues in public health and communicable diseases. It is one of the six existing chief officers within SA Health that supports and advises in key areas of clinical, public health, scientific, or allied health services [2]. Other chief officers include the Chief Medical Officer, Chief

COVID-19 Article

Nurse and Midwifery Officer, Chief Pharmacist, Chief Psychiatrist, and the Chief Allied and Scientific Health Advisor. During the COVID-19 pandemic, four deputy Chief Public Health Officers were also appointed to support the Chief Public Health Officer. They each lead a workstream with its specific focus, but all work together to ensure a comprehensive approach to the COVID-19 responses. In brief, these workstreams had a focus on public health responses, clinical systems and high acuity care, primary care and out-of-hospital services, and whole-ofgovernment responses.

Reflection Placement activities at the Department for Health and Wellbeing I was fortunate to work with the Chief Public Health Officer and her deputies in these various workstreams, as well as personnel from various functional units including the Communicable Diseases Control Branch, Health Protection and Licensing Services, Office of the Chief Medical Officer, and the Office of the Chief Pharmacist. My placement activities varied from day to day and changed over time, reflecting the rapid developments of the COVID-19 situation and the department’s response accordingly. Some of these activities included preparing for case interview and contact tracing, synthesising published literature and grey literature to inform and guide the COVID-19 responses, and to provide industry-specific advice. Other activities included working with Human Biosecurity Officers on risk mitigation plans for people and organisations intending to enter Aboriginal and Torres Straits Islander communities, attending State Emergency Centre briefings, participating in various projects and discussions for policymaking, and attending stakeholder consultations and/or site visits. Shadowing the Chief Public Health Officer gave me a behindthe-scenes look into the reasoning behind public health decisions and the considerations taken into account. Similar to the learning process of developing clinical acumen, this was especially interesting where there was a lack of conclusive evidence, when such evidence needed to be extrapolated, and when different conclusions were drawn based on the same evidence. It was also fulfilling to observe effective rapportbuilding and communication skills, especially in instances where there were conflicting stakeholder and public health interests. Another memorable experience during my placement at SA Health was reviewing the Australian Football League (AFL)’s COVID-19 protocol and the Adelaide Oval’s reopening strategy, as well as attending two rounds of AFL matches to observe these mega events from a public health perspective [3]. One of these matches, dubbed “a showdown like no other”, represented the first sporting event in Australia to allow spectator attendance since the interruption of sport leagues following COVID-19 [4].

Multidisciplinary and systems approach within SA Health I quickly realised during my placement that SA Health is equipped with many professions both within and beyond the health sector, each of whom contributes to an effective system that enables SA Health to carry out its service deliveries and COVID-19 response.

As an example, I was able to participate in the pilot of COVID19 swab collection aimed at opportunistically testing patients with COVID-19 symptoms who present to pharmacies [5]. This rationale was informed by a regular population health survey which identified a significant percentage of symptomatic people not presenting for COVID-19 testing [6]. While the rationale was simple and straightforward, the launch of this pilot required input from various subject matter experts. Experts in project delivery and implementation science provided tools and frameworks to ensure timeliness of project delivery and adequate considerations of various aspects of the project. The Office of the Chief Pharmacist was instrumental in liaising with individual pharmacies and regulatory bodies including the Pharmacy Guild, Pharmacy Board of Australia, and the Pharmacy Society of Australia. Meanwhile, the general practitioner liaison, as well as media and communications were involved in communicating with other representative bodies and the general public. Legal and insurance services were also consulted in the planning of this pilot. Other professions who had significant input into the COVID-19 response included data analytics and digital solutions, crucial in facilitating various dashboards and reporting; procurement and supply chain management and infectious diseases specialists, who ensured ongoing adequate personal protective equipment for clinical use; intergovernmental relations who played an important role in communicating with the Commonwealth and other agencies; and health translation and health economic experts who provided data and guidance on the COVID-19 response.

Interagency collaboration in the COVID-19 response This multidisciplinary collaboration in the COVID-19 response also extends to other governmental agencies. For instance, this is represented through the interagency collaboration that is the mandatory quarantine of all international arrivals at a designated facility. Each repatriation flight requires significant planning and organisation of logistics, with input from several agencies during each phase. A manuscript outlining the planning and preparedness response for these operations is currently in preparation [7]. As part of the whole-of-government workstream, I was also able to work with personnel from other governmental agencies, including the Department for Education on school-related matters in the context of COVID-19, the Department of the Premier and Cabinet on issues affecting Aboriginal and Torres Strait Islander communities, South Australian Police, and Department for Transport and Infrastructure. In working with these different agencies, I was able to identify preconceptions and assumptions in my understanding of how these agencies work, as well as how different public health actions affect the agencies and the community. South Australian Police, for example, has a strong emphasis on taking an educational approach to their enforcement of various COVID19 restrictions, as opposed to a punitive approach. It is my understanding that such an approach is important in keeping the community on board with the COVID-19 response. Successful collaboration among these different agencies was enabled by a shared understanding of the public health situation in South Australia, the need for ongoing measures, and

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the impact of various restrictions on all agencies, as well as the inter-organisational linkages which enabled nurturing of relationships among personnel from various agencies [8]. An understanding of how each discipline or agency fits into the broader picture and the governance structure provides a clarity in effective planning and delivery of services, especially where a systems approach is required. It also provides insight into how conflicting priorities could be resolved. I am confident that my learnings and reflections in working with personnel from various agencies will enable me to work in multidisciplinary teams, both within and outside the healthcare setting. Spending time in SA Health also gave me an appreciation of the underlying systems and structures that allow effective delivery of health services, which I believe will help me consider the big picture and navigate the best course of action when advocating for the health and wellbeing of my patients, whether as individuals, communities or as a population.

Surveillance and monitoring of COVID-19 and other diseases A key learning point during my placement is that there is loss of information at each stage of surveillance. Such loss of information can occur when symptomatic patients do not present for testing or when health practitioners decide that testing is unnecessary. Additionally, in the context of certain surveillance systems, positive testing may not always lead to notification. Consequently, positive notifications to the health department only represent a certain percentage of the population who indeed have the disease. While largely accepted for many conditions, there is a need for this loss of information to be minimised in the context of COVID-19. This was precisely the rationale behind opportunistic testing of symptomatic people who do not present for testing but present to pharmacies for over-the-counter medications or health advice. Other methods that have been employed in Australia to reduce such loss of information include encouraging healthcare personnel to request a COVID-19 test for any patients who have symptoms, public health messaging through different forms including social media, and hardship payments to encourage testing and isolation following testing. Additional testing sites that were set up in South Australia in response to COVID-19, including the ones deployed to the South Australian - Victorian borders, aim to improve access and to reduce barriers to testing by geographical areas. These initiatives were beneficial in consolidating my previous learning of these public health principles through an elective [9]. An understanding of surveillance systems and the approaches to increasing the effectiveness of such systems in different contexts is essential in making evidence-based decisions to protect and promote the health of populations. Future surveillance of communicable diseases could include modelling based on travel pattern and mobility data, instead of current assumptions of a homogenous, well-mixed population, although there may be ethical and/or legal concerns in the acquisition of such baseline data.

Early learnings in the factors contributing to health, illness, and success of interventions

COVID-19 is a novel pandemic with many unknowns. As an example, while most severe cases were attributed to advanced age or pre-existing co-morbidities, some patients with severe

outcomes had none of these risk factors, including a South Australian who acquired the disease on a cruise ship and required a prolonged stay in the intensive care unit [10]. His wife, who was on the same cruise, did not acquire the infection. Yet amidst these unknowns, some trends have been noted both in Australia and overseas. Early in the pandemic, most COVID19 cases in South Australia were reported in returning overseas travellers, many of whom resided in suburbs considered to be of higher socioeconomic status [11]. This was in contrast to diseases such as Hepatitis C, which disproportionately affect marginalised populations [12]. However, the ‘second wave’ in Victoria was seen to predominantly affect people from culturally and linguistically diverse communities, many of whom worked in casual positions at multiple work locations and could not afford to self-isolate following testing. This also resulted in difficulties in case interviewing, where interpreters were introduced to the already lengthy phone interview process. Further issues arose in contact tracing, where confirmed cases of COVID-19 reportedly refused to name their close contacts, given their concerns that anyone named during this process would similarly need to quarantine and would suffer a loss of income as a result.

Patient-centred approach in public health interventions and health delivery An initial consultation between SA Health and representatives of the culturally and linguistically diverse population identified several misconceptions among these communities, including that testing would incur a cost. One community leader identified that there was a prevalent conspiracy theory around COVID-19 testing being used to also test for other diseases such as HIV. Evidence that such psychological barriers have implications on testing rates has also been previously documented [13]. Some community leaders also identified the wide-ranging sources of information within their community, as well as some illiteracy among community members, highlighting the areas that require further effort and support by SA Health. The setting up of Aboriginal and Torres Strait Islanders as cordon sanitaires under the Biosecurity Act 2015 also had unintended consequences, as the well-intentioned legislation to protect communities from COVID-19 inevitably introduced strict requirements for people entering and leaving the communities. Especially in communities with geographical proximity to a major town, members of these communities routinely leave the “Designated Areas” to access essential supplies or services or rely on members outside of the communities to bring in such supplies or services. As a result of these unintended consequences, all Aboriginal and Torres Strait Islander communities that opted in as a Designated Area under this Act subsequently withdrew from such arrangement. These experiences led me to reflect on the necessity for a patient-centred approach of healthcare and for a partnership with consumers in providing health services. While the delivery of health services has moved away from the traditional paternalistic approach, with some specialties even engaging consumers in the research process and empowering them to participate in scientific meetings [14], healthcare providers need to be mindful of how preconceptions and assumptions can subconsciously affect their course of action. Open

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communication seeking to understand the priorities of individual patients or communities will allow for any treatment or intervention to be oriented towards the patient or the community’s desired outcome.

Conclusion A perceived dilemma between public health and clinical practice is that the focus of public health is predominantly on a community or the population, although the benefits of any public health intervention ultimately impact on individual patients, whereas clinical practice is predominantly focused on

the patient in front of the clinician, although positive outcomes through individual consults ultimately affect population health. Reflecting on my placement has encouraged me to consider a dual career in clinical practice and public health. I will keep in mind the need for individual patients’ health and wellbeing as well as that for communities and populations to be balanced. There is a need for exposure to public health among medical students, whether in the form of teaching or experiential placements.

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S.A. Health. SA government and SA health emergency management overview [Internet]. 2018 [cited 2020 Jul 23]. Available from: https://www.sahealth.sa.gov.au/wps/wcm/connect/40d51c525c24-4cdc-a67b-822ba26be823/SA+Govt+and+SA+Health++Emergency+Management+Overview+October+2018_final....pdf ?MOD=AJPERES&amp;CACHEID=ROOTWORKSPACE-40d51c525c24-4cdc-a67b-822ba26be823-n5ijRCC S.A. Health. Our chief officers. 2020 [cited 2020 Aug 20]. Available from: https://www.sahealth.sa.gov.au/wps/wcm/connect/public+conte nt/sa+health+internet/about+us/about+sa+health/our+chief+o fficers Chan JEZ, Lee A, Lease C, Spurrier N. Recommencement of sport leagues with spectators at the Adelaide Oval during the COVID19 pandemic: planning, experience and impact of a globally unprecedented approach. Front. Public Health. 2021 Jul 23;9:676843. doi:10.3389/fpubh.2021.676843 Walsh L, Hough A, Russell C, Sunday Mail. After 293 days on the bench, Showdown 48 brings crowds back to Adelaide Oval – get your poster now [Internet]! 2020 [cited 2020 Jun 14]. Available from: https://www.adelaidenow.com.au/news/southaustralia/after-293-days-on-the-bench-showdown-48-bringscrowds-back-to-adelaide-oval-get-your-poster-now/newsstory/8ade99bb70835045ce9813523f24674b?fbclid=IwAR2uE8Jh zNGWjRbjhr5kE1bIQHPRr1i1PNmMNL8r4ipd1or2V0S1lavBE2o Smith M. COVID-19 tests at chemists trialled to boost number of South Australians getting checked. The Advertiser; 2020 [cited 2020 Jul 23]. Available from: https://www.adelaidenow.com.au/coronavirus/covid19-tests-atchemists-trialled-to-boost-number-of-south-australians-gettingchecked/news-story/c6f206cf93906764f54b440942e82800 Hough A, Sulda D. Sick snub COVID-19 testing pleas as SA Health warns of mounting complacency [Internet]. The Advertiser; 2020 [cited 2020 Jul 23]. Available from: https:// www.adelaidenow.com.au/coronavirus/sick-snub-covid19testing-pleas-as-sa-health-warns-ofmountingcomplacency/news-story/9b2dbeb749dff27897a31380f4aed568

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Meena S, Chan J, Phan TV, Butenko S, Hurley J, McGowen P, et al. Repatriation operation in South Australia during the COVID-19 pandemic: initial planning and preparedness. Commun Dis Intell. 2021 May 27;45. doi:10.33321/cdi.2021.45.29 Bistaraki A, McKeown E, Kyratsis Y. Leading interagency planning and collaboration in mass gatherings: public health and safety in the 2012 London Olympics. Public Health. 2019 Jan;166:19-24. doi:10.1016/j.puhe.2018.09.031 Mahmood MA. Health Systems of the World: Access and Equity: University of Adelaide; 2016. Hough A. Ruby Princess passenger Paul Faraguna won COVID battle doctors thought him doomed to lose [Internet]. The Advertiser; 2020 [cited 2020 Jul 23]. Available from: https://www.adelaidenow.com.au/coronavirus/ruby-princesspassenger-paul-faraguna-won-covid-battle-doctors-thoughthim-doomed-to-lose/newsstory/619c19d9b1705d81f480dedd16a487dc S.A. Health. COVID-19 dashboard [Internet]. 2020. Available from: https://www.sahealth.sa.gov.au/wps/wcm/connect/public+conte nt/sa+health+internet/conditions/infectious+diseases/covid+20 19/covid-19+dashboard Edmunds BL, Miller ER, Tsourtos G. The distribution and socioeconomic burden of Hepatitis C virus in South Australia: a cross-sectional study 2010-2016. BMC Public Health. 2019 May 8;19(1):527. doi:10.1186/s12889-019-6847-5 Ford CL, Wallace SP, Newman PA, Lee SJ, Cunningham WE. Belief in AIDS-related conspiracy theories and mistrust in the government: relationship with HIV testing among at-risk older adults. Gerontologist. 2013 Dec;53(6):973-84. doi:10.1093/geront/gns192 Duncanson E, Dansie K, Gutman T, Tong A, Howell M, Jesudason S, et al. 'Knowledge is power': a framework for partnering with consumers in developing and delivering a scientific meeting in nephrology. Nephrology (Carlton). 2020;25(5):379-83. doi: 10.1111/nep.13570

Acknowledgements: The author would like to acknowledge Chief Public Health Officer Prof. Nicola Spurrier and her deputies Dr Chris Lease, Dr Evan Everest, Dr Michael Cusack, Dr Emily Kirkpatrick; all members of the COVID-19 workstream; Minister for Health and Wellbeing Hon. Stephen Wade MLC; Department for Health and Wellbeing Chief Executive Chris McGowan and deputy Don Frater; State Commander Paul McGowen and deputy Monique Anninos, as well as other staff in the State Control Centre (Health); Communicable Diseases Control Branch Director Dr Louise Flood and deputy Dr Ann Koehler, Director of COVID-19 Operations Dr Robert Hall, public health registrars Dr Sonali Meena and Dr Tuong-Vi Phan, as well as other members of the branch; Angela Lee, David Cunliffe and staff of the Health Protection and Licensing Services; Chief Pharmacist Naomi Burgess and COVID-19 Pharmacy Liaison Michael Broadbent; Clinical Services Director Dr Tom Dodd and staff from SA Pathology; staff in the Department for Health and Wellbeing and the Office of the Minister for Health and Wellbeing for their contribution to a pleasant placement experience complete with valuable learning opportunities. The author also thanks personnel from other governmental and non-

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governmental agencies whom the author had the opportunity of working with. The author would like to thank Dr Hannah Myles from University of Adelaide for her role as the author’s reflective learning coach during the COVID-19 modified placement structure, and for her recommendation to submit this reflection piece for publication in the Australian Medical Student Journal; as well as Deputy Chief Public Health Officer Dr Emily Kirkpatrick for reviewing and approving this manuscript on behalf of the Department for Health and Wellbeing. Finally, the author would like to thank friends and family who were of great support during these unprecedented times. Conflict of interest statement: The author has no conflicts of interest to disclose. Funding: None Author contribution statement: JC is the sole author of this manuscript. Cite as: Joel EZC. COVID-19 as a valuable learning opportunity. Aust Med Stud J. 2020;1:748–51. Correspondence: Joel Ern Zher Chan, joelernzher.chan@student.adelaide.edu.au Date of submission: 27 July 2020 Date of acceptance:: 16 November 2020 Date of publication: 21 November 2020 Editor: Onur Tanglay Senior Editor: Mabel Leow Proofreaders: Abhishekh Srinivas, Trung Tran Senior Proofreader: Emily Feng-Gu

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COVID-19: Adaptations to Primary Care in Australia James Pietris 1 1

Bond University James Pietris is 4th year medical student at Bond University, and originally hail from South Australia but have resided in Queensland for the last 4 years.

Key learning points • Effective implementation of telehealth in primary care settings in Australia can help to reduce the transmission and spread of COVID-19. • More evidence is required to accurately assess the effectiveness and practicality of the public use of face masks. • Despite being incredibly effective at reducing the spread of COVID-19, physical distancing has resulted in devastating economic impacts globally. Abstract Introduction: The Australian Government has implemented its National Primary Care Response action plan to combat the growing threat of the COVID-19 pandemic across the country. The plan recognises the integral role of primary care services in protecting the most vulnerable citizens of our nation and recommends a number of interventions aimed at reducing transmission, including expanding telehealth services, physical distancing measures, and the use of personal protective equipment. The efficacy of these suggested measures needs to be evaluated to ensure everything is being done to maximise the safety of Australia’s primary care system while maintaining the highest level of care possible. Summary: This review article delves into the benefits and limitations of the interventions suggested in the National Primary Care Response action plan and formulate recommendations on each intervention based on the currently available literature. Based on the literature findings, recommendations have been made to implement telehealth, physical distancing, and face masks in primary care settings across Australia to curb the transmission of COVID-19 across the country.

Keywords: Telehealth, physical distancing, primary care, COVID-19, coronavirus. Introduction Since late December 2019, a novel coronavirus COVID-19 spread rapidly across the globe from its origin in Wuhan, China, causing pneumonia-like respiratory illness. A global pandemic was officially declared on 11 March 2020 [1]. Lessons learnt from past outbreaks of disease underline the critical frontline role of primary care, and the need for clear, regular communication between the community and the primary care workforce [1]. In

early March, as part of the Australian Health Sector Emergency Response Plan for the novel coronavirus, the Australian Government announced the National COVID-19 Primary Care Response, an action plan that aims to protect the nation’s health care system and most vulnerable citizens through facilitating rapid implementation of initiatives to optimize workforce capacity, efficiency, and safety. The four key objectives to the Primary Care Response are: 1. Protection of vulnerable citizens, 2. Function of the healthcare system, 3. Support and treatment, and 4. Capacity to maintain stocks of personal protective equipment [2]. Many components are integral to the Primary Care Response. These include the creation of General Practitioner (GP)-led respiratory clinics, public fever clinics, changes to influenza vaccination recommendations, and increasing research funding, among others. This article will focus on three of these components; the expansion of telehealth services, the implementation of physical distancing measures in face-to-face consultation situations, and the use of personal protective equipment (PPE) in primary care settings. These components have been chosen to reviewed as they have been the most publicised and implemented strategies across Australia during this pandemic [3]. Evaluating the available evidence of the efficacy and practicality of these measures in the primary care setting will provide valuable insight into the value of the implementation of these measures across Australia.

Methods A literature search was performed of trials published from 2005 to 2020 involving telehealth practices, physical distancing, and past and current global health emergencies. The search terms and keywords used were ‘telehealth’, ‘physical distancing’, ‘primary care’, ‘COVID-19’, and ‘coronavirus’. Four databases (EMBASE, Google Scholar, Cochrane, and PubMed), were searched. The inclusion criteria required the studies to be published in English language journals, published between the years of 2005 – 2020, and be sufficiently relevant to the topic of the article. Using these inclusion criteria, 12 scientific articles relevant to the topic were chosen to include. Local and foreign government websites were also searched for relevant official documents, policies, and statistics.

Telehealth

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Telehealth use – using technologies to promote and support long-distance clinical care – has over the past decade seen a dramatic increase in correlation with the increased frequency and severity of disasters across the world [4]. There is strong evidence for the efficacy of using telehealth to decrease patient flow through primary care facilities and emergency departments alike, decreasing the strain on these facilities and allowing them to operate more efficiently [5]. The American city of Houston has rolled out mobile home healthcare units to chronic disease patients at home, allowing remote monitoring of these patients to prevent their repeated exposure to healthcare workers through in-person primary care consultations and emergency department admissions. Implementation of these measures showed a 56% decrease in exposure to healthcare workers compared to the control group [6]. In Australia, the accessibility of telehealth for people in rural and remote communities is another big advantage. Patient care can be more effectively delivered with less patients lost to follow up as the need to travel to consultations will be much less frequent, and access to services for people in areas where there are no local health services will be increased [7]. In addition to this, the cost of providing telehealth services is minimal, with each consult resulting in net savings mainly due to the avoidance of travel costs [8]. With rapid implementation of new initiatives comes unique limitations, and these are evident with telehealth. A major concern of telehealth consultations is patient confidentiality and privacy. Due to the remote nature of telehealth, the confidentiality of the consultation cannot be guaranteed by the practitioner and sensitive health information may inadvertently become the knowledge of a larger than intended group [9]. The Australian Government, in conjunction with the Royal Australian College of General Practitioners (RACGP), has provided guidelines to be used to maximise the confidentiality of telehealth consultations. These guidelines recommend verifying the patient’s identity and the identity of anyone else in attendance, confirming verbal consent, and keeping accurate and up to date documentation in the same manner as is required for a face-to-face consultation [9]. These measures are designed to optimise the privacy of patients while still allowing an effective consultation but are still far from comparable to the level that can be achieved in a traditional consultation. Most telehealth services are being delivered via telephone in Australia and hence availability is not an issue, but adequate platforms for the delivery of video services, such as tablets or computers, are not immediately available in numbers large enough to service entire countries, especially with the disruptions in international supply chains that have been seen throughout the COVID-19 pandemic. The standard of patient care delivered through a telephone consultation must be questioned when the visual cues of the patient cannot be interpreted and the level of understanding gained from body language in a traditional consultation is lost. Hence, this can potentially adversely affect patient outcomes [10]. Thus, the quality of care delivered through telehealth compared to traditional consultations must be questioned, and more research is needed in this area to allow a direct comparison of care before telehealth can be considered a viable alternative to traditional face-to-face primary care.

Physical Distancing Physical distancing measures have been perhaps the most widely implemented initiative across the world in response to the COVID-19 pandemic. There is ample evidence to emphasise the benefits of physical distancing with respect to reducing both the severity and number of cases [11,12]. The basic reproductive number, R0, reflects the number of individuals directly infected by an infectious person in an otherwise susceptible population. The lower the R0 value, the lower the number of newly infected people. An R0 value of 1 suggests a disease is endemic, whereas if R0 is less than zero, the case numbers will likely be in decline. The R0 value is influenced by the number of contacts an infectious person has, the risk of transmission per contact, and the duration of contagiousness of the disease [13]. Physical distancing principles mostly relate to the first factor – reducing the number of contacts an infected person has. The second concept to consider is the notion of a negative multiplier effect. The negative multiplier effect refers to the exponential decrease in case numbers that is seen with effective physical distancing measures, as illustrated in Figure 1 below [14]. It can therefore be suggested that implementation of adequate physical distancing measures in the primary care setting, as well as the wider community, will lower the rate of transmission and hence reduce the R 0 value, contributing to reduced overall numbers of the disease. With regard to primary care, there are a number of very simple physical distancing measures that can be immediately implemented to reduce infection rates and transmission. These include no handshaking, coughing, and sneezing etiquette (into the elbow), paying by card instead of cash, and making videoconferencing the default for staff and multidisciplinary team meetings. These measures and their swift implementation are all supported by the World Health Organization [15]. Limitations to the implementation of physical distancing are relatively minimal, as the above measures are free of cost, not impacted by supply chain disruptions, and are effective across all demographic groups. However, the economic cost of physical distancing has been significant. Industries such as hospitality, live music, air travel, and tourism have all been severely affected. Restrictions on international and domestic flights, as well as laws preventing large gatherings of people have resulted in steep downturns in business, resulting in an estimated $34.2 billion decrease in Australia’s gross domestic product (GDP) over the next year [16]. In addition to this, the practicality of enforcing physical distancing rules in every domain is limited in certain situations. Essential services such as public transport and grocery stores see a large amount of unavoidable foot traffic throughout the day, and hence it is difficult to practice physical distancing in these settings due to the inherently high demand for these services [17].

Personal Protective Equipment It is universally agreed that personal protective equipment (PPE) is essential to prevent the spread of COVID-19 to healthcare workers in the hospital setting. The use of PPE by the public, particularly face masks, is much more contentious, especially

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when it comes to environments outside the hospital, such as the primary care setting. Surgical face masks are protective against medium to large droplet spread, and N95 masks are protective against small droplet spread [18]. The literature in this area is rapidly changing and there are many contrasting conclusions on the benefits and risks of mask use outside of hospital facilities [19]. A review conducted by the Bond University Institute for Evidence-Based Healthcare has recently suggested that wearing face masks did lead to a significant reduction in incidence of influenza-like illness, based on observational data from the severe acute respiratory syndrome (SARS) epidemic [20]. Research from the United Kingdom (UK) suggests that widespread community use of face masks possibly reduced the transmission of SARS, and there is clear evidence that face masks should be used in households and facilities that are caring for COVID-19 positive patients for extended periods of time [21]. Recently, a recommendation has been made by the US Centres for Disease Control and Prevention that fabric masks be used at the community level, although due to a lack of data this is based on laboratory studies investigating the effectiveness of different materials at trapping particles of different sizes [22]. It is important that masks fit for use in hospitals are not redirected away from vital healthcare supplies in hospital facilities, and hence supply is the major limitation to the recommendation of face masks in primary care settings as well as in the wider community. More evidence and community input

into the effectiveness and practicality of this initiative is needed before a reasonable recommendation can be made regarding the use of face masks.

Conclusion It is evident that COVID-19 will continue to disperse and circulate across the globe for some time, with waves of infections likely for the foreseeable future. The relevance of the aforementioned adaptations will become increasingly pertinent as the pandemic develops. Due to the rapidly developing nature of the situation, evidence on the efficacy of individual measures in preventing COVID-19 is not widely available. Despite this, there is definite evidence for the benefits of telehealth and physical distancing measures in the primary care setting, and hence it is proposed that these measures be utilised, resources permitting, to their full potential across the Australian primary care landscape. This is further emphasised by the relatively low cost and little harm of these measures. Based on the currently available evidence, a recommendation can be made advocating the use of face masks at the community level to prevent virus transmission, although this continues to be a divisive issue across the country. The Victorian Premier, Daniel Andrews, has since made the wearing of face masks mandatory for Victorians outside their homes. This is an unprecedented step in Australia’s fight against COVID-19, and the outcome of this measure remains to be seen.

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site. https://www2.gov.bc.ca/assets/gov/health/about-bc-shealth-care-system/office-of-the-provincial-health-officer/covid19/guidance_to_grocery_stores_april_25_final.pdf Accessed August 14, 2020. Mukerji S, MacIntyre CR, Newall AT. Review of economic evaluations of mask and respirator use for protection against respiratory infection transmission. BMC Infect Dis. 2015;5:413. Greenhalgh T, Schmid MB, Czypionka T, et al. Face masks for the public during the covid‐19 crisis. BMJ. 2020;369:1435. Jefferson T, Jones M, Al Ansari LA, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Part 1 - Face masks, eye protection and person distancing: systematic review

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and meta-analysis. Medrxiv Preprint. 2020;1. doi: https://doi.org/10.1101/2020.03.30.20047217 Public Health England. The use of facemasks and respirators during an influenza pandemic: scientific evidence base review. Crown Department of Health Web site. https://assets.publishing.service.gov.uk/government/uploads/sys tem/uploads/attachment_data/file/316198/Masks_and_Respirato rs_Science_Review.pdf Published 1 May, 2014. Accessed May 7, 2020.

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Acknowledgements: I would like to express my appreciation to Dr Anne Spooner and Dr Mark Morgan for their valuable suggestions, constructive criticism, and guidance throughout the development of this literature review. Conflict of interest statement: The author has no conflicts of interest to disclose. Funding: None Author contribution statement: James Pietris made substantial contribution to the conception & design of the work, the analysis and interpretation of data for the work, and final approval of the version to be published. Cite as: James P. COVID-19: Adaptations to Primary Care in Australia. Aust Med Stud J. 2020;1:748–51. Correspondence: James Pietris, james.pietris@gmail.com Date of submission: 15 July 2020 Date of acceptance:: 28 December 2020 Date of online publication: 3 January 2021 Editor: Onur Tanglay Senior Editor: Mabel Leow Proofreaders: Margaret Hezkial, Ke Sun Senior Proofreader: Emily Feng-Gu

COVID-19 Article

Social Distancing and Domestic Violence: An Exploration of the Paradoxical Impact of Our Public Health Response to COVID-19 Sivasaaini Sivakumaran1 1

Bond University Sivasaaini Sivakumaran is a fifth-year medical student who shares a great interest in advocating for women’s health. Born in Papua New Guinea, she has come to appreciate the importance of women’s health,

Key learning points • The COVID-19 pandemic has exacerbated rates of domestic violence. • Public health response and policies in response to COVID-19 have contributed to tipping vulnerable relationships into abusive connections. • Strategies need to be implemented on a legislative and social level to lower domestic violence rates. Abstract The public health response and policies implemented during the COVID-19 pandemic have had a substantial influence on the incidence of domestic violence globally. Whilst regulations are in place to protect lives and livelihoods, an evaluation of these measures reveals the paradoxes of such actions on individuals who are vulnerable to such interpersonal abuse. Considerations into the catalysts which prompt such a rise in rates as a result of increased psychosocial pressures are discussed. Furthermore, strategies which could potentially be instigated on a legislative and social level to counter these issues are deliberated.

Keywords: COVID19, Domestic Violence, Health, Public Health, Social Distancing

Women’s

Introduction As the COVID-19 pandemic overwhelms systems globally, the mantra of our governments has always been to “stay home, save lives” [1]. Unbeknownst to some, we are fighting a simultaneous battle of a silent, yet deadly public health issue – domestic violence [2]. Worldwide, one in three women, as well as some men, experience intimate partner violence within their lifetimes [1]. Subjecting these vulnerable populations to lockdown laws where they are forced to spend more time with abusers has facilitated the rise in such rates [3]. The troubling paradoxes which result from social distancing and isolation measures precipitate problems for those who are living in and surviving abusive relationships [3,4]. As a result, this has led to people spending more time at home as they begin to work from home

especially in the global context and aspires to one day be an obstetrician and to volunteer in a few developing countries. with public entities such as restaurants, pubs, clubs, and many leisure activities having to come to a close. Additionally, many people that have never previously been in pressured relationships of domestic violence have been tipped into experiencing it for the first time during this pandemic [1]. The increasing psychosocial pressures in tandem with households spending more time in close proximity with each other breed opportunities for abuse through surveillance, controlling behaviours, and coercion [2]. A false paradigm is envisaged of a home as a safe haven but in its very nature it can be a place where power dynamics are distorted or subverted by those who abuse [4]. These isolation measures unintentionally prevent survivors from seeking help and reduce their ability to flee from such situations [3].

Discussion In Australia, an increase in the demand for domestic violence services coincided with the implementation of government enforced restriction policies [5,6]. An 11% increase in domestic dispute call-outs to organisations such as 1800RESPECT and a 75% increase in internet searches relating to domestic abuse were observed [2,6]. This may reflect the influence of government implemented policies but also the loss of jobs, increased global uncertainty, and the lack of access to resources which would otherwise have defused such situations. These trends in statistics are not merely a national matter but are very much a global concern. A positive correlation between the number of reported cases of COVID-19 and domestic violence cases has been identified in countries including the United States, Argentina, France, Cyprus, and Singapore [7]. An article published by The Guardian reported a 25% increase in the reported calls to the United Kingdom (UK) Domestic Violence helpline seven days after the announcement of restrictions by the UK government [1]. Additionally, China - which was the first country to impose mass quarantine – saw a threefold rise in abuse incidents in February 2020 [6]. Perpetrators are capitalising on precautions related to COVID19 to use coercive control mechanisms specifically through the use of containment, fear, and threat of contagion [1]. As echoed by The United States National Domestic Violence Hotline, 5.8% of victims experienced a new form of manipulation from fear tactics of prohibiting access to hospital care and withholding necessary items such as hand sanitisers [3]. In keeping with the unknown of what goes on “behind closed doors”, lockdown

COVID-19 Article

measures have inadvertently granted abusers or potential abusers the ability to act in ways that give them increased power to exploit with less scrutiny from others [4]. Our public health response and policies not only restrict people living in volatile situations of family violence to their homes but also serve as catalysts to tip at-risk relationships into violence [1]. Isolation at home coupled with psychological and economic stressors, stemming from unemployment, fear, frustration, anxiety, boredom and financial burden, increases one’s susceptibility to mental health issues [6,7]. These heightened stressors act as triggers which unravel negative coping mechanisms through excessive alcohol consumption and substance misuse [6]. In Australia, as social distancing measures were implemented, the sales of alcohol rose 36% [6]. Given the closure of pubs and bars, it comes as no surprise that people are drinking more due to boredom and stress release within the confines of their homes [6,7]. With more than half of perpetrators reported to having been under the influence of alcohol at the time of domestic abuse, it becomes apparent that the aforementioned risk factors act as a medium for exacerbating pre-existing familial conflicts adding to the catastrophic milieu [6,7]. Governments and policymakers should use this rise in domestic violence precipitated by the pandemic as an opportunity to implement new protocols and approaches. Although there was some awareness around this matter prior to COVID, planting seeds to create greater understanding will be essential in building the foundation of methods to address this matter. Information about services available locally, such as hotlines, telehealth, respite services, shelters, rape crisis centres, and counselling, should be reinforced through policy change [6]. Stakeholders can integrate discrete reporting platforms into grocery stores or other essential public spaces, as already exemplified in France since May 2020 where pharmacies and shops have initiated emergency warning systems through posters placed in toilets to enable people in danger to use code words like “mask 19” to alert staff [1,6]. On a legislative level, governing bodies should apply a gendered lens to funding and

an economic stimulus to industries that are not solely male dominated as a means of allowing both genders to return to work and essentially spend more time outside the confines of their home [8]. Moreover, as seen in the reallocation of funding in Victoria, the 20 million dollar package by the State Government providing accommodation for perpetrators represents a shift in approach we have for reducing family violence [9]. Equally important is to see more women being included in the decision making and planning of interventions to provide a different perspective [10]. Services including therapists and frontline healthcare workers should provide further support and care to survivors experiencing immediate danger and distress during this pandemic [4]. Thus, it is critical for governments to increase the capacity for helpline services, targeted campaigns, and training of these workers to cope with such cases [11]. Providers should also normalise screening by using routine and standardised questions through telemedicine appointments to ensure all patients are aware of resources available to them as well as safety planning if relevant [7,12]. Incorporating screening for domestic violence into COVID-19 testing sites is another way to overcome the barriers to seeking help [1]. The importance of neighbours, friends, and families to encourage conversation and provide support during these hard times is also highly recommended [6]. Equally important is mitigating the psychological trauma after this pandemic has subsided and providing the essential funding to support the mental health sequelae [13].

Conclusion The COVID-19 pandemic has served as a critical point for individuals to be aware of the repercussions of our emergency health response. Whilst “staying safe” alludes to remaining virus-free, it is imperative during such adversity that we fight for those who are vulnerable and under-represented within the political spheres. In light of the policies set to overcome COVID19, a need to implement guidelines to protect our domestic violence victims is more important now than ever before.

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Anurudran A, Yared L, Comrie C, Harrison K, Burke T Domestic violence amid COVID‐19. Int J Gynaecol Obstet. 2020;150(2):2556. Neil J. Domestic violence and COVID-19: our hidden epidemic. Aust J Gen Pract. 2020;49. Boxall H, Morgan A & Brown R 2020. The prevalence of domestic violence among women during the COVID-19 pandemic. Statistical Bulletin no. 28. Canberra: Australian Institute of Criminology. https://www.aic.gov.au/publications/sb/sb28 Bradbury‐Jones C, Isham L. The pandemic paradox: the consequences of COVID‐19 on domestic violence. J Clin Nurs. 2020;29(13-14):2047-9. Mills T. New reports of family violence spike in COVID-19 lockdown, study finds [Internet]. The Age. 2020 [cited 24 October 2020]. Available from: https://www.theage.com.au/national/victoria/new-reports-offamily-violence-spike-in-covid-19-lockdown-study-finds20200607-p55096.html Usher K, Bhullar N, Durkin J, Gyamfi N, Jackson D. Family violence and COVID‐19: increased vulnerability and reduced options for support. Int J Ment Health Nurs. 2020;29(4):549-52.

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Acknowledgements: Thank you to Dr Annelise Wan for guiding me in the production of this article. Conflict of interest statement: The author has no conflicts of interest to disclose. Funding: None Author contribution statement: Sivasaaini Sivakumaran is the sole author of this manuscript. Cite as: Sivasaaini S. Social distancing and domestic violence: an exploration of the paradoxical impact of our public health response to covid-19 . Aust Med Stud J. 2021;1:748–51. Correspondence: Sivasaaini Sivakumaran, sivasaaini_1999@hotmail.com Date of submission: 13 November 2020 Date of acceptance:: 14 April 2021 Date of publication: 17 April 2021 Senior Editors: Mabel Leow, Onur Tanglay Proofreader: Ke Sun, Trung Tran Senior Proofreader: Emily Feng-Gu

Feature Article

Climate Emergency in Australia and the Need for Inclusion of Indigenous Peoples in Solutions Hayden Burch1 1

University of Melbourne

Hayden Burch is a dual Doctor of Medicine and Master of Public Health student at the University of Melbourne. Key learning points

•

Australia’s greenhouse gas emissions are continuing to increase, with Australia set to drastically miss its Paris Agreement targets and face worsening implications on the health of Australians and the practice of healthcare. Current federal policy still relies on fundamental Western principles that exclude time-tested, Australian-specific Indigenous expertise on strategies to address greenhouse gas emissions and broader sustainability. To achieve meaningful inclusion of Indigenous experiences the fundamental causes of exclusion must be acknowledged and addressed such as constitutional recognition and ratification of Indigenous people’s rights.

Abstract Introduction: Climate change is the greatest threat to human health this century. With a view that the planet’s resources are infinite, the ongoing production and consumption of fossil fuels is driving environmental changes that undermine the determinants of health. In accordance with the Paris Climate Accord, it is imperative that societies transition to sustainable existences to keep the earth’s temperature below two degrees Celsius. To date, Australia’s responses to climate change continue to propagate the marginalisation of Aboriginal and Torres Strait Islander populations. There is an increased burden on Indigenous peoples as a known vulnerable population. Further, nearly all policy areas that contribute to increasing greenhouse gas emissions, such as agricultural systems, could achieve immediate and significant reductions in Australia’s carbon footprint if they embedded evidencebased and native alternatives. Summary: This article outlines the benefits of including the voices and experience of Aboriginal and Torres Strait Islander peoples. Through collaboration and shared political decision-making with Indigenous peoples in a genuine and substantial way, Australia may better support self-determination and address exclusion as significant drivers of ongoing health disparities amongst Aboriginal and Torres Strait Islander peoples. Contemporary Australia may also gain access and privilege to time-tested, Australian-specific expertise on both adaptive and mitigative strategies to the greatest existential threat to civilisation this century.

Keywords: Climate Change, Health, Indigenous Peoples, Human Rights Introduction Our identity as human beings remains tied to our land, to our cultural practices, our systems of authority and social control, our intellectual traditions, our concepts of spirituality, and to our systems of resource ownership and exchange. Destroy this relationship and you damage — sometimes irrevocably — individual human beings and their health. Pat Anderson 1996 (page 15)[1] Why is a changing climate an issue? The health impacts of climate change are already being felt today, with future projections presenting unprecedented risks to the human right to health [2]. As such, climate change will alter the way in which we manage and seek to ensure the highest attainable standards of health for billions of people within Australia and worldwide [2,3]. The major threats to humanity are via increased temperatures and extreme weather events leading to changing patterns of disease, water and food security, vulnerable shelter, population growth, and migration. The impacts will be both direct and indirect, especially among vulnerable populations [2-6]. Globally, the disease burden depends on the existing climate and development of particular nations. For example, underdeveloped countries are experiencing a larger burden from vector-borne diseases, while more developed countries are experiencing a greater burden from cardiovascular and respiratory diseases [2,7]. Australia is particularly vulnerable to the impacts of climate change [4,8-10], due to high susceptibility to increased temperatures and the resultant disasters of heatwaves, bushfires, droughts and flooding that are occurring with increasing frequency and severity. Australian agriculture is particularly under threat as a result of growing water scarcity and population growth in flood zones [8]. Additionally, the frequency and duration of heatwaves is increasing, with Melbourne projected to experience twenty-four days per year over 35°C, with the urban heat island effect anticipated to amplify the impact within cities [11]. Impacts on Indigenous Australians Indigenous Australians are known to be more vulnerable to climate change due to existing vulnerabilities resulting from

Feature Article

historic and ongoing colonisation [8]. For example, there is unequal access to primary health care, effective sewerage systems, rubbish collection services and housing. These effects are amplified by the undermining of environmental determinants of health such as clean air, water, and sufficient food [3]. The significant socioeconomic disadvantage experienced by Aboriginal and Torres Strait Islander people places them at increased risk of suffering from environmental health risk factors [12]. These impacts are of particular significance to medical professionals whom are tasked with managing the health consequences of these broader sociopolitical drivers. The consequences not only relate to the right to health but recognise that health is closely related to, and dependent on, other determinants such as access to food and water that promote the conditions for a healthy life [13]. This is of particular relevance to all Australians. Therefore, there is an impetus for Australia to reduce greenhouse gas emissions in line with the preservation of the human right to health for all and with particular focus on those most marginalised and vulnerable. Despite the current and future threat, addressing climate change also poses the greatest global health opportunity of this century [2]. Meaningful actions toward a sustainable economy will accrue co-benefits that reduce the burden of disease in line with achieving the Sustainable Development Goals and the 2015 Paris Agreement [2,14]. Australia’s current responses to climate change Australia is one the world’s largest emitters of greenhouse gasses per capita with over 22 tones per person in 2015 [11]. Under the Paris Climate Accord, Australia has an international responsibility to address the social, economic, and environmental impacts that threaten the right to health across the globe [15]. In 2015, the Australian Government announced a target to reduce national emissions by 26-28% below 2005 levels by 2030 [16,17]. This target, known as the Intended Nationally Determined Contribution (INDC), is supposedly to be achieved through the Australian Government’s newly rebranded Climate Solutions Package [18]. The package contains two main approaches - soil sequestration of carbon dioxide and a reverseauction mechanism through an Emissions Reduction Fund (ERF). These have the objectives of “lowering business costs, improving competitiveness, and protecting the environment for current and future generations”[19]. Despite the political rhetoric [18], independent analysis has demonstrated that the package is neither substantial enough to meet Australia’s Independent Nationally Determined Contribution (INDC), nor meet the targets set under the plan itself [18,20-22]. For example, approximately 60% of the Climate Solutions Package emissions reductions are relying on hypothetical soil sequestration schemes that exist within unsustainable agricultural models for the Australian landscape. The remaining mechanisms rely mostly on funding the largest polluters through the reverse-auction mechanism of the Emissions Reduction Fund [17,19].

In relation to Indigenous Australians, the current Climate Solutions Package does include the Arnhem Land Fire Management Strategy [17]. This strategy employs Indigenous rangers to utilise long-standing landscape and fire management knowledge to methodically burn bushland, such that the release of methane and nitrous oxide is reduced and carbon dioxide is maximally sequestrated in dead organic matter. The project is celebrated by the Australian Government as partnering “thousands of years of Aboriginal traditional land management practice with modern scientific knowledge” [17]. Absence of Indigenous expertise Beyond the inclusion of a Northern Territory specific fire management strategy, there is a clear absence of Aboriginal and Torres Strait Islander input. Climate change is an interdisciplinary and multifaceted issue which Indigenous people can, and have the right to, participate in. A national climate policy package that embedded Indigenous sustainability values into the upscale of renewables, food and agricultural production, waste management, acceleration of electric vehicles, and energy efficiency in homes and industry would be able to achieve carbon neutral status by 2050, whilst growing the economy at 2.4% per annum [21,23]. In regard to current federal policy, the Arnhem Land Fire Management Strategy is not transferrable to other states or territories. This is because the environment, bush density (fuel load), local building codes (regulations regarding constructing new buildings), and burn-off protocols (bushfire prevention protocols) differ significantly [24]. Additionally, in areas such as the Kimberly, government incentivised burn-offs have resulted in approximately 30% of ochre rock art being destroyed that had previously been preserved for thousands of years [25]. In regard to agriculture, approximately one fifth of Australia’s emissions are attributed to the sector [6]. Over the past 200 years, 60% of the Australian landmass has been managed by farmers who, despite improving technology and efficiency of their practices, undertake land clearing, rely on fertilisers and pesticides, and persist with growing non-native and unsustainable crops, such as cotton or cattle, that are all large emitters of greenhouse gases [1,26]. Conversely, Indigenous peoples have been conducting experiments in their regions for thousands of years and have an expertise regarding traditional ecological knowledge [26]. A recent report by the Farmers for Climate Action emphasises that the agricultural sector will face significant threats to viability unless there is a structural transformation of food production and land management in line with ultimate sustainability objectives [27]. This has already been witnessed in the last twelve months alone. Three mass fish deaths across Australia have occurred due to drought and excess water diversion for irrigation of Western-style managed land [28]. Addressing these agricultural choices and principles is a fundamental issue of long-term sustainability and land management that is neglected under Australia’s current strategy yet central to the culture and experience of Indigenous Australians. What is clear is that the landmasses around the world that have the best sustainable outcomes are those that are managed by Indigenous peoples [26]. Agricultural growers who have

Feature Article

transitioned to focussing on plant nutrition, soil health, and diversity founded on Indigenous regenerative agricultural practices are reaping the benefits of fundamentally embedding sustainability into practice [29]. Agricultural businesses in Western Australia are obtaining the same grain price as farmers who are not undertaking regenerative techniques, however, regenerative farmers are benefiting from boosted productivity of up to 30%, increased pasture and soil quality, reduced soil erosion and chemical use [29]. More so, these positive consequences also result in larger carbon sequestration into soil, with further benefit to Australia’s carbon neutral ambitions. An example of deep-rooted racism? Firstly, the minimal engagement with Indigenous peoples to contribute their in-depth knowledge and understanding on sustainability across many sectors of modern Australian society points to the longstanding issues of colonisation still present today. Secondly, it points to a failure of our economic system to adequately price the services the environment provides – such as clean water, arable land, fisheries, and a climate conducive with human existence and development. This valuation of biodiversity is embedded into thousands of years of Indigenous culture [24]. Understanding why Indigenous Australians are not included in a meaningful way is to understand the historic and ongoing socio-political context of Australia. In 2007 the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) was released calling for recognition of the land and territorial rights of Indigenous peoples [30]. Australia voted against the declaration. All of the members of the United Nations Human Rights Council and 143 other country representatives voted in favour [30]. Underpinning the ongoing resistance from Australia is the absence of Truth Telling [31] surrounding Terra Nullius, the dispossession of ancestral lands, impacts from genocide, conflict, and forced assimilation into mainstream society, loss of control over natural resources, and knowledge and integration into the market economy [32]. In line with the historic structural violence imposed on Indigenous peoples, it is of benefit to colonising interests to portray Indigenous peoples as tribal and simplistic. This strategy ignores the wealth of evidence-based experience on living sustainably in Australia and allows for specific portions of Australia to profit. If climate change was indeed appreciated as the existential threat to human existence described by scientists [8,10], the inclusion and collaboration with people whom have expert engineering, scientific, agricultural, geographic, economic, and astrological knowledge would be occurring “in a canter” [8, 17]. High-level solutions For Australia to catch up to world leaders on both Indigenous rights and climate change, mitigation recommendations that address both overarching racism and greenhouse gas emissions are central. Such responses require leadership at the highest

level. To date, Australia still opposes the United Nations Declaration on the Rights of Indigenous Peoples. Recognition and respect for Indigenous people’s rights, as contained in the UNDRIP, acknowledges Indigenous peoples as environmental managers with immense ecological knowledge and as crucial collaborators in efforts to address the loss of biodiversity and climate change [30]. Early engagement and participation by Indigenous peoples with relevant skills and expert knowledge can assist in subsequently reducing Australia’s emissions. Second, the Uluru Statement from the Heart brings together over 250 Aboriginal and Torres Strait Islander leaders calling for the establishment of a ‘First Nations Voice’ in the Australian Constitution [33]. Supporters argue that basic inclusion and recognition of Indigenous peoples within modern Australian society is at the core of addressing the longstanding issues that continue to impact on Indigenous Australians and obstruct their opportunity to flourish and contribute to all facets of modern Australian society. This includes contributing experience regarding environmental sustainability. Global leadership examples These solutions ultimately require social and political will. To date, the Prime Minister does not support enshrining a voice within the constitution [34]. Ongoing advocacy regarding the role of Indigenous peoples as important knowledge holders and land managers, crucial to reducing greenhouse gas emissions, is important to achieving health and wellbeing for all Australians. Other governments have demonstrated implementation pathways through higher-level inclusion and active listening to First Nations people. For example, New Zealand have integrated Maori First Law with contemporary law after parliamentary vote [32]. This has led to the Whanganui River receiving status as a legal person. This means that the environment and biodiversity can operate hand-in-hand with contemporary law and society.

Conclusion Bipartisan support is critical for contemporary Australia to address both climate change and the ongoing disparities commonly experienced by Indigenous peoples. The opportunity to combine traditional Indigenous knowledge with contemporary practices is crucial to taking meaningful steps towards greater inclusion and participation of Indigenous peoples in line with the highest standard of human rights, and to provide a genuine attempt by the Australian government to rapidly decarbonise in a time-tested, sustainable way. By focussing public health efforts at the highest level, promoting the signature of the UNDRIPs, and promoting the Uluru Statement from the Heart, Australia can achieve multiple benefits for the community, the environment, and the local economy. Implementation ultimately lies with the voting constituency to support bipartisan agreement allowing for constitutional inclusion and collaboration to begin.

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Acknowledgements: Within this feature article Aboriginal and Torres Strait Islander peoples are referred to as ‘Indigenous peoples’. In doing so, I acknowledge the distinct cultures and societies of different Aboriginal peoples and Torres Strait Islanders. The term ‘peoples’ is also used to recognise the collective aspect of Indigenous people, with distinct cultural beliefs that differentiate them as a group from other Australians. Conflict of interest statement: The author has no conflicts of interest to disclose. Funding: None Author contribution statement: Hayden Burch is the sole author of this manuscript. 30| Australian Medical Student Journal © 2022 Volume 11 (Issue 1)

Feature Article

Cite as: Hayden B. Climate emergency in Australia and the need for inclusion of indigenous peoples in solutions. Aust Med Stud J. 2020;1:748–51. Correspondence: Hayden Burch, hburch22@gmail.com Date of submission: 18 July 2020 Date of acceptance:: 11 August 2020 Date of online publication: 22 September 2020 Editor: Mabel Leow Senior Proofreader: Emily Feng-Gu Proofreaders: Margaret Hezkial, Ivy Jiang

Feature Article

Continuity of care; a final year medical students’ professional and personal experience in rural Australia whilst on a longitudinal placement in Broken Hill, New South Wales. Sarah Wray1 1

University of Wollongong Sarah Wray is a postgraduate student with a passion for both women’s health and critical care. Initially from Cairns, she has an interest in tropical medicine and scuba diving!

Abstract A final year medical students professional and personal experience of a longitudinal rural placement in Broken Hill, New South Wales, Australia. The placement was 18 months in duration and highlighted some of the hardships of working and living in a rural area. The particular area of note was the accessibility to services and the continuity of healthcare in this isolated location. Continuity is a difficult concept to teach and one that hopefully all medical students will be able to appreciate through rural and remote placements.

Keywords: Rural, Continuity Of Care, Medical Student Placement.

Living in Broken Hill, New South Wales (NSW) for the past 14 months has been an interesting glimpse into rural life. I was initially appointed to Broken Hill for a 12-month longitudinal placement, as part of the rural component of my medical degree. The unforeseen global pandemic extended my stay in Broken Hill as my original overseas electives were cancelled. Such a stay has provided me with a number of interesting learning opportunities. Page and Birden comment that in comparison to metropolitan hospitals, rural placements provide access to a wider variety of unique learning opportunities [1]. Anecdotally, I agree. Broken Hill has been a unique learning experience both professionally and personally. The Royal Flying Doctor Service (RFDS) has been one of the key highlights of my placement, it has encouraged me to reflect upon my experiences, particularly with continuity of healthcare in rural settings. Continuity of care is difficult to define but is in essence, is a strong health practitioner – patient relationship which retains patient choice and satisfaction [2]. It is a multifactorial concept that is reliant heavily on therapeutic communication and

access. Continuity and access to healthcare has been an ongoing issue for many years in rural Australia. With regards to the provision of healthcare services in rural and remote areas of Australia, healthcare providers face the challenges of geographical spread, low population density, limited infrastructure, and the higher cost of delivery [3]. These barriers limit the ability of Australians living in rural and remote areas to access quality and continuous primary and specialist health care. Consequently, Australians living outside of metropolitan areas have a lower life expectancy, with higher morbidity and mortality rates associated with chronic disease [3]. One of the unique and iconic ways Australia has addressed this is through the RFDS. Throughout the year I have had the pleasure of experiencing a number of outreach flights across far western NSW with the RFDS. One of the most memorable flights was to the remote town of Tibooburra. If you look on a map of NSW, you would spot Tibooburra near the far northeast corner, a stone’s throw away from Queensland. To put this in perspective, Broken Hill is 1143 km from Sydney and Tibooburra is 331 km north of Broken Hill. Most of the roads to Tibooburra are unsealed, making them a challenge to access by road. Tibooburra, with its population of 134 people, is an example of a rural community with no permanent general practitioners (GPs), dentists, or allied health professionals. The community is reliant on a once weekly RFDS outreach clinic for their primary healthcare needs [4]. Specialist appointments are few and far between and most individuals have to travel hundreds, if not thousands, of kilometres to attend their appointments. This set of circumstances, however, is not unique to Tibooburra and is the norm rather than the exception for many other rural towns in Australia. In 2017-2018, the RFDS facilitated 16,209 primary health visits and held 44 clinics per day across remote Australia [4]. Thankfully, Tibooburra and 17 other remote locations are serviced by the Broken Hill RFDS outreach clinics.

Feature Article

The experiences I have had whilst living and working in Broken Hill for the past 14 months have enabled me to better understand some of the challenges associated with health care in a rural setting. One of these challenges is continuity; being on a longitudinal placement has meant that I have had the opportunity to experience what continuity means to a patient. A key value of a longitudinal medical student placement is establishing the value of continuity of care, which is difficult to appreciate with short-term placements [5]. Wright comments that understanding and gaining clarity of continuity of care is a difficult task and has been referred to as ‘continuous confusion’ in some literature [2]. During my stay I have realised that rural GPs have busy clinics with appointments few and far between. According to the Australian Institute of Health and Welfare (AIHW), 21% of people living in rural areas waited longer than they felt was acceptable to get an appointment with a GP, compared to 18% in major cities [3]. Since the global pandemic, GP telehealth and phone consultations have temporarily become the new norm, which has improved appointment availability. I found that when trying to book an appointment for myself, the only appointments available were phone consults. Unfortunately, when I tried to book a face-to-face follow up, I was told the GP I wanted to see was based in Melbourne. I was extremely surprised that my phone consultation was with a Melbourne based GP. I was disappointed and frustrated at the thought of having to reiterate my story to another doctor, delaying the process of investigation even further. I realised that this lack of continuity is exactly how rural Australians must feel. This was a moment of individualised learning, as it was my first personal health experience whilst living rurally. According to the AIHW, this is not an unusual situation; 33% of rural Australians reported that they could not see their preferred GP on one or more occasion, compared to 25% in major cities [3].

was working with had been visiting Tibooburra once per week for a few months. The first patient of the day walked in and said “thank goodness it is you this week”, as the GP had returned from three weeks of holiday leave. The patient continued to comment that repeating their story and feeling like they were starting at ‘square one’ with a new GP at each appointment had proven extremely frustrating. I was empathetic towards the patient at the time but did not fully appreciate her frustration until after my own experience. It is well documented that continuity becomes a challenge if the same provider cannot be regularly accessed. Interestingly, a study conducted by Wong and Regan analysed rural patient perspectives on accessing primary care [6]. Participants emphasised that a lack of continuity of care through high turnover of staff, lack of specialists, miscommunication between teams, and ‘feeling comfortable’ was a major challenge. Leach supports this and outlines that improved continuity of care results in better patient satisfaction and treatment compliance [7]. My experiences outlined above has allowed me to understand and appreciate the importance of continuity of care. It is a term regularly used in healthcare delivery but the importance of it easily overlooked. However, as previously mentioned, continuity of care is difficult to traditionally teach and is best appreciated through experience. To conclude, living in Broken Hill and the experiences I have had with the RFDS outreach clinics have been invaluable. It has opened my eyes to some of the challenges that people face in rural Australia, particularly with continuity of care. As mentioned above it is an easily overlooked aspect of health delivery but arguably one of the most important. I have appreciated that high standard medical practice is both a science and an art.

My own experience of telehealth with a GP across the country made me reflect back to my experience in Tibooburra. The GP I

References 1. 2. 3.

Page S, Birden H. Twelve tips on rural medical placements: what has worked to make them successful. Med Teach. 2008; 30:592-96. Wright M. Continuity of care. Aust J Gen Pract. 2018; 47:661. Australian Institute of Health and Welfare. Australia’s Health 2018. [internet]. Sydney. 2018 [updated 2018; cited 2020 Nov 20]. Available from: https://www.aihw.gov.au/getmedia/0c0bc98b-5e4d-4826-af7fb300731fb447/aihw-aus-221-chapter-5-2.pdf.aspx

5. 6.

Flying doctor clinics [internet]. Royal Flying Doctor Service; 2018 [updated 2020; cited 2020 october 14]. Available from: https://www.flyingdoctor.org.au/what-we-do/clinics/ Vogt HB, Lindemann JC, Hearns VL. Teaching medical students about continuity of patient care. Acad Med. 2000; 75:1-58. Wong ST, Regan S. Patient perspectives on primary health care in rural communities: effects of geography on access, continuity and efficiency. Rural Remote Health. 2009;9:1142.

Acknowledgements: I acknowledge the supporters and employees of the RFDS, and the Broken Hill Hospital who hosted my placements throughout the previous 18 months. Conflict of interest statement: A former student of the Rural Department of Health and Broken Hill Hospital, with a longitudinal placement at the RFDS base. Funding: None to declare 33| Australian Medical Student Journal © 2022 Volume 11 (Issue 1)

Feature Article

Author contribution statement: SW wrote the feature article using her personal experiences during a final-year medical student placement in Broken Hill. Cite as: Sarah Wray. Continuity of care; a final year medical students professional and personal experience in rural Australia whilst on a longitudinal placement in Broken Hill, New South Wales.. Aust Med Stud J. 2021;1:748–51. Correspondence: Sarah Wray, Sew062@uowmail.edu.au Date of submission: 16 May 2020 Date of acceptance: 26 January 2021 Date of online publication: 28 January 2021 Editor: Onur Tanglay Senior Editor: Mabel Leow, Justin Smith Senior Proofreader: Emily Feng-Gu

Literature Review

Simulation Training In Laparoscopic Surgery Daisy Lu1, Alex Ades 2, Pavitra Nanayakkara 3 Monash University of Melbourne Epworth Hospitals 3 1

2 University

Daisy Lu, BMedSc (Hons) BMedSc/MD, is currently a fifth year student at the Monash University

Key learning points • Simulation is a tool that can supplement the early portion of the learning curve in laparoscopic surgical training. • The development of a laparoscopic simulation curriculum should involve the consideration of simulation modality, cost, transfer of skills into the operating theatre, and long-term retention. • Further high-powered, long-term trials are needed to characterise how to optimise these elements in a training curriculum. . Abstract Introduction: This article summarises the evidence surrounding the development of simulation-based training curriculums in laparoscopic surgery. Summary: Laparoscopic or “keyhole” surgery involves the use of small incisions and delicate instruments to perform abdominal surgery. This minimally invasive procedure has significant benefits in patient outcomes over open surgery. However, the learning curve for acquiring skills in laparoscopy differs from open surgery, primarily due to the greater requirements for manual dexterity and coordination. Additionally, the transference of skills from open to laparoscopic surgery is minimal, indicating the need for new methods of training. There has been a growing body of research to suggest that simulation-based training can supplement the early portion of the learning curve for acquiring laparoscopic skills and is most effective if delivered in a structured course. Yet, there is still no standardised laparoscopic simulation course in Australia nor a framework for curriculum development. This review explores current evidence surrounding the development and implementation of simulation-based education curriculums in laparoscopic surgery.

Keywords: Simulation, Laparoscopy, Education Introduction Simulation is a technique used to “replace or amplify real experience with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion” [1]. Advancements in medical technology and restrictive work hours, have seen a shift in Halsted’s traditional “see one, do one, teach one” training

paradigm and simulation training is becoming widely adopted within the medical field [2]. Simulation has long been a core component of training in other high-risk professions, including training of pilots and military personnel. In healthcare education, simulation is used to recreate the clinical and intraoperative experience. Due to an increasing number of medical graduates and pressure for reduced work hours, trainees have less exposure to patients than previous generations [3]. Didactic lectures, case-based learning, and direct supervision are insufficient replacements for clinical experience, particularly in surgical specialties [3]. Although trainees’ quality of life has improved, opportunities to develop proficiency in skills has become limited, and there is an increasing need to train outside of direct clinical exposure [3]. Simulation training allows for deliberate practice and immediate feedback, facilitating skill acquisition in a safe environment before moving into the operative field; this is particularly true in procedures that require advanced technical skills such as laparoscopic surgery [4]. Laparoscopic surgery has brought benefits to both the patient and surgeon including shorter operation time and improved patient outcomes such as quicker recovery, smaller wounds, reduced rates of infection, and less pain [5]. The learning curve of laparoscopic surgery differs from open surgery, due to the higher requirement for manual dexterity, hand-eye coordination, and adaption to the fulcrum effect [6]. Consequently, the technical skills acquired from open surgical experience has limited transference to minimally invasive techniques [6]. Simulation training can supplement the early portion of the learning curve and a structured curriculum can further shorten the learning curve inside the operating room [4, 7]. Randomised control trials show that residents who received a simulationbased laparoscopy curriculum before entering the operating theatre had fewer errors and improved performance when compared to those who received conventional training [4]. A 2013 systematic review showed that simulation training for laparoscopic skills was significantly more effective than standard training, regardless of study design, previous experience of participants, outcomes tested, or specific skills measured [8]. Laparoscopy is preferred over open surgery when possible, but with the difficult learning curve, it is both unsafe and timeconsuming to begin by practicing on real patients. Simulation training is an advantageous method for training in laparoscopy, with a strong body of supporting evidence. Despite this, there is no standardised laparoscopic simulation curriculum in Australia, likely a result of multiple factors including costs, lack of

Literature Review

infrastructure, and limited understanding of how best to integrate the technology into practice. The development of such a curriculum should be evidence-based, to optimise the different components of training and maximise its benefits. This review explores current evidence surrounding the development and implementation of simulation-based education curriculums in laparoscopic surgery. The authors hope that by raising awareness of the benefits of such a curriculum, training centres may be encouraged to implement such programs, and trainees may be more inclined to pursue these. Figure 1: Representative images of laparoscopic surgery simulators. A. Box trainers use synthetic materials that are placed inside the box, real-time performance is captured by a camera and projected on an external monitor. B. Virtual reality (VR) simulators utilize computers and specially designed laparoscopic arms to generate realistic simulations of laparoscopic surgery. A

Simulation modalities Multiple modalities exist for simulated training. Traditionally, animal models and human cadavers were used to simulate disease and practice laparoscopic techniques [9]. However, animal models differ from human anatomy, and whilst cadaveric models are the closest replication of reality, they are both costly and are limited in availability. Box trainers and virtual reality simulators present a new method of training technique [10, 11].

Box trainers Box trainers present a simple, low-cost method for training basic laparoscopic skills, including suturing and knot tying [10]. Synthetic materials or animal tissues are placed inside the box; performance is captured by a laparoscope and viewed in realtime on an external monitor (Figure 1A). In a Cochrane systematic review of surgical trainees with no prior laparoscopic experience, box trainers improved time to task completion and reduced errors when compared to no training [10]. However, the majority of studies on the efficacy of this modality are limited to small, short-term, single-centre trials that are prone to bias, and many of which are difficult to compare in method and outcomes measured [10].

Virtual reality Virtual reality (VR) training uses computer-generated simulations and specially designed laparoscopic arms to simulate laparoscopic surgery (Figure 1B). There are multiple systems available to facilitate the training of basic skills to entire operations [11]. VR training has been validated by the landmark randomised controlled trial by Seymour et al., which demonstrated that VR simulation improved operating room performance in laparoscopic cholecystectomies [12]. Since then, there has been a growing body of research exploring the integration of VR training into the surgical curriculum.

Comparing box trainer and VR training There is no consensus on the best simulation training in laparoscopic surgery; both box and VR simulators have their advantages (Table 1). Some evidence favours box trainers as an equally if not more effective and more feasible training option than VR training [8]. A recent meta-analysis of 14 randomised controlled trials showed that VR was significantly more efficient than box trainers in improving the time to complete the peg transfer task [13]. In all other areas, including performance scores for basic skills and advanced tasks, box trainers and VR were equivalent [13]. This marginal improvement questions whether the cost of VR is justified by its additional benefit. Again, there is a significant gap in the evidence exploring the impact on clinical outcomes between these two modalities. Interestingly, some studies show that skills learned on box trainers are transferrable to VR simulators, but not all skills learned on VR training can be transferred to box trainers [14]. This suggests that VR allows for the acquisition of skills that cannot be learned on the bench-top models alone. However, this also represents a concept that can be transferred to multimodal models for training; which trainees can begin with box trainers and transition to VR simulators with more complex tasks. Unfortunately, one of the biggest gaps in the literature is the cost-effectiveness and long-term clinical benefit of both interventions. Additionally, the majority of trials investigating the efficacy of simulation training in laparoscopy are single centre studies involving small sample sizes, and often use different methodologies and outcome measures [10, 13, 15]. There remains a need for larger, multi-centre trials, and consistent standardised methodology to allow for better comparison. Importantly, there seems to be one consensus in the literature and that is either modality is better than no simulation training at all [8, 10, 15].

Literature Review

Table 1: Comparison of box and virtual reality trainers Advantages Box trainer

• • •

Virtual reality trainer

•

Disadvantages

Trainees prefer box trainers, owing to more realistic depth perception and tactile sensation [40]. Flexibility of take-home box trainers allows trainees to take a more individualised training approach [41]. Greater construct and predictive validity: better physical representation of the intraoperative environment and predictor of true intraoperative skills [42].

•

Computers can act as a “virtual tutor”, evaluate performance, and provide real-time feedback [15]. This allows for independent practice, reduces the need for an expert trainer, and eliminates inter-rater variability. Can simulate entire operations and complex tasks [14].

•

Considerations for practice Certain elements need to be considered when developing a curriculum. This article explores the transfer of skill into the operating theatre, cost, and factors that influence long-term retention.

Transfer of skill In laparoscopic surgery, the transfer of skills from simulation to the intraoperative environment is incomplete. Residents trained to the same level of proficiency as experienced surgeons in the simulation laboratory, do not translate to equal proficiency in the operating room [16]. Addressing this performance gap is important when considering the transition between the simulator and operative environment, thus identification of factors contributing to these factors and developing an intermediary platform is warranted. The gradual incrementation of real-life intraoperative tasks alongside simulation training, beginning with basic skills and progression to complete procedures, may aid this transition. A major barrier for transfer is that intraoperative performance is not determined by technical proficiency alone, but is also combined with surgical judgment, quick decision-making skills, aptitude, temperament, and background of experience gained so far by the trainee. The global operative assessment of laparoscopic skill (GOALS) was developed and the objective structured assessment of technical skill (OSATS) scoring systems was adapted for objective assessment in laparoscopic surgery [17, 18]. However, these systems purely test technical skills, and do not assess non-technical skills such as surgical judgment. In real operations, anatomical variations and unplanned complications require quick decision-making skills from the attending surgeon [19]. This ability to adapt and use intuitive judgment is underdeveloped in novice surgeons [19]. In laparoscopic simulation training, we still lack an objective method of teaching and assessing intraoperative judgment. Another reason for incomplete transfer of skills pertains to differences in the training environment and the distracting conditions of realistic clinical practice. Studies that incorporate the addition of realistic distractions, such as noise, into the design model showed improved surgical proficiency in the operating room [20]. Another hypothesis is that increased stress impacts laparoscopic skills transfer. Arora et al. established the empirical link between stress and psychomotor performance on

•

Only able to teach one specific procedural skill at a time, therefore not suited towards practicing entire operations or advanced skills [14]. Meaningful feedback requires an external expert to demonstrate and appraise, which incurs an additional cost of trained personnel [41]. VR equipment is expensive and therefore less accessible, especially in areas with limited resources [22, 41]. Housed in dedicated facilities or “laboratories”, requiring dedicated maintenance and trained staff [41].

a VR simulator. They found that higher levels of stress, measured by heart rate, salivary cortisol, and an anxiety inventory, correlated with the number of errors [21]. The transition from the laboratory to the real intraoperative environment is difficult, stressful, and leads to an incomplete transfer of skill [21]. Indeed, it seems simulation alone is not sufficient to adequately train laparoscopic surgeons to expert proficiency.

Cost Cost is a barrier in the uptake of simulation training in laparoscopic surgical programs and laparoscopic surgery, particularly in less developed nations. This is largely due to the lack of a long-term funding structure to support the maintenance of laparoscopic facilities and equipment, trained supervisors and staff, and costs of resource utilisation [22]. The development of low-cost programs is therefore an incredibly important aspect to improve access to sustainable minimally invasive surgery. A step-wise approach is the most time and cost-efficient way of training laparoscopic surgeons [7]. Learning basic laparoscopic skills shortens the learning curve for more complex tasks with subsequent cost savings on materials and supervising personnel salary [7]. Additionally, learning tasks through a series of stepwise advances reduces the amount of time needed to learn the full task [23]. This suggests that a training curriculum involving a multistage progressive approach is substantially more timeefficient and likely more cost-effective. Some evidence supports the effectiveness of video tutorials in teaching laparoscopic techniques and optimising learning on simulator trainers [24]. Video tutorials minimise the need for supervision and thus reduce the costs associated with supervision salary [24]. However, video learning alone is not as effective as simulators in skill acquisition processes [8]. Combining video tutorials and simulator training may optimise cost reduction without sacrificing the quality of skill development.

Long-term retention The decay of acquired surgical skills and subsequent need for retraining represents a significant but potentially avoidable cost burden. Whilst short-term training can be effective in acquiring proficiency in basic laparoscopic skills, these skills are likely to decay over time [25, 26].

Literature Review

One of the proposed methods for improving long-term retention is spaced training sessions, deemed the “spacing effect” [25]. A recent systematic review showed that the spacing effect in surgical skills programs improved long-term retention when compared to mass learning [25]. However optimal duration and frequency of practice between each training session are unclear, and there is minimal evidence on the impact of spaced training on current programs and the costeffectiveness of spaced programs. Simulation modality and skill type may also affect retention. Box trainers have been shown to lead to more consistent retention of basic laparoscopic skills six months post-training when compared to VR simulators [27]. Additionally, different skills seem to deteriorate quicker than others and may require more frequent sessions [26]. This suggests curriculum adaptions need to be made between different skills, as well as different modalities of training, to maximise long-term retention. Ongoing training is also shown to aid the maintenance of skill proficiency. Adding maintenance training sessions has been shown to not only reduce skill loss but also improve performance [28]. Although there is no consensus yet on how best to structure these post-training intervals in the literature; there is support for monthly [28], three-monthly [29], and biannual [30] training sessions. A higher number of repeat practices have also been shown to improve the speed of task completion, without sacrifice in precision, accuracy, and performance [14]. If improvement in task time translates to clinical practice, this could potentially reduce operative time, shorten hospital stay, and further reduce the risk of infection from prolonged exposure. Others argue it is not the number of practices but rather “deliberate practice” which leads to the most improvement. Deliberate practice is a theoretical framework proposed by Ericsson and colleagues describing the actions for optimal learning to reach expert performance, including motivated learners, focused tasks, feedback, and area for repetition to refine performance [31]. A combination of simulation-based training and deliberate practice is suggested to be most beneficial, particularly in virtual reality-based curriculums [32]. The difficulty in studying long-term retention of skills is in part due to the high number of non-completers, withdrawals, and loss to follow up. This combined with the niche study population and small sample sizes make it difficult to establish highpowered results. There is a need for high-powered, long-term trials to truly characterise effective methods of improving longterm retention in laparoscopic surgical trainees.

Timing of training delivery Multiple factors influence the suggested timing of laparoscopic simulation in the surgical curriculum. This includes, but is not limited, many of the components previously mentioned in this article; including trainee experience levels, the availability and flexibility of facilities, the availability of training staff, and the opportunity to practice in the intraoperative environment. In trials assessing simulation training for basic laparoscopic skills, the target population has predominantly consisted of surgical trainees in their early postgraduate years, with some studies investigating medical students [13]. Studies involving more

difficult and specialised techniques, including multistep procedures, have targeted advanced trainees [13]. Simulation training can, therefore, support the acquisition of skill at all training levels. However, it is not sufficient alone; laparoscopic simulation training should be strategically implemented alongside real-life intraoperative experience to utilise the technology to its fullest potential.

Current curriculums In Australia, there is no standardised national curriculum for training basic laparoscopic skills. Instead, laparoscopic surgery forms a component of the specialty-specific logbooks as part of the competency-based assessment [33]. Whilst there are some specialty accredited short courses and workshops that utilise simulation training to teach basic laparoscopic techniques, the evidence for these courses are often limited to small, singlecentre studies [34]. Consequently, a simulation-based curriculum for laparoscopic surgery, with a strong evidence base and robust evaluation, is lacking in Australia and needs development. Currently, the only standardised laparoscopic training curriculum is the Fundamentals in Laparoscopic Surgery (FLS) certification in the United States, developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Introduced over a decade ago, FLS is a board certification and pre-requisite for general surgery residency training in the United States [35]. FLS comprises online education modules, hands-on box model training, and examination testing both cognitive and motor skills. Despite the widespread acceptance of the FLS certification in the United States, the program still has its limitations. First, there is little evidence on the impact on patient outcomes, likely because FLS was only adopted recently as the gold standard for general residency board certification [36]. Secondly, the significant costs associated with implementing the program may not be feasible in low-income countries. Solutions presented for this issue are to cut costs by replacing dedicated human and material resources in specific tasks and using lower-cost equipment [37]. However, the lower cost adapted simulators are not as validated in the literature as the commercially available simulators. This highlights how simulation in laparoscopic surgery is also driven by industry; the widespread dissemination and testing of simulation technology, such as the FLS, is central to its implementation into the surgical training curriculum. Thirdly, there is currently no recommended time for residents to undertake the examination for the FLS certification. Although increased success rates for successful certification are associated with a more senior level of training, there is no current recommended time for application [36]. Lastly, although the FLS program was initially intended to apply to multiple surgical specialties, the literature suggests the FLS is not universally applicable. For example, in gynaecology, FLS falls short in the cognitive skills and testing [38]. Researchers have begun to develop a tailored curriculum for this specialty [39]. However, FLS is the only program to date to be extensively investigated in the literature. Consequently, FLS has the highest validity compared with other programs, which are by contrast still in their infancy.

Literature Review

Conclusion Simulation is recognised as an important component of surgical training in the current landscape. This is particularly relevant in the acquisition of the necessary psychomotor skills in minimally invasive surgery. Within the last two decades, there has been an overwhelming amount of research supporting the efficacy of simulation in laparoscopic training. We are now transitioning from the phase of ‘if we should’ to ‘how we should’ integrate

this into practice. This paper has discussed several factors that should be considered during the development of a training curriculum, including method of simulation, transfer to the operating theatre, cost implications, and improving long term retention. There is a need for further analysis into costeffectiveness, long-term and larger trials, and a more rigorous standardised method for trials to be adequately compared. Regardless, it is clear that the era of “see one, do one, teach one” is over; now is the time for “see some, simulate some, do some, teach some”.

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Acknowledgements: The author would like to acknowledge Dr. Pavitra Nanayakkara and A/Prof. Alex Ades for their guidance and support with this paper. Conflict of interest statement: The author has no conflicts of interest to disclose. Funding: None Author contribution statement: P.N. and A.A. devised the original concept, provided critical revisions, and supervised this project. D.L. wrote and revised the manuscript. Cite as: Daisy L, Alex A, Pavitra N. Simulation training in laparoscopic surgery. Aust Med Stud J. 2020;1:748–51. Correspondence: Daisy Lu, daisylu878@gmail.com Date of submission: 25 March 2020 Date of acceptance:: 5 September 2020 Date of online publication: 10 September 2020 Editor: David Chen Senior Editor: Justin Smith Proofreader: Alistair Lau Senior Proofreader: Emily Feng-Gu

Original Research

Exploring the Reasons for Medical Student Participation in Peer Mentoring Programs Warren Policha1, Pippa Burns 1, Warren Policha1* University of Wollongong

Warren Policha has a background in physiotherapy and has been working in health for over 10 years. After working in Extended Scope Physiotherapy roles for several years, Warren enrolled in the Doctor of Medicine course at the University of Wollongong, where he is currently in the process of completing his final year. His interests include Primary Care, Emergency Care, Orthopaedics, and clinical education.

Key learning points • Participation in peer mentoring is influenced by participant age, relationship status, previous experience with mentorship, and structure of medical degree. • Peer mentoring programs should be individually tailored to suit the cohort and course structure. • Formal evaluation of each peer mentoring program should be undertaken to identify strengths, weaknesses, and possible alterations that may improve participation as associated benefits for students. Abstract Background: Peer mentoring in medical programs can result in improved academic performance and personal wellbeing. This is important as medical students function within a competitive environment and have a relatively high risk of burnout, mental illness, and suicide in comparison to age-matched controls. Despite recognition of the benefits of mentorship, medical students often don’t participate in available mentoring programs. In order to optimise medical student uptake of peer mentoring programs it is important to explore the factors that influence participation. Materials and Methods: An online survey was distributed to current and former students of a graduate medicine program to explore the factors that influence medical students’ participation in student-led peer mentoring programs. Results: A total of 77 students completed the online survey. The majority of respondents had positive experiences with mentoring (82%, n=56). Older students, those in a relationship, and those with dependents were less likely to participate in peer mentoring programs. Respondents identified improved academic performance and overall wellbeing as positive factors associated with mentoring, which is consistent with previous research. The structure of the degree requires many students to relocate after 18 months, which influences participation in mentoring. The most common reason for peer mentoring relationships ending was due to the mentor moving

Darryl McAndrew, PhD, MSc (OH&S), is a clinical anatomist and exercise physiologist. His research includes the neural control of eccentric muscle contractions, non-invasive identification of muscle fibre types, control of voluntary muscle activation and generation of muscle force, and how humans maintain balance and posture during normal everyday tasks. He also collaborates on research focusing on surgical techniques (anatomical approaches) and medical education. away for university placements. Conclusion: Age, relationship status, previous experience with mentorship and structure of the medical degree were all shown to influence medical student participation in mentoring programs. Tailoring mentoring programs to the student cohort and course structure may improve participation rates and subsequently personal wellbeing and academic performance of students. These benefits may assist medical students to navigate the competitive and often stressful profession of medicine.

Keywords: Mentoring, Medicine, Students, Wellbeing, Medical Education Introduction Mentoring can be defined as a symbiotic, dynamic relationship whereby a more experienced individual provides a novice with knowledge, skills, and guidance to help them succeed [1]. Research has shown that mentoring can be a valuable tool in many different environments and can lead to a greater sense of wellbeing and satisfaction for the mentee and the mentor [2]. In the medical profession, having a mentor can lead to greater job satisfaction and be valuable in helping guide students in areas such as professionalism, ethics, curriculum navigation, and the art of medicine [3]. Benefits of being mentored extend to doctors-in-training, with mentored junior doctors experiencing higher rates of confidence, career progression, and improved exam performance [4]. The availability of mentoring programs is of particular importance for the profession of medicine. Medical school has a demanding workload and is a challenging environment that can leave students and doctors feeling pressured and overwhelmed [5]. High rates of stress, burnout, and mental health issues amongst medical students are well documented [6]. Rates of depression, anxiety, and attempted suicide are significantly higher in medical students than those within the general population [7]. Therefore, mentoring programs can decrease personal and academic burdens, as well as guide students through the challenging, competitive environment of medicine [3,4].

Original Research

Current evidence supports the implementation of formal mentoring programs for students [8]. Many schools have successfully implemented student-to-student peer mentoring programs using a variety of strategies such as incoming students being assigned a more senior student mentor [9]. However, despite research demonstrating that there are benefits associated with mentoring and the availability of mentoring programs, only 50-60% of medical students participate in the available mentoring programs [10-12]. This low participation rate is somewhat surprising, as 80% of medical students identified mentoring as being important to them [10]. As mentoring has potential benefits for medical students both academically and personally, it is important to understand the reasons why students engage or fail to engage in peer mentoring programs. This knowledge will aid the development, implementation, and adaptation of successful mentoring programs. In turn, this may help improve the quality of peer mentoring, overall wellbeing, and academic outcomes of medical students, as well as decrease the stress and mental health issues that are prevalent within the competitive environment of medicine. Improved academic performance has been identified by students as a potential reason to participate in mentoring programs [8,13]. This is supported by studies that found that students’ academic performance improved when they were mentored [14,15]. However, academic benefit was not found in all research, suggesting that the academic benefit from mentoring may be influenced by student demographics, stage of their education, mentor characteristics, and the delivery and style of the mentoring program [10]. Another potential reason that medical students participate in mentoring programs is to make personal connections with professionals in the field. Furthermore, medical students identified desirable qualities in mentors as sincerity, honesty, understanding, and good active listening skills as well as viewing mentors as role models, friends, and a safe place to talk about moral and ethical issues [16,17]. Additionally, mentoring has been found to decrease stress in medical students which may help manage the high workload and demands of medical education [9,14,18]. Nevertheless, despite research suggesting that mentoring can benefit medical students in multiple ways, the literature also demonstrates that there are difficulties in the recruitment and retention of mentee students to these programs [10-12]. The low participation rates for medical students in mentoring programs suggest that there are factors that can prevent some students from engaging with mentors. The literature suggests that mentors should ideally be selected by the mentees and not assigned, as selection by mentees based on knowledge, competence, and a willingness to teach and share provided better outcomes and increased participation rates [13,19,20]. Other potential barriers to engagement with mentoring programs include lack of time, lack of funding, inadequate training for mentors, students feeling that they don’t need a mentor, and a poor fit between mentor and mentee [8,17,21]. The impact these issues have on participation rates of medical students in mentoring programs is not clear and further research is required.

There is limited research that directly examines why medical students choose to participate in peer mentoring programs. Most research examines the positive and negative aspects of mentoring and whilst this information provides some insight into students’ views on mentoring, it does not always allow definitive conclusions to be made about the reasons that students choose to engage and disengage in mentoring programs. Further research is required in order to explore the reasons medical students engage and fail to engage in peer mentoring programs.

Methods Ethics approval for this study was granted by the Health and Medical Human Research Ethics Committee at the University of Wollongong (Ethics number 2019/383).

University of Wollongong Medical Student Mentoring Program Currently, the peer mentoring program at University of Wollongong (UOW) Graduate Medicine is a student led initiative whereby members of the Wollongong University Medical Student Society (WUMSS) assign incoming students to a mentor in the year above via an opt-in system for both mentors and mentees. The program was initiated shortly after the establishment of the UOW Graduate Medicine course in 2007 to help incoming students transition into the course and provide them with additional support. Students are matched by WUMSS representatives based on factors such as previous degree, age, and gender. There has been minimal formal evaluation of participation and any potential associated benefits of program. The study aims to explore the reasons students participate in the program to establish overall participation rates as well as to identify potential barriers and benefits associated with the program. The results have the potential to improve the WUMMS peer mentoring program and other similar programs which may optimise benefits of such programs for students. The medical program at UOW is a four-year graduate program which is delivered in four phases, beginning with the medical science phase (18 months). A twelve-month hospital placement phase follows, with students participating in five rotations across medicine, obstetrics and gynaecology, paediatrics, psychiatry, and surgery. In phase three (twelve-months), students undertake practice-based placements in one of eleven communities across New South Wales. During phase four, the final six months of the course, students undertake three rotations, each of six weeks duration. This course structure often requires students to relocate after the first 18 months.

Research methods A survey containing 24 multiple choice questions was designed and distributed via Qualtrics to explore factors that may impact student participation in peer mentoring programs. The survey was distributed to past and present students of the UOW Graduate Medicine program through private cohort and alumni Facebook pages. Demographic information, such as age, gender, and relationship status were collected. Possible influential factors such as previous experience with mentoring, perceptions about positive and negative aspects of mentoring, as well as specific reasons that impact on students engaging or

Original Research

not engaging in mentoring programs were also included (see Appendix 1 for full survey). Statistical analysis was completed using the Qualtrics Data Analysis tool. Descriptive statistics were primarily reported. Chisquared tests were used to analyse categorical variables when

observed frequencies in each cell were five or greater. Fisher's exact test was used for categorical variables when the observed frequency in at least one expected cell was less than five.

Table 1 Participant demographics Age 20-25 26-30 31-35 36-40 41-45 46-50 Over 50

n (%) 30 (39) 27 (35) 6 (8) 12 (16) 1 (1) 0 (0) 1 (1)

Gender Female Male Not identified

n (%) 44 (57) 30 (39) 3 (4)

Relationship Single In a relationship Married Other

16 (22) 42 (57) 15 (20) 1 (1)

Year of education Year 1 Year 2 Year 3 Year 4 Junior medical officer Registrar Advanced trainee Consultant Dependents Yes No

Results A total of 77 students completed the survey with most being female (n=44, 57%) and aged 20-30 years old (74%, n =57). Of those surveyed, 77% (n=57) were either in a relationship or married and 14% (n=11) of all respondents had dependents. Most respondents (93%, n=72) were current students in years one to four of their medical education (Table 1). The response rate for the survey was approximately 10%.

Experience and future intentions towards being mentored. Previous experience of participation in a program where they were assigned a mentor was identified by 86% (n=66) of respondents. Most respondents rated their overall experience with being a mentee as “Extremely positive” on a 5-point Likert scale (62%, n=36; Figure 1). “Guidance for study” was the most commonly identified benefit of being mentored (90%, n=69; Figure 2). “Friendship” and “Better understanding of Australian culture for overseas students” were some of the potential benefits reported by respondents in the “Other” category. Several negative aspects to participating in a mentoring program were identified by respondents with “Being assigned an unsatisfactory mentor” the most common response (62%, n=48). Other reasons included the mentor “lacking insight” and “having a different study method” (Figure 3). Approximately half of those assigned a peer mentor (49%, n=36) did not continue with that mentor (Figure 4). Course structure impacted mentoring with the “mentor moving away for ongoing study/work” being the most common reason for the discontinuation of mentoring (44%, n=19). Other reasons included “Mentor leaving the course”, “Mentor failing their phase”, and a “Perceived lack of interest from the mentor”. With regard to being mentored in the future, most respondents (71%, n=52) indicated that they were likely to take on a mentor in the future.

Experience and future intentions towards being a mentor. In total, 75% (n=58) of the respondents were involved in mentoring a student that had been assigned to them during

n (%) 15 (20) 12 (16) 28 (37) 15 (20) 3 (4) 0 (0) 1 (1) 1 (1) n (%) 11 (14) 66 (86)

their medical education. Of respondents that were assigned a mentee, 30% (n=22) did not continue the relationship. The average length of a discontinued mentorship relationship was 3.8 months (Figure 5). There were various reasons identified by respondents regarding why they discontinued their relationship as a mentor to another student. Having to relocate for study was the single most common reason (26%, n=6) followed by time constraints (21%, n=5). A “Lack of interest from the mentee”, “Taking time off study”, and “Failing the phase” were some of the specified responses in the “Other” category. Respondents reported positive experience as a mentor (89%, n=49). Only 7% (n=4) reported a negative experience. When considering the future 83% (n=60) indicated that they intend on being a mentor, 3% (n=2) did not intend on being a mentor, and 14% (n=10) were undecided. Respondents were more likely to have an intention to be a mentor in the future if they had been mentored themselves (Chi-Squared Test, p=0.0003). “Helping other people” was the most commonly identified benefit from mentoring another student (84%, n=65 Figure 6). “Potential for revision” and “Opportunity to support some minority groups” were some of the other identified benefits. The most common potential negative factor identified with being assigned a mentee was “Increased demands on time” (74%, n=57). “Sense of responsibility for a mentees poor performance” and “Not being able to meet a mentees expectation” were also some of the specified responses in the “Other” category (Figure 7).

Factors influencing participation in mentoring programs Age significantly influenced whether or not respondents were assigned a mentor. People aged 26-30 were more likely to be assigned a mentor, (Chi-Squared Test, p=0.003) and people aged 36-40 were likely to be assigned a mentor (Chi-Squared Test, p=0.003). People aged 26-30 were also more likely to become a mentor (Chi-Squared Test, p=0.01). Relationship status was also found to influence participation in mentoring programs, as people who were married were less

Original Research

likely to participate in programs where they were assigned a mentor (Chi-Squared Test p=0.002). Respondents without dependents were significantly more likely to take part in a peer mentoring program where they were assigned a mentor (Fisher’s Exact Test, p=0.006). Previous participation in programs where respondents were assigned mentors was positively correlated with being a mentor in the future (Fisher’s Exact Test, p=0.0003). 34% (n=26) of respondents indicated that they were more likely to participate in mentoring programs if they could choose their mentor. However, 22% (n=17) were undecided about whether

Figure 3 Potential negatives from being assigned a mentor.

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or not being able to choose their mentor would influence their participation in a mentoring program. Respondents who were previously assigned a mentor were more likely to identify “Access to potential source of knowledge” (89%, n=69) as a potential benefit to having a mentor when compared to those who weren’t assigned a mentor (64%, n=seven). They were also more likely to identify “Guidance for study” (92%, n=61) as a potential benefit compared to those who weren’t assigned a mentor (72%, n=8). All respondents thought that there were potential benefits to being a mentor.

Reasons mentees discontinued seeing mentors

Figure 5 Length of time of discontinued mentoring relationship

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Students who were older and married were less likely to participate in mentoring. This is likely to reflect an increased level of personal support associated with being married. Kalen et al. [16] and Singh et al. [9] identified that mentoring can provide medical students with an increased level of personal support. Therefore, it would be reasonable to theorise that already having adequate personal support may negatively influence participation. Older students having an increased demand on their time due to extra-curricular factors such as marriage, dependents, and employment may explain the decrease in participation in mentoring associated with age. Increased demands on time associated with mentoring was a common negative factor identified by respondents, which is consistent with findings of previous research [21]. Respondents without dependents were more likely to participate in mentoring (p=0.006), presumably as they had fewer family commitments. Those aged under 30 made up most of the respondents (74%, n=57) which may explain the higher participation rates found in the study. In total, 86% (n=66) of respondents reported participating in mentoring during their medical education. This is higher than participation rates reported in the literature for other mentoring programs (50-60%) [10-12]. WUMSS does not keep records of participation rates in mentoring programs, so it is not clear if the actual participation rate is higher than other studies or if responder bias occurred. One limitation of this study is that it was only distributed to past and present students active on cohort Facebook groups.

Potential benefits from mentoring…

Influence of previous experience with mentoring

NUmber of Responses

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0 Less 6-12 1-2 than 6 Months Years month

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Figure 6 Potential benefits from mentoring another student

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Figure 7 Potential negatives from being a mentor to another student.

Potential negatives from being a mentor to another student

Discussion The survey findings demonstrate that medical student participation in peer mentoring programs is influenced by multiple factors such as an individual’s personal demographics, previous experience with mentoring, and the structure of the available mentoring program and the medical program.

The influence of personal factors on participation

Students who had participated in previous mentorship programs were more likely to participate in future mentoring (p=0.0003). This is likely due to respondents experiencing benefits associated with mentoring. 82% (n=56) of respondents reported a positive experience with mentoring and identified potential benefits including both improved academic performance and increased personal wellbeing, which is consistent with previous research [9,13-15,18]. There were multiple potential negative factors to mentoring identified such as being assigned an unsatisfactory mentor, personality differences, and an increased demand on time. Due to the high participation rate found in this study, it appears that the potential negative aspects associated with mentoring do not significantly deter people from participating in mentoring programs.

Influence of the structure of the available mentoring program and medical program This study identified that the structure of the WUMSS mentoring program influenced participation such as the mentor relocating. While many of the positive and negative aspects of mentoring identified by respondents were similar to those identified in other studies, the most common reason for the termination of a mentoring relationship was unique to the WUMSS mentoring program. Having the mentor move away was identified by 44% (n=19) of those who had their relationship with their mentor end. While it is commonplace for medical students to relocate upon completion of their degree, many students in the UOW Graduate Medical program begin to move away after the first

Original Research

18 months of the course due to the structure of the program. This demonstrates that the structure of the mentoring program within a medical program can influence participation. Identifying factors that influence mentoring program participation can be useful so that programs can be restructured to address them, such as having the option to be reassigned another mentor or implementing the use of web-based meeting platforms. It should be noted that this research occurred prior to the COVID-19 pandemic and the pivot to online teaching. Further research is required to determine whether students are utilising web-based methods of communication for their mentoring relationships. Although only identified by two respondents, having a mentoring relationship end due to a student failing a year or dropping out further highlights how a simple restructuring of the current WUMSS mentoring program to allow participants to be reassigned mentors each year could improve overall participation. Interestingly, another aspect of the WUMSS led program, mentor choice, that has been shown to negatively impact participation in other research did not seem to have the same influence in this study. This study found that only 34% (n=26) of respondents would be more likely to participate in mentoring programs if they could choose their mentor, which is lower than other studies. Jayalakshmi et al. [13] found that 73% of medical students wanted to have some choice in their mentor, suggesting that being assigned a mentor rather than choosing a mentor is a possible reason that medical students don’t participate in mentoring programs. This claim is strengthened by Guse et al. [20] who found that a mentor-mentee “speeddating” session, where students met with potential mentors and had input into who they were assigned to improved rates of overall satisfaction and longevity of mentoring relationships for

medical students. It is not clear why the influence of the ability to choose a mentor in the WUMSS program is lower than rates reported in other studies. As most respondents reported positive experiences with being mentored, it may be a further indication of a possible responder bias that is also implicated by the aforementioned high participation rate. The study findings demonstrate that improved wellbeing and academic results are associated with mentoring and may help counteract some of the stress and burnout associated with medicine. The majority of respondents identified decreased stress and anxiety (56 %, n=43), improved overall wellbeing (52%, n=40), and improved academic results (51%, n=39) as potential benefits of being mentored. These findings are consistent with previous research [8, 9,13,14,18]. Future research could use interviews to further explore potential barriers and enablers to participation in mentoring and the reasons some students do not have a positive experience with peer-mentoring.

Conclusion Students who were older and married were less likely to participate in the mentorship program. Students who had participated in previous mentorship programs were more likely to participate. Tailoring a mentoring program to the student cohort and course structure may improve participation rates and subsequent personal wellbeing and academic performance of those involved in the program. Improvements in personal wellbeing and academic performance may assist medical students to navigate the competitive and often stressful profession of medicine. Future research should focus on evaluating individual programs to identify barriers to participation and possible ways to address them.

References 1. Zerzan, JT, Hess, R, Schur, E, Phillips, RS, Rigotti, N. Making the most of mentors: a guide for mentees. Acad Med. 2009; 84(1):140-4. 2. Taherian, K, Shekarchian, M. Mentoring for doctors. do its benefits outweigh its disadvantages? Med Teach. 2008; 30:95–9. 3. Henry-Noel, N, Bishop, M, Gwede, CK, Petkova, E, Szumacher, E. Mentoring in medicine and other health professions. J Cancer Edu. 2019;34(4):629-37. doi: 10.1007/s13187-018-1360-6 4. Ong J, Swift C, Magill N, Ong, S, Day, A, Al-Naeeb, Y, Shankar, A. The association between mentoring and training outcomes in junior doctors in medicine: an observational study. BMJ Open. 2018;8(9):e020721. doi: 10.1136/bmjopen-2017-020721. 5. Huang, Y, Chua, TC, Saw, R, Young, CJ. Discrimination, bullying and harassment in surgery: a systematic review and metaanalysis. World J Surg; 2018:1-7. 6. Heinen, I, Bullinger, M, Kocalevent, RD. Perceived stress in first year medical students - associations with personal resources and emotional distress. BMC Med Edu. 2017;17(4). doi:10.1186/s12909-016-0841-8 7. Wu, F, Ireland, M, Hafekost, K, Lawrence, D. National mental health survey of doctors and medical students. 2013; Australia: Beyond Blue. Available from: https://www.beyondblue.org.au/docs/default-source/researchproject-files/bl1132-report---nmhdmss-full-report_web 8. Frei, E, Stamm, M, Buddenberg-Fischer, B. Mentoring programs for medical students – a review of the PubMed literature 20002008. BMC Med Edu. 2010;10(32)

9. Singh, S, Singh, N, Dhaliwal, U. Near-peer mentoring to complement faculty mentoring of first-year medical students in India. J Edu Eval for Health Prof. 2014;11(12). 10. Fallatah, HI, Soo Park, Y, Farsi, J, Tekian, A. Mentoring clinical-year medical students: factors contributing to effective mentoring. J Med Educ Curric Dev. 2018;5:1-6. 11. Kurre, K, Bullinger, M, Petersen-Ewert, C, Guse, A. Differential mentorship for medical students: development, implementation and initial evaluation. Int J Med Edu. 2012;3:216-24. 12. Nimmons, D, Giny, S, Rosenthal, J. Medical student mentoring programs: current insights. Adv Med Educ Pract. 2019;10:113– 123. doi:10.2147/AMEP.S154974. 13. Jayalakshmi, L, Sampath Damodar, K, Nadig, P. Mentoring for medical undergraduates - feedback from mentees (Need For Training of Mentors). Asian J Med Sci. 2011;2:151-8. 14. Dimitriadis, K, Borch, P, Störmann, S, Meinel, F, Moder, S, Reincke, M, Fischer, M. Characteristics of mentoring relationships formed by medical students and faculty. Med Educ Online. 2012;17:1-9. 15. Saraf, C, Itagi, AB, Gade, S, Arora, DB, Gosewade, N, Deb, B. Role of mentoring in improving academic performance among low achievers in a medical college of Chhattisgarh, India. J Educ Tech Health Sci. 2017;4(3). 16. Kalen, S, Ponzer, S, Seeberger, A, Kiessling, A, Silen, C. Continuous mentoring of medical students provides space for reflection and awareness of their own development. Int J Med Educ. 2012;3:23644. 17. Sambunjak, D, Straus, SE, Marusic, A. A systematic review of qualitative research on the meaning and characteristics of

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mentoring in academic medicine. J Gen Intern Med. 2009;25(1):72-8. 18. Chanchlani, S, Chang, C, Ong, J, Anwar, A. The value of peer mentoring for the psychosocial wellbeing of junior doctors: a randomised controlled study. The Med J Aust. 2018;209 (9):4015. doi: 10.5694/mja17.01106. 19. Moutsopoulos, HM. Mentoring in medicine. Eur J Clin Invest. 2019;49(8).

20. Guse J, Schweigert E, Kulms G, Heinen, I, Martens C, Guse AH. Effects of mentoring speed dating as an innovative matching tool in undergraduate medical education: a mixed methods study. PLoS One. 2016;11(2). doi.org/10.1371/journal.pone.0147444. 21. Sheri, K, Too, J, Chuah, S, Toh, YP, Mason, S, Radha Krishna, LK. A scoping review of mentor training programs in medicine between 1990 and 2017. Med Edu Online. 2019;24(1). doi:10.1080/10872981.2018.1555435.

Acknowledgements: None. Conflict of interest statement: The authors have no conflicts of interest to disclose. Funding: None Author contribution statement: Warren Policha: Study design, ethics approval, data collection, data analysis, writing of manuscript. Dr Pippa Burns: Data analysis, writing of manuscript. Dr Darryl McAndrew: Primary project supervisor, study design, ethics approval, data analysis, writing of manuscript. Cite as: Warren P, Pippa B, Darryl M. Exploring the reasons for medical student participation in peer mentoring programs. Aust Med Stud J. 2020;1:748–51. Correspondence: Warren Policha,wrp675@uowmail.edu.au Date of submission: 9 June 2020 Date of acceptance: 29 December 2020 Date of online publication: 30 December 2020 Editor: Shahzma Merani, Mabel Leow Proofreader: Annora Kumar, Pabasha Nanayakkara Senior Proofreader: Emily Feng-Gu

Original Research

Enablers and obstacles to medical student satisfaction during obstetrics and gynaecology rotations Jordanna Mladenovic1, Sandhya Gupta1, Torres Woolley1, Ajay Rane1 1

James Cook University, QLD Jordanna Mladenovic is in her final year of Bachelor of Medicine/Bachelor of Surgery at James Cook University. Her current interests include obstetrics and gynaecology and critical care medicine. Dr Sandhya Gupta is a consultant Obstetrician and Gynaecologist at Townsville University Hospital and senior lecturer of obstetrics and gynaecology at James Cook University.

Abstract Introduction: Providing care for pregnant women and responding to obstetric emergencies are tasks which medical graduates are expected to be competent in performing. To ensure this, Australian medical schools have set clinical learning objectives for students to achieve during their obstetrics rotation. Alarmingly, several studies have shown students are struggling to participate in these clinical experiences, especially the birthing process. Further evaluation of student experiences on labour ward is needed to identify common concerns and to improve the overall educational experience. Methods: Year 5 medical students from James Cook University completed an optional anonymous questionnaire at the end of their Reproductive and Neonatal Health (RNH) rotation. A cross-sectional analysis was performed on responses. Open-ended responses underwent a content analysis and both common positive and negative themes were identified. Results: Assisting in deliveries and surgical procedures were regarded as highly valuable learning experiences. Male students reported that their gender was a clear drawback to their rotation experience (p <0.001). Competition with midwifery students and poor interactions with midwifery staff were common themes reported and contributed to 57% of students experiencing difficulty gaining clinical exposure whilst on labour ward. Conclusion: Difficulty in gaining clinical experience within labour wards is increasing as the number of health care students continues to rise and the birth rate falls. The presence of gender bias and misunderstanding of student learning objectives by midwives further contributes to the competitive environment experienced by medical students during their obstetrics term. Greater collaboration and communication between medical schools and midwifery staff is vital to ensure quality education continues to be delivered and clinical requirements are achieved. The use of simulation training should also be further explored as a means to provide standardised educational experiences.

Dr Torres Woolley is the Evaluation Coordinator at the School of Medicine and Dentistry. Torres has been an active researcher over the last 15 years in both quantitative and qualitative methodologies. He has completed a Masters in Public Health and Tropical Medicine, and a PhD in skin cancer, with interests in all things rural, remote, Indigenous and tropical. Prof. Ajay Rane is the Director of Urogynaecology at Townsville University Hospital, Director of Mater Pelvic Health and Research and Head of Obstetrics and Gynaecology at James Cook University (JCU).

Keywords: medical student, obstetrics, labour ward, gender, midwifery Introduction Despite the obstetrics and gynaecology curriculum for medical students sharing core components with that of midwifery students,

there

appears

little

interdisciplinary

collaboration and sharing of teaching opportunities. This has resulted in the formation of a competitive framework within the labour wards and a struggle to gain clinical experiences [1]. It is imperative for junior doctors to have sufficient knowledge of the basics of obstetrics and gynaecology and have the appropriate clinical experience to provide care for pregnant women and respond to obstetric emergencies [1]. Whilst the Australian Medical Council has no graduate outcome requiring the completion of certain skills in obstetrics and gynaecology, RANZCOG expects all medical school graduates to be competent in managing normal labour under supervision [2]. To ensure clinical competency and promote active participation on the labour ward, James Cook University (JCU) students are required to follow the management of five deliveries in birth suite and perform at least two normal deliveries during their rotation. Similar clinical objectives are observed throughout medical schools Australia wide. These hands-on experiences are highly valued by students and are recognized to develop and consolidate their knowledge base. However, a 2015 study of Australian medical schools highlighted that in practice students are not always able to complete set clinical objectives [3]. Common resistive factors contributing to decreased educational experiences include gender bias, competition with midwifery

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staff and students and the misunderstanding of roles within the

practical skills, experiences on the labour ward and whether

labour ward [1,3]. Reduced clinical exposure due to these factors

gender was perceived as a drawback or benefit to students

has the ability to contribute to an overall negative placement

during their terms. A Chi-Square test for trend was then

experience, especially for male students, and adversely shape

performed on the crosstab data and the p-value for each

their view towards obstetrics and gynaecology, creating the

variable was documented.

potential for deterrence from the specialty.

A content analysis was performed on the answers given in the

To evaluate student experiences and identify common resistive

open-ended responses. Each response was analysed and

factors faced within their rotation, JCU medical students were

common themes were identified. The most common positive

asked to complete an anonymous survey at the completion of

experiences were grouped into; shadow

their six-week term. It is hoped that the identification of

participating in deliveries, theatre time, structured teaching and

common

for

participation in clinics. The most common negative experiences

improvements to the way that reproductive care term is

included; competition with midwifery students, negative

delivered to medicals students.

interactions or experiences with nursing and midwifery staff,

struggles

faced

students

will

allow

on-call shifts,

negative interactions or experiences with doctors, difficulty

Methods

participating in deliveries, difficulty being included in clinic

Institutional permission was obtained from the department of

consultations, and poor rotation scheduling. Each student

Obstetrics and Gynaecology, and the use of anonymous student

response was coded and allocated to one of the common

responses for the purpose of this study was approved by JCU

themes listed.

Reproductive and Neonatal Health rotation (RNH) module coordinators along with the JCU Year 5 Student Committee.

Results

A cross-sectional study was conducted analysing responses to a

A total of 162 questionnaires were collected from 2016 to 2019.

student feedback questionnaire on experiences within the RNH

Approximately 93% of the study cohort completed their rotation

rotation at JCU from 2016 to 2019. Students who completed the

in Townsville, 4% in Mount Isa and 1% in both Mackay and

survey were based in Townsville, Cairns, Mackay and Mount Isa

Cairns. As the questionnaire was voluntary, response rates

hospitals. At the completion of each rotation, all students

varied across the years; 27% of participants completed the

attended a mandatory debrief with academic staff and were

survey in 2019, 40% in 2018, 25% in 2017 and only 8% of

supplied with either a paper-based version of the questionnaire

answers were from 2016. Response rates to individual questions

or a link to an online version (Appendix 1). This provided all

also fluctuated and only an estimated 79% of surveys had all

students who completed the RNH rotation with the opportunity

answer fields filled. Blank responses were omitted when

to participate in the voluntary survey, allowing for responses

tabulating results in order to ensure accurate data analysis,

from a wide spectrum of students. The questionnaire was

therefore resulting in less than 162 responses documented for

certain questions.

and aimed to assess the experience of fifth year medical

Of the 162 students who participated, 45% were male, 54% were

students in their obstetrics and gynaecology rotation. The

female, and one student did not nominate a gender. Male

questionnaire was designed to be neutral and questions were

gender appeared to have a negative effect on student

neither ambiguous nor biased. Initial questions were closed and

experience (Table 1); 48% of male students reported their

allowed students to respond to statements with disagree,

gender was a drawback to their experience in their RNH rotation,

neutral, agree or strongly agree. Open ended questions were

whilst only 6% of females felt their experience was hindered by

then included and provided students the opportunity to

gender (p<0.001). Those female students who regarded their

describe both negative and positive experiences and suggest

gender as a drawback found they experienced more

improvements to the rotation.

competition with nursing and midwifery staff compared to their

All responses were voluntary and were deidentified to ensure

male colleagues, with some reporting “it was evident that the

student privacy. The results were tabulated and analysed using

boys had a better experience with the midwives than the female

IBM SPSS Statistics Program for macOS (IBM Corp, Armonk, NY,

students did” and “patient wise it [the rotation] was okay, but

USA). Students were asked to nominate their placement site,

staff wise I find it can be quite competitive with nursing staff and

gender and the term in which they completed their rotation.

students.”

Gender was the only variable which appeared to significantly

Our results showed that 32% of female students and 25% of

influence student responses. A crosstab analysis was therefore

male students reported difficulty gaining clinical experience on

performed to assess the statistical relationship between gender

labour ward. Female students reported their greatest barrier to

and improvement in communication skills, improvement in

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Table 1: Crosstab analysis of Medical students’ reported experience in obstetrics and gynaecology (O&G) rotation. Male Year 5 JCU medical students

Female Year 5 JCU medical students

(n=73)

(n=88)

35 (48%)

5 (6%)

No impact

33 (45%)

47 (53%)

Benefit

5 (7%)

36 (41%)

Variable

pvalue*

Has gender been of benefit or drawback during the RNH rotation? Drawback

p<0.001

My practical skills have improved from my RNH term Disagree/Neutral

8 (11%)

Agree

42 (58%)

Strongly Agree

23 (31%)

20 (23%) 49 (57%)

p=0.020

17 (20%)

My communication skills have improved because of my RNH term, especially regarding obstetrics and gynaecology 16 (22%)

22 (26%)

Agree

45 (62%)

54 (63%)

Strongly Agree

12 (16%)

10 (12%)

36 (49%)

31 (36%)

Agree

19 (26%)

27 (31%)

Strongly Agree

18 (25%)

28 (32%)

12 (16%)

12 (14%)

Agree

46 (63%)

50 (58%)

Strongly Agree

15 (21%)

24 (28%)

Male Year 5 JCU medical students

Female Year 5 JCU medical students

(n=73)

(n=88)

35 (48%)

5 (6%)

33 (45%)

47 (53%)

5 (7%)

36 (41%)

Disagree/Neutral

p=0.381

I found it difficult to gain experience in labour ward Disagree/Neutral

p=0.111

Overall, I found RNH to be a good experience Disagree/Neutral

Variable

p=.322

p-value*

Has gender been of benefit or drawback during the RNH rotation? Drawback No impact Benefit

p<0.001

* 2-sided Chi-square test for trend being involved in patient interactions on the labour ward was

clinical experience. One student reported “there was a lot of

resistance from midwives or nursing staff, whilst male students

competition from midwifery students, who I felt were given

report their greatest resistance was from patients. A combined

preference over medical students by many of the midwives. This

total of 57% of students reported some difficulty in birth suite

made it quite difficult to see enough birth.” Some students

and both genders identified competition with midwifery

elected to spend additional hours on labour ward in order to

students as being a common obstacle to achieving a satisfying

overcome these obstacles, though still felt dissatisfied with their

Original Research

experience, one student recalled “I even went to birth suite on

concentrated periods of time spent with senior doctors, which

days I was not rostered to witness labour. I only manage to

resulted in students receiving subjectively better teaching

deliver 1 baby.”

experiences. “Doctors wanted to involve you in the procedures

Both male and female students felt their communication skills in

and made theatre experience much more enjoyable than other

relation to discussing obstetrics and gynaecology topics had

surgical terms.”

improved during their rotation, at 78% and 75% respectively. Meanwhile, 89% of males and 77% of females also noted an

Table 2. Content analysis of positive experiences within the

improvement in their practical skills, such as performing

RNH rotation.

speculum examinations. Students who reported finding no

Themes

Male responses (n= 58)

Female responses (n=71)

Shadow-on call shifts

6 (4.6%)

10 (7.7%)

Participating in births

21 (16.2%)

24 (18.6%)

Theatre time

24 (18.6%)

19 (14.7%)

Structured teaching Participation in clinic

15 (11.6%)

20 (15.5%)

9 (6.9%)

22 (17%)

improvement in communication and practical skills stated this resulted from experiencing an observer type role in clinic consultations. Students found that their ability to interact independently with patients was largely reliant on facilitation by the senior doctor, spare clinic rooms and consent from patients. Those who were able to conduct their own clinical interviews found great benefit, with one student reporting “when it comes

No gender specified (n=1)

to history taking and examinations I believe my time in the RNH term has helped me improve my communication skills with women, especially when discussing specific problems or symptoms.” Overall, 84% of the study cohort regarded their rotation as a good overall experience. The open-ended response questions allowed students to list specific examples of the positive and negative experiences they had within their RNH rotation. Students often gave multiple examples, the most common themes amongst responses are listed below (Table 2,3).

Positive Experiences We found that 129 students provided examples of positive experiences in their RNH term (Table 2), while 33 students did not respond to this question. Participating in and observing the process of labour was the most common positive experience reported by students (35%). Students reported enjoying the practical aspect of labour ward and found the opportunity to be actively involved in the birthing process extremely valuable, one student reporting they had “great clinical exposure and opportunity to practice clinical skills that I may never get the chance to practice again until I need to use them in my career e.g. VE in labour, performing [a] delivery.” Many students also enjoyed the rapport they were able to establish with labouring women and their families whilst on birth suite, describing their time as “extremely rewarding and educational.” Students appreciated opportunities to perform practical skills such as cannulations, pelvic examinations, and assisting in theatre. We found that 33% of responses discussed positive experiences students had whilst in theatre, including observing and assisting in caesarean sections. “Getting to assist in a caesarean section was amazing, it was nice to see the doctor step through the procedure and learn technical skills, i.e. how to

1 (0.7%)

Structured teaching throughout the rotation was another positive aspect reported in 27% of the responses. Rostered tutorial sessions, including practice objective structured clinical examination (OSCE) sessions, provided guidance and support to students and many reported this improved their overall RNH experience. “The teaching in RNH was really good. I felt better guided in this rotation compared to previous ones.” “All the doctors were very keen on teaching (especially doctors who are involved academically) and making sure the students have the best experience in RNH.”

Negative Experiences We found that 106 students provided examples of negative experiences they had within their rotation, 34 students did not respond, and 22 students had only positive experiences and were unable to identify any negative incidents (Table 3). Of those students who responded, 36 reported experiencing negative interactions with nursing and midwifery staff, with 55% of these responses being from female students. Many responses mentioned mistreatment and bullying within the labour ward and students felt that midwives were “very resistant to the medical students”, “unaccommodating”, “dismissive” and “clearly don’t want medical students there”. One student wrote, “I would go home crying every day and would leave early because the environment was that bad. I felt bullied by midwives and midwifery students.” Another student shared, “..midwife ignored me the entire time, unable to go into the room with the mother although the mother consented to my presence.”

hold the different equipment.” Time in theatre also allowed for

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Table 3: Content analysis of negative student experiences

tutorials, which they felt would have been of greater educational

within the RNH rotation.

benefit. The restricted time-frame students spent on the labour

Themes

Competition with midwifery students Negative experience with nursing and midwifery staff Negative experience with doctors Difficulty participating in births and/or clinics Poor rotation organisation No negative experience

Male responses (n=57)

Female responses (n=70)

3 (2.3%)

9 (7%)

16 (12.5%)

20 (15.6%)

No gender specified (n=1)

ward was also seen as a disadvantage to the rotation, with many students reporting it made achieving clinical objectives, such as assisting in births and performing vaginal examinations in labour simply unachievable. Discussion

3 (2.3%)

6 (4.7%)

19 (14.8%)

11 (8.6%)

1 (0.8%)

10 (7.8%)

19 (14.8%)

1 (0.8%)

9 (7%)

13 (10%)

Students also found their labour ward experience challenging due to the presence of midwifery students and described having to ‘compete’ with student midwives in order to participate in deliveries. Students felt there was often preferential treatment of midwifery students, and this created barriers in forming rapport with midwives and being given the opportunities to participate in the process of labour. Students shared their disappointment in the feedback saying, “[I was] not able to assist with or witness births easily because we were informed that midwifery students take preference over medical students and often students who had been with mothers for a number of hours were asked to leave rooms if a midwifery student appeared and wanted to go in” and “I was in a room with a patient in labour and was assigned to deliver by the midwife, then another midwife said her midwifery student will do the birth….outside the room I could hear midwives and midwifery students talking about how medical students don't need births.” Of respondents, 24% reported having limited opportunities to participate in clinical settings, such as the labour ward and clinic consultations. The majority of these responses were from male students (61%). Patient refusal was the most common resistive factor mentioned in responses, followed by congestion on labour ward with both midwifery and medical students and reduced numbers of patients in birth suite. The culmination of these factors contributed to decreased learning opportunities experienced by students. The overall structure and organisation of the rotation was mentioned as a negative aspect of the rotation in 23% of responses. Students found that mandatory attendance at certain low-yield clinics interfered with their ability to attend

Overall, students regarded their RNH rotation as an enjoyable term, with many reporting improvements in both practical and communication skills. Students felt having a ‘hands on’ approach allowed them to develop useful skills whilst consolidating their knowledge base and increasing their clinical confidence. However, there was notable disparity between experiences, with some students struggling to even witness a vaginal birth by the completion of their rotation. The difference in clinical opportunities appeared to result from multiple factors including gender bias, competition with midwifery students, and poor interactions with midwifery staff. Student responses highlighted a statistically significant correlation between male gender being a drawback and female gender being of benefit during placement in obstetrics and gynaecology (p<0.001). Of the male respondents, 48% identified their gender as hinderances to their experience during the RNH rotation, and 14.8% reported difficulties gaining experiences in both labour ward and clinic environments. Students felt that resistance from patients was the main factor leading to reduced opportunities to observe and participate, particularly with intimate examinations. The influence of gender on student experience in obstetrics and gynaecology is well documented throughout literature. Akka et al. [4] analysed gender differences in the teaching of intimate examinations and reported male students were more often refused patient consent for examination as compared to their female colleagues (p= 0.0001). The theme of gender bias was also demonstrated in a prospective study by Chang et al. [5], where male students experienced patient refusal more often than female students in both clinical interview participation (61% vs 17%, respectively; p<0.0001) and physical examination (82% vs 37%, respectively; p<0.0001). Reduced clinical exposure has been shown to negatively impact examination performance and may also contribute to declining rates of males pursuing a career in obstetrics and gynaecology [6]. In 1978, the membership base of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) was 95% male, though a surge in female applicants over the past twenty years has caused a drastic reversion. In 2018, a mere 20% of applicants to the college were male [7]. RANZCOG now has the has the highest percentage of female members in comparison to other Australian and New Zealand medical colleges. Whilst reasons for a reduction in male applicants may be multifactorial, prejudice against male medical students during their medical school rotation cannot be overlooked as a potential deterrent. Competition between midwifery and medical students for clinical experience on labour wards is a common theme observed in hospitals nation-wide. Hogan et al. [3] surveyed 18 Australian medical schools, with eight schools specifically reporting competition from midwifery students as a problem in

Original Research

the provision of clinical experience for medical students. As birth is the central event to both midwifery and obstetrics, the learning objectives of both groups are comparatively similar. Unfortunately, the exponential increase in health students undertaking placement within the obstetrics field is conversely accompanied by a declining birth rate, and together these factors contribute to difficulty facilitating the needs of both student groups. Additionally, Quinlivan et al. [4] proposed that the misunderstanding of the respective learning roles of both medical and midwifery students further adds to the competitive framework seen in birth suite. Within the current study, thirtysix students reported negative interactions with nursing and midwifery staff during their obstetrics rotation, and a vast majority were a result of midwifery staff being misinformed of student learning objectives and therefore providing resistance to student participation. Midwives play an integral role in the RNH rotation and many students report positive and valuable learning experiences when given the opportunity to work closely with midwifery. However, survey responses indicate that many midwifes were unfamiliar with student learning objectives and this contributed to difficulty facilitating opportunities to participate as an accoucheur, particularly when in competition with a midwifery student. Deficiency in the understanding for the need for medical students to have hands-on learning experiences was reported by Cheng et al. [1] in 2018. Responses indicated that many midwives were unaware that junior doctors may be faced with emergency management of labour or pregnancy complications with little help and no additional training after medical school. This misapprehension of roles on labour ward has the ability to influence the attitude of midwives and subsequently their willingness to involve medical students in teaching activities. The voluntary nature of the questionnaire acts as a limitation as it made capturing responses from the entire student cohort difficult, and also allowed students to omit certain questions. Another limitation is the possibility that only students with either strongly negative or strongly positive experiences were likely to participate. Whilst the majority of students were based in the Townsville hospital, there was a minority completing their rotation at smaller hospitals, and therefore their experience may have differed.

Delivery of quality training in obstetrics and gynaecology for medical students remains challenging. Student experiences are ultimately influenced by gender, interactions with health care staff, in addition to the consent from the woman herself. As the annual intake of medical students continues to rise and competition with midwifery students looks to worsen, developments must be made to prevent a declining standard of clinical experience. Rostering adjustments to increase time spent in birth suite and limit student congestion is a small step which can be taken. Encouraging senior members of staff to introduce medical students to patients may also facilitate better patient engagement and foster clinical environments where patients feel comfortable with the involvement of male medical students. Greater collaboration and communication between medical schools and midwifery staff is also vital to ensure adequate understanding of student learning needs and equitable access to birth suite opportunities [3,8]. Mires et al. [9] analysed the effects of introducing an interdisciplinary educational programme for medical and midwifery students at the University of Dundee. Students were found to highly benefit from the multidisciplinary teaching approach and increased not only their knowledge regarding normal labour but also their own awareness of professional responsibilities and roles in women’s health. Simulation training is also being explored as another means to further equalise the educational experience available in labour wards. Everett et al. [10] discussed the effectiveness of simulation training in providing students with opportunities to perform valuable yet invasive skills, such as vaginal examinations in labour. Simulation training removes barriers such as gender bias, consent refusal and interdisciplinary competition for skill exposure, whilst also preventing patients from being exposed to multiple examinations and potential safety risks. Educating through simulation has shown to increase student confidence whilst providing a standardised learning platform and is an avenue which should be further researched and implemented into medical student training. Ultimately, there are a number of viable interventions available and further research should be conducted to determine the most effective and achievable methods to enhance the educational experience of medical students in obstetrics and gynaecology.

References 1. Cheng HC, de Costa C. Woods C. Medical students and midwives – How do they view each other? Aust N Z J Obstet Gynaecol,. 2018;58:586-9. doi: doi:10.1111/ajo.12803 2. Medical Schools Curriculum- Obstetrics and Gynaecology. Royal Australian and New Zealand College of Obstetricians and Gynaecologists. 2019. [Cited 10th August 2020]. Available from: https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOGMEDIA/About/RANZCOG-Undergraduate-Curriculum-in-Womens-Health.pdf 3. Hogan EW, C. Buttrose, M. Abethum, L. Cheng, H. De Costa, C. The changing birth suite experience for Australian medical students. Aust N Z J Obstet Gynaecol. 2016;56:537–42. doi: 10.1111/ajo.12495

4. Akkad A, Bonas, S. and Stark, P. Gender differences in final year medical students’ experience of teaching of intimate examinations: a questionnaire study. BJOG. 2008; 115:625-32. doi:10.1111/j.14710528.2008.01671.x 5. Chang JC OM, McIntyre-Seltman K. The effect of student gender on the obstetrics and gynecology clerkship experience. J Womens Health (Larchmt). 2010;19:87‐92. doi: doi:10.1089/jwh.2009.1357 6. Craig L.B B-JSD, Bliss S, Everett E.N, Forstein D.A. To the point: gender differences in the obstetrics and gynecology clerkship. Am J Obstet Gynecol 2018.;219(5):430 ‐ 5. doi:10.1016/j.ajog.2018.05.020 7. Gender Equity and Diversity Report [press release-Internet]. Royal Australian and New Zealand College of Obstetricians and Gynaecologists. 2019. [Cited 2020 May 1st]. Available from: https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-

Original Research

MEDIA/Our%20College/Gender%20Equity%20and%20Diversity/G ender-Equity-and-Diversity-Report.pdf 8. Quinlivan JT, C. Black, K. Kornman, L. McDonald, S. Medical and midwifery students: how do they view their respective roles on the labour ward? Aust N Z J Obstet Gynaecol 2002;42(2):403.doi: 10.1111/j.0004-8666.2002.00403.x 9. Mires G.J, Williams R.M, Harden R.M, Howie M, McCarey A, Robertson A. Multiprofessional education in undergraduate

curricula can work. Med Teach. 1999;21(3);281-5, doi: 10.1080/01421599979536 10. Everett E, Forstein D.O, Bliss S, Buery-Joyner S.D, Craig L.B, Graziano S, Hampton B.S. To the Point: The expanding role of simulation in obstetrics and gynecology medical student education. Am J Obstet Gynecol. 2019;220 (2):129-41. doi:https://doi.org/10.1016/j.ajog.2018.10.029

Acknowledgements: We would like to thank Mr Venkat Venagaveti and all the James Cook University medical students who participated in this survey. Conflict of interest statement: The author/s have no conflicts of interest to disclose. Funding: None to declare Author contribution statement: Jordanna Mladenovic: Collation of data, construction of manuscript, revision of manuscript, Dr Sandhya Gupta: Formulation of study questionnaire, revision of manuscript , Prof. Ajay Rane: Conception of study, revision of manuscript, Torres Wooley: Interpretation of data Ethics board approval: This study was approved by the clinical board of studies JCU School of Medicine. This is a routine collection of confidential data and was approved on 12.1.2016. Due to its low-risk nature and audit nature, specific ethics approval was not deemed necessary. Cite as: Mladenovic J, Gupta S, Woolley T, Rane A. Enablers and obstacles to medical student satisfaction during obstetrics and gynaecology rotations. Aust Med Stud J. 2020;1:748–51. Correspondence: Jordanna Mladenovic, jordanna.mladenovic@my.jcu.edu.au Date of submission: 4 March 2020 Date of acceptance: 6 October 2020 Date of online publication: 10 October 2020 Senior Editor: Justin Smith, Mabel Leow Senior Proofreader: Emily Feng-Gu Proofreader: Ke Sun

AMSJ Executive Board

AMSJ EXECUTIVE BOARD

Teresa To (External Director)

Sinali Seneviratne (External Deputy Director)

Sean Mangion (Internal Director)

Mabel Leow (Editor-In-Chief)

Annora Kumar (Internal Deputy Director)

Alex Savage (Secretary)

AMSJ Staff Members

STAFF CONTRIBUTION EDITORIAL TEAM

Annora Kumar Pabasha Nanayakkara Alistair Lau Abhishekh Srinivas Trung Tran

EXTERNAL TEAM

INTERNAL TEAM

Deputy External Director Teresa Sheng En To (2020) Sinali Seneviratne (2021)

Editor-in-Chief Mabel Qi He Leow Senior Editors Justin Smith (Surgery) Subhashaan Sreedharan (Psychosocial) Shahzma Merani (Preventive Medicine) Daniel Wong (Medicine) Associate Editors Onur Tanglay Marisse Sonido David Chen Cameron Wright Elizabeth Kaganov Dhruv Jhunjhnuwala Sharon Del Vecchio Naomi Cohen Victor Lai Aloysius Ng Domenico Nastasi Marisse Sonido Esther Johns Mark Ranasinghe Nikhil Dwivedi Dion Paul Ross Andrew Robertson Simran Dahiya

Internal Director Sara Kim (2021) Sean Mangion (2022) Deputy Internal Director Sean Mangion (2021) Annora Kumar (2022) Secretary Alex Savage Expert Liaison Officer Sophia Jin Creative Officer Emanuel Cabral

External Director Zak Doherty (2020) Teresa Sheng En To (2021-2022)

Publicity Officer Kaela Armitage Print Publications Officer Faraz Torabi Graphic Design Officer Isabel Lee Isha Singh Online Publications Officer Ashly Liu Sponsorship Officer Sinali Seneviratne (2020) Yasmina Rahbarinejad (2021-2022) Social Media Officer Sarah Loria Marita Bolic Finance Officer Cathy King

AMSJ Staff Members

We are grateful to the following reviewers for this issue Dr William Huynh - Prince of Wales Hospital, Sydney Dr Elizabeth McCarthy - University of Melbourne Dr Alka Kothari – University of Queensland Dr Robert Norton - Townsville University Hospital Dr Stephanie Jones - Monash Health Dr Kate Clezy - Clinical Excellence Commission Dr John Fraser - University of New England Dr Nancy Sturman - University of Queensland Dr Keng Lim Ng - Frimley Benign Prostate Clinical Research Centre Dr Darren Gold – University of New South Wales Dr Sajid Malik

AMSJ Volume 11, Issue 1 2022

Articles inside

Climate Emergency in Australia and the Need for Inclusion of Indigenous Peoples in Solutions

COVID-19: Adaptations to Primary Care in Australia

COVID-19 as a Valuable Learning Opportunity

Book review – Are you passionate about paediatrics?

Skin Rash in a Patient using Antiepileptic Medications, What Could it be?

An Unusual Presentation of Perforated Appendix Mimicking a Liver Abscess in an Aboriginal Male