Tuesday, February 20, 2007

The progressive destruction of Australian medical education

By Dr Amanda Neill -- a former lecturer in anatomy and related disciplines

Medical education is in serious trouble, and has been for a number of years. Recently there have been several articles questioning the level of the most basic knowledge of the medical graduates, much of it coming from the new graduates and students themselves. Surveys - some of them initiated by medical students - have revealed that they do not feel they know enough anatomy, physiology and pathology; that they are not taught, but rather thrown into a "sea" to learn in a "self-directed" fashion, and that they do not feel prepared enough to go out to practise medicine. Never has a profession's education been so mutilated, mucked-about-with, or mucked-up.

It is obvious to anyone that to fix a human body one should at least know about its components (anatomy), how these components interact (physiology), and what can potentially go wrong with them (pathology). All the rest is smoke and mirrors.

Yet the smoke and mirrors is all that the medical schools are teaching. Students these days can have remarkably good understanding of technologies such as magnetic resonance imaging, while remaining startlingly ignorant of the bones, fascia and other structures of the hand. No GP surgery will have an MRI scanner, yet every GP will routinely see patients with sore or injured hands.

One of the major reasons for the shift in what is being taught is that medical education is not being taught by doctors. Doctors are not teaching student doctors; rather science and other graduates with or without PhDs have gazumped university staff teaching appointments. It is very difficult to find a medical graduate on any university staff, and even rarer to find them in the medical schools. This is no accident.

In the 80s and certainly the 90s, medical schools started to rid themselves in a determined fashion of medical graduates on their staff and employ science graduates with strong research backgrounds to teach medical students - when they had the time. These researchers on the whole did not have any vocational training, had never been on a ward or treated a patient, and did not have a strong interest in teaching. Certainly they did not have, and were not required to have, teaching as their main priority, and still do not. Teaching of vocational degrees such as medicine, dentistry, pharmacy and veterinary science should never have been given to those in a research-focused environment such as the modern university. Neither teaching nor research is then done well.

When medicine and then other vocational courses first became taken over by this shift in thinking, initially medicine was taught by medical graduates, who knew what was needed, had been on the wards, and had a thorough knowledge of the human body. Gradually the art of teaching medical subjects and the need to teach them became lost as the ever-increasing number of PhDs grew and vied for positions on the university staff. After all as John Collins, dean of education for the Royal Australasian College of Surgeons, wrote in Weekend Health (December 16-17, 2006), there has been an explosion of medical knowledge and technology.

Whatever explosion there may be, a leg is still a leg and a stomach still a stomach. Despite Darwin's theory of evolution, these are remarkably constant, and the structures are unchanging. To fix them (the leg and the stomach and all the other structures in the body), to understand them, the doctor needs to know where they are, what is above, below, in front and behind, and what common variations of these arrangements may exist. This knowledge should not just be the province of the surgeon and the radiologist.

We live in dangerous times. Universities are currently agitating to take over, or have already taken over, the teaching of other vocational courses such as for ambulance officers, paramedics, police, physiotherapists, chiropractors, occupational therapists and nurses - and in each case the pattern is the same. Less and less of the training is done by those who have been working in the relevant profession, and more and more PhD graduates with a research focus take on the teaching and designing of courses, with a view to teaching on the side and/or to protecting their area of expertise, no matter how irrelevant. They also have minimal teaching experience. Students learn more and more about less and less relevant material. They are less ready to take on their role as a doctor, or the work necessary to do this job.

Currently in many courses textbooks are no longer prescribed, but a recommended reading list and stacks of photocopied papers and hastily prepared lecture notes are given to the students. They are told to go and get on with it - and this is in the more structured courses. Others are completely self-directed and there is no actual teaching at all. This is lazy and cannot readily be evaluated. It is subject to change on a whim and leaves the student floundering in a sea of few definites. Facts, half facts, and fashionable views are weighted the same and it is difficult to gain an ability to determine what is true and what is "true for the moment".

Most doctors want to be doctors, and although many have open and enquiring minds and may want to go further into research and other developments, this is not what medicine is all about. It is about medicine, not the latest whiz-bang gadget, or the latest theoretical approach. By all means if this is the direction the student/doctor wants to take after graduation, so be it. But a lot of current research is too narrow, precisely because many researchers lack a basic comprehensive knowledge of the body's structures. For example, pathology of the liver can affect the eye, but research about the eye will be flawed if those conducting it lack this basic understanding of other organs and what relevance this may have.


Museum DNA test proposal

Fake Aborigines (some with blond hair) who roll in affirmative action privileges fear exposure

The Natural History Museum in London wants to use the remains of Tasmanian Aborigines to develop a simple DNA test for Aboriginal ancestry. A report obtained by The Weekend Australian says research into the DNA of the remains it holds could provide a key to creating such a test. "DNA analysis of the remains and subsequent comparisons with (the) Tasmanian community may allow the establishment of Aboriginal descent in the absence of documentation," it says, provoking condemnation from Aboriginal groups. The report cites the development of such DNA testing as a key "benefit" of allowing the NHM to hold on to the remains.

Australian researchers said such DNA testing could be done, but suggested it would only demonstrate Aboriginal descent "on the balance of probabilities". They also expressed concern some right-wing commentators might demand DNA vetting of those claiming government-funded Aboriginal cultural and welfare programs. The number of Australians identifying themselves as Aboriginal in the census has risen sharply from 265,459 in 1991 to 410,000 in 2001.

Indigenous Affairs Minister Mal Brough said he was not interested in the DNA test. "There is only one issue that concerns us and that is respecting the remains of indigenous people and rightful custodians of those remains," Mr Brough said. "The distress caused to indigenous people in Tasmania far outweighs any potential scientific gains."


Huge uni expenses bill to be audited

Another low-quality affirmative action appointment exposed

MACQUARIE University has ordered a second audit of its accounts as allegations of poor administration widened to include the university's international office, which paid an employee's daughter-in-law $400,000 to design a brochure, and 74 trips to Melbourne taken by three staff members over nine months.

The Weekend Australian understands that auditors Deloitte have uncovered anomalies in entertainment and travel expenses worth several hundred thousand dollars over the past 12 months, incurred by staff in the international office.

Di Yerbury, whose 20-year administration of the university in Sydney is already the subject of one audit, stood down as vice-chancellor last February but was appointed the university's international ambassador, with responsibility for the international office.

Auditors have discovered that the office's taxi bill for the past 12 months is tens of thousands of dollars, about 40 times higher than at a comparable university, with some individual vouchers as high as $770. Three staff made personal trips to Melbourne at the university's expense and resigned when asked to explain the trips.

The second audit follows one instigated in September by the new vice-chancellor Steven Schwarz into the administration of Professor Yerbury. It was ordered after the discovery that university records were incomplete, particularly regarding Professor Yerbury's employment entitlements, and confusion over the ownership of artworks after her collection was mingled with the university's. The Weekend Australian understands the auditors were told that when the university's financial officer queried the expenses, her concerns were overruled by Professor Yerbury. The interim audit report in December, of which Professor Yerbury or her lawyers are yet to receive a copy, also alleges perceived or possible conflicts of interest in Professor Yerbury's position on several company or organisation boards with her job as vice-chancellor.

Professor Yerbury yesterday denied any wrongdoing or improper conduct and accused Professor Schwarz of conducting "an absolute witch-hunt". "I fiercely reject and refute any suggestion that I've acted improperly. I am extremely protective of proper procedure which may lead to a conflict of interest," she said. "He (Professor Schwarz) has engaged in all sorts of bullying, harassment, intimidation and highly discriminatory treatment toward me. "He has treated me openly and overtly at Macquarie as if I was a criminal and completely untrustworthy."

Last night Professor Schwarz said the issue was about public money being spent and it needed to be accounted for. "Consistent attempts to deflect attention from the main issue by defaming me aren't going to work because the issue remains, and that's one of poor record keeping and poor policy adherence," he said.

The interim audit report estimates the Theatre Of Image, a youth community group, received assistance worth about $200,000 in money, equipment or university staff while Professor Yerbury was its chairwoman. The university funds cultural groups such as the TOI as part of its community outreach program but the auditors "were unable to identify any policies or criteria how TOI was selected as a community outreach program or partner". "Payments were made to TOI from invoices initiated by TOI and send to the vice-chancellor's office," the report says. "There was some evidence (eg 10 October 2005 email from the TOI general manager to Professor Yerbury) that the quantum of some TOI invoices was discussed in advance between TOI and Professor Yerbury. "Professor Yerbury's position as chair of TOI may have given rise to an actual or perceived conflict of interest through her competing duties as vice chancellor by signing grant applications/terms and conditions and approving payment of invoices to TOI."

The report raises another perceived conflict of interest with the appointment of Professor Yerbury to the board of private education company IBT Education in March last year, two months after signing a contract with the company to establish Macquarie University College, in the Sydney CBD, licensed to deliver Macquarie degrees. Professor Yerbury said she did not take up her appointment as a non-executive director until after stepping down as vice-chancellor last February and was always careful to signal any potential conflicts of interest.

The Weekend Australian also understands that an initial inspection of the Killara house, owned by the university on Sydney's north Shore, where Professor Yerbury has lived for the past 20 years, is in such poor condition that it has recommended demolition.

Professor Yerbury said she was unaware a second audit was being conducted and denied the expenses it was investigating were incurred by her. While she travelled extensively overseas in her ambassadorial role, Professor Yerbury said all travel was approved by Professor Schwarz and she had never entertained anyone at the university's expense, had paid for all her own taxis, and had not flown between Sydney and Melbourne or given such trips to non-university staff.

Professor Yerbury was on a salary package worth about $600,000, of which between $110,000 and $114,000 a year was taken out to cover the rent of the Killara house as well as utilities, maintenance and upkeep. She said she was not surprised the university might decide to demolish the house rather than renovate it, and said it was in such poor condition when she first moved that many of the rooms were only fit for storage. "It's not in good shape and it was a house that wasn't suitable for the purposes for which a vice-chancellor might use it, such as to entertain," she said. "Some rooms weren't carpeted, only two rooms had curtains, in some of the rooms the blinds were broken."

Professor Schwarz said he commissioned Deloitte to review matters pertaining to Professor Yerbury after gaps in the university's records became apparent, particularly related to its art collection and the employment details of Professor Yerbury. He said the issues arose when Professor Yerbury began negotiations for an early departure. The talks identified a number of questions about her accrued annual leave entitlements, termination payment and the ownership of artworks. "The matters are related to good record keeping and orderly governance. We've been presented with incomplete files, incomplete information and as a consequence we are obligated - because it is government money - to fill in those gaps," he said. Professor Schwarz would not comment on whether the audit had identified further anomalies, saying he was reluctant to discuss the details until the audit had been finalised.


Dangerous decisions: Courts should steer well clear of the carbon debate

THERE are some decisions that are too important to be left to the judiciary. And a carbon tax is one of them. But while governments debate the issue and agonise about the details, green activists are working through the courts to bypass the democratic process and force such a tax on the coal industry. Unlike governments, judges and tribunal members cannot equip themselves with sufficient information to make an informed decision about how to deal with climate change. For this reason, they must be stripped of the power to intervene in this area before the environmental lobby persuades activist judges that they alone can save the world.

There is another reason why judges should bow out of this area. And it was spelt out as recently as last week by High Court Chief Justice Murray Gleeson. Judicial officers risk a loss of public confidence if their rulings are considered to be no more than the imposition of their personal social goals. The green campaign, which started in NSW, received a welcome setback in Queensland this week. A tribunal headed by Greg Koppenol exposed the flawed logic of those who wanted to use Mr Koppenol's tribunal to force a coalmine to reduce greenhouse gas emissions. Had they succeeded, it would have had the same effect as a carbon tax: the cost of the mine's coal would have risen and consumers would have bought their coal elsewhere. And it would have been a tax that would have been passed without a single vote by a representative body. Mr Koppenol made the right call. But that's not the point. Unless the states prevent judges and tribunals from venturing into this area, the nation is at risk of being lumbered with an inconsistent network of court-imposed carbon taxes.

For proof, just look at last year's loopy decision by NSW Land and Environment Court judge Nicola Pain. She ruled that an environmental impact statement for the Anvil Hill coalmine in the Hunter Valley was invalid because it failed to consider the emission of greenhouse gases. Ms Pain was an environmental activist before she was appointed to the bench by NSW Attorney-General and Environment Minister Bob Debus.

On this issue, the NSW Labor Government has betrayed the coal industry. Coalmining jobs are now at risk because of the actions of the state Labor Government. Instead of legislating to overturn Ms Pain's ruling and seeking a consistent national approach, the NSW Government has embraced her mad plan. It has asked the mine to respond to a Greens suggestion that factor into its costbase $109 a tonne for carbon dioxide emissions. Such a tax, which was calculated according to data in the much-criticised Stern review of climate change, would render the mine economically unviable. The issue of climate change demands a national approach, not an ad hoc network of inconsistent state taxes. Despite what some governments might think, taxes are not the solution to all the world's problems.


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