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Ophthalmology and medical education in Australia
SURVEY OF OPHTHALMOLOGY
VOLUME 28 - NUMBER 6. MAY-JUNE 1984
OPHTHALMOLOGY
INTERNATIONAL
JULES FRANCOIS, EDITOR
Ophthalmology ARTHUR
H. KEENEY,
Department
and Medical Education
in Australia
M.D., D.SC..
of Ophthalmology.
l’niaersity
of Louisville
School
9‘ .Eledicine.
Loui.wille.
Renturkv
Abstract. Australian
medicine and ophthalmology both began as extensions of British traditions. financial and national independence, they have acquired indigenous strength and An original triumvirate of medical schools launched a century ago have t,ern augmented by seven additional schools, particularly since lt’orld War II. Both general medical and specialty education are now well obtainable in Australia. The quality of ophthalmology is high and research has been movine upward since World War II. New buildings are replacing old. The organization ofregistrars (residents) is blending with that orunion-type workers and reflects widespread though locally autonomous unions in almost every field of endeavor. Canberra and the National University are recent major additions to cultural and scientific aKairs or Australia. The Royal Flying Doctors Service has since 1928 cast an increasingly elective “mantle ofsarety“ over the outback. Reductions in federal funds and student numbers have paralleled similar occurrences in the U.S. in the 1980s. Geriatric ophthalmology has made a major step forward and the organization of examinations and policing of medicine have been greatly strengthened in the past decade. (Surv Ophthalmol 28:677-686, 1984) With growing characteristics.
Key words.
Australia
l
medical
education
0
Growth of Medical Education and Ophthalmology
phthalmology and medical education as initiated in Australia have been largely extensions of the British system. Australia launched a triumverate of early medical faculties in state universities: University of Melbourne, 1862; University of Sydney, 1883; University ofadelaide, 1885. With the exception of the University of Queensland initiating a medical faculty in Brisbane in 1936, there was no incremental activity for more than four decades. In the mid 196Os, however, the combination of technical progress, perceived need, and increasing independence of commonwealth nations led to doubling of undergraduate medical education and postgraduate specialty training.
CHANGES AFTER WORLD WAR II The late 1950s and 1960s were marked by expanding Australian independence and prosperity leading to increasing funds for medicine and ophthalmology. Australia launched new medical faculties in Perth (University of Western Australia, 1957); Melbourne (Monash University, 1961); Sydney (University of New South Wales, 196 1); Hobart (University of Tasmania, 1965); and Adelaide (Flinders University, 1969). Lastly, at University of Newcastle (1978) the most recent faculty was 677
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launched and produced its first medical graduates in 1982. Though some ophthalmic instruction has been shoehorned into all undergraduate medical curricula, departments of ophthalmology and full professors (equivalent to U.S. department chairmen) emerged much later and in five medical schools are functionally not yet present. From the late 1960s through the 1970s several schools have compressed the traditional British six year program of combined pre-clinical and clinical education. This system requires seven years of primary school, completion of secondary education about the age of 18, and passing prescribed university entrance examinations. Though there is considerable variation in curricula among the schools, several such as Sydney and New South Wales did reduce medical students’ years from six to five. A few even stated their actions ‘&in response to a worldwide pattern of change.” This excluded in-depth cultural studies such as English literature, history, and humanities. Melbourne and Monash in the same city have held to the six year base. The realities of needing to teach more facts in fewer years, however, have led several of the Australian schools to convert back to a six year base hoping to enhance the total background of their graduates. Particularly in the new schools, clinical experience has greatly exceeded attention to such major heritages as Shakespeare, Chaucer, and even Arthur Conan Doyle, ophthalmologist turned Sherlock Holmes writer. Further, the ophthalmic programs require three years of graduate prespecialty preparation in internal medicine and various disciplines of surgery or medical practice before entering as a registrar in ophthalmology. Medical graduates, on completing requisite examinations, are awarded the first medical degree, Bachelor of Medicine and Bachelor of Surgery (M.B.B.S.) and after one year’s internship, are entitled to registration as commonwealth practitioners under Medical Acts of the United Kingdom. More advanced degrees such as the Master’s or the Doctorate of Medicine or the Doctor of Philosophy require a research thesis. Diplomas from Royal Colleges entail three years specialty registrar training and examinations which are didactic and clinical. THE GREAT PROFESSIONAL OF AUSTRALIA
STREETS
Macquarie Street in Sydney; Collins Street in Melbourne; North Terrace in Adelaide; and Wickham Terrace in Brisbane: These elegant avenues began as equivalents of Harley Street, London. They have persisted more clearly through the urban changes of the less large cities.
KEENEY In Sydney, Macquarie Street was, without question, the prime location for leading ophthalmologists. To practice elsewhere in the year between the wars was to forego elegance. Good ophthalmic care is now available in all suburbs and is marked by an occasional expression of pride in higher level performance of one suburb versus another. For the most complicated of ocular problems and sophisticated eye surgery, however, the old Sydney Eye Hospital, with its new clinics and its professorial department presents a prime image. Some concerns of town vs. gown are roughly paralleled in Macquarie Street vs. the major urban spread to dozens of beautiful residential communities and to the industrial westside. A similar rivalry occurs between the historic University ofSydney with its long established Eye Hospital and the counterforce of the young New South Wales University. In Melbourne, Collins Street still retains dignified elegance with the Melbourne, the Atheneum, and other stately clubs of historic elegance. Adelaide, though extending beautifully across large plains and beyond its “green belt,” still holds fast to North Terrace traditions of elegance. The south side of North Terrace looks proudly across to the University of Adelaide, stately government buildings, and museums. In bustling Brisbane, Wickham Terrace has been home for almost every opthalmologist well into the 1970s. It is still the prime location for ophthalmologists, but Brisbane has now spread to beautiI‘ul water side communities along the river and harbour. MEDICAL
QUALIFICATION
AND LICENSURE
Basic and specialist medical qualifications come under federal surveillance for the purpose of practice under the National Health Act, but the individual states control all medical registrations. The General Medical Council of the U.K. which supervises standards of medical education in the British Isles and grants reciprocal recognition to medical qualifications of other Commonwealth countries, approves the courses offered by medical schools. Thus, once the student has earned his M.B.B.S. he is eligible for initial registration by the Medical Board of his state, and following his compulsory internship or residency in an approved hospital is eligible for final registration which is reciprocal with the various states of Australia and most nations of the British Commonwealth. All states and both territories have their own boards of licensure. Doctors graduating in medicine must be registered (licensed) in the state where they will practice but examinations are not conducted by the individual state and territorial boards; they accept qualifications issued by approved institutions such as Uni-
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versities, Colleges or Associations within Australia or overseas. For the coveted position of registrar in ophthalmology, as in most specialties, there is steep competition and many fewer positions than applicants. The various Royal Colleges are professional and examining organizations. They attest to postgraduate training and the qualification of young physicians, and further require and police certain professional standards throughout their careers. Clinical components of medical education were entirely taught by honorary faculty until shortly after World War II. The first full-time professor or chair in ophthalmology at a medical faculty was established at the University of Melbourne in 1963. The most recent dates from 1980 at Flinders University in Adelaide and the only other ones are at the University of Sydney, University of New South Wales, and the University of Perth. Each has its initial appointee. EXAMINATIONS
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OPHTHALMOLOGY
FOR OPHTHALMOLOGY
American ophthalmologists have generally viewed Part I fellowship examination by the Royal College of Surgeons as being ofgreater minutiae and basic science than examination by the American Board of Ophthalmology. Australia and New Zealand, in recent years, have come to an efficient and sensible synthesis of examination by the Royal Australasian College of Surgeons and the Royal Australian College of Ophthalmologists. By using Fellows from both colleges, a new two-part examination replaces separate examinations by each. Part one (basic science) consists of three-hour written papers and oral examinations in: a) ophthalmological anatomy, histology, and embryology; b) physiology related to ophthalmology; c) optics related to ophthalmology. Part two consists of threehour written papers on: 1) medical ophthalmology, 2) surgical ophthalmology, and 3) pathology and microbiology related to ophthalmology. There are also clinical and oral examinations under these divisions. Part one may be taken prior to beginning the specialist training. Part two may be taken in the third year ofspecialist appointment, but the qualification is not issued until the full training is completed. ‘4n essential prerequisite for the examinations is a log book containing accounts of surgery and other procedures performed under approved supervisors. Successful completion gives the registrar fellowship in both the Royal Australasian College of Surgeons and the Royal Australian College of Ophthalmologists. The State Government in New South Wales also performs periodic “Inspection of Training Posts” to review on site the various registrar programs.
The Colleges in the British Commonwealth System, unlike the American Boards, control the entrance of a physician into post or practice and monitor ethical activities. The Colleges have power of censure which does not exist in American Board structure. Breaches of professional ethics are adjudicated by the Australian Medical Association. New Zealand, with its smaller population of 75 ophthalmologists, contrasted to more than 500 in Australia, provides some examiners and accepts this system of examination with the same validity it receives in Australia. There is considerable desire for further increase in the collaboration between the ophthalmologists of Australia and New Zealand.
Australian Ophthalmology and Its Geographic Centers SYDNEY (NEW SOUTH
WALES)
Ophthalmology in Sydney, an often beautiful but farflung city of three million, presents many variations. The century old University of Sydney Faculty of Medicine and the new University of New South Wales Faculty of Medicine hold similar admission requirements and years in training but beyond that contribute to the diversity of medicine and ophthalmology in this city. The elegant old facade which has housed the Sydney Eye Hospital (est. 1882) for nearly a century, emphasizes cleanliness and not the creature comforts of wash basins or air conditioning. The new wing, poured of concrete about 1970, houses modern outpatient clinics, subspecialty services, four new operating rooms, a gracious library, and a few research labs. An endowed professorship has been available for about fifteen years but has only been tilled since the appointment of Frank A. Billson in 1976. Both hospital and educational financing are heavily dependent upon the New South Wales government and the federal government. The Sydney Eye Hospital has had a steady growth in outpatient visits reaching nearly 75,000 visits by 36,000 patients in 1979-80. Nearly 40,000 visits were made to the casualty or emergency clinics and over 10,000 to the general ophthalmic clinics. The 19 registrars in training for three years rotate through nine different hospitals. Nearly all inpatient admissions are surgical with over 2,100 major operations and 500 minor operations in 197980. These were divided into approximately 20% retinal, 10% corneal, 5% glaucoma, 9% strabismus, and 25% cataract. Subspecialty clinics are well developed. Registrars (residents) are classified as hourly rated employees under collective bargaining provisions. Formal educational sessions are therefore designed primarily outside “working hours.” Compensation to the registrars is generally
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higher than U.S. standards. Sydney Eye Hospital houses the Department of Ophthalmology of the University of Sydney with occasional challenges over distribution of space or responsibilities between faculty members and hospital staff members. Nearly 50% of all tertiary eye care in New South Wales is performed at the Sydney Eye Hospital. The graduate program for ophthalmic nurses produces about six graduates annually. Orthoptics occupies a large role as in most British oriented systems with nearly 10,000 visits in 1979. Approximately 15,000 refractions were done in the same period. Demanding and excellent education is a source of pride to Sydney Hospital, technically the parent of Sydney Eye Hospital over its 193 years of service. Two Nobel Laureates add luster to the medical staff. The first special clinical department to be created by Sydney Hospital was that of Ophthalmology. Its first director was Gordon McLeod from 1895. Other notable hospitals are the Royal Prince Alfred Hospital and the Royal Alexandra Hospital for Children. The most outstanding ophthalmologist to both of these was Norman Gregg, knighted for his spectacular discoveries concerning rubella in the pregnant mother. His observations were made in his clinic at the Royal Alexandra Hospital and in his private practice. The Faculty of Medicine (we would call it the School of Medicine) of the University of New South Wales, Sydney, is affiliated with eleven teaching hospitals varying from 1,244 to 140 beds for a total of 4,190. This includes the Institute of Sport Medicine (Lewisham Hospital, 175 beds). Collectively, this provides about six beds per registrar and seven beds per student for the University 0fN.S.W. There is no eye hospital as such. Most of the hospitals, particularly the large and older ones were previously affiliated with the University of Sydney but since the creation of the NSW Faculty in 1961 have been transferred for teaching purposes to this school. They operate largely under the NSW Hospital Commission and the Regional Health Commission. A few are privately owned but in Australia the universities own no hospitals. Collectively, they provide for more than 700 residents and registrars. Associate Professor, Fred Hollows, heads ophthalmic services in each of the institutions. He represents the aggressive and non-traditional atmosphere sought by the institution. The Lidcombe Hospital of New South Wales, located on 500 beautiful, open acres in western Sydney, has nearly a century of history as a residential and medical agency. As Rockwood Asylum for the Aged and Infirmed it was primarily custodial from 1893 to 1906 when its emphasis became distinctly medical and its name
KEENEY changed to the “State Hospital and Home.” The original buildings are attractive bungalows set in street formation resembling a township. An institute of clinical pathology and medical research was added in 1959 and an occupational health division in 1967. An eye clinic was opened in 1965 with the addition of ophthalmic research particularly concerning problems of aging, the basement membranes, drusen, and advanced EM studies of retinal details under the inspiration and supervision of Dr. Shirley Sarks. The new ward block opened in 1978 is a complete service hospital accommodating 892 inpatients. Additionally, the grounds accommodated another 741 residential patients for a total of approximately 1633 beds. This is the largest residential and hospital institution for the aging in the Southern Hemisphere. MELBOURNE
(VICTORIA)
With a population of 2.75 million, Melbourne is the second largest city of Australia and presents a more cultural background than the premier city, Sydney. Its immense Port Phillip Bay rivals Sydney Harbour, but its art museums and Victorian elegance at their best exceed Sydney. It is also a sporting mecca where the 1956 Olympic Games were held, Davis Cup matches are played, and once each year the state “closes” for the Melbourne Cup Race. From hundreds of small neighborhood clubs and leagues to the huge Melbourne football grounds, a strong commitment to “mates” and fellowship pervades all aspects of life. Though Victoria is Australia’s smaIIest mainland state, the first of Australia’s gold rushes (1850-1900) brought great financial strength. The secret ballot introduced first in Victoria (1856) nurtured the democratic spirit and became nationwide by 1870. The old University of Melbourne and the recent Monash University provide splendid urban and suburban campuses respectively. THE ROYAL HOSPITAL
VICTORIAN
EYE AND EAR
This nine-story, modern, red-brick and concrete institution located on Victoria Parade in east Melbourne is a bright star of ophthalmology. It takes origin from a small series of rented residences between 1863 and the obtaining of its own ground by government grant in 1877.’ It occupied its first building built for the purpose with tower and elegant styling in 188 1. Growing space needs were met by acquisition of contiguous structures and the building of wings on the initial two story building. The present efficient and air-conditioned block was opened in two stages, 197 1 and 1974. Operating rooms are on the first sublevel; admission offices and administration are on the ground floor. The second
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floor is entirely occupied by the Melbourne University Department of Ophthalmology, offices for the professor and small full-time staff, teaching rooms, laboratories and clinical investigation space. The Department of Otolaryngology has similar housing on the third floor. The upper six floors are inpatient bed space, mostly four-bed units. The initial building was demolished in 1979 almost on the centenary ofits construction. A new outpatient facility is being erected on that ground. A major tunnel has been completed under the principal street dividing the Eye and Ear Hospital from St. Vincent’s Hospital. This is a resplendid general medical and surgical hospital under the direction of famed Sister Fabian. Its 350 beds provide overflow needs and services of other specialists. The Royal Victorian Eye and Ear serves as home for the Department of Ophthalmology of the Faculty of Medicine of the University of Melbourne. Nineteen ophthalmic registrars rotate through several affiliated hospitals including the large and academically oriented Royal Children’s Hospital a few miles away. Operating theaters are large and well equipped with line microscopes, vitreo-retinal instruments, and surgical apparatus developed by Prof. Gerard Crock. Most surgery is done under general anesthesia administered by a competent staff of visiting anesthesiologists. A group of classically honorary (v,oluntary) opththalmologists utilize the hospital for their private patients and augment the teaching program. In recent years, these ophthalmologists receive a small teaching stipend of approximately $80.00 to $102.00 per session ofservice which is usually a half day in clinics, operating theater, casualty service or teaching programs. Significant town and gown differences exist. Teaching of undergraduate medical students has become largely separate from the responsibilities of the Professor (chairman) and have been unusually sparked by the active Group Captain John Colvin, a senior ophthalmolo,gist of the Royal Australian Air Force Reserve. A hallmark of service in The Royal Victorian Eye and Ear is the constant wearing of the Crock spectacle-type indirect ophthalmoscope developed in the late 1960s. Since the early 197Os, “Combined Operation Magnifiers and Miniature Indirect Ophthalmoscopes” (COMMIDO) with belt or pocket supported power packs free the examiner from plugging in to electrical outlets and provide light, loupe, and indirect scope in portable fashion. Any visiting ophthalmologist is advised to come with his own COMMIDO to obtain maximum advantage of rapid rounds with the brilliant professor and staff. The library of the Royal Australian College of Ophthalmologists is incorporated as the main li-
brary of the Hospital. It houses nearly all English language ophthalmic literature of the last century and many European titles. The honorary librarian. Ronald F. Lowe, M.D., in 1973 capped many contributing ophthalmic roles by appointment to the Emeritus Honorary Ophthalmic Surgical Staff. He follows carefully the activities of the librarian, Miss
(SOUTH
AUSTRALIA)
Probably the best kept secret in Australian medicine is the relatively new Flinders University Faculty of Medicine established in the mid-1960s. This beautiful modern complex in the hills overlooking Vincent Gulf is far across Adelaide from the century-old Universitv of Adelaide Faculty of Medicine. The University of Adelaide, snug between North Terrace and Torrence River, has lived a valuable monopoly in medical education for South Australians and for patient care in the Adelaide area. The University of Adelaide continues to rely proudly on the honorary (unpaid) faculty of instruction. Flinders has moved to a nucleus of onsite full-time and salaried professors. The Flinders professorial chair in ophthalmology was filled February 1980 by the charter appointment of Douglas Coster, though funds from the Lions of South Australia had been avrailable for nearly five years. In a unique intimacy, the physical plant of Flinders currently provides for 500 inpatients,
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about 360 medical students, plus all basic research and animal facilities under one roof. Both clinical and basic research are flowering here to a degree somewhat unique among Australia’s ten medical schools. Though registrars are drawn widely from other medical schools, undergraduate students tend to come largely from the region of the town (south Adelaide) surrounding the school. The plant is well equipped. The modular units of many laboratories and offtces as well as patient care areas can be interchanged to meet future needs. Concerns of animal odors being near patients are safeguarded by double airlock doors at the animal quarters. Both animal surgery and human surgery are accommodated in large operating theaters with good support services. The students, curriculum, and facilities are nontraditional in a good sense. About nine registrars in ophthalmology rotate between the two medical schools and affiliated general plus one pediatric hospital. The eye department sees about 22,000 outpatient visits a year or nearly half the volume seen at the Royal Adelaide Hospital across town. CANBERRA
(CAPITAL
TERRITORY)
Canberra began to flourish in the 1960s. Federalization of the six states and two territories, even as a concept, dates only from the turn of the century and began architecturally in temporary buildings in the late 1920s. Parliament reluctantly moved from its quarter-of-a-century operation in Melbourne to the new Capital Territory at the end of the 1920s. Canberra is home for the Australian National University and its John Curtin School of Medical Research. Here Peter Bishop, known worldwide for his decades of intense studies in neurophysiology, has built visual research as the exclusive subject of his Department of Physiology. Though no undergraduate medical faculty exists in Canberra, it is the home of Australia’s National Library opened in 1968, the Academy of Science, the National Health and Medical Research Council, the Commonwealth Scientific and Industrial Research Organization, and most federal programs. The magnificent scope of the city resembles the more recent Brazilia, also several hundred miles from the traditional capital of Rio de Janeiro. REGULATION
OF VISION
KEENEY
1984
AND TRANSPORT
The Federal or “Commonwealth” Department of Transport for Australia is located in Canberra. The office of Road Safety was moved to Canberra in 1980 but the director of Aviation Medicine (Dr. John C. Lane) is in the Department of Transport and deals with civil aviation from offrces in Melbourne. Each of the six states and two territories has its own transport licensing authorities and the most
populous state, New South Wales, has the largest Department of Motor Transport. This is directed by Mr. David Herbert with a “Traffic Research Unit” headed by a young physician, Robert Arthurson, qualified in both medicine and engineering. The Traffic Research Unit includes crash simulator tracks, plus a good selection of test dummies with instrumentation for kinematic studies. Laws enacted in every state and the territories requiring a three-point suspension harness to be worn by all front seat passengers (other than in public taxicabs) have reduced crash fatalities by 20%. This is a world leading accomplishment. Eye injuries and facial lacerations have similarly fallen in the ensuing several years. An important influence is the Road Trauma Committee of the Royal Australasian College of Surgeons. Advisors in vision and participants in standard setting agencies include the Prevention of Blindness and Sight Rehabilitation Committee of the Royal Australian College of Ophthalmologists plus optometrists, ranging from deans of the schools of optometry (Victoria College of Optometry at the University of New South Wales) to individual practitioners. Other ophthalmologists such as John Colvin, serve among the six ophthalmic standards committees of the Standards Association of Australia. NEWCASTLE
(NEW SOUTH
WALES)
Newcastle is a bustling coal mining and port city named after its prototype in England. Its major hospital (Newcastle Hospital) has more than 800 beds. This hospital has received registrars from the University of Sydney and the University of New South Wales for more than two decades. Its clinical facilities have been competent and secure. The University of Newcastle buildings opened in 1978. Core faculty was in place in 1976 and the present curriculum was laid out as a five-year all medical course with no classics. The full-time faculty numbers approximately fifty and the entering class, beginning in 1976, numbers sixty-four students. Each entering class is divided into two equal groups of thirty-two students, one-half the class being admitted solely on academic scores and the other half being admitted on academic scores plus conpersonal evaluations and ventional interviews, subjective criteria. The faculty hopes in a decade or so to assess the validity of the admission process by comparing these two groups. The charter Dean Maddison, who unfortunately died in mid 198 1, was an aggressive psychiatrist committed to improvement in the basic methods and efficiency of education. The first class graduated in 1982. All education
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is clinically correlated through problem case presentation from the first day of medical school. Students arrive at approximately age eighteen and are equivalent to our high school graduates. Each study unit is based on a clinical problem, involving anatomy, physiology, pharmacology, therapy, counseling, psychiatric aspects, and all components of an individual disease. The problem units are tightly interlocked and build progressively with advanced units depending heavily on earlier units. By extensive brainstorming, the faculty has delineated small numbers of problem units beginning with no more than six to eight in the Grst semester. Any change in these units would significantly alter the flow and scope of subsequent units. Students are organized in very small groups having close association with a faculty member who leads them through all aspects of a problem and is not confined to his basic disciplinary area. Reliance is still made upon practicing clinicians in the community and nearby cities such as Gosford, to supply clinical reality and outpatient care examples. Ophthalmology has a close relation with the department of psychology and associated areas. Though there is no professor or Department of Ophthalmology, good clinical instruction is contribpracticing ophthalmologists. uted by “honorary” BRISBANE
(QUEENSLAND)
This business hub of more than a million population rightly boasts of its magnificent harbors and cvaterways and also its Queensland Symphony. The University of Queensland Faculty of Medicine dates from 1936 and has a well organized, honorary group in ophthalmology. There is knowledgeably keen competition for 11 registrar positions. Conferences are stimulating and well attended. Clinical care functions at a high level. Clinical teaching is based in good hospitals, but ones largely of less recent vintage. The Brisbane Children’s Hospital continues the pattern found in most prime cities of a superior pediatric facility, usually incorporating a superior eye service. The endorsement of attracting a few registrars who are second generations in ophthalmology attests to faculty quality even without a full-time professor (chairman). Funds are being collected to found a chair of ophthalmology but meanwhile a university lecturer has been appointed. ALICE SPRINGS
(NORTHERN
TERRITORY)
The Alice Springs Hospital is located in the heart of the “red center” of Australia named for its more than a half million square miles of dry red earth which feels more like sandstone than soil. The 200bed, modern, air conditioned hospital is operated by the Northern Territories Department of Health un-
der the direction of a dedicated pediatrician, Doctor Terry Kirk. Attractive three-story, beige brick, pavilion-type buildings are connected by covered walkways. More recently, some trailer-type and corrigated steel buildings have been placed among the original facilities for classrooms and clinics to meet growing needs. Though the hospital offers full general medical and surgical care, it provides outpatient clinics, patient and family education, demonstration areas, and registrars’ facilities which considerably exceed the floor space for inpatients. The eye clinic is clearly located by schematic pictures of the eye and directional arrows. The high incidence of trachoma (“sandy blight”), cornea1 disease, cataract, and blindness among aborigines was documented by extensive field survey in 197679 led by Professor Fred C. Hollows.’ Mobile teams included at times as many as sixty individuals, a covey of four-wheel drive vrehicles, and even mobile surgical facilities. The survey was followed promptly by treatment and surgery. Strabismus, myopia, and refractive errors were again documented to be less than half as frequent among aborigines as among European settlers. In some remote communities trachoma rates were as low as 15% and 20%, but among the older aborigines trachoma scars and active disease were seen in up to 95%. The “National Trachoma and Eye Health Program” was sponsored by the Royal Australian College of Ophthalmologists and funded by the Commonwealth Government at a cost of more than $2 million.
Special Attributes of Australian Ophthalmology ROYAL FLYING DOCTORS THE MANTLE OF SAFETY
SERVICE:
The Royal Flying Doctors Service of Australia is a remarkable network of physicians, nursing sisters, radio and air links over more than two million square miles or an area larger than western Europe. Service was initiated in Queensland in 1928 by the late Very Rev. John Flynn on the stimulus of an article written by a medical student, Clifford Peel, October 1918 in a journal, “The Inlander,” edited and published by Rev. Flynn. The young Australian student, later killed in action with the Australian Fying Corps in France, realized the looming value of air transport and radio to medical care. For several decades and even through the worldwide depression of the 193Os, most workers were voluntary. A small bush airline, Qantas, (Queensland And Northern Territory Aerial Service, begun in 1920, while Cobb & Co. were still operating horse coaches in Queensland), provided by contract a pilot, an aircraft, and servicing. H. V. McKay Charitable Trust provided vital funds and stimulated the gifts of many others.
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Today, the service owns and operates 28 fixedwing aircrafts out of 13 bases and is linked by 2,200 outstation transceivers. Monthly visits are made to isolated communities with small nursing-type hospitals. Early radios were pedal-powered Morse code equipment. The Flying Doctors truly have been a concurrent development of aircraft, radio, and medical technology. This is assisted by a standard wooden medical chest or “bush pharmacy” at each outstation. Medical calls held at 10 a.m. and 3 p.m. daily provide often the only contact between isolated families on a remote outback station and their neighbors a few hundred miles away as well as access to the “School of the Air” for their children. Transceivers at the Base Station are never closed. At the beginning of each morning’s medical report a nursing sister who has made rounds in the base hospital in Alice Springs advises family members (and listening friends) as to patient progress. A radio clinic follows where general physicians or consultants provide guidance to nursing sisters or directly to patients hundreds of miles away. The consultant may be in his home, the hospital, his aircraft, or at an outstation. All listen in and thereby gain education in medical care. The types of flights are (1) emergency, (2) mercy, a life and death situation that calls for compromises in normal air safety standards, or (3) clinic flights. About 23,000 radio consultations are held each year and more than 65,000 patients are attended by Flying Doctors. The 1980 budget of more than $7 million remarkedly indicates that each patient flight service prorates to about $100. In addition to emergency care, ophthalmologists voluntarily fly scheduled missions for eye clinics. FINANCIAL MEDICINE
FACTORS
IN AUSTRALIAN
Australian medical schools and hospitals are currently being subjected to two restraining factors. First is a reduction in the actual numbers of medical students in training as well as a reduction of registrars’ positions in many specialties. Second is a general cutback in federal funding for medicine. Particularly, the umbilicated institutions of established and traditional medical schools are coping with budget reduction under terms such as “rationalization” of funding. For example, the sprawling 400bed Royal Alexandra Hospital for Children in Sydney, which has been growing each year since its opening in 1879, withstood in its centenary year a budget reduction of $1.96 million with obligations to close 30 occupied beds in the hospital and transfer 30 convalescent beds elsewhere; at the same time, inpatient population increased 5% compared to the previous year and length of stay fell from 6.2
KEENEY to 5.9 days. Every hospital and medical school labors each year in what is almost a bargaining confrontation with the Health Commission and seeks concurrently to augment its private support. OPHTHALMIC
RESEARCH
IN AUSTRALIA
Approximately 0.2% of the health budget of Australia is directed to research. Basic science schools (departments) in most of the ten faculties of medicine have ongoing laboratory research. Most major hospitals with teaching programs have published commitment to investigation. For instance, the Children’s Medical Research Foundation, initiated by the late Sir Lorimer Dodds on the grounds of the Royal Alexandra Hospital for Children (Sydney) and now directed by Professor Peter Rowe, has independent research endowments of approximately $6 million and supports 10 or 12 research fellows including the Norman Gregg Research Fellow. Investigative reports in Australian medicine stem from clinically related subjects several-fold more frequently than from basic laboratory studies. However, pride in two Nobel Laureates, Sir John Carew Eccles (1963) and Sir Frank MacFarlane Burnet (1960), is apparent in every research program. Australia’s National Health and Medical Research Council, a mini-edition of our N.I.H., currently underwrites approximately $20 million a year in competitive research grants (this is about l/l 0 the annual appropriation for the Commonwealth Scientific and Industrial Research Organization). Funds are not subdivided categorically but rather all applicants compete with each other. The Institute ofAviation Medicine (at the RAAF Academy in Melbourne), under the direction of Wing Commander Paul Shumack, M.D., has heavy concerns with visual aspects of flying and aviation medicine. A very small full-time staff, however, is expected to accomplish research as part of its usual duties and receives only $20 titular funding for any given research undertaking. For capital equipment, application is through Air Force channels and competes with all capital needs. Private industrial resources, at times, support research programs in aviation medicine similar to the way in which pharmaceutical and equipment producers support university research. Both ultimately aspire to recommendation, adoption, or sale of related products. In the early 1930s the major opticianry, Ophthalmic Prescription Spectacle Makers (OPSM), began a program uniquely supportive of ophthalmology. For several decades they would manufacture only on the prescription of an ophthalmologist. In recent years, this policy has been widened but OPSM has regularly supported eye research and in the early 1960s donated $150,000 toward an endowed chair
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for the professor ofophthalmology at the University of Sydney. The University provided the remainder of the funds. OPSM has also been scientifically supportive of patient needs in contact lenses by many different formats with ophthalmologists. They have become one of the nation’s largest providers of industrial safety gear including head, face, and respiratory protecting devices. Subsidiary companies in industrial safety are Surguard and Protector, both headquartered in Sydney. In 1978, OPSM established a Research and Charitable Foundation with an initial endowment of $500,000 (Australian) to provide funds for ophthalmic research within universities and teaching hospitals throughout Australia. In Adelaide a similar Pank Ophthalmic Trust was founded for ophthalmic research. The Ophthalmic Research Institute of Australia was estabalished in 1952 with a $300,000 endowment from an anonymous donor, to finance research in any ophthalmic program of the nation. This has strengthened both academics and Prevention of Blindness units. Capital assets of three-quarters of a million dollars (Australian) have been accumulated and about $100,000 (Australian) was available for direct research support in 1983. Specific yields from this program are the retino-vitreal surgical instruments and COMMIDO spectacle mounted examining instruments of Professor Crock, new insights on the natural history of drusen as predictors and accompaniments of macular involution developed by Shirley Sarks, and the research into angle closure glaucoma by Ronald Lowe. These funds supplement other private resources such as the Denise Appeal Trust. Unique support comes from many women’s bowling groups (e.g., New South Wales Women’s Bowl for Others Club). Further, the Lions, Kiwanis, and the Rotary Clubs are strong supporters of ophthalmic education, research and service. At The Royal Victorian Eye and Ear Hospital, the “Eye, Ear, Nose and Throat Research Institute” is a vehicle to receive donations and tender support to investigators within their Melbourne hospital. At the “National Vision Research Institute” in Melbourne, both structurally and ideologically a wing of the Department of Optometry, there is tinancial support currently of about $500,000 a year from the National Health and Medical Research Council. Subjects range from cat histology and “developmental vision” to more optometrically related studies of contrast perception and temporal relation among stimuli. Uniquely accomplishing ophthalmic research has been long ongoing in the capital of Canberra at the
John Curtin School of Medical Research, one of seven schools which constitute the Institute of Advanced Studies at the National University. The University was created by parliamentary enabling act in 1946 and began to blossom in postgraduate research in the early 1950s. Undergraduate teaching was added in 1960. Graduate programs enroll about 1,000 students and undergraduates now number more than 4,000. Among the 10 departments at the John Curtin School, the Department of Physiology headed by Peter 0. Bishop, M.B.B.S., F.R.S., (formerly at the University of Sydney), devotes its entire energies to basic neurology of sight. Dr. Bishop has carried the Department forward as successor to Sir John C. Eccles, Nobel Prize winner in neurologic studies in the same laboratories. Dr. Bishop and a senior colleague, W. R. Levick, M.B.B.S., M.Sc., keep about 20 projects operational in eight major laboratories all of which are well equipped. With the assistance of approximately a dozen research fellows, this Department is an international center in neurologic and psychophysical aspects of vision and its cortical relations. Approximately 25 former students now hold professorial appointments throughout the world. Among Bishop’s graduates are Associate Professor Jonathan M. Stone, Ph.D., visual neuroanatomist in the School of Anatomy, University of New South Wales, and Professor Ronald Penny in immunology of uveitis at St. Vincent’s Hospital, Sydney. The Department is well funded by a budget through the parent university. There is also modest additional foundation and grant support in which the Lions have again been active. As part of the intensified commitments to academics, the Australian Academy of Science was founded by Royal Charter from Queen Elizabeth in 1954, in parallel to our National Academy of Sciences. Of the approximately 200 fellows, a few have earned medical degrees like Nobel Laureate, Sir MacFarlane Burnet, but there is no medical section in the Academy. Nine new fellows may be elected each year. The Academy is handsomely housed under an oval copper dome with 16 supporting points curving from the roof to the ground in a perfect circle. Though the construction was entirely financed by private donations, the federal government now supplies about half the operating costs to the Academy. PROFESSIONAL ORGANIZATIONS
OPHTHALMIC
The oldest Australian ophthalmological society was established in the colony of Victoria in 1899.” This was modeled on the Ophthalmological Society ofthe United Kingdom. As an expression ofAustra-
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lian unity the Ophthalmological Society of Australia was founded in 1938 subsequent to a proposal at the British Medical Congress of 1937 held in Adelaide. Sir James Barrett, “as a matter of course,” became its first president. He was the indisputable chancellor of the University of Melbourne and though he had passed his seventy-fifth birthday in 1938 was still active in nearly two dozen national committees and served as senior officer for half of them. The distinguished roster of past presidents includes Sir Norman Gregg ( 1944-45) and Joseph Ringland Anderson ( 1945-46). The Society became more clearly an arbitor of its own membership by elevation to the role of “Australian College of Ophthalmologists” in 1969. Qualification examinations and censure became formalized through the “college” organization. Again with extensive preparation, the title “Royal” was added by grant of Queen Elizabeth in 1977; it then became a colleague of the Royal Australasian College of Surgeons and joined a sibship of colleges in other specialties. ’ Necessarily close liaison exists between the Royal College, the curriculum of the medical schools, programs for registrars in ophthalmology, and registration as a practitioner.
In constraint of mercantilism, the College maintains a prohibition of Fellows engaging in the merchandising of spectacles, medications, and devices. A similar position was historically held though with less enforceability by the antecedent Society. This professional stance against merchants in ophthalmology was assisted from the early 1930s by the major opticianry program of the Ophthalmic Prescription Spectacle Manufacturers (OPSM). This has supported professionalism in ophthalmology, and OPSM continuously flourished to become the largest dispensing optical organization in Australia.
References 1. Hollows FC (cd): TheNational Trachomd B Eve Health Program oj‘the Ro_valAustralian College of Ophthalmologists. Sydney, RACO, 1980 2. Lowe RF: Early Melbourne Eye & Ear Hospitals. Austr Ne’erel Zea J Surg 50:5+&549, 1980 3. Lowe RF: Ophthalmological Society of Melbourne. dust. J Ophthalmol R:257-270, 1980 1. Royal Australian College ofOphthalmologists (editorial). .MedJ. .4ust 2:347-48, 1977
Reprint requests should be addressed to Arthur H. Keeney, M.D., D.Sc.. University of Louisville, School of Medicine, Department of Ophthalmology, 301 E. Muhammad Ali Blvd., Louisville, KY 10202.
VOLUME 28 - NUMBER 6. MAY-JUNE 1984
OPHTHALMOLOGY
INTERNATIONAL
JULES FRANCOIS, EDITOR
Ophthalmology ARTHUR
H. KEENEY,
Department
and Medical Education
in Australia
M.D., D.SC..
of Ophthalmology.
l’niaersity
of Louisville
School
9‘ .Eledicine.
Loui.wille.
Renturkv
Abstract. Australian
medicine and ophthalmology both began as extensions of British traditions. financial and national independence, they have acquired indigenous strength and An original triumvirate of medical schools launched a century ago have t,ern augmented by seven additional schools, particularly since lt’orld War II. Both general medical and specialty education are now well obtainable in Australia. The quality of ophthalmology is high and research has been movine upward since World War II. New buildings are replacing old. The organization ofregistrars (residents) is blending with that orunion-type workers and reflects widespread though locally autonomous unions in almost every field of endeavor. Canberra and the National University are recent major additions to cultural and scientific aKairs or Australia. The Royal Flying Doctors Service has since 1928 cast an increasingly elective “mantle ofsarety“ over the outback. Reductions in federal funds and student numbers have paralleled similar occurrences in the U.S. in the 1980s. Geriatric ophthalmology has made a major step forward and the organization of examinations and policing of medicine have been greatly strengthened in the past decade. (Surv Ophthalmol 28:677-686, 1984) With growing characteristics.
Key words.
Australia
l
medical
education
0
Growth of Medical Education and Ophthalmology
phthalmology and medical education as initiated in Australia have been largely extensions of the British system. Australia launched a triumverate of early medical faculties in state universities: University of Melbourne, 1862; University of Sydney, 1883; University ofadelaide, 1885. With the exception of the University of Queensland initiating a medical faculty in Brisbane in 1936, there was no incremental activity for more than four decades. In the mid 196Os, however, the combination of technical progress, perceived need, and increasing independence of commonwealth nations led to doubling of undergraduate medical education and postgraduate specialty training.
CHANGES AFTER WORLD WAR II The late 1950s and 1960s were marked by expanding Australian independence and prosperity leading to increasing funds for medicine and ophthalmology. Australia launched new medical faculties in Perth (University of Western Australia, 1957); Melbourne (Monash University, 1961); Sydney (University of New South Wales, 196 1); Hobart (University of Tasmania, 1965); and Adelaide (Flinders University, 1969). Lastly, at University of Newcastle (1978) the most recent faculty was 677
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launched and produced its first medical graduates in 1982. Though some ophthalmic instruction has been shoehorned into all undergraduate medical curricula, departments of ophthalmology and full professors (equivalent to U.S. department chairmen) emerged much later and in five medical schools are functionally not yet present. From the late 1960s through the 1970s several schools have compressed the traditional British six year program of combined pre-clinical and clinical education. This system requires seven years of primary school, completion of secondary education about the age of 18, and passing prescribed university entrance examinations. Though there is considerable variation in curricula among the schools, several such as Sydney and New South Wales did reduce medical students’ years from six to five. A few even stated their actions ‘&in response to a worldwide pattern of change.” This excluded in-depth cultural studies such as English literature, history, and humanities. Melbourne and Monash in the same city have held to the six year base. The realities of needing to teach more facts in fewer years, however, have led several of the Australian schools to convert back to a six year base hoping to enhance the total background of their graduates. Particularly in the new schools, clinical experience has greatly exceeded attention to such major heritages as Shakespeare, Chaucer, and even Arthur Conan Doyle, ophthalmologist turned Sherlock Holmes writer. Further, the ophthalmic programs require three years of graduate prespecialty preparation in internal medicine and various disciplines of surgery or medical practice before entering as a registrar in ophthalmology. Medical graduates, on completing requisite examinations, are awarded the first medical degree, Bachelor of Medicine and Bachelor of Surgery (M.B.B.S.) and after one year’s internship, are entitled to registration as commonwealth practitioners under Medical Acts of the United Kingdom. More advanced degrees such as the Master’s or the Doctorate of Medicine or the Doctor of Philosophy require a research thesis. Diplomas from Royal Colleges entail three years specialty registrar training and examinations which are didactic and clinical. THE GREAT PROFESSIONAL OF AUSTRALIA
STREETS
Macquarie Street in Sydney; Collins Street in Melbourne; North Terrace in Adelaide; and Wickham Terrace in Brisbane: These elegant avenues began as equivalents of Harley Street, London. They have persisted more clearly through the urban changes of the less large cities.
KEENEY In Sydney, Macquarie Street was, without question, the prime location for leading ophthalmologists. To practice elsewhere in the year between the wars was to forego elegance. Good ophthalmic care is now available in all suburbs and is marked by an occasional expression of pride in higher level performance of one suburb versus another. For the most complicated of ocular problems and sophisticated eye surgery, however, the old Sydney Eye Hospital, with its new clinics and its professorial department presents a prime image. Some concerns of town vs. gown are roughly paralleled in Macquarie Street vs. the major urban spread to dozens of beautiful residential communities and to the industrial westside. A similar rivalry occurs between the historic University ofSydney with its long established Eye Hospital and the counterforce of the young New South Wales University. In Melbourne, Collins Street still retains dignified elegance with the Melbourne, the Atheneum, and other stately clubs of historic elegance. Adelaide, though extending beautifully across large plains and beyond its “green belt,” still holds fast to North Terrace traditions of elegance. The south side of North Terrace looks proudly across to the University of Adelaide, stately government buildings, and museums. In bustling Brisbane, Wickham Terrace has been home for almost every opthalmologist well into the 1970s. It is still the prime location for ophthalmologists, but Brisbane has now spread to beautiI‘ul water side communities along the river and harbour. MEDICAL
QUALIFICATION
AND LICENSURE
Basic and specialist medical qualifications come under federal surveillance for the purpose of practice under the National Health Act, but the individual states control all medical registrations. The General Medical Council of the U.K. which supervises standards of medical education in the British Isles and grants reciprocal recognition to medical qualifications of other Commonwealth countries, approves the courses offered by medical schools. Thus, once the student has earned his M.B.B.S. he is eligible for initial registration by the Medical Board of his state, and following his compulsory internship or residency in an approved hospital is eligible for final registration which is reciprocal with the various states of Australia and most nations of the British Commonwealth. All states and both territories have their own boards of licensure. Doctors graduating in medicine must be registered (licensed) in the state where they will practice but examinations are not conducted by the individual state and territorial boards; they accept qualifications issued by approved institutions such as Uni-
AUSTRALIAN
versities, Colleges or Associations within Australia or overseas. For the coveted position of registrar in ophthalmology, as in most specialties, there is steep competition and many fewer positions than applicants. The various Royal Colleges are professional and examining organizations. They attest to postgraduate training and the qualification of young physicians, and further require and police certain professional standards throughout their careers. Clinical components of medical education were entirely taught by honorary faculty until shortly after World War II. The first full-time professor or chair in ophthalmology at a medical faculty was established at the University of Melbourne in 1963. The most recent dates from 1980 at Flinders University in Adelaide and the only other ones are at the University of Sydney, University of New South Wales, and the University of Perth. Each has its initial appointee. EXAMINATIONS
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FOR OPHTHALMOLOGY
American ophthalmologists have generally viewed Part I fellowship examination by the Royal College of Surgeons as being ofgreater minutiae and basic science than examination by the American Board of Ophthalmology. Australia and New Zealand, in recent years, have come to an efficient and sensible synthesis of examination by the Royal Australasian College of Surgeons and the Royal Australian College of Ophthalmologists. By using Fellows from both colleges, a new two-part examination replaces separate examinations by each. Part one (basic science) consists of three-hour written papers and oral examinations in: a) ophthalmological anatomy, histology, and embryology; b) physiology related to ophthalmology; c) optics related to ophthalmology. Part two consists of threehour written papers on: 1) medical ophthalmology, 2) surgical ophthalmology, and 3) pathology and microbiology related to ophthalmology. There are also clinical and oral examinations under these divisions. Part one may be taken prior to beginning the specialist training. Part two may be taken in the third year ofspecialist appointment, but the qualification is not issued until the full training is completed. ‘4n essential prerequisite for the examinations is a log book containing accounts of surgery and other procedures performed under approved supervisors. Successful completion gives the registrar fellowship in both the Royal Australasian College of Surgeons and the Royal Australian College of Ophthalmologists. The State Government in New South Wales also performs periodic “Inspection of Training Posts” to review on site the various registrar programs.
The Colleges in the British Commonwealth System, unlike the American Boards, control the entrance of a physician into post or practice and monitor ethical activities. The Colleges have power of censure which does not exist in American Board structure. Breaches of professional ethics are adjudicated by the Australian Medical Association. New Zealand, with its smaller population of 75 ophthalmologists, contrasted to more than 500 in Australia, provides some examiners and accepts this system of examination with the same validity it receives in Australia. There is considerable desire for further increase in the collaboration between the ophthalmologists of Australia and New Zealand.
Australian Ophthalmology and Its Geographic Centers SYDNEY (NEW SOUTH
WALES)
Ophthalmology in Sydney, an often beautiful but farflung city of three million, presents many variations. The century old University of Sydney Faculty of Medicine and the new University of New South Wales Faculty of Medicine hold similar admission requirements and years in training but beyond that contribute to the diversity of medicine and ophthalmology in this city. The elegant old facade which has housed the Sydney Eye Hospital (est. 1882) for nearly a century, emphasizes cleanliness and not the creature comforts of wash basins or air conditioning. The new wing, poured of concrete about 1970, houses modern outpatient clinics, subspecialty services, four new operating rooms, a gracious library, and a few research labs. An endowed professorship has been available for about fifteen years but has only been tilled since the appointment of Frank A. Billson in 1976. Both hospital and educational financing are heavily dependent upon the New South Wales government and the federal government. The Sydney Eye Hospital has had a steady growth in outpatient visits reaching nearly 75,000 visits by 36,000 patients in 1979-80. Nearly 40,000 visits were made to the casualty or emergency clinics and over 10,000 to the general ophthalmic clinics. The 19 registrars in training for three years rotate through nine different hospitals. Nearly all inpatient admissions are surgical with over 2,100 major operations and 500 minor operations in 197980. These were divided into approximately 20% retinal, 10% corneal, 5% glaucoma, 9% strabismus, and 25% cataract. Subspecialty clinics are well developed. Registrars (residents) are classified as hourly rated employees under collective bargaining provisions. Formal educational sessions are therefore designed primarily outside “working hours.” Compensation to the registrars is generally
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1984
higher than U.S. standards. Sydney Eye Hospital houses the Department of Ophthalmology of the University of Sydney with occasional challenges over distribution of space or responsibilities between faculty members and hospital staff members. Nearly 50% of all tertiary eye care in New South Wales is performed at the Sydney Eye Hospital. The graduate program for ophthalmic nurses produces about six graduates annually. Orthoptics occupies a large role as in most British oriented systems with nearly 10,000 visits in 1979. Approximately 15,000 refractions were done in the same period. Demanding and excellent education is a source of pride to Sydney Hospital, technically the parent of Sydney Eye Hospital over its 193 years of service. Two Nobel Laureates add luster to the medical staff. The first special clinical department to be created by Sydney Hospital was that of Ophthalmology. Its first director was Gordon McLeod from 1895. Other notable hospitals are the Royal Prince Alfred Hospital and the Royal Alexandra Hospital for Children. The most outstanding ophthalmologist to both of these was Norman Gregg, knighted for his spectacular discoveries concerning rubella in the pregnant mother. His observations were made in his clinic at the Royal Alexandra Hospital and in his private practice. The Faculty of Medicine (we would call it the School of Medicine) of the University of New South Wales, Sydney, is affiliated with eleven teaching hospitals varying from 1,244 to 140 beds for a total of 4,190. This includes the Institute of Sport Medicine (Lewisham Hospital, 175 beds). Collectively, this provides about six beds per registrar and seven beds per student for the University 0fN.S.W. There is no eye hospital as such. Most of the hospitals, particularly the large and older ones were previously affiliated with the University of Sydney but since the creation of the NSW Faculty in 1961 have been transferred for teaching purposes to this school. They operate largely under the NSW Hospital Commission and the Regional Health Commission. A few are privately owned but in Australia the universities own no hospitals. Collectively, they provide for more than 700 residents and registrars. Associate Professor, Fred Hollows, heads ophthalmic services in each of the institutions. He represents the aggressive and non-traditional atmosphere sought by the institution. The Lidcombe Hospital of New South Wales, located on 500 beautiful, open acres in western Sydney, has nearly a century of history as a residential and medical agency. As Rockwood Asylum for the Aged and Infirmed it was primarily custodial from 1893 to 1906 when its emphasis became distinctly medical and its name
KEENEY changed to the “State Hospital and Home.” The original buildings are attractive bungalows set in street formation resembling a township. An institute of clinical pathology and medical research was added in 1959 and an occupational health division in 1967. An eye clinic was opened in 1965 with the addition of ophthalmic research particularly concerning problems of aging, the basement membranes, drusen, and advanced EM studies of retinal details under the inspiration and supervision of Dr. Shirley Sarks. The new ward block opened in 1978 is a complete service hospital accommodating 892 inpatients. Additionally, the grounds accommodated another 741 residential patients for a total of approximately 1633 beds. This is the largest residential and hospital institution for the aging in the Southern Hemisphere. MELBOURNE
(VICTORIA)
With a population of 2.75 million, Melbourne is the second largest city of Australia and presents a more cultural background than the premier city, Sydney. Its immense Port Phillip Bay rivals Sydney Harbour, but its art museums and Victorian elegance at their best exceed Sydney. It is also a sporting mecca where the 1956 Olympic Games were held, Davis Cup matches are played, and once each year the state “closes” for the Melbourne Cup Race. From hundreds of small neighborhood clubs and leagues to the huge Melbourne football grounds, a strong commitment to “mates” and fellowship pervades all aspects of life. Though Victoria is Australia’s smaIIest mainland state, the first of Australia’s gold rushes (1850-1900) brought great financial strength. The secret ballot introduced first in Victoria (1856) nurtured the democratic spirit and became nationwide by 1870. The old University of Melbourne and the recent Monash University provide splendid urban and suburban campuses respectively. THE ROYAL HOSPITAL
VICTORIAN
EYE AND EAR
This nine-story, modern, red-brick and concrete institution located on Victoria Parade in east Melbourne is a bright star of ophthalmology. It takes origin from a small series of rented residences between 1863 and the obtaining of its own ground by government grant in 1877.’ It occupied its first building built for the purpose with tower and elegant styling in 188 1. Growing space needs were met by acquisition of contiguous structures and the building of wings on the initial two story building. The present efficient and air-conditioned block was opened in two stages, 197 1 and 1974. Operating rooms are on the first sublevel; admission offices and administration are on the ground floor. The second
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floor is entirely occupied by the Melbourne University Department of Ophthalmology, offices for the professor and small full-time staff, teaching rooms, laboratories and clinical investigation space. The Department of Otolaryngology has similar housing on the third floor. The upper six floors are inpatient bed space, mostly four-bed units. The initial building was demolished in 1979 almost on the centenary ofits construction. A new outpatient facility is being erected on that ground. A major tunnel has been completed under the principal street dividing the Eye and Ear Hospital from St. Vincent’s Hospital. This is a resplendid general medical and surgical hospital under the direction of famed Sister Fabian. Its 350 beds provide overflow needs and services of other specialists. The Royal Victorian Eye and Ear serves as home for the Department of Ophthalmology of the Faculty of Medicine of the University of Melbourne. Nineteen ophthalmic registrars rotate through several affiliated hospitals including the large and academically oriented Royal Children’s Hospital a few miles away. Operating theaters are large and well equipped with line microscopes, vitreo-retinal instruments, and surgical apparatus developed by Prof. Gerard Crock. Most surgery is done under general anesthesia administered by a competent staff of visiting anesthesiologists. A group of classically honorary (v,oluntary) opththalmologists utilize the hospital for their private patients and augment the teaching program. In recent years, these ophthalmologists receive a small teaching stipend of approximately $80.00 to $102.00 per session ofservice which is usually a half day in clinics, operating theater, casualty service or teaching programs. Significant town and gown differences exist. Teaching of undergraduate medical students has become largely separate from the responsibilities of the Professor (chairman) and have been unusually sparked by the active Group Captain John Colvin, a senior ophthalmolo,gist of the Royal Australian Air Force Reserve. A hallmark of service in The Royal Victorian Eye and Ear is the constant wearing of the Crock spectacle-type indirect ophthalmoscope developed in the late 1960s. Since the early 197Os, “Combined Operation Magnifiers and Miniature Indirect Ophthalmoscopes” (COMMIDO) with belt or pocket supported power packs free the examiner from plugging in to electrical outlets and provide light, loupe, and indirect scope in portable fashion. Any visiting ophthalmologist is advised to come with his own COMMIDO to obtain maximum advantage of rapid rounds with the brilliant professor and staff. The library of the Royal Australian College of Ophthalmologists is incorporated as the main li-
brary of the Hospital. It houses nearly all English language ophthalmic literature of the last century and many European titles. The honorary librarian. Ronald F. Lowe, M.D., in 1973 capped many contributing ophthalmic roles by appointment to the Emeritus Honorary Ophthalmic Surgical Staff. He follows carefully the activities of the librarian, Miss
(SOUTH
AUSTRALIA)
Probably the best kept secret in Australian medicine is the relatively new Flinders University Faculty of Medicine established in the mid-1960s. This beautiful modern complex in the hills overlooking Vincent Gulf is far across Adelaide from the century-old Universitv of Adelaide Faculty of Medicine. The University of Adelaide, snug between North Terrace and Torrence River, has lived a valuable monopoly in medical education for South Australians and for patient care in the Adelaide area. The University of Adelaide continues to rely proudly on the honorary (unpaid) faculty of instruction. Flinders has moved to a nucleus of onsite full-time and salaried professors. The Flinders professorial chair in ophthalmology was filled February 1980 by the charter appointment of Douglas Coster, though funds from the Lions of South Australia had been avrailable for nearly five years. In a unique intimacy, the physical plant of Flinders currently provides for 500 inpatients,
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about 360 medical students, plus all basic research and animal facilities under one roof. Both clinical and basic research are flowering here to a degree somewhat unique among Australia’s ten medical schools. Though registrars are drawn widely from other medical schools, undergraduate students tend to come largely from the region of the town (south Adelaide) surrounding the school. The plant is well equipped. The modular units of many laboratories and offtces as well as patient care areas can be interchanged to meet future needs. Concerns of animal odors being near patients are safeguarded by double airlock doors at the animal quarters. Both animal surgery and human surgery are accommodated in large operating theaters with good support services. The students, curriculum, and facilities are nontraditional in a good sense. About nine registrars in ophthalmology rotate between the two medical schools and affiliated general plus one pediatric hospital. The eye department sees about 22,000 outpatient visits a year or nearly half the volume seen at the Royal Adelaide Hospital across town. CANBERRA
(CAPITAL
TERRITORY)
Canberra began to flourish in the 1960s. Federalization of the six states and two territories, even as a concept, dates only from the turn of the century and began architecturally in temporary buildings in the late 1920s. Parliament reluctantly moved from its quarter-of-a-century operation in Melbourne to the new Capital Territory at the end of the 1920s. Canberra is home for the Australian National University and its John Curtin School of Medical Research. Here Peter Bishop, known worldwide for his decades of intense studies in neurophysiology, has built visual research as the exclusive subject of his Department of Physiology. Though no undergraduate medical faculty exists in Canberra, it is the home of Australia’s National Library opened in 1968, the Academy of Science, the National Health and Medical Research Council, the Commonwealth Scientific and Industrial Research Organization, and most federal programs. The magnificent scope of the city resembles the more recent Brazilia, also several hundred miles from the traditional capital of Rio de Janeiro. REGULATION
OF VISION
KEENEY
1984
AND TRANSPORT
The Federal or “Commonwealth” Department of Transport for Australia is located in Canberra. The office of Road Safety was moved to Canberra in 1980 but the director of Aviation Medicine (Dr. John C. Lane) is in the Department of Transport and deals with civil aviation from offrces in Melbourne. Each of the six states and two territories has its own transport licensing authorities and the most
populous state, New South Wales, has the largest Department of Motor Transport. This is directed by Mr. David Herbert with a “Traffic Research Unit” headed by a young physician, Robert Arthurson, qualified in both medicine and engineering. The Traffic Research Unit includes crash simulator tracks, plus a good selection of test dummies with instrumentation for kinematic studies. Laws enacted in every state and the territories requiring a three-point suspension harness to be worn by all front seat passengers (other than in public taxicabs) have reduced crash fatalities by 20%. This is a world leading accomplishment. Eye injuries and facial lacerations have similarly fallen in the ensuing several years. An important influence is the Road Trauma Committee of the Royal Australasian College of Surgeons. Advisors in vision and participants in standard setting agencies include the Prevention of Blindness and Sight Rehabilitation Committee of the Royal Australian College of Ophthalmologists plus optometrists, ranging from deans of the schools of optometry (Victoria College of Optometry at the University of New South Wales) to individual practitioners. Other ophthalmologists such as John Colvin, serve among the six ophthalmic standards committees of the Standards Association of Australia. NEWCASTLE
(NEW SOUTH
WALES)
Newcastle is a bustling coal mining and port city named after its prototype in England. Its major hospital (Newcastle Hospital) has more than 800 beds. This hospital has received registrars from the University of Sydney and the University of New South Wales for more than two decades. Its clinical facilities have been competent and secure. The University of Newcastle buildings opened in 1978. Core faculty was in place in 1976 and the present curriculum was laid out as a five-year all medical course with no classics. The full-time faculty numbers approximately fifty and the entering class, beginning in 1976, numbers sixty-four students. Each entering class is divided into two equal groups of thirty-two students, one-half the class being admitted solely on academic scores and the other half being admitted on academic scores plus conpersonal evaluations and ventional interviews, subjective criteria. The faculty hopes in a decade or so to assess the validity of the admission process by comparing these two groups. The charter Dean Maddison, who unfortunately died in mid 198 1, was an aggressive psychiatrist committed to improvement in the basic methods and efficiency of education. The first class graduated in 1982. All education
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is clinically correlated through problem case presentation from the first day of medical school. Students arrive at approximately age eighteen and are equivalent to our high school graduates. Each study unit is based on a clinical problem, involving anatomy, physiology, pharmacology, therapy, counseling, psychiatric aspects, and all components of an individual disease. The problem units are tightly interlocked and build progressively with advanced units depending heavily on earlier units. By extensive brainstorming, the faculty has delineated small numbers of problem units beginning with no more than six to eight in the Grst semester. Any change in these units would significantly alter the flow and scope of subsequent units. Students are organized in very small groups having close association with a faculty member who leads them through all aspects of a problem and is not confined to his basic disciplinary area. Reliance is still made upon practicing clinicians in the community and nearby cities such as Gosford, to supply clinical reality and outpatient care examples. Ophthalmology has a close relation with the department of psychology and associated areas. Though there is no professor or Department of Ophthalmology, good clinical instruction is contribpracticing ophthalmologists. uted by “honorary” BRISBANE
(QUEENSLAND)
This business hub of more than a million population rightly boasts of its magnificent harbors and cvaterways and also its Queensland Symphony. The University of Queensland Faculty of Medicine dates from 1936 and has a well organized, honorary group in ophthalmology. There is knowledgeably keen competition for 11 registrar positions. Conferences are stimulating and well attended. Clinical care functions at a high level. Clinical teaching is based in good hospitals, but ones largely of less recent vintage. The Brisbane Children’s Hospital continues the pattern found in most prime cities of a superior pediatric facility, usually incorporating a superior eye service. The endorsement of attracting a few registrars who are second generations in ophthalmology attests to faculty quality even without a full-time professor (chairman). Funds are being collected to found a chair of ophthalmology but meanwhile a university lecturer has been appointed. ALICE SPRINGS
(NORTHERN
TERRITORY)
The Alice Springs Hospital is located in the heart of the “red center” of Australia named for its more than a half million square miles of dry red earth which feels more like sandstone than soil. The 200bed, modern, air conditioned hospital is operated by the Northern Territories Department of Health un-
der the direction of a dedicated pediatrician, Doctor Terry Kirk. Attractive three-story, beige brick, pavilion-type buildings are connected by covered walkways. More recently, some trailer-type and corrigated steel buildings have been placed among the original facilities for classrooms and clinics to meet growing needs. Though the hospital offers full general medical and surgical care, it provides outpatient clinics, patient and family education, demonstration areas, and registrars’ facilities which considerably exceed the floor space for inpatients. The eye clinic is clearly located by schematic pictures of the eye and directional arrows. The high incidence of trachoma (“sandy blight”), cornea1 disease, cataract, and blindness among aborigines was documented by extensive field survey in 197679 led by Professor Fred C. Hollows.’ Mobile teams included at times as many as sixty individuals, a covey of four-wheel drive vrehicles, and even mobile surgical facilities. The survey was followed promptly by treatment and surgery. Strabismus, myopia, and refractive errors were again documented to be less than half as frequent among aborigines as among European settlers. In some remote communities trachoma rates were as low as 15% and 20%, but among the older aborigines trachoma scars and active disease were seen in up to 95%. The “National Trachoma and Eye Health Program” was sponsored by the Royal Australian College of Ophthalmologists and funded by the Commonwealth Government at a cost of more than $2 million.
Special Attributes of Australian Ophthalmology ROYAL FLYING DOCTORS THE MANTLE OF SAFETY
SERVICE:
The Royal Flying Doctors Service of Australia is a remarkable network of physicians, nursing sisters, radio and air links over more than two million square miles or an area larger than western Europe. Service was initiated in Queensland in 1928 by the late Very Rev. John Flynn on the stimulus of an article written by a medical student, Clifford Peel, October 1918 in a journal, “The Inlander,” edited and published by Rev. Flynn. The young Australian student, later killed in action with the Australian Fying Corps in France, realized the looming value of air transport and radio to medical care. For several decades and even through the worldwide depression of the 193Os, most workers were voluntary. A small bush airline, Qantas, (Queensland And Northern Territory Aerial Service, begun in 1920, while Cobb & Co. were still operating horse coaches in Queensland), provided by contract a pilot, an aircraft, and servicing. H. V. McKay Charitable Trust provided vital funds and stimulated the gifts of many others.
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Today, the service owns and operates 28 fixedwing aircrafts out of 13 bases and is linked by 2,200 outstation transceivers. Monthly visits are made to isolated communities with small nursing-type hospitals. Early radios were pedal-powered Morse code equipment. The Flying Doctors truly have been a concurrent development of aircraft, radio, and medical technology. This is assisted by a standard wooden medical chest or “bush pharmacy” at each outstation. Medical calls held at 10 a.m. and 3 p.m. daily provide often the only contact between isolated families on a remote outback station and their neighbors a few hundred miles away as well as access to the “School of the Air” for their children. Transceivers at the Base Station are never closed. At the beginning of each morning’s medical report a nursing sister who has made rounds in the base hospital in Alice Springs advises family members (and listening friends) as to patient progress. A radio clinic follows where general physicians or consultants provide guidance to nursing sisters or directly to patients hundreds of miles away. The consultant may be in his home, the hospital, his aircraft, or at an outstation. All listen in and thereby gain education in medical care. The types of flights are (1) emergency, (2) mercy, a life and death situation that calls for compromises in normal air safety standards, or (3) clinic flights. About 23,000 radio consultations are held each year and more than 65,000 patients are attended by Flying Doctors. The 1980 budget of more than $7 million remarkedly indicates that each patient flight service prorates to about $100. In addition to emergency care, ophthalmologists voluntarily fly scheduled missions for eye clinics. FINANCIAL MEDICINE
FACTORS
IN AUSTRALIAN
Australian medical schools and hospitals are currently being subjected to two restraining factors. First is a reduction in the actual numbers of medical students in training as well as a reduction of registrars’ positions in many specialties. Second is a general cutback in federal funding for medicine. Particularly, the umbilicated institutions of established and traditional medical schools are coping with budget reduction under terms such as “rationalization” of funding. For example, the sprawling 400bed Royal Alexandra Hospital for Children in Sydney, which has been growing each year since its opening in 1879, withstood in its centenary year a budget reduction of $1.96 million with obligations to close 30 occupied beds in the hospital and transfer 30 convalescent beds elsewhere; at the same time, inpatient population increased 5% compared to the previous year and length of stay fell from 6.2
KEENEY to 5.9 days. Every hospital and medical school labors each year in what is almost a bargaining confrontation with the Health Commission and seeks concurrently to augment its private support. OPHTHALMIC
RESEARCH
IN AUSTRALIA
Approximately 0.2% of the health budget of Australia is directed to research. Basic science schools (departments) in most of the ten faculties of medicine have ongoing laboratory research. Most major hospitals with teaching programs have published commitment to investigation. For instance, the Children’s Medical Research Foundation, initiated by the late Sir Lorimer Dodds on the grounds of the Royal Alexandra Hospital for Children (Sydney) and now directed by Professor Peter Rowe, has independent research endowments of approximately $6 million and supports 10 or 12 research fellows including the Norman Gregg Research Fellow. Investigative reports in Australian medicine stem from clinically related subjects several-fold more frequently than from basic laboratory studies. However, pride in two Nobel Laureates, Sir John Carew Eccles (1963) and Sir Frank MacFarlane Burnet (1960), is apparent in every research program. Australia’s National Health and Medical Research Council, a mini-edition of our N.I.H., currently underwrites approximately $20 million a year in competitive research grants (this is about l/l 0 the annual appropriation for the Commonwealth Scientific and Industrial Research Organization). Funds are not subdivided categorically but rather all applicants compete with each other. The Institute ofAviation Medicine (at the RAAF Academy in Melbourne), under the direction of Wing Commander Paul Shumack, M.D., has heavy concerns with visual aspects of flying and aviation medicine. A very small full-time staff, however, is expected to accomplish research as part of its usual duties and receives only $20 titular funding for any given research undertaking. For capital equipment, application is through Air Force channels and competes with all capital needs. Private industrial resources, at times, support research programs in aviation medicine similar to the way in which pharmaceutical and equipment producers support university research. Both ultimately aspire to recommendation, adoption, or sale of related products. In the early 1930s the major opticianry, Ophthalmic Prescription Spectacle Makers (OPSM), began a program uniquely supportive of ophthalmology. For several decades they would manufacture only on the prescription of an ophthalmologist. In recent years, this policy has been widened but OPSM has regularly supported eye research and in the early 1960s donated $150,000 toward an endowed chair
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for the professor ofophthalmology at the University of Sydney. The University provided the remainder of the funds. OPSM has also been scientifically supportive of patient needs in contact lenses by many different formats with ophthalmologists. They have become one of the nation’s largest providers of industrial safety gear including head, face, and respiratory protecting devices. Subsidiary companies in industrial safety are Surguard and Protector, both headquartered in Sydney. In 1978, OPSM established a Research and Charitable Foundation with an initial endowment of $500,000 (Australian) to provide funds for ophthalmic research within universities and teaching hospitals throughout Australia. In Adelaide a similar Pank Ophthalmic Trust was founded for ophthalmic research. The Ophthalmic Research Institute of Australia was estabalished in 1952 with a $300,000 endowment from an anonymous donor, to finance research in any ophthalmic program of the nation. This has strengthened both academics and Prevention of Blindness units. Capital assets of three-quarters of a million dollars (Australian) have been accumulated and about $100,000 (Australian) was available for direct research support in 1983. Specific yields from this program are the retino-vitreal surgical instruments and COMMIDO spectacle mounted examining instruments of Professor Crock, new insights on the natural history of drusen as predictors and accompaniments of macular involution developed by Shirley Sarks, and the research into angle closure glaucoma by Ronald Lowe. These funds supplement other private resources such as the Denise Appeal Trust. Unique support comes from many women’s bowling groups (e.g., New South Wales Women’s Bowl for Others Club). Further, the Lions, Kiwanis, and the Rotary Clubs are strong supporters of ophthalmic education, research and service. At The Royal Victorian Eye and Ear Hospital, the “Eye, Ear, Nose and Throat Research Institute” is a vehicle to receive donations and tender support to investigators within their Melbourne hospital. At the “National Vision Research Institute” in Melbourne, both structurally and ideologically a wing of the Department of Optometry, there is tinancial support currently of about $500,000 a year from the National Health and Medical Research Council. Subjects range from cat histology and “developmental vision” to more optometrically related studies of contrast perception and temporal relation among stimuli. Uniquely accomplishing ophthalmic research has been long ongoing in the capital of Canberra at the
John Curtin School of Medical Research, one of seven schools which constitute the Institute of Advanced Studies at the National University. The University was created by parliamentary enabling act in 1946 and began to blossom in postgraduate research in the early 1950s. Undergraduate teaching was added in 1960. Graduate programs enroll about 1,000 students and undergraduates now number more than 4,000. Among the 10 departments at the John Curtin School, the Department of Physiology headed by Peter 0. Bishop, M.B.B.S., F.R.S., (formerly at the University of Sydney), devotes its entire energies to basic neurology of sight. Dr. Bishop has carried the Department forward as successor to Sir John C. Eccles, Nobel Prize winner in neurologic studies in the same laboratories. Dr. Bishop and a senior colleague, W. R. Levick, M.B.B.S., M.Sc., keep about 20 projects operational in eight major laboratories all of which are well equipped. With the assistance of approximately a dozen research fellows, this Department is an international center in neurologic and psychophysical aspects of vision and its cortical relations. Approximately 25 former students now hold professorial appointments throughout the world. Among Bishop’s graduates are Associate Professor Jonathan M. Stone, Ph.D., visual neuroanatomist in the School of Anatomy, University of New South Wales, and Professor Ronald Penny in immunology of uveitis at St. Vincent’s Hospital, Sydney. The Department is well funded by a budget through the parent university. There is also modest additional foundation and grant support in which the Lions have again been active. As part of the intensified commitments to academics, the Australian Academy of Science was founded by Royal Charter from Queen Elizabeth in 1954, in parallel to our National Academy of Sciences. Of the approximately 200 fellows, a few have earned medical degrees like Nobel Laureate, Sir MacFarlane Burnet, but there is no medical section in the Academy. Nine new fellows may be elected each year. The Academy is handsomely housed under an oval copper dome with 16 supporting points curving from the roof to the ground in a perfect circle. Though the construction was entirely financed by private donations, the federal government now supplies about half the operating costs to the Academy. PROFESSIONAL ORGANIZATIONS
OPHTHALMIC
The oldest Australian ophthalmological society was established in the colony of Victoria in 1899.” This was modeled on the Ophthalmological Society ofthe United Kingdom. As an expression ofAustra-
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lian unity the Ophthalmological Society of Australia was founded in 1938 subsequent to a proposal at the British Medical Congress of 1937 held in Adelaide. Sir James Barrett, “as a matter of course,” became its first president. He was the indisputable chancellor of the University of Melbourne and though he had passed his seventy-fifth birthday in 1938 was still active in nearly two dozen national committees and served as senior officer for half of them. The distinguished roster of past presidents includes Sir Norman Gregg ( 1944-45) and Joseph Ringland Anderson ( 1945-46). The Society became more clearly an arbitor of its own membership by elevation to the role of “Australian College of Ophthalmologists” in 1969. Qualification examinations and censure became formalized through the “college” organization. Again with extensive preparation, the title “Royal” was added by grant of Queen Elizabeth in 1977; it then became a colleague of the Royal Australasian College of Surgeons and joined a sibship of colleges in other specialties. ’ Necessarily close liaison exists between the Royal College, the curriculum of the medical schools, programs for registrars in ophthalmology, and registration as a practitioner.
In constraint of mercantilism, the College maintains a prohibition of Fellows engaging in the merchandising of spectacles, medications, and devices. A similar position was historically held though with less enforceability by the antecedent Society. This professional stance against merchants in ophthalmology was assisted from the early 1930s by the major opticianry program of the Ophthalmic Prescription Spectacle Manufacturers (OPSM). This has supported professionalism in ophthalmology, and OPSM continuously flourished to become the largest dispensing optical organization in Australia.
References 1. Hollows FC (cd): TheNational Trachomd B Eve Health Program oj‘the Ro_valAustralian College of Ophthalmologists. Sydney, RACO, 1980 2. Lowe RF: Early Melbourne Eye & Ear Hospitals. Austr Ne’erel Zea J Surg 50:5+&549, 1980 3. Lowe RF: Ophthalmological Society of Melbourne. dust. J Ophthalmol R:257-270, 1980 1. Royal Australian College ofOphthalmologists (editorial). .MedJ. .4ust 2:347-48, 1977
Reprint requests should be addressed to Arthur H. Keeney, M.D., D.Sc.. University of Louisville, School of Medicine, Department of Ophthalmology, 301 E. Muhammad Ali Blvd., Louisville, KY 10202.