new m.d.
Ophthalmology: Australian Style

Recently, we had a big day here in Melbourne. The city again came to a grinding halt, as it has the first Tuesday of November since 1861. It was a public holiday, and people of all shapes and sizes "frocked up" and made their way to the racetrack for the beloved Melbourne Cup horse race. It was a celebration characterized by a peculiar mix of tradition, sport, fashion and excessive consumption of alcohol — a unique combination which I fondly recognize as "Australian." Events like these highlight the differences between this distant continent of 20 million people from an American culture which is far more familiar to me. It is the day-to-day differences encountered in the hospital that make this year of training gratifying, insightful and fascinating.  

Antibiotics Used Sparingly

As a cornea fellow, treating bacterial keratitis at times can become mundane and prosaic. What makes this endeavor easier, and far different from back home, is the relative paucity of microbial resistance. Antimicrobials are guarded and utilized judiciously with far more discretion than at home, and when prescribing a medication such as ofloxacin, a call to the authorities in Canberra to obtain authorization is compulsory.

Because of these regulations, it is rare to come across patients who have been started on potent antibiotics inappropriately for things such as "a red eye." Moreover, it is not the standard of care to prophylax cataract patients with a quinolone prior to or following surgery. Because of these differences in prescribing practices, it is exceptionally rare to come across organisms resistant to some of the older agents, such as ofloxacin or ciprofloxacin, obviating the need for even more potent and expensive agents such as gatifloxacin and moxifloxacin. I found the circumspect use of antibiotics a considerable contrast to my experience back home in the states.

Another striking difference to the United States is the widespread use of the topical antibiotic chloramphenicol. It is not the most effective antimicrobial, and only has bacteriostatic activity, but in Australia, it is used extensively and is adequate for post-cataract antibiosis. In fact, this inexpensive medication is safely utilized as a topical agent throughout the world. Its lack of availability in the United States is puzzling. It is hard to believe that its absence is solely due to the irrational fear of the rare complication of aplastic anemia; the cases reported in the literature from the topical use of this medication are unimpressive. Perhaps there were other forces at work prohibiting the availability of this inexpensive medication, opening the door to other, more expensive agents. Whatever the reason, to me, it is yet another example of our grossly inefficient system, where we spend far more money per capita on health care than any other country, yet are unable to offer basic healthcare to all of our citizens.

Pleasant Working Conditions

I wasn't surprised to find my new colleagues in Australia, whether attending or resident, ophthalmologist or neurologist, as a whole, a good-natured and affable bunch. Australians in general have that reputation. I'm not sure what it is, but I am starting to believe that we physicians in the United States are just a crankier group of people. Is that possible? Perhaps it is because docs in Australia do not have to quarrel with insurance companies. They simply bill their patients whatever fee they feel is reasonable, and it's the patients' responsibility to get reimbursed by their insurance carrier, meaning far less hassle for physicians. Perhaps the residents are a pleasant bunch because they work reasonable hours, are well compensated and get twice as much vacation as their counterparts in the States. It's impressive what unionization has done for them.

The provision of health care in Australia is different than what I have been accustomed to, and these differences have added a new dimension to my training. They offer insight into the practice of medicine and an alternative view. Having the day off for the sake of a horse race seemed pretty odd to me, but having the day off to celebrate the birthday of the queen is something else.

Howard Amiel, M.D., is a fellow at the Royal Victorian Eye and Ear Hospital in Melbourne, Australia. His e-mail is howard_amiel@brown.edu.