Pediatric ophthalmology in Australia

Abstract

A ustralia is a modern and prosperous Western country of some 20 million people. Although Australian culture has traditionally been British, immigration during the last 50 years has changed the cultural and social milieu, and Australia is now a successful multicultural European and Asian society. The main cities are Sydney (population of 4 million) and Melbourne (population of 3 million), and three other cities each have a population of more than 1 million. To gain entry into one of Australia’s 10 medical schools, students must achieve extremely high marks in the final year of high school. The medical course lasts 6 years plus 1 year of compulsory internship, but some programs last 5 years with 2 years of internship. An increasing number of medical schools now accept graduate students who perform well on a nationally administered examination and who complete a 5-year course. After completing medical school and a compulsory year of internship, aspiring ophthalmologists typically spend 2 or 3 more years in hospitals on medical and surgical rotations before competing for admission to the 5-year ophthalmology training program. This process is supervised by the Royal Australian and New Zealand College of Ophthalmologists. Most primary eye care is provided by optometrists and family doctors who refer patients to an ophthalmologist if appropriate. General ophthalmologists are widely distributed and probably perform the majority of pediatric ophthalmology and strabismus care for their communities. Ophthalmologists with recognized training in pediatrics or strabismus are less accessible and in general are associated with the larger institutions in sizeable cities. Most optometrists treat children, and a small number practice as dedicated pediatric optometrists. Two orthoptic schools produce graduates who usually work in an ophthalmologist’s office in much the same capacity as an ophthalmic technician does in the United States (rather than in classical orthoptics). Complex financial and legislative arrangements involving federal and state governments exist for funding and administering health care in Australia. Medicine is practiced both in the private fee-paying sector and in government funded “free” facilities, and there is much overlap between the private and government sectors. Teaching hospitals are mostly in the state government sector, and it is here that undergraduate and postgraduate medical training takes place and professional prestige resides. The government sector is largely staffed at the senior level by part-time attending consultants who spend most of their time in private practice. Most of the population undergoes surgery performed at no cost in state government facilities, and all are eligible to use these facilities. Despite the universal availability of these free services, approximately 40% of the population has private insurance that pays for private hospital care. The federal government subsidizes 30% of such insurance to make it more affordable. Some 50% of consultation and surgical fees in private practice are subsidized by the federal Medicare scheme. Pharmaceuticals are subsidized by a different national federal government scheme with a small “top up” (partial recompense for out-of-pocket costs) available from private insurers. Doctors have the right to charge whatever fees they like; however, there is considerable pressure to adhere to recommended fees. If doctors charge only recommended fees, then insured patients have no copayments. However, remuneration for strabismus consultations and surgery is poor when compared with remuneration for, say, cataract treatment. Pediatric ophthalmology and strabismus developed in Australia as separate clinical and intellectual streams modeled more on the European rather than the American approach. Strabismus has developed in association with eye hospitals (Melbourne and Sydney each have a freestanding one) and pediatric ophthalmology in association with children’s hospitals. Each large city has an ophthalmology department as part of the children’s hospital. Before the 1970s, these departments were staffed by general (adult) ophthalmologists with an interest in pediatric ophthalmology. Prominent historical figures included Sir Norman Gregg, who in the 1960’s recognized the ophthalmic and nonophthalmic features of rubella embryopathy. He shared the Encyclopedia Britannica award for medicine with Dame Kate Campbell of Melbourne, a pediatrician who in 1951 showed that advanced retinopathy of prematurity (ROP) was linked to oxygen toxicity. In 1969, Frank Bilson headed the clinic at the Royal Children’s Hospital in Melbourne where he introduced the indirect ophthalmoscope and the operating microscope to Australian pediatric ophthalmology. Subsequently, he was appointed Professor in Sydney in the late From the Ocular Motility Clinic,a Royal Victorian Eye and Ear Hospital, East Melbourne, and the Department of Ophthalmology,b University of Melbourne, Victoria, Australia. Submitted April 29, 2003. Revision accepted May 21, 2003. Reprint requests: Lionel Kowal, FRANZCO, Private Eye Clinic, 19 Simpson St, E Melbourne, Victoria, Australia, 3002. Copyright © 2003 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2003/$35.00 0 doi:10.1016/S1091-8531(03)00184-8