Letters

Before impeaching facet joint consistently superior to the 2 Rados I, Sakic K, Fingler M, Kapural L. Efficacy of interlaminar vs transforaminal epidural steroid injections and medial branch blocks, interlaminar route for radiculopathy. injection for the treatment of chronic unilateral and thereby medial branch Further, we note that when the radicular pain: prospective, randomized study. neurotomies, as well as lumbar evidence for transforaminal injections Pain Med 2011; 12: 1316-1321. these 3 Abdi S, Datta S, Trescot AM, et al. Epidural transforaminal epidural steroid is isolated to placebo-controlled trials, steroids in the management of chronic spinal injections, Harris and Buchbinder the evidence is based on very few “procedures pain: a systematic review. Pain 2007; should consider: studies. The largest of these showed help people 10: 185-212. 4 Pinto RZ, Maher CG, Ferreira ML, et al. Epidural • interprofessional patient-centred marginal short-term (2-week) struggling to corticosteroid injections in the management of improvement in the steroid and local sciatica: a systematic review and meta-analysis. approaches are key; continue in • pharmacological management is anaesthetic group over the saline Ann Intern Med 2012; 157: 865-877. social roles 5 Karppinen J, Malmivaara A, Kurunlahti M, et al. often ineffective; group for the primary outcome (leg Periradicular infiltration for sciatica: a • their view does not reflect the pain), an effect that was not sustained and maintain randomized controlled trial. Spine 2001; 26: current practice of Australian pain by 4 weeks.5 Short-term relief is a quality of life 1059-1067. 6 Boswell MV, Colson JD, Sehgal N, et al. A medicine ; common finding in studies that use systematic review of therapeutic facet joint • these procedures help people local anaesthetic in the active group. interventions in chronic spinal pain. Pain struggling to continue in social roles We consider the evidence for the Davies et al Physician 2007; 10: 229-253. ❏ and maintain quality of life, so they effectiveness of transforaminal ” help to reduce the economic impact steroids over placebo to be neither of spinal pain on Australian society. strong nor consistent (within or Students as teachers We support education to improve between studies). We suggest that the evidence-based practice of gem in the bathwater be subject to TO THE EDITOR: Silbert and interventional procedures. more scrutiny and weighed against colleagues highlight the benefits of peer-assisted learning (PAL).1 They Stephanie J Davies Head of Pain Medicine Unit,1 the risks and costs. and Adjunct Associate Professor2 We thank Davies and colleagues for allude to the number of overseas Malcolm N Hogg Head of Pain Services,3 and their comments about medial branch medical schools that provide tutor 4 President blocks and transforaminal epidural training programs, and to the Eric J Visser Pain Medicine Physician and possibility that Australian medical 1 steroid injections. We have addressed steroid Anaesthesiologist students are missing out on this the latter in our response above. Our “injections in 1 Fremantle Hospital and Health Service, Perth, WA. article does not extend beyond the opportunity. We agree that PAL is 2 School of Physiotherapy, Curtin University, Perth, WA. the spine have use of steroids to procedures such useful, but not all Australian medical 3 Royal Hospital, Melbourne, VIC. as neurotomy, so we have not no specific students have been deprived. Since 4 Australian Pain Society, Sydney, NSW. therapeutic 2008, Monash University has been [email protected] commented on this procedure here. Regarding medial branch blocks, effect beyond running VESPA (Vertical Study Acknowledgements: We acknowledge Andrew Briggs, Program), an optional PAL program.2 John Quintner, Nicholas Cooke and Helen Slater for their we note that in a systematic review natural history, assistance with this letter. Initiated by a group of medical mentioned by Davies and colleagues, the effect of any Competing interests: All authors work in public pain each of the randomised trials showed undergraduate students, it continues medicine units and perform interventional pain proce- concomitant to be largely student-driven, with dures. Stephanie Davies has a private fee-for-service prac- no significant difference in the tice; Stephanie Davies and Malcolm Hogg are board response between groups treated with treatment faculty support. Further, our program members of the Australian Pain Society, which has a has had international impact.3 position statement on interventional pain management steroid and those treated with local or any placebo procedures published in March 2010. anaesthetic alone.6 This reinforces our effect VESPA is open to all students in the doi: 10.5694/mja13.11206 point that steroid injections in the 5-year undergraduate and 4-year 1 Harris IA, Buchbinder R. Time to reconsider spine have no specific therapeutic graduate-entry streams. Students meet steroid injections in the spine? Med J Aust 2013; after hours to discuss a case, which is 199: 237. effect beyond natural history, the Harris et al authored by students and reviewed by 2 Sehgal N, Dunbar EE, Shah RV, et al. Systematic effect of any concomitant treatment review of diagnostic utility of facet ” a medical graduate. The objectives of or any placebo effect. (zygapophysial) joint injections in chronic spinal our program are to provide an effective pain: an update. Pain Physician 2007; 10: 213-228. 1 Ian A Harris Professor of Orthopaedic Surgery forum for revision in the setting of 3 Lord SM, Barnsley L, Wallis BJ, et al. Percutaneous radio-frequency neurotomy for chronic cervical Rachelle Buchbinder Rheumatologist and vertically integrated assessment, to Director,2 and Professor3 zygapophyseal-joint pain. N Engl J Med 1996; 335: develop a culture of collaboration 1721-1726. 1 South Western Sydney Clinical School, University of New and peer support, and to foster the 4 van Kleef M, Barendse GA, Kessels A, et al. South Wales, Sydney, NSW. Randomized trial of radiofrequency lumbar facet 2 Monash Department of Clinical Epidemiology, Cabrini development of teaching and facilitation denervation for chronic low back pain. Spine Health, Melbourne, VIC. skills of pre-intern participants.4 1999; 24: 1937-1942. 3 Department of Epidemiology and Preventive Medicine, Our model emphasises facilitation 5 Vad VB, Bhat AL, Lutz GE, et al. Transforaminal School of Public Health, Monash University, Melbourne, epidural steroid injections in lumbosacral VIC. rather than didactic teaching; we radiculopathy: a prospective randomized study. [email protected] provide optional, small-group Spine 2002; 27: 11-15. ❏ Competing interests: No relevant disclosures. facilitation training for senior doi: 10.5694/mja13.11159 students. This is far less IN REPLY: We thank Bogduk for his 1 Gharibo CG, Varlotta GP, Rhame EE, et al. comprehensive than the Teaching comments, but, based on previous Interlaminar versus transforaminal epidural on the Run model,1 yet we hope this reviews and some comparative steroids for the treatment of subacute lumbar “taster” encourages students to seek 1-4 radicular pain: a randomized, blinded, studies, do not consider the prospective outcome study. Pain Physician 2011; and practise their teaching skills in transforaminal route to be clearly and 14: 499-511. other settings.

754 MJA 199 (11) · 16 December 2013 Letters

PAL is a valuable learning strategy, The knowledge and skills and skilled surgical educators remains which should be more widely used competency of students must also be substantial. Development of a to optimise medical graduates’ ascertained before placing a teaching comprehensive array of educational education and communication skills. burden on them. Where a person is programs is the current focus of the Future doctors who are eager and able on his or her personal learning curve RACS Academy of Surgical to teach may alleviate the forecasted will influence that person’s ability to Educators.4 The Academy provides medical educator shortage.5 teach.3 As a result, it is essential that curriculum delivery with oversight, as medical students and junior doctors well as the exchange of educational Joanna H-M Tai VESPA Co-Chair 2013, and PhD Candidate, HealthPEER are deemed competent in performing ideas through a combination of a task before the responsibility of workshops, face-to-face activities Sumudu P Cooray VESPA Co-Chair 2013 teaching is thrust on them. and digital delivery. Jonathan K Kam Past VESPA Co-Chair (2008–2011) To ensure safety and high-quality However, as Silbert et al highlight, health care provision, the role of a the skills for being an educator HealthPEER, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC. trainer must be given to a select group need to be developed early. There [email protected] with the right attributes, competence is increasing focus on the early Acknowledgements: Thanks to Rob Mitchell, Sheila levels and passion for teaching. It is this the skills postgraduate years and the Australian Vance and Elaine Halley for being instrumental in group that needs to be trained, allocated “for being an Curriculum Framework for Junior developing the VESPA case night, and to the Faculty 4 of Medicine, Nursing and Health Sciences, Monash time, resourced and rewarded. The educator need Doctors provides clear expectations University, for its ongoing support. responsibility to teach should be an for self-directed learning, teaching, to be developed Competing interests: No relevant disclosures. honour bestowed on a few rather than supervision and career development. doi: 10.5694/mja13.11058 a rite or obligation for all. early However, like many other key skills, the time to start this development is 1 Silbert BI, Lam SJP, Henderson RD, Lake FR. Michael Pearson Master of Health Services Students as teachers. Med J Aust 2013; 199: Management Student in undergraduate medical courses. It Tobin et a l 164-165. Monash University, Melbourne, VIC. is here that programs such as those 2 Kam J, Mitchell R, Tai J, et al. A peer-assisted [email protected] ” highlighted by Silbert et al or courses vertical study program (VESPA) for medical like Teaching on the Run are critical. students: results of a pilot study. Focus on Health Competing interests: No relevant disclosures. Professional Education 2010; 11: 76-79. doi: 10.5694/mja13.11199 Along with other medical colleges, 3 McAleer E, Parker R, Griffiths OR. Medical schools RACS is now becoming more specific 1 Silbert BI, Lam SJ, Henderson RD, Lake FR. should develop medical educators, not just Students as teachers. Med J Aust 2013; 199: about the requirements for potential doctors. Med Teach 2013; 35: 698. 164-165. trainees. With the substantial increase 4 Kam JK, Tai J, Mitchell RD, et al. A vertical study 2 Kendall ML, Hesketh EA, Macpherson SG. The in medical schools (now 18) and programme for medical students: peer-assisted learning environment for junior doctor training — learning in practice. Med Teach 2013; 35: what hinders, what helps. Med Teach 2005; 27: graduates (expected to be 3832 per 5 e943-e945. 619-624. year by 2017), variability in graduate 5 Hu W, McColl G, Thistlethwaite JE, et al. Where 3 Derrick S, Badger B, Chandler J, et al. The training/ attributes and skills is increasing. is the next generation of medical educators? service continuum: exploring the training/service RACS is responding by having more Med J Aust 2013; 198: 8-9. ❏ balance of senior house officer activities. Med Educ 2006; 40: 355-362. clearly specified expectations of the 4 Landau LI. Quality junior doctor training, improved experiences that potential surgical workforce outcomes and patient safety. Aust trainees should have. Being a TO THE EDITOR: Silbert and Health Rev 2007; 31 Suppl 1: S106-S108. ❏ colleagues propose that teaching competent teacher is one of them. skills training should be compulsory Formal programs in education and documented teaching experience are for all medical students, to be used in TO THE EDITOR: The articles by Hu both important if we are going to be peer-assisted learning programs and and colleagues1 and Silbert and 1 able to answer the concerns raised later in postgraduate roles. As the colleagues2 highlight the imperatives about medical educators and their quality of student training will have for medical educators. The future career paths.1 an enduring impact on the provision requires the ability to teach as a The more skilled our potential of quality care and patient safety, the distinct set of skills that need to be trainees are in teaching, as well as in responsibility for this important role identified early and then encouraged understanding (their) learning, the should be entrusted to a select group throughout one’s career. Silbert et al better Australian postgraduate rather than an obligation imposed advocate a comprehensive, vertically training will be. This will help achieve on all. integrated student teaching program a connection to better workplaces and Those undertaking teaching roles using peer-assisted learning (PAL).2 improved patient care. must possess a commitment to The Royal Australasian College of 1 teaching and be good role models Surgeons (RACS) strongly supports Stephen A Tobin Dean of Education,1 and Surgeon2 who can build trainees’ self-esteem, this approach to teaching theoretical David J Hillis Chief Executive Officer1 and foster a supportive and safe information as well as clinical Julian A Smith Chairman, Academy of Surgical environment.2 The choice of a select examination and procedural skills. Educators1 group with the right characteristics to Despite curriculum frameworks 1 Royal Australasian College of Surgeons, Melbourne, VIC. be effective teachers will benefit the such as CanMEDS3 clearly outlining 2 Ballarat, VIC. quality of student training, and affect the expectations for the competence [email protected] Competing interests: We are all members of the RACS the quality and safety of health care in of “scholar”, the work required to Academy of Surgical Educators. the future. develop an ongoing cohort of willing doi: 10.5694/mja3.11129

756 MJA 199 (11) · 16 December 2013 Letters

1 Hu WC, McColl GJ, Thistlethwaite JE, et al. Where is 1 Silbert BI, Lam SJ, Henderson RD, Lake FR. alcohol consumption in pregnancy the next generation of medical educators? Med J Students as teachers. Med J Aust 2013; 199: 5,6 Aust 2013; 198: 8-9. 164-165. has not been established. 2 Silbert BI, Lam SJP, Henderson RD, Lake FR. 2 Dandavino M, Snell L, Wiseman J. Why medical Women seek pregnancy Students as teachers. Med J Aust 2013; 199: students should learn how to teach. Med Teach information from many sources, and 164-165. 2007; 29: 558-565. more highly educated women will 3 Frank JR, Danoff D. The CanMEDS initiative: 3 Ten Cate O, Durning S. Peer teaching in medical have access to more information implementing an outcomes-based framework education: twelve reasons to move from theory to of physician competencies. Med Teach 2007; 29: practice. Med Teach 2007; 29: 591-599. sources. Doctors need to be aware 642-647. 4 The Bridging Project. Competencies comprising of what information is out there and 4 Collins JP, Gough IR. An academy of surgical the role doctor as educator. http:// be willing to counter misinformation educators: sustaining education — enhancing thebridgingproject.com.au/thebridgingproject/ when it arises. Consumption of innovation and scholarship. ANZ J Surg 2010; 80: 200812/index.htm (accessed Oct 2013). 13-17. 5 Health Workforce . National clinical alcohol has no health benefits in 5 Medical Training Review Panel. Medical Training supervision competency resource: validation pregnancy, so when weighed against Review Panel: sixteenth report. Canberra: edition — May 2013. https://www.hwa.gov.au/ known and unknown (but plausible) Department of Health, 2013. http://www. sites/uploads/HWA-National-Clinical- health.gov.au/internet/publications/ Supervision-Competency-Resource-VE- possible risks, surely the best advice publishing.nsf/Content/work-pubs-mtrp-16-toc 201305.pdf (accessed Oct 2013). ❏ that we can give our patients is to (accessed Nov 2013). ❏ avoid alcohol during pregnancy.

Tracy W Soh Addiction Medicine Specialist IN REPLY: We agree that the quality Advising pregnant women Turning Point Alcohol and Drug Centre, Melbourne, VIC. [email protected] of student training and competence of to avoid alcohol Competing interests: No relevant disclosures. those delivering it are of utmost TO THE EDITOR: I thank Cameron doi: 10.5694/mja13.11208 importance. However, we disagree The concept of and colleagues for their timely report,1 with Pearson’s opinion that teaching “a clinical trial of 1 Cameron CM, Davey TM, Kendall E, et al. Changes particularly in the context of publicity “should be an honour bestowed on a in alcohol consumption in pregnant Australian for a new self-help book by economist a recreational women between 2007 and 2011. Med J Aust 2013; few rather than a rite or obligation for Emily Oster, which questions advice substance ... 199: 355-357. all” and that only these “honourable 2 Oster E. The pregnancy studies to take notice of. 1 about avoiding alcohol during to see if it Essential Baby 2013; 31 Aug. http:// few” should be trained. Involvement 2,3 pregnancy. I note with interest that causes any www.essentialbaby.com.au/action/ in any teaching confers benefits printArticle?id=4708242 (accessed Sep 2013). 1-3 Cameron et al’s study reports that to both tutors and tutees and, harm in 3 Oster E. Take back your pregnancy. Wall Street proportionally more of the women although some may stand out, all Journal 2013; Aug 9. http://online.wsj.com/article/ who consumed alcohol beyond the pregnancy SB10001424127887323514404578652091268307 junior doctors are involved in peer first trimester were older and more is plainly 904.html (accessed Sep 2013). teaching on an almost daily basis 4 Wattendorf DJ, Muenke M. Fetal alcohol spectrum highly educated. ridiculous and should be trained to do so. disorders. Am Fam Physician 2005; 72: 279-285. Oster has commented in the media Supporting this, the Bridging Project 5 Flak AL, Su S, Bertrand J, et al. The association of on the lack of randomised controlled mild, moderate, and binge prenatal alcohol — an Australian initiative to develop trials and poor evidence of causality, Soh exposure and child neuropsychological outcomes: a vertically integrated curriculum — a meta-analysis. Alcohol Clin Exp Res 2013; 1 Aug even where there is a proven [Epub ahead of print]. doi: 10.1111/acer.12214. has defined “doctor as educator” 2,3 ” association. While unsurprising 6 National Health and Medical Research Council. competencies beginning at the Australian guidelines to reduce health risks from 4 that someone without a health medical student level. Finally, it drinking alcohol. Canberra: NHMRC, 2009. http:// background can misunderstand should be recognised that senior www.nhmrc.gov.au/_files_nhmrc/publications/ how evidence is used clinically, it is clinicians who do much of the attachments/ds10-alcohol.pdf (accessed Sep concerning that responsible health 2013). ❏ teaching and supervision of students advice is being questioned on this are not assessed on their competence basis. The concept of a clinical trial to teach.5 Until we “assess” our senior of a recreational substance (such as CORRECTION teachers we cannot assess our junior alcohol or caffeine) to see if it causes teachers, but should take an approach Incorrect footnote: In “Australia is continuing to make any harm in pregnancy is plainly to improve the quality of all. progress against cancer, but the regional and remote ridiculous. disadvantage remains” in the 4 November 2013 issue of Benjamin I Silbert Student Grand Rounds Alcohol is a known neurotoxin that 1 the Journal (Med J Aust 2013; 199: 605-608), there was an Co-ordinator 2010 crosses the placenta.4 Studies of the error in Box 2 (page 607). There should be two separate Stephanie J P Lam Student Grand Rounds effects of alcohol have consistently Co-ordinator 20111 footnotes for Box 2A and Box 2B: the footnote to Box 2A shown that even intermittent Robert D Henderson Student Grand Rounds should state “Based on age- and sex-specific rates for 1 moderate to heavy (binge) drinking Co-ordinator 2011 metropolitan areas”, and the footnote to Box 2B should during pregnancy increases risks of Fiona R Lake Head of School and Eric Saint Chair state “Based on age- and sex-specific rates for Australia 2 cognitive and behavioural problems in Medicine for 1997–2000”. for the child. Although no correlation 1 Western Australian Medical Students’ Society, There was also an error in the year groupings University of Western Australia, Perth, WA. has been shown between light described in the Methods (page 605). This should read: 2 School of Medicine and Pharmacology, University of drinking during pregnancy and “The expected number of deaths was obtained by Western Australia, Perth, WA. developmental problems in the child, applying the 5-year age- and sex-specific mortality rates [email protected] methodological inconsistencies for 1997–2000 to the corresponding age- and sex-specific Competing interests: No relevant disclosures. between studies limit meta-analysis populations for each subsequent year through to 2010.”❏ doi: 10.5694/mja13.11353 of combined data.5 A safe level of

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