Volume 177 Issue 1

A good screening tool seems to offer the best hope, but meanwhile best possible care includes definitive staging and surgery by experienced specialist teams Ovarian cancer is the leading cause of death from gynaecological cancer in Australia, and indeed most Western countries. In the absence of effective primary prevention strategies and screening for early disease, the best possible management of patients with suspected or established ovarian cancer assumes critical importance if inroads are to be made in reducing morbidity and mortality from this disease. In this issue of the Journal (page 11), Grossi et al have reviewed the management of women with ovarian cancer diagnosed in Victoria during the period 1993 to 1995.1 Despite methodological difficulties with research of this type in terms of accurately defining variables such as stage and residual disease, the study is valuable for reflecting what actually happens in everyday clinical life. It shows that more than one in five patients did not undergo a laparotomy, which is required both to make a definitive diagnosis and to adequately stage the disease. Furthermore, a large proportion of patients with this disease are treated by specialists who are not specifically trained in gynaecological oncology, or are treated outside major teaching institutions. This problem is by no means confined to Victoria or indeed Australia. In a recent review of patterns of care of patients with ovarian cancer in the United States, Carney et al found that, of 848 patients with epithelial ovarian cancer, only 333 (39.3%) were seen (not necessarily treated) by a gynaecological oncologist "at some time during their cancer diagnosis and/or treatment".2 The situation in Victoria, as reported by Grossi et al, compares favourably with the US experience. However, both studies clearly demonstrate that significant change is required if women with this kind of gynaecological cancer are to receive the best possible treatment. The Victorian survey suggests that triage of patients to appropriately staffed and equipped gynaecological cancer centres is inadequate. In some measure this may be the result of the relatively low number of patients who had imaging (such as ultrasound) and tumour marker studies (such as carcinoma antigen [CA] 125). These investigations are important in patients who present with a pelvic mass, as, if they suggest a significant risk of malignancy, appropriate referrals can be arranged. This issue is especially important, as Grossi et al have shown that less adequate surgery adversely affects outcomes. Somewhat disturbing is the finding that, even in the hands of trained subspecialist gynaecological oncologists, fewer than half of the patients with apparently early disease had adequate staging performed. For women with early-stage disease the outlook is excellent, and every effort should be made to perform adequate surgery so as to avoid overtreating those whose outcome is not improved by adjuvant chemotherapy and to select those who might benefit from additional therapy. Epithelial ovarian cancers may occur in young women, and in many cases it is possible to both adequately treat the cancer and preserve reproductive function.3 Also revealed by the Victorian survey is the apparent inadequacy of cytoreductive surgery, even when performed by subspecialist gynaecological oncologists. Although residual disease did not appear to be significant in the Victorian survey, other studies have shown that the amount of residual disease at the end of cytoreductive surgery has a major influence on survival,4 and it is accepted that every effort should be made to "debulk" the tumour to the minimum size possible. This can require major resection of bowel or other organs and it can be a formidable undertaking for both the patient and the treating team. Such extensive surgery should only be performed by appropriately trained teams in major centres. Many gynaecological oncology centres both in Australia and overseas report rates of "optimal debulking" of over 70%.5,6 The article by Grossi and colleagues demonstrates that it is a major challenge to ensure that patients with ovarian cancer have timely access to these facilities. What else can be done to improve the outcome for women with ovarian cancer? Ultimately, prevention would be the ideal solution. For women with familial forms of ovarian cancer appropriately timed oophorectomy may offer a high degree of protection. However, for most women, the development of a reliable and acceptable screening method to detect early-stage disease offers the best hope. Currently, there is no acceptable screening method available, but some studies using CA125 and transvaginal ultrasound as screening tools have shown promise.7 A number of large international trials are currently under way to determine if screening will have a significant impact on the mortality of this disease.

Anthony M Proietto BSc(Med), MB BS, FRANZCOG, CGO

No one, least of all nursing-home staff, likes to see people in pain Most older people, despite limitations, live happy and active lives. Only a small proportion of them — those with major disabilities and complex medical needs — spend their final days in nursing homes. While these residential facilities may aspire to provide quality care for their residents, there are important gaps. As McClean and Higginbotham point out in this issue of the Journal (page 17),1 one such deficiency is in recognising and managing chronic pain. Disability in older people is still substantial and the trend for compression of morbidity (ie, a reduction in mortality accompanied by a greater reduction in morbidity, resulting in a longer life with more disability-free years) seen in some countries in the past 10 years has, regrettably, been less marked in Australia.2 Chronic pain can be an unfortunate consequence of several degenerative diseases associated with ageing, such as vascular insufficiency, sensory neuropathies, osteoarthritis, osteoporosis, spinal stenosis and vertebral collapse. Such conditions, and the suffering they cause, are major contributors to disability. While older women enjoy greater longevity than men, a disadvantage of their longer lifespan is increased susceptibility to these chronic, disabling, painful diseases. Depression and poor psychological adjustment are also more prevalent in older people who are in pain.3 Moreover, depression appears to heighten the suffering caused by pain.4 Predictably, the prevalence of chronic pain is high among nursing home residents. The Standards and guidelines for residential aged care services manual (Standard 2.8)5 drew specific attention to the need for nursing homes to develop policies and practices to assess and manage chronic pain in nursing home residents. As McClean and Higginbotham show, pain is still underdiagnosed and undertreated, despite these guidelines. Their survey of nursing homes in New South Wales revealed that for many residents who reported being in pain there was no history of pain recorded in their case notes. Furthermore, dialogue with residents about pain was often suboptimal or non-existent, and a substantial number of patients had inadequate pain relief. No one, least of all nursing-home staff, likes to see people in pain. We know that pain prevalence is high in this population, so why are we still failing to discern it? One possible reason is a lack of knowledge about geriatric pain. Undergraduate programs often devote little time teaching about geriatric pain management.6,7 Another probable reason is simply that medical and nursing staff fail to enquire adequately about pain8 or are too busy to spend much time with individual patients. Some staff dismiss pain that does not seem to have an identifiable medical reason and thereby underestimate personal suffering.9 Elderly people themselves often minimise their own pain, putting it down to "getting old",10 and stoically suffer in silence, not wanting to be "a bother". McClean and Higginbotham's study focused on residents' self-report in addition to caregivers' observations, and they rightly point out that deeper probing may have yielded even higher pain prevalence. The authors specifically looked at patients who could communicate about pain, but excluded the 40% of patients who could not. The prevalence of undetected pain is likely to be even higher among people who cannot communicate their pain than in people who can. The prevalence of pain ascertained by McClean and Higginbotham was lower than the rate found in some other studies, but this finding is no excuse for complacency. Although the guidelines may have helped to increase awareness of pain among nursing home residents, it is clear that we are still failing to achieve high-quality pain management. Pain is composed of a sensory component (nociception), a cognitive–affective component that causes the patient to suffer, and a communicative component that expresses the pain to others verbally and/or by pain-related behaviours. Effective pain management needs to assess and manage all these components. Contrary to popular opinion, ageing does not decrease nociception or suffering.11 However, patients with dementia do have less sophisticated ways of communicating pain. While nociception and suffering may be no less in patients with dementia, subjective report is certainly less, and behavioural change may be the main indicator of distress.12 It is essential that anyone working with older people become expert at observing and interpreting visual cues and behavioural indicators of pain.13 Often caregivers put older patients' behavioural changes down to perverseness, personality, or attention-seeking rather than entertain the possibility of pain.5 Frequently, the first-line treatment is antipsychotics or benzodiazepines, drugs that can mask a pain problem or make it worse. As McClean and Higginbotham found, many patients reporting pain had inadequate or irregular analgesia. Had the study included the non-communicating group, it is possible pain treatment in the nursing homes surveyed would have been found even more deficient. Many doctors are reluctant to give analgesics, particularly opioids, to older people. They worry that these powerful drugs may be addictive, produce dangerous side effects, or cause constipation, falls or delirium. Certainly, ageing brain and organ systems are sensitive to opioid analgesics, but withholding them from people in need can have the paradoxical effect of making management even more difficult if patients are behaving in a very uncooperative manner. Most of these drugs are safe if they are sensibly prescribed and the patient is regularly monitored for side effects. Not all patients need strong opioids and many would benefit from milder analgesics. Too many older people have "as required" medication, which is the least effective method to attain adequate blood levels of analgesic. A mild analgesic, such as paracetamol, given regularly in sufficient doses, is safe and effective even in very elderly polymedicated patients.14 Overall, the literature on pain treatments for the elderly is deficient and the area deserves more research attention. Why is it important to address this issue? For the simple reason that chronic pain is unnecessary. Work in palliative care has shown that pain can be correctly identified and effectively managed. The Australian guidelines recommend using pain-assessment tools to ascertain pain.5 While these may be useful, there is no substitute for greater awareness, direct enquiry, clinical intuition, and commitment to alleviate pain whatever its intensity. Evaluating pain in older people may be challenging, but alleviation of another's pain and suffering can be deeply gratifying. Yes, with more focus on the problem, we can improve pain management in our nursing homes.

Pamela S Melding MBChB FFARCS FRANZCP

Improving health outcomes for women with this enigmatic disease Endometriosis remains an enigma despite having been extensively studied. Its aetiology remains unclear, although there is a positive correlation with retrograde menstruation, probably with a background genetic predisposition. Traditionally, the symptoms of endometriosis are said to be pelvic pain and infertility, but, while a causal link between these symptoms and the disease is sometimes clear, the link is not always established. Treatment aimed at eliminating endometriotic deposits is effective in controlling symptoms in a proportion of patients, but recurrence is common. The diagnostic dilemmaEndometriosis is considered difficult to diagnose because the extent of the disease (endometriotic deposits and scar tissue) does not correlate with symptoms. The only accepted diagnostic test is direct visualisation (usually laparoscopically) by an experienced surgeon.1 Arguably, as endometriosis can be diagnosed in up to 40% of menstruating women at laparoscopy,2 it may be detected in all women at some stage of their reproductive lives, only to regress spontaneously in some. In addition, some symptoms associated with endometriosis are common. For instance, dysmenorrhoea occurs in up to 60% of women with regular menses3 and infertility occurs in about 15% of the population (of whom 30% have endometriosis).4 Hence, common conditions (mild endometriosis) may be associated with common symptoms (eg, dysmenorrhoea) by chance, not causally. The enormous variation in symptomatic expression and lack of clear correlation with the extent of endometriosis suggest the need for epidemiological studies of each symptom and of women with either mild or severe disease. This would exclude the possibility that mild endometriosis may be a normal finding in women. Epidemiological studies of women with endometriosis associated with dysmenorrhoea may find a causal link only in women with progressive dysmenorrhoea. In addition, epidemiological studies confined to specific symptoms causally associated with endometriosis (eg, dyspareunia and endometriosis in the uterosacral ligaments, progressive dysmenorrhoea and American Fertility Society stage III and IV endometriosis5) may result in consistent findings of the role of genes in disease development. 6 Management issuesFrom observations that pregnancy resolves symptoms, particularly of dysmenorrhoea, "mimicking pregnancy" became a treatment option. Medications that resulted in amenorrhoea (such as GnRH analogues, danazol and high-dose progestogens) have been used. These work by antagonising the growth-promoting effect of oestrogens or reducing the oestrogenic stimulus for growth, as well as increasing apo-ptosis. Each of these medications has been shown in a recent Cochrane meta-analysis of randomised controlled trials to be equally effective in control of dysmenorrhoea, dyspareunia and pelvic pain, and in decreasing the bulk of endometriotic tissue.7 However, the follow-up period in these trials was usually only three to six months. Annual recurrence rates of endometriosis after treatment are generally accepted to be of the order of 10%.8 Hence, further trials with longer follow-up, and possibly comparisons with the oral contraceptive pill (which has a better side-effect profile than the other drugs), in three-monthly cycles, would be beneficial. That medical therapies are not effective for infertility associated with mild endometriosis has been well established in large-scale, randomised controlled trials.9 Another Cochrane review showed that laparoscopic ablation or excision of the endometriotic tissue is effective in treating endometriosis associated with pelvic pain. However, this conclusion was based on one randomised controlled trial10 and further trials are needed to confirm this finding. Similarly, further evidence to support the effectiveness of laparoscopic surgery for subfertility associated with endometriosis is needed to support the beneficial finding in one randomised controlled trial. This is the aim of a protocol developed by the Cochrane Library.11 While the above conclusions are based on Cochrane reviews of the best available evidence, doubt remains. All trials are subject to a chance of showing a real effect when there is a probability that there is no effect. Continued development of well conducted randomised trials will reduce the probability of an incorrect conclusion. In addition, expert opinion based on the current extensive body of literature, and taking into account the basic mechanisms of the disease process of endometriosis, will help distinguish the causal relationship between each symptom associated with endometriosis. In turn this would lead to improved clinical outcomes for patients with associated dysmenorrhoea, chronic pelvic pain, dyspareunia and infertility. It is argued that current evidence for effective treatment of each of the symptoms associated with endometriosis could be further improved by further randomised controlled trials with clearly defined patient groups (eg, chronic pelvic pain in association with mild endometriosis, in-vitro fertilisation for three to five years of infertility associated with mild endometriosis). In addition, if results of epidemiological studies show no probable causal link between endometriosis and dysmenorrhoea then therapeutic regimens targeted at both symptom relief and monitoring progression of the disease may be more efficacious than excision of endometriotic tissue alone. While many of our current treatment regimens are effective in some patients, continued improvement in long term health outcomes for women with endometriosis requires a mindset open to critical evaluation.

Kevin L Forbes MB BS, FRACOG

Objective: To describe the management of and outcomes in patients with newly diagnosed ovarian cancer during 1993, 1994 and 1995 in Victoria.Design and setting: Retrospective cohort study conducted by surveying doctors involved in managing incident ovarian cancer cases identified from the population-based Victorian Cancer Registry. The survey was conducted in 1997 and the cohort was followed up until the end of 1999 to obtain at least four years of follow-up data on all patients.Patients: All women with invasive epithelial ovarian cancer diagnosed during 1993, 1994 and 1995.Main outcome measures: Reported management in terms of staging, treatment and survival.Results: Management details were obtained for 84.5% (562/665) of eligible patients. Median age at diagnosis was 66 years (range, 22–98 years). Surgery was the primary therapy in 77.2% of women (434/562). Only one in three women had adequate surgery, which was less likely to be performed by general gynaecologists and general surgeons than gynaecological oncologists (21.3% [35/164] v 13.3% [8/60] v 52% [105/202]). After surgery 78.6% of women (341/434) received chemotherapy, usually with platinum-based regimens. The overall five-year relative survival was 46% for women treated surgically; poor survival was related to increasing age, later tumour stage, presence of ascites, residual disease > 2 cm and poorer histological differentiation of the tumour.Conclusions: For optimal care a preoperative carcinoma antigen (CA)-125 assay, chest x-ray and pelvic ultrasound should be performed, and early referral to a multi-disciplinary unit for definitive surgery is advised. Every effort should be made to adequately stage or debulk the tumour. Women with high-risk early-stage and advanced disease should be considered for platinum-based chemotherapy.

Marisa Grossi MB BS, FRACP · Prudence A Francis MB BS, FRACP · Michael A Quinn MB ChB, MGO · Robert M Rome FRCS(Edin), FRANZCOG · Robert S Planner MB BS, FRANZCOG · Vicky J Thursfield BSc, GradDipApplStat · Graham G Giles MSc, PhD

Objective: To measure the prevalence of pain among residents of rural and regional nursing homes in northern New South Wales and to describe the procedures used for pain management.Design: Cross-sectional survey using interviews and audit of medical records.Setting and participants: 917 nursing home residents in 15 nursing homes within a northern NSW area health service in 1998–1999.Main outcome measures: Number of residents experiencing pain at the time of interview; sites of pain and magnitude of pain problem; diagnoses relevant to pain; analgesic prescribing patterns; non-pharmacological treatments for pain; and the extent of pain documentation in nursing records.Results: The prevalence of pain present at interview was 27.8% (95% CI, 21.8%–33.8%). Women reported pain more often than men (31% v 21%; χ22 = 5.38; P = 0.02), but pain was not significantly associated with age, length of stay, or diagnoses of arthritis or dementia. Common sites for pain were the limbs, joints and back; 22% of residents reporting pain had no record of analgesic medication, and 16% had had no form of pain treatment ordered. Agreement between the nursing record and the residents' pain symptoms was borderline poor/fair (κ, 0.24).Conclusions: The prevalence of pain is high among nursing home residents in rural NSW who are able to communicate their pain. Descriptive data suggest that pain management activities could be substantially improved.

William J McClean MB BS, MMedSci, FRACP · Nick H Higginbotham PhD

Objectives: To examine the prevalence of psychotropic medication use by children with attention-deficit/hyperactivity disorder (ADHD) and children without ADHD. To identify factors associated with stimulant use by children in the community.Design: A representative, multistage probability sample of Australian households was conducted in 1998. Parents completed questionnaires assessing children's mental health problems and health-related quality of life. They also completed a structured interview to identify children's psychiatric disorders and their use of medications during the previous six months.Participants: Parent or main caregiver of 3597 children aged 6–17 years.Main outcome measures: Rates of use of stimulants (dexamphetamine and methylphenidate), antidepressants and clonidine by children.Results: Overall, 1.8% of children (95% CI, 1.5%–2.3%) were receiving stimulant medication. Of those with ADHD, 12.6% (95% CI, 9.8%–16.1%) were being treated with stimulants, 2.3% (95% CI, 1.3%–4.3%) with antidepressants, and 1.9% (95% CI, 1.0%–3.7%) with clonidine. Among children without ADHD, 0.5% (95% CI, 0.3%–0.8%) were receiving stimulant medication. This represented 22.9% (95% CI, 14.6%–34.0%) of all the children who were receiving stimulants. Variables significantly associated with stimulant use were being male, having ADHD, attending a paediatrician, and having higher scores on the Aggressive Behaviour and Attention Problems scales on the Child Behaviour Checklist.Conclusions: About 13% of Australian children with ADHD, and a substantial number of children without ADHD, are taking stimulants. The question of whether Australian children are being undertreated or overtreated with stimulant medication depends on the criteria used to assess the appropriateness of stimulant use. Additional information is needed to clarify when stimulants should be used to treat ADHD.

Michael G Sawyer MB BS, PhD · Brian W Graetz MPsych (Clin) · Jennifer J Clark BA(Hons), DipEd · Peter A Baghurst PhD · Joseph M Rey MB BS, PhD

Objectives: To determine (i) factors which predict whether patients hospitalised with acute myocardial infarction (AMI) receive care discordant with recommendations of clinical practice guidelines; and (ii) whether such discordant care results in worse outcomes compared with receiving guideline-concordant care.Design: Retrospective cohort study.Setting: Two community general hospitals.Participants: 607 consecutive patients admitted with AMI between July 1997 and December 2000.Main outcome measures: Clinical predictors of discordant care; crude and risk-adjusted rates of inhospital mortality and reinfarction, and mean length of hospital stay.Results: At least one treatment recommendation for AMI was applicable for 602 of the 607 patients. Of these patients, 411(68%) received concordant care, and 191 (32%) discordant care. Positive predictors at presentation of discordant care were age > 65 years (odds ratio [OR], 2.5; 95% CI, 1.7–3.6), silent infarction (OR, 2.7; 95% CI, 1.6–4.6), anterior infarction (OR, 2.5; 95% CI, 1.7–3.8), a history of heart failure (OR, 6.3; 95% CI, 3.7–10.7), chronic atrial fibrillation (OR, 3.2; 95% CI, 1.5–6.4); and heart rate ≥ 100 beats/min (OR, 2.1; 95% CI, 1.4–3.1). Death occurred in 12.0% (23/191) of discordant-care patients versus 4.6% (19/411) of concordant-care patients (adjusted OR, 2.42; 95% CI, 1.22–4.82). Mortality was inversely related to the level of guideline concordance (P = 0.03). Reinfarction rates also tended to be higher in the discordant-care group (4.2% v 1.7%; adjusted OR, 2.5; 95% CI, 0.90–7.1).Conclusions: Certain clinical features at presentation predict a higher likelihood of guideline-discordant care in patients presenting with AMI. Such care appears to increase the risk of inhospital death.

Ian A Scott FRACP, MHA · Catherine M Harper BSc, MPHTM

Objective: To evaluate adherence to an agreed minimum dataset for patient medication information exchange between hospitals and general practitioners.Design: Quasi pre–post design with a supplementary post-program comparison group; sequential descriptive surveys of patients following recent discharge from public hospitals; opinion questionnaire for key hospital informants; stakeholder forum to review data and Quality Use of Medicines (QUM) action plans between pre- and post-program surveys.Participants and setting: GPs and hospitals from the South East Area Health Service, Sydney. During 2000–2001, 81/124 GPs (65%) returned 147 patient questionnaires in initial follow-up; 88/119 GPs (74%) returned 131 questionnaires in final follow-up; a supplementary group of 54/120 GPs (45%) returned 66 questionnaires; 32/45 (71%) of nominated key informants responded to the hospital survey.Results: Direct notification of GPs by hospitals of their patient's admission was unchanged from the initial level of 22%. The proportion of GPs providing medication information to the hospital increased from 38% to 51% at Stage 2 (P < 0.05) and remained at 52% at Stage 3. The proportion of GPs receiving discharge summaries directly (initially 2%) increased to 26% at Stage 2 (P < 0.001) and remained at 27% at Stage 3.Conclusions: System change is slow to occur, but changes that are implemented are maintained. The stakeholder forum suggested that a specific person should be responsible for GP liaison.

Andrea Mant MD, MA · Nicole L Cockayne BSc(Hons) · Linda Kehoe MSc · Karen I Kaye BPharm, DipHospPharm · Wendy C Rotem MA, MHA

Each year many people are killed or injured by lightning due to misinformation and inappropriate behaviour during thunderstorms.1 Analysis of the circumstances surrounding lightning strikes shows that, while there has been a large decrease in the number of lightning casualties in farming and outdoor work, there has been a smaller relative increase in sports-related casualties.2,3 Moreover, with large crowds gathering to participate in or watch an outdoor event, the potential exists for mass casualties to occur from a lightning strike at any one venue. Hence, there is a need to develop specific approaches for lightning safety at sports events. In Australia, fatality rates for lightning strikes have fallen from 0.21 per 100 000 population in 1910–19194 to about 0.01 per 100 000 population in the 1990s. From 1990 to 1999, 23 fatalities were directly attributable to lightning (Australian Bureau of Statistics, personal communication). Furthermore, from 1993 to 1998, lightning was responsible for 95 hospital admissions (Dr R Cripps, Research Centre for Injury Studies, Flinders University, 2001, personal communication). From these figures, we can estimate that the mortality rate from lightning strikes in Australia is currently about 10%. This is below the generally accepted mortality rate of 30%,5 although other authors have reported mortality rates as low as 5%.6 In 1998, the Lightning Safety Group, a group of lightning experts in the United States, developed guidelines for lightning safety,7 which have since been applied to a variety of sports and recreational pursuits.8-11 However, there have been no clear recommendations for lightning safety at events with large numbers of spectators. Our aim is to present specific, practical recommendations to reduce the risk of lightning casualties in outdoor sporting and recreational activities in Australia. General guidelinesThe general guidelines presented here are based on the recommendations made by the Lightning Safety Group and those adopted by the US National Athletic Trainers' Association (Box 1).6,7 Proactive planThe proactive plan should commence on the day before activity, where weather forecasts provide important warning of possible thunderstorm activity.8 Increased awareness of lightning risk should continue on the day of activity until play has finished and the crowd has dispersed. The most basic level of warning involves observation of the weather in the local area. The first flash of lightning or clap of thunder, no matter how far away, should heighten lightning-awareness. The level of risk depends to a large degree on one's location relative to the storm system, which can be determined by the "flash-to-bang" rule (see below). Further useful information can be obtained by liaison with the Bureau of Meteorology <http://www.bom.gov.au>. In recent years, major advances have been made in technology for identifying and locating lightning. In Australia, there is a network of sensors that enable cloud-to-ground flashes to be mapped to within a few hundred metres. Together with other details about local weather conditions, the Lightning Location System can provide real-time displays of lightning strikes and determine the speed and direction of movement of the thunderstorm. This information can be used to estimate the likely future path of the thunderstorms and their probable arrival times at various venues. Chain of commandDuring the formulation of specific lightning safety guidelines, a specific person should be given responsibility for monitoring the weather for signs of a developing thunderstorm. The nominated "weather watcher" should have the authority to postpone the event and have competitors, officials and spectators moved to safe areas. Appropriate people to nominate as weather watchers include the event supervisor, trainers or other medical personnel, or the ground manager. When lightning threatens, the weather watcher is responsible for recognising the danger and activating the lightning protection plan. This should include a signal to the referees and umpires, as well as a method of informing those at risk (ie, players, officials and spectators) of the action required. Safe structures and locationsNo place is absolutely safe from the lightning threat; however, some places are safer than others (Box 1).1,12 It is important to have already identified safe structures and the most appropriate way of moving people into these facilities. The best choice is a large, fully enclosed building. Criteria for suspension and resumption of activitiesThe "30/30" rule is recommended for lightning safety and serves as a guide for the suspension and subsequent resumption of activity.7,13 The first part of this rule (a flash-to-bang count of 30 s) is a guide to the suspension of activity. The flash-to-bang count is one of the most practical techniques for estimating the distance to lightning activity. It is based on the fact that light travels faster than sound. Given that sound travels at a speed of about one kilometre every three seconds, the time that elapses between the flash of lightning and clap of thunder can be divided by three to give a measure of how far away the storm is in kilometres.8,14 The overall message is to seek shelter when the lightning activity is too close, but how do we define what is meant by too close? Currently, most experts agree that the accepted "safe" distance is no less than 10 km.1,7-10,15 This means that as the flash-to-bang count approaches 30 seconds, all people at risk should be seeking or already inside safe shelters. The second part of the 30/30 rule provides the criteria for resumption of play. Here it is recommended that people wait 30 minutes after the last sight of lightning or sound of thunder. This figure is based on the observation that a typical storm moves at about 40 km/h. Thus, waiting 30 minutes allows the thunderstorm to be about 20 km away, minimising the probability of a nearby strike. It is important to emphasise that blue skies and lack of rainfall are not adequate reasons to breach the 30-minute return-to-play rule.1,7,9 Dissemination of InformationIt is important that all participants, officials and spectators are warned of the potential dangers of lightning and how to minimise their risk of lightning-related injury. Practical ways in which this can be achieved include: reading lightning safety messages over the public address systems; and placing notices and safety instructions in event programs and in high-traffic areas at each venue (eg, entrance, change rooms, clubhouse). The information should contain clear and specific instructions about: criteria for suspension and resumption of athletic and recreational activities; and locations of the safety shelters and the best way to access them, as well as suitable alternative shelters. It is important to have a back-up plan in the case of power or equipment failure. Crowd strategiesThe first critical issue in crowd safety is that of safe shelters for large numbers of people. Ideally, crowds should be evacuated to safe areas before the storm is within 10 km of the venue (30-second flash-to-bang count). Given the practical constraints of moving large crowds, it is imperative that a formal assessment is made of existing structures (eg, grandstands, lightning gantries), as simple, cost-effective modifications can dramatically improve the protection offered to the crowd by these structures. Guidelines are provided by the Australian Standard on Lightning Protection.16 Spectators present in structures that are certified as lightning-safe can be advised to remain seated at times of increased lightning risk. Conversely, spectators present in unsafe areas or in structures that have had no formal assessment must be evacuated to safe shelters (Box 1). The importance and size of the event are also critical in decisions regarding safety of spectators. When larger groups are involved, more time is required to properly secure the area. Thus, as time requirements change, the distance at which lightning is considered a threat must be increased. In their report to the Organising Committee for the Sydney Olympic Games, Andrews and Mackerras (personal communication) recommended three phases of lightning safety (Box 2). Their recommendations, which were based on use of the Bureau of Meterology's Lightning Location System, should be implemented for major events where large crowds are expected. ConclusionThe important components of any lightning safety policy include a proactive approach; vigilant monitoring of the local weather; a specific chain of command; a method of delivering the message to those at risk; definition of safe structures; and definition of the criteria for both suspension and resumption of activity. Large events require careful consideration of crowd numbers, length of time required to ensure protection for all present, and appropriate shelters. The more far-reaching the event and the more people involved, the more economical it may be to use formal lightning location systems in early-warning surveillance. 1: General lightning safety recommendations Develop a proactive approach that includes monitoring the local weather from the day before activity until play has finished and the crowd has dispersed. Establish a specific chain of command. This includes choosing a designated weather-watcher and specifying the method of warning the people at risk. Define and list safe structures and locations. Define the criteria for both suspension and resumption of activity. Safe structures Large/substantial building (with electric and telephone wiring and plumbing to provide a safe pathway for the current to the ground). Fully enclosed metal vehicle (acts as a Faraday cage and guides the lightning current around the passengers). Buses are an excellent shelter and can be strategically placed around a venue to protect larger groups of people. Unsafe locations and situations Open field. Close vicinity to the tallest structure in an area (eg, tree, communication tower, light pole). Small structures such as rain/picnic shelters, tents, interchange bench. Indoor and outdoor swimming pools. Use of indoor phones. Umbrellas, golf clubs, bats, or any other object that increases an individual's height. The "30/30" rule A flash-to-bang count of 30 seconds indicates that lightning is 10 km away. This is associated with significant risk that the next strike could be at the observer's location. Thus, activity should be suspended and people moved to designated safe shelters. Wait 30 minutes after the last lightning or thunder before recommencing play. 2: Three phases of lightning safety for the Sydney 2000 Olympic Games Yellow: State of increased lightning awareness Intended to give 60 minutes advanced warning of a storm front reaching 10 km from a venue. (The direction and speed of travel of the storm front are taken into consideration, so that the anticipated time taken for the storm to reach 10 km from the venue is 60 minutes.) Orange: Activation of the lightning protection plan Intended to give 30 minutes advanced warning of a storm front reaching 10 km from a venue. Depending on the venue's requirements, all competitors should be moved to protected areas. Patrons should be advised to remain in position if they are already in a safe area, or move to a protected area as shown on a map. Individuals in transit should be advised to complete their transit as soon as possible. People in cars and buses should be advised not to commence transit and to remain in their vehicles. Red: State of increased lightning risk Declared when lightning activity is within 10 km of a venue. By this stage, all movements and evacuations should be complete, with the venue now secure from lightning. (Adapted from Andrews and Mackerras, 2001, personal communication.)

Michael Makdissi MB BS, BSc(Hons) · Peter Brukner MB BS, FACSP

As lack of exercise is an established major risk factor for many chronic illnesses (particularly heart disease) and premature mortality, it is incumbent on government bodies to promote physical activity.1 However, one in five adult Australians is prevented from being more physically active by injury or disability.2 Thus, minimising injury associated with sports and physical exercise also needs to be a government priority. Sports injuries in Australia are treated by a combination of medical and paramedical services, occasionally in public or private hospitals, but mainly in an outpatient setting. Although the Australian healthcare system provides universal "safety net" coverage for sports injuries at a relatively affordable cost, it has no plan for prevention of sports injuries. Perhaps this is because the government departments concerned with sport and health consider there is insufficient evidence to show that the burden of sports injuries is substantial and that many of these injuries could be prevented. But government bodies would be unwise to ignore the recent trend in Australia towards the regular occurrence of serious sports injuries that are leading to an increase in liability claims. The flow-on increases in insurance premiums are placing many community sports events, active recreation facilities and voluntary service providers under great financial pressure. The burden of sports injuriesThe cost of sports injuries in Australia was an estimated $1 billion a year in 19903 (we are not aware of any more recent published figure). Extrapolating from cost estimates made in a 1998 Victorian study,4 we estimate that sports injuries now directly cost the Australian community at least $1.65 billion a year. Although this figure may be disputed, it is a circular argument to suggest that no resources should be devoted to accurately counting the costs of sports injuries in Australia because there is no hard proof that the costs are substantial. Both injury frequency and associated costs need to be counted to derive cost–benefit ratios for any countermeasures implemented.5,6 Moreover, injury surveillance is the first stage in any program of sports injury prevention.7 Various factors conspire to prevent the incidence and public health burden of sports injuries in Australia from being adequately monitored.6 The Burden of Illness and Injury estimates for Australia8 do not reflect the true burden of sports injuries because (a) such injuries are rarely fatal;9 (b) limitations of the International Classification of Diseases (ICD-9),10 upon which they are based, prevent adequate identification of sports injuries;11 and (c) most sports injuries are not treated in hospital settings, where patient data would be retained centrally.11 The Medicare system that operates outside hospitals does not collect information about diagnosis or associated factors for patient consultations. It also prevents any other body from providing rebates for outpatient doctor visits, so there is no other organisation that could easily collect information about the number and cost of sports injuries treated by doctors in private practice. Moves towards national injury surveillance and prevention in AustraliaThe Australian Sports Injury Data Working Party was established in 1997 to draw up guidelines for sports injury surveillance, but, despite the release of a working data dictionary,12 no national body has since been funded to implement an Australia-wide approach to sports injury surveillance. In 1997, a Federal Government partnership led to the development of a national sports safety framework.13 However, since the late 1990s, there has been a notable lack of national leadership to implement this framework. The Strategic Injury Prevention Partnership, a group set up in August 2000 that represents health departments in all jurisdictions, is responsible for implementing the National injury prevention plan: priorities for 2001–2003. However, the Plan does not list the prevention of sports injuries as a priority.14 One major reason for this is that considerably less is known about sports injuries and their risk factors than other injuries such as falls, drownings and road trauma.5,15 New Zealand's sports injury compensation schemeFor a model of sports injury surveillance, Australia could look to New Zealand, which already has in place the infrastructure to monitor sports injuries. New Zealand's Accident Compensation Corporation (ACC) monitors sport, traffic and work injuries as a distinct segment of the healthcare system. The ACC can accurately determine the cost of treating sports injuries in New Zealand (eg, the cost was NZ$100 million in 2000).16 Furthermore, ACC statistics have shown that the number of sports injuries in New Zealand has fallen over recent years.16 Perhaps this decline is partially due to the preventive efforts of the ACC. It is quite possible that, in relative terms, the cost of sports injuries in New Zealand is lower than the cost in Australia, as New Zealand's scheme focuses on preventing injuries.16 The New Zealand system also has the advantage of being a "no-fault" insurance scheme that prevents sporting participants taking common law action against either the doctors or administrators associated with sporting events. Similar restrictions to liability actions from sporting participants are needed in Australia to prevent the cost of running sports events from becoming prohibitive, and to remove the fear of lawsuits that is developing among volunteers (including doctors) who cover sporting events. Plaintiff advocate groups currently argue that common law actions should not be restricted because injured athletes in Australia have no form of redress other than through the courts. Australian initiativesAnterior cruciate ligament (ACL) injuries to the knee, which occur primarily during sporting activities, provide a concrete example of the way that preventive measures could result in huge cost savings to the community. The Australian Football League (AFL), which monitors the number and circumstances of ACL injuries, has estimated that these injuries cost the AFL well over $1 million a year.17 The AFL has found that ACL injuries are twice as likely to occur in the more northern States of Australia as in Victoria.17,18 Research into the reason for this difference is helping to develop ways to prevent these injuries among professional footballers.18 By the same token, any differential patterns of injury observed in the general population would become an important public health issue. However, because of the lack of national injury surveillance, it is not known whether there are significant regional or other differences in injury patterns at the community level. One Australian State government has established a body specifically for compensating serious sports injuries, the New South Wales Sporting Injuries Insurance Scheme. This is a successful, non-compulsory, non-profit government insurer for catastrophic sports injuries (ie, those involving more than 35% permanent loss of use of a body part). The Scheme is cost-neutral and provides an incentive to actively prevent injury through promotion of safe sport practice and funding of injury prevention research. It is possible that the existence of the Scheme has lowered the risk of catastrophic injury in New South Wales relative to other States, but, once again, comparisons are not possible with incomplete data — the NSW Scheme is not compulsory for all sports and no other State has good records of catastrophic sports injuries. The Federal Government body devoted to sport, the Australian Sports Commission (ASC), has been extremely successful in promoting and developing Australian sport at the elite level. However, it does not consider itself responsible, in any major way, for the promotion of safe sport at the community level, and devotes most of its resources to the areas for which it is accountable, such as Australia's performance in elite sporting events. The approach to road trauma in Australia is a good example of how the healthcare system could better manage sports injuries. Traffic accidents are managed entirely outside the Medicare system, through bodies such as the Transport Accident Commission in Victoria. These bodies provide an infrastructure to support and develop preventive measures and actively engage in data collection to monitor injury trends. That Australian roads are much safer today than they were 20–30 years ago is testament to the success and extent of this preventive approach. ConclusionThe New Zealand approach to managing the problem of sports injuries may not be perfect, but it is surely better than the Australian approach of having no overall plan. Australian government bodies concerned with health and sport need to establish a body with national responsibility for sports safety and injury surveillance, exploring options such as a New Zealand-style national sports injury insurance scheme. It is only with an established infrastructure for monitoring sports injuries that significant advances will be made towards preventing sports injuries and ensuring safe, lifelong participation in physical activity for all Australians.

John W Orchard FACSP, PhD · Caroline F Finch PhD

Three articles in the Christmas issue of the Journal,1-3 responding to media coverage of a proposed clinical trial,4 failed to address the objections raised to conducting the trial without patient consent. The proposed trial, the Royal North Shore (RNSH) and Ambulance Regional Study of a Stenting Strategy as an Alternative to Lytic/Medical Therapy in Acute Myocardial Infarction (RARE SALAMI), was to be conducted in Sydney's Northern Area Health Service. The aim was to compare two regimens of management of patients with acute myocardial infarction and determine whether, despite some additional transit time, diverting ambulances past local hospitals (where patients would receive thrombolytic treatment) and on to the services at RNSH (where patients would be treated with percutaneous coronary intervention) would be beneficial to patients (Box 1).1 The trial would involve the ambulance service, RNSH and the emergency departments of four district hospitals within the health area. Senior medical staff from two of the emergency departments were among those who expressed concerns in the media reports.4 Diversions from standard treatmentInherent in the trial were a number of diversions from standard treatment and procedures. These included contravening the standard advice provided to the community regarding emergency cardiac care — to attend the nearest hospital emergency department as quickly as possible; interference in established therapeutic networks and ongoing therapeutic relationships, including relationships with hospitals; and, most importantly, delays in time to treatment. Delays in time to treatment were to be caused by: Performing a resting 12-lead electrocardiogram (ECG) at the point of ambulance pick-up of patients with cardiac symptoms for the purpose of the selection and allocation of trial subjects; Informing the allocating person at the ambulance control centre of the computer report of the ECG and awaiting randomisation; Transport of subjects randomised to the experimental group past hospitals with facilities for thrombolytic treatment and a private tertiary hospital providing acute invasive cardiac procedures, thereby adding up to about 40 km of suburban roads to the emergency dash. Adding uncontrolled clinical variables (eg, intercurrent illnesses) and location difficulties caused by heavy traffic at peak periods, a lift bridge and intermittent road closures due to environmental hazards (eg, low-level flooding, bushfires). Opposition to the trialIt was evident from all the MJA articles that many people within the profession and in the community opposed the trial. There are several reasons for this opposition, including: local geographical issues of transport and the present distribution of health services; issues of risk and inconvenience for patients; methodological issues such as experimental design, rationale and execution of the trial; and no provision for meaningful consent before entry into the trial.1-4 Despite this opposition, at the time of the media investigation the trial was about to be implemented. Members of the community and hospital and ambulance staff not wanting to be involved in the trial were about to be included. Indeed, in the period between the media reports and the Christmas issue of the MJA, one metropolitan council included in the trial area formally documented its view in relation to the proposed trial and conveyed this to the relevant ethics committee.5 The following motion was carried unanimously: Council opposes the conducting of medical trials on any member of the community without their full informed consent — this particularly applies in the treatment of cardiac conditions. Patient consentIn the MJA articles it was proposed that "ethics committees (can) assume the responsibility of giving consent on behalf of patients",1 and that, "almost by definition, people in the midst of life-threatening medical emergencies, who may be unconscious, in shock, in extreme pain or delirious, surrender their normal sentient ability to consent".2 However, this denies one of the cornerstones of medical ethics — the patient's right to self-determination. This is not to say that clinical trials should be discarded. Experimenting on patients, often in the form of a clinical trial, is an essential element of evaluating drugs and therapeutic innovations. Patients are patients because they present for and need treatment. They are entitled to a treatment that is tried and true — in this case, standard rescue protocols for myocardial infarction — and, unless otherwise indicated, they must reasonably trust that that is what they are getting. Accordingly, medical staff and, in this case, ambulance personnel are obliged to provide such care. Service organisations and clinician-researchers may experience tension between their obligation to provide a certain type of treatment and the need to divert from accepted standards for research purposes. Fortunately, there are guidelines to ease this tension and to chart the correct course of action. The Nuremberg Code of 19476 is the modern forerunner of these guidelines. It has the appeal of being a simple 10-point code and, until 1964, when the World Medical Association (WMO) produced its first set of guidelines (the Declaration of Helsinki), was the only code of its kind. Subsequently, there have been revisions of the WMO's Declaration7 and the development of various national codes, including the Australian National Health and Medical Research Council (NHMRC) statement on research involving humans. The NHMRC's 1999 National Statement8 is currently the primary guide to clinical research in Australia. As with other guides, it emphasises the importance of fully informed consent and sets out the circumstances in which patients can be included in clinical trials without their knowledge or consent. Criteria for proceeding without consentConsent is reviewed in considerable detail in the NHMRC Statement on Ethical Conduct in Research Involving Humans.8 Statements relating to areas where consent is either waived or considered not necessary appear in paragraphs 1.11, 6.9, 14.4, 15.8, 16.13 and 17.1 and 17.2. Paragraphs 14.4, 15.8 and 16.13 relate to identifiable data, tissue samples and genetic issues. Interestingly, even in survey-type activities where consent is not required, Part 17 ensures there should be no element of deception. Part 6 considers emergencies, intensive care, terminal care, those with impaired capacity for communication, those highly dependent on care, and the unconscious (see summary in Box 2). In relation to emergency situations, the vulnerability of patients and relatives is acknowledged, as is the inability to obtain consent. When research may produce a ". . . reduction of potential benefits", Part 6.9 gives specific guidance, stating that the research should not be contrary to the patient's interests; must be based on valid scientific hypotheses; must ensure that the patient/relatives are able to give consent or withdraw the patient from the research as soon as reasonably possible; and, most importantly, must ensure that there is no increased risk to the individual. Leeway has been allowed for proceeding with experimental techniques without consent when a number of the conditions are met. The essence of these can be summarised as follows: The choice is between essentially no treatment and experimental treatment; The experimental treatment offers the chance of benefit and no greater harm; and There are reasonable grounds for assuming that the patient would consent if he or she were able to. Similar leeway has been allowed by the Food and Drug Administration (FDA) in the United States. The FDA undertook review of this area in response to concerns expressed by researchers that ". . . current rules are making high quality acute care research difficult or impossible to carry out when the need for such research is increasingly recognized". As a result, regulation 50.24 became effective in 1996.9 These guidelines are summarised in Box 3. While institutional ethics committees may interpret the FDA guidelines differently for specific treatments,10 the circumstances that allow waiver of consent in emergency situations are similar to those outlined by the NHMRC. They include proceeding with acute resuscitation that is experimental at the time of a cardiac arrest when standard treatment has failed; trialling the acute use of a neuroprotective agent when a patient arrives in the emergency department in a deeply comatose state; or, as recently reported, the administration of standard anticonvulsants by ambulance personnel.11 Will patients be harmed?The downside of any clinical experiment is that the hypotheses may turn out to be wrong and patients may be harmed. The RARE SALAMI trial requires delaying accepted efficacious cardiac treatment in emergency situations in which there is a very high mortality rate in the first hours. The hypothesis that no harm will be done to the patients is put forward in one of the articles as a foregone conclusion,1 but doctors with a working knowledge of local practicalities of the catchment area were clearly not convinced by these arguments,4 and neither were the intended research subjects, their representatives and statutory authorities, who were moved to formalise concerns.1,5 Such situations are succinctly covered in the Nuremberg Code. Point 5 states: No experiment should be conducted where there is an a priori reason to believe that death or disabling injury will occur; except, perhaps, in those experiments where the experimental physicians also serve as subjects. ConclusionsKomesaroff is correct in stating that this imbroglio provides several important lessons about process.3 In addition, it is a reminder of the need to guard against confusing "consent to treatment" with "consent to research", and to avoid distorting what the guidelines say. This applies particularly to what the NHMRC National Statement says about consent for research in persons highly dependent on medical care. Finally, it is most important to remember what calling an ambulance is all about. With regard to consent, the trial cannot be imposed on an unwilling community and unwilling doctors. It should not proceed until the following conditions are met: 1. At the community level There is factual agreement between the researchers and the community as to the time delays involved; There is broad agreement within the profession as to the risk to patients; There is agreement between researchers and the local community, including local general practitioners and specialists, as to the disruptions that would be caused by the trial; Arrangements are in place to detect and make good any harms caused; and The community agrees that the benefits of the project to their community are worth the costs to the community. 2. At the level of individual research subjects All persons in the communities involved with the trial have been informed of the details of the proposal, including the risks and benefits to research subjects, by means of mailing and public meetings, and their comprehension of the information has been established by a survey; and There are provisions for opting out and confirmation of informed consent at the point of first contact by ambulance personnel. This is informed consent in action. Without it, some experiments simply cannot be done. 1: Proposed sequence of events for a trial to compare two regimens of management for acute myocardial infarction 2: Summary of National Health and Medical Research Council guidelines for research without consent Paragraph 1.7 If a participant lacks competence to consent, a person with lawful authority is provided with the information and exercises that choice. Paragraph 6.9 When conformity to the principle of consent (paragraph 1.7) is not feasible, and neither the participant nor the individual's representative can give consent in advance, a Human Research Ethics Committee may approve a research project without prior consent provided the proposal (a) is not contrary to the patient's interest; (b) does not place the patient at any more risk than that which is inherent in the patient's condition; (c) is based on a valid hypothesis; and (d) the patient, the patient's relatives and legal representatives will be informed as soon as possible and given the choice to continue the experiment or withdraw the patient. 3: Summary of FDA Guidelines for research without consent 1. Life-threatening situation, available treatments unproven or unsatisfactory and an experiment, including the use of placebo, is needed to answer the question. 2. Consent not feasible because (a) of the medical condition, (b) it must be administered before an authorised person can give consent, (c) it is not possible to identify subjects before the condition occurs. 3. Subjects may benefit because (a) they are in a life-threatening situation, (b) animal or preclinical studies show the potential for benefit, (c) the risks are reasonable allowing for what is known about the condition. 4. The study could not be conducted without a waiver. 5. The time window for the experimental intervention is defined and during this time the investigator is committed to finding the subject's duly authorised representative rather than proceeding without consent. 6. Community consultation before the study to explain risks and expected benefits. 7. Public disclosure of the results. 8. Independent monitoring of the results. 9. The subjects (or their representatives) are informed as soon as possible as to their inclusion in the study.

Michael C Kennedy MD, FRACP

Case report A 63-year-old woman with hypertension and non-insulin-dependent diabetes underwent restudy coronary angiography for recurrent angina. She had had coronary angioplasty in 1991 and coronary arterial bypass surgery in 1998 with two saphenous vein grafts and a left internal mammary artery graft. Angiography of her native coronary arteries, both saphenous vein grafts, and a left ventriculogram were completed without difficulty. The left internal mammary artery was more difficult to engage selectively. The left vertebral artery, which was adjacent, was outlined by contrast. During this time the patient's blood pressure increased to 200/110 mmHg and she became nauseous and vomited. She complained that "everything has gone black". The study was terminated with a non-selective injection into the left subclavian artery, which showed an adequate left internal mammary artery graft. A total of 160 mL of non-ionic, low-osmolar contrast agent ("Ultravist") containing iopromide was used. During post-procedure monitoring she could not see light or objects and complained of headache. There was impaired alertness. Her blood pressure stabilised at 140/80–160/90 mmHg. Her pupils were equal and reactive to light. Extraocular muscle movements were normal. Funduscopy revealed "copper wiring" of hypertension without significant diabetic retinopathy. Cranial nerve, peripheral motor and sensory examinations were normal. Bilateral cortical blindness was diagnosed. Computed tomography (CT) brain scan was performed three hours after the completion of coronary angiography. No additional contrast was used. The CT brain scan (Box 1) showed marked bilateral contrast enhancement of the occipital lobes and no evidence of a cerebral haemorrhage. Intravenous heparin treatment was commenced. By the following day, she was able to see shapes and shadows but had persistent headache and nausea. A repeat CT brain scan did not show any residual abnormality. During the next 48 hours, her vision progressively returned. She described flashing lights in her right eye and had evidence of right homonymous hemianopia. Magnetic resonance imaging (MRI) showed increased signals in the grey matter of the medial aspect of the left occipital lobe, on a background of longstanding mild ischaemic changes consistent with her age and cardiac risk factors (Box 2A). Magnetic resonance angiography (MRA) showed patency of both posterior cerebral arteries, with dilatation of branches supplying the left occipital lobe (Box 2B). Heparin therapy was ceased, as there was no evidence of acute thromboembolism or acute infarction. She fully regained her vision five days after coronary angiography. Transient cortical blindness related to coronary angiography was first reported in 1970.1 Since then there have been fewer than two dozen cases recorded, some of which include angiography of coronary bypass grafts.2-5 This is a rare neurological complication given the widespread and frequent use of such investigations worldwide. The incidence of cerebrovascular complications in diagnostic cardiac catheterisations and coronary angiography is low. The National Institutes of Health in America reported a rate of 0.03%,6 and the British Cardiac Society report from 34 041 patients gave an incidence of 0.06%.7 This included cerebrovascular accidents, transient ischaemic attacks and amaurosis fugax. Neither study described transient cortical blindness. Usually neuro-ophthalmologic complications of cardiac catheterisation relate to embolic phenomena or migraine. Cortical blindness is better recognised as a complication of cerebral and vertebral angiography, with an incidence of 0.3%–1.0%,8 but as high as 4% when hyperosmolar iodinated contrast agents are used.3 However, it can occur with newer low-osmolar and non-ionic radiographic contrast media, and this potential complication is indicated in the product information. Review of clinical information available from English language reports of transient cortical blindness after coronary angiography showed 17 cases.2-5,8-12 Thirteen of these involved men, and only four involved women, but this reflects the greater number of men who have coronary artery investigations. The average age of the patients was 58 years, and more than half (10 patients) had known systemic hypertension. Eleven (65%) had angiography of internal mammary artery grafts. Another five had additional aortography or coronary angioplasty. The volume of contrast dye used ranged from 80–400 mL. The time taken to recover normal vision varied from 15 minutes to three weeks, with an average of three days. Selective vertebral angiography carries the highest risk of neurological complication.13-15 As the internal mammary artery used for coronary grafting is adjacent to the origin of the vertebral artery, it is likely that a direct injection into the vertebral artery occurs. The cerebral reaction is not patient-specific, as later rechallenge with contrast medium has produced no recurrence.3 Minimising the amount of dye used is also advisable.3 PathophysiologyThe mechanism of cerebral injury remains speculative. It is thought that contrast agents disrupt the blood–brain barrier in the occipital lobes and exert a neuronal toxic effect.13 The posterior cerebral circulation is known to be more susceptible to such injury and this may relate to differences in sympathetic innervation.14 There may be a relationship to hypertensive encephalopathy, a clinical syndrome which can include visual disturbances. Imaging in hypertensive encephalopathy, including eclampsia, has shown bilateral abnormalities in the occipital lobes, involving the subcortical white matter and often extending to the cortical surface.16 Reversible oedema, localised mainly to the occipital lobes, is a prominent feature. Our patient was known to be taking drugs for chronic hypertension and had a documented acute blood pressure rise during the procedure. More than half the patients in previous reports had chronic hypertension, although the details of pressure changes during angiography have not usually been reported. Hypertensive encephalopathy is thought to result from sudden elevation of systemic blood pressure exceeding the auto-regulatory capacity of the cerebral vessels, producing regions of vasodilatation and vasoconstriction with a breakdown of the blood–brain barrier and focal transudation of fluid.16 These mechanisms seem possible in our patient, and they were supported by the results of imaging studies. There were bilateral occipital lobe changes when she had clinical cortical blindness (Box 1), representing oedema and passage of contrast across the blood–brain barrier. Cortical blindness is synonymous with bilateral homonymous hemianopia from involvement of the occipital cortex.1 When our patient was recovering and exhibiting right homonymous hemianopia, there were MRI changes in the left occipital gyrus, and differences in the calibre of the vessels on the two sides (Box 2). PrognosisIt is devastating for the patient, the family and the person carrying out the procedure when cortical blindness complicates coronary angiography. Cerebral embolism and haemorrhage have to be excluded by CT scan or MRI studies. Fortunately, the condition is usually transient. Lessons from practice Transient cortical blindness is a rare but alarming complication of coronary angiography. It has to be differentiated from an embolic problem. Computed tomography or magnetic resonance imaging is necessary. Oedema secondary to disturbance of autoregulation of the posterior cerebral vessels is a possible mechanism. Vision is usually recovered fully within a few days. 1: Computed tomography scan of the patient's brain three hours after completion of coronary angiography, when she had cortical blindness No additional contrast was given. There is marked bilateral contrast enhancement of the medial aspect of both occipital lobes in a symmetric distribution (arrows). 2: Magnetic resonance imaging (MRI) of the patient's head 48 hours after coronary angiography, when she had right homonymous hemianopia A: MRI (FLAIR image) shows increased signals in the medial aspect of the left (compared with the right) occipital gyrus separated by a fissure (arrow). Scattered foci of longstanding ischaemic damage on the rim of the lateral ventricles and frontal horns are consistent with the patient's age and risk factors. B: A magnetic resonance angiogram (MRA) at the same time shows that both posterior cerebral arteries are patent. The peripheral branches on the left side are larger (arrow).

Kiam K Lim MB BS · Dorothy J Radford MD FRACP

Hendra virus infection should be suspected in someone with close association with horses or bats who presents acutely with pneumonia or encephalitis (potentially after a prolonged incubation period). Australian bat lyssavirus infection should be suspected in a patient with a progressive neurological illness and a history of exposure to a bat. Rabies vaccine and immunoglobulin should be strongly considered after a bite, scratch or mucous membrane exposure to a bat. Japanese encephalitis vaccine should be considered for people intending to reside in or visit endemic areas of southern or eastern Asia for more than 30 days.

Series Editors:

To the Editor: Recent astronomic awards for medical mishaps, and the follow-on medical indemnity crisis, bring back memories of an earlier editorial I wrote for the Journal dealing with some aspects of this problem. Its message is worth repeating. In 1990, a letter by Armstrong was published in the Journal,1 which enclosed a newspaper advertisement for a firm of solicitors, Messrs Stern, Stern & Tanner, inviting custom from anyone who may have been a victim of "obstetric negligence", "even if your child was born as long ago as 1965 or even earlier. Initial consultation free". The Journal's then editor invited me to write an accompanying editorial. The editorial, published simultaneously with Armstrong's letter and accompanying advertisement, was headed "No hawkers, canvassers or solicitors".2 It began with a quotation from United States Chief Justice Burger: "Never, never, never under any circumstances hire an advertising lawyer!".3 It noted that some solicitors claimed to possess special expertise in asbestos-related diseases, others claimed to know all about defoliants. I suggested, in those innocent days, that "obstetric negligence" was a new subspecialty which should henceforth be known as Stern–Tanner disease. (If Drs Guillain and Barré were to be forever enshrined in medicine's Hall of Fame, why not Messrs Stern and Tanner?) My editorial suggested a remedial response, stating that "the law permits parties to any contract to abrogate, limit or qualify their legal rights, duties, liabilities and remedies which might otherwise arise. Thus, while the courts — both here and in the United Kingdom — tend to lean against total exclusion from liability, they are, surprisingly, more benevolent towards clauses which limit liability, however contemptuous the specified amount." I adhere to that view. I can see no reason why doctors — save in an emergency — cannot demand that patients enter into a written "contract of treatment" which limits the treating doctor's liability to a specified amount. And while such contracts will not be valid against children born impaired as a result of "obstetric negligence", I can see no reason why the courts should deny the validity of such contracts as a matter of public policy. Why should "contracts of treatment", entered into between consenting adults, be any different from those entered into with lawyers or dry cleaners? It may seem a trifle offensive, but then the practice of medicine is treated in law as a business, much the same as touting lawyers or dry cleaners. If doctors were once put on a pedestal, this pedestal has been effectively knocked down by astronomic awards of damages freely awarded by the courts — whether by judge or jury — largely as a result of the freely expanded constituent elements of the tort of negligence. I researched the law relating to "limitation of liability" clauses, which was published in the Australian Law Journal4 and quoted in the MJA editorial: "Why the courts should be more benevolent to clauses of limitation than to clauses of exemption is not easy to comprehend. . . . The principle, it seems to the present writer, is much the same: Exclusion clauses save a party from having to pay anything, whilst a limitation saves him from having to pay as much as he would otherwise have to pay. [ . . . ] Alas, the last word on this seems to have been spoken for some time to come." As far as I am aware, the law has not changed since the publication of my earlier research.

Paul Gerber

To the Editor: The ME/Chronic Fatigue Syndrome Association of Australia Limited. has expressed its concern over the content of the Royal Australasian College of Physicians' clinical practice guidelines on chronic fatigue syndrome, published as a recent supplement to the Journal.1 Recognising a shared objective to overcome the challenges of chronic fatigue syndrome (CFS), neither the Association nor the College believes that conflict will provide a useful path to future answers. Accordingly, as the Chairman of the ME/Chronic Fatigue Syndrome Association of Australia and the President (at the time the guidelines were published) of the Royal Australasian College of Physicians, we would like to document the common ground we have identified. We acknowledge, as do the guidelines, that CFS is a serious, disabling illness. There is no evidence that the illness is primarily psychological in origin. There is significant evidence of a range of biological abnormalities occurring in people with CFS. It remains unclear whether these are primary or secondary. Treatment should be personalised according to the symptoms and circumstances of the individual patient. Treatment plans should be worked out by the patient together with a healthcare professional and designed to be within the capabilities of the patient. Scientific evidence on aetiology, pathophysiology and treatment is, at this stage, grossly deficient. More research is required to understand the biological mechanisms involved and to clarify the role that genetic, environmental and infectious agents might have in the aetiology and pathophysiology of this complex and debilitating illness. The medical community, other health professionals and patients and their families should work together to encourage increased funding and research into the epidemiology, aetiology and pathophysiology of CFS so that we may find more effective treatments for this condition (or these conditions). All clinical guidelines should be viewed as documents that will, in time, require refinement, rewriting and replacement. Doctors must be cognisant of the limitations of all such guidelines and be aware that the investigation and management of a patient's condition must be determined with the assistance of the best and latest information as it emerges and, in all instances, be tailored to the needs of the individual patient.

Richard G Larkins · Simon R Molesworth

To the Editor: I read with interest the article by Goldsworthy and McFarlane on Howard Florey, Alexander Fleming and penicillin.1 With regard to the cause of Florey's "famous pinched smile", which allegedly hid tooth erosion caused by his drinking dilute hydrochloric acid prescribed for achlorhydria, a more prosaic yet interesting explanation is found in the memoirs of Raymond Valentine Hennessy. Hennessy was Senior Ear, Nose And Throat Surgeon at St Vincent's Hospital, Melbourne, between 1928 and 1951.2 Howard Florey in the late 1930s In August 1936, Florey, who was then Professor of Pathology at Oxford, visited his dying mother in Melbourne. He and his family stayed with his sister, Dr Hilda Gardner. Florey had a supply of sulfanilamide, probably the first in Melbourne, to treat his daughter, who was convalescing from a recent mastoid operation. During his stay, Florey attended a local dentist for treatment of a painful lateral incisor tooth. Some days later (on a Saturday evening), his face had become swollen and he began having rigors. His sister, a medical graduate who was then working as a clinical pathologist and microbiologist at the Melbourne Hospital, appreciated the danger — an abscess of a lateral incisor tooth can produce a cavernous sinus thrombosis — and quickly contacted Raymond Hennessy, who lived nearby. Hennessy had graduated as a dentist before pursuing a career as an ear, nose and throat surgeon and had written about the dangers of a lateral incisor dental abscess.3 After examining Florey, Hennessy told him that the offending tooth required extraction that night. Initially, Florey refused to heed his advice, preferring to see his own dentist the following Monday. Fortunately for Florey, he was persuaded by his sister to have the extraction. Hennessy then telephoned a dentist colleague, and they all met at the latter's surgery in Collins Street, where Hennessy gave Florey a gas–oxygen anaesthetic, and the nervous dentist proceeded to extract the incisor. However, he extracted the normal central incisor, not the offending lateral! On realising his mistake, the dentist "went to water", but Hennessy immediately rose to the occasion and extracted the correct tooth. When Florey woke from the anaesthetic, as Hennessy well remembered, he was not amused. Later, he had a dental plate made but did not like wearing it. Whether he took the sulfanilamide is not known. This episode is not mentioned in Gwyn Macfarlane's biography of Florey.4 However, the photograph of Florey in the frontispiece of this book shows the gap in his upper incisors (pictured). I believe this is the explanation for Florey's "famous pinched smile".

Ivo D Vellar · Thomas B Hugh

To the Editor: The patronising article by Goldsworthy and McFarlane on the discovery of penicillin1 depicts the popular heroic view of Alexander Fleming as a myth, but also promulgates myths of its own. Their description of the Fleming saga is historically accurate. Fleming searched for an answer to the riddle of infection, and, to paraphrase Pasteur, chance in the form of a spore of a rare subtype of Penicillium favoured his prepared mind. Whether or not the spore came through an open window is irrelevant, but the windows in Fleming's laboratory — now preserved as a museum (pictured) — could be opened3 and probably were on occasion, as Fleming was a heavy smoker. Fleming perceived the significance of inhibition (or, more correctly, lysis) of staphylococcal colonies, named the active agent "penicillin" and studied its effect on animals. Goldsworthy and McFarlane are "astonished" that he failed to inject it into infected animals to investigate its therapeutic effect, but the reason is simple: Fleming discovered that penicillin was rapidly inactivated by serum, dashing his hopes for its use as a systemic agent.3 Although he met opposition from his chief, Almroth Wright (known to his students as "Almost Right"), who rejected the view that penicillin might be a useful therapeutic agent, it is absurd to say that Fleming was "a victim of the pessimistic mind-set against toxic chemical antimicrobials". His confidence in its lack of toxicity led him, in 1929, to use penicillin to treat pneumococcal conjunctivitis in one of his assistants, with dramatic success.2 Site of Fleming's laboratory The Clarence Wing, St Mary's Hospital, London, in 1910. Fleming's laboratory, where penicillin was discovered in 1928, was on the third floor of the tower on the right. The windows of the laboratory could be opened by an internal system of ropes and pulleys, but a more likely source of the Penicillium spore was a dumb-waiter shaft communicating with a mycology laboratory on the floor below.2 To say that "Fleming had little idea what to do with his mould apart from dabbing it on infected wounds" unfairly trivialises his actions after the discovery. In addition to clinical and animal studies, he had the mould identified, deposited a culture with the collection held by the Medical Research Council and published his observations. He set two researchers to work purifying the active principle of the mould broth, and established that penicillin was soluble in alcohol and that its stability was pH-dependent. He also developed an assay for penicillin and defined the range of organisms that were sensitive to it. He sent cultures of the penicillin-producing strain to many laboratories, including Oxford, where that very culture later provided the starting point for Chain and Florey's work. Fleming's subsequent work on penicillin was stalled by his lack of biochemical expertise; he was unable to overcome the difficulties of purification and stabilisation.2 Fleming is recorded as saying, "It's up to the chemists now, I'm no chemist".2 It is quite untrue that "he then effectively forgot about it for 13 years". Although Fleming ceased clinical work on penicillin in 1934, he continued with laboratory studies. A contemporary at St Mary's Hospital, Dr A G Cross, recalled that in the 1930s "penicillin was on his mind all the time and in the minds of those who worked with him".2 Fleming had his faults, but the genius of his prepared mind did indeed present humanity with a fairy tale come true. Perhaps Ernst Chain, who did not particularly like Fleming, should have the last word: "There is no doubt that this discovery, which changed the history of medicine, has justly earned [Fleming] a position of immortality."2

Ivo D Vellar · Thomas B Hugh · Peter D Goldsworthy MB BS · Alexander C McFarlane MD, Dip Psychother, FRANZCP

In reply: Our article aimed to show how history is often rewritten in narrative forms that are more appealing to the human need for heroes and for clear, memorable moral lessons.1 The challenge is to sort out whether the matters at stake are those of narrative style or substantial differences of fact. Hugh felt our approach was patronising to Fleming — but we were at pains to emphasise his "genius" for making important causal connections. He also had a genius for seeking adulation — which in no way disqualifies him from deserving to share the Nobel Prize for Medicine with Chain and Florey. Hugh also criticised our assertion that "Fleming had little idea what to do with his mould apart from dabbing it on infected wounds" — yet his counterexample, that in 1929 Fleming used "penicillin to treat pneumococcal conjunctivitis in one of his assistants", illustrates the point. Let us also not forget that a Belgian group had discovered the penicillin mould in 1920, and recognised its antimicrobial properties well before Fleming did. The challenge is to foresee and drive the application of knowledge rather than to leave facts in a dormant but pregnant state. Vellar's fascinating letter proposes that a dental abscess and two extractions, rather than Florey's drinking of hydrochloric acid, caused his "pinched smile". A mutually compatible hypothesis is that Florey was prone to this infection because of tooth damage caused by the acid. Vellar also provides further support for the quixotic spread of knowledge and the personal motivations and obsessions that influence researchers. Florey's transport of sulfanilamide to Melbourne was apparently not to popularise the new and revolutionary drug, but to treat his daughter. It also raises a fascinating, if ironic, possibility: was Florey's life saved by sulfanilamide, allowing him to continue on his yet-to-be-forged endeavour of the purification of penicillin?

Ivo D Vellar

To the Editor: Perhaps for reasons of space, Tobin et al, in their article on community versus individual benefit,1 have omitted an important public health justification for confidentiality. If patients are fearful that the doctor's obligation to notify the authorities could lead to a loss of privileges (in the case cited, a driver's licence), they may fail to attend for diagnosis and treatment. This understandable anxiety warrants a mention in this debate.

Peter C Arnold · Bernadette M Tobin · Steven R Leeder · Ernest R Somerville

In reply: Arnold makes a good point. We agree with him, and would resist today's increasing tendency, on public health grounds, to make it mandatory for doctors to report a variety of conditions suffered by their patients. In general the community is well served if doctors have the discretion to decide, in any particular case, whether the public interest in maintaining a patient's confidentiality is outweighed by the public interest in breaching that confidentiality in order to protect innocent third parties.

Peter C Arnold · Bernadette M Tobin MA PhD · Steven R Leeder PhD FRACP FFPHM · Ernest R Somerville MB BS FRACP FRCP

To the Editor: End-of-life issues: Case 11 illustrates an increasingly common scenario confronting physicians caring for older patients. The case example of a nursing home resident with stroke, dementia and the onset of pneumonia highlights the importance of encouraging patients to prepare for future medical decision-making. This can be done through the use of enduring guardianship, medical powers-of-attorney or advance care directives ("living wills"). Documenting these matters allows people to appoint others to make healthcare decisions on their behalf, and to indicate what treatment they would want in various clinical circumstances, should they no longer be competent to do so. If "Mrs W" had appointed an enduring guardian to deal with issues of healthcare and medical consent, or had indicated in an advance care directive what her wishes would be if she were to become seriously ill, the decision-making process may well have been clearer. The other issue this scenario raises is the need to check whether Mrs W's daughter could have made medical decisions for her mother. In New South Wales, if the daughter had been in a caring role for her mother before nursing-home placement, she could be considered the "person responsible" (similar to the old concept of "next of kin"). Under the Guardianship Act 1987 (NSW), the "person responsible" is able to act as a substitute decision-maker for healthcare and medical treatment. While it would clearly still be good, sensible medical practice to involve other family members in discussion about Mrs W's future, it would ultimately be the daughter, as the "person responsible", who would be able to make those decisions.

Susan E Kurrle

In reply: We agree with Kurrle about the importance of encouraging patients to prepare for future medical decision-making. The strategies she suggests are practical and useful. However, we believe that the difficulties confronting physicians in caring for older patients require us to go further and to rethink what represents excellent care at the end of life. Today, death from acute illness has largely been superseded by death from chronic illness, and the latter generally follows one of three main trajectories: cancer, organ system failure or dementia/frailty.1 Our systems of care for people who are near the end of life need to reflect the ways in which elderly people actually decline and die. If we wish to promise elderly people what a decent society should be able to promise them (accurate diagnoses, excellent control of symptoms, the absence of any gaps in care and of any "surprises" in their condition and its treatment, clarity about the role of their family in caring for them, a way of dying that accords with their hopes, and, most importantly, help to live the remaining part of their lives "to the full"), we need to rethink the care provided during hospitalisation of older people at the end of their lives.1

Susan E Kurrle · Bernadette M Tobin MA PhD · Ian D Cameron FACRM FAFRM PhD

To the Editor: Community-acquired methicillin resistance in Staphylococcus aureus was only reported in eastern Australia as recently as 1998.1 We report a case of community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) causing cellulitis and bacteraemia. A 30-year-old man presented to the emergency department with a short history of heel pain. There was no history of trauma, diabetes, drug misuse, contact with hospitals or previous antibiotic treatments before the current illness. Examination showed that he had a temperature of 37.7°C and sinus tachycardia of 120 beats per minute. There was extensive cellulitis surrounding a superficial collection of pus over the left heel; this was incised and drained. Initial investigations showed only neutrophilia. Blood cultures, but no swabs, were taken. Therapy with daily intravenous injections of 1 g ceftriaxone, given at home by an ambulatory care service, was initiated. The following day, blood cultures showed the presence of gram-positive cocci identified as a Staphylococcus sp., and the treatment was changed to 2 g of cephazolin 12-hourly, intravenously. On the second day Staphylococcus aureus resistant to oxacillin was isolated. There was susceptibility to erythromycin, clindamycin, tetracycline, ciprofloxacin, vancomycin, rifampicin and fusidic acid. Treatment with vancomycin (1 g 12-hourly, by means of a peripherally inserted central catheter) resulted in clinical improvement within 48 hours and was continued for a total of two weeks, followed by oral rifampicin and fusidic acid. A bone scan and echocardiogram showed no significant abnormality. Resolution was complete at six weeks and the patient returned to work. Methicillin-resistant Staphylococcus aureus (MRSA) is now a common cause of skin and soft tissue infections.2-4 MRSA was not acquired outside hospital until the 1980s, when intravenous drug users from Detroit were reported with MRSA bacteraemia. Such community-acquired strains have now been reported worldwide, including in Australia.5 These strains are usually non-multiresistant MRSA,3 which are highly pyogenic, readily communicable and predominantly cause skin and soft tissue infections. However, CAMRSA endocarditis and a bacteraemic osteomyelitis have been described. We believe this to be the first case of CAMRSA bacteraemia to be reported in Australia. Community-acquired MRSA strains have become a common cause of community-acquired staphylococcal infection in Australia.2,3 It is now recommended that swabs be routinely taken to cover the possibility of drug-resistant organisms such as MRSA.1-3 The appropriate initial management of suspected or high-risk cases is unclear, but might include treatment with vancomycin or gentamicin before the availability of antibiotic sensitivity test results.

Nicholas Collins · lain B Gosbell · Stephen F Wilson

At the 3rd and 4th National Forums on Prevocational Medical Education, held in 1998 and 1999, it was realised that the issues surrounding students and junior doctors who are distressed warranted further attention. As a consequence, this Conference, The student and junior doctor in distress — "our duty of care", was arranged with the aim of formulating recommendations to educational bodies, health departments and medical boards. More than 100 delegates representing the diversity of stakeholders were involved in stimulating discussions over the two days of the Conference in July 2001. We were fortunate to have talented speakers and participants to address the issues involved, which pose many challenges to educational and health institutions, as well as to the health professions and workplaces. The transition from university to workplace is inherently stressful for medical students and junior doctors. However, changes in the workplace and society are making it even more stressful than in the past. The stressors include the rapid pace of change in the health system and spiralling healthcare costs, as well as the demanding nature of the job, with long working hours and heavy responsibilities. Also, there is often conflict between educational and workplace imperatives. The working environment is not always as supportive as it could be, and the traditional culture of the medical profession and its workplaces has not fostered an environment where distressed students and junior doctors are able to acknowledge their need for help. Nor does the system always make it easy for them to find appropriate help. Drug and alcohol abuse and mental illness can also affect the ability of students and junior doctors to do their job. It is not only the health and the future of young doctors that are at stake; problems which impair their performance in the workplace may also jeopardise patient safety and wellbeing. Students and young doctors who may be at particular risk include those from non-English-speaking backgrounds and those who are socially and professionally isolated. They were described by one Conference participant as "the lurkers" — those who sit at the back in lectures, do not participate in discussion and do not engage with their peers. Several case studies explored at the Conference illustrated that, with appropriate intervention and support, students and doctors in distress can be helped and can return to productive careers. However, for this to happen expeditiously and extensively requires a cultural change, so that doctors in universities and hospitals are more aware of their duty of care to colleagues and prepared to identify those in distress and help ensure that they receive appropriate care. There is also a need to encourage better self-care and systems of peer support. It was noted that medical boards can play an important role in helping students and doctors resolve serious problems and return to practice, but the widespread misperception — that the boards' roles are mainly punitive — can discourage approaches to these bodies. An important unresolved issue was whether universities should pass on information to hospitals and other employers about students who have had problems. This raises sensitive privacy and legal issues that warrant further exploration. Repeated emphasis was given to the importance of maintaining confidentiality, wherever possible, when managing the problems of students and junior doctors in distress. Fear about the career consequences of being labelled with a particular problem is a major barrier to identifying students and junior doctors in distress. Finally, the importance of using appropriate language was also stressed. It was noted that the term "impaired doctor", although enshrined in legislation, has negative connotations that could be counterproductive. It implies that a doctor is damaged, when the reality is that some doctors have health problems or other troubles that can often be resolved or managed so that they are able to maintain an appropriate practice. The issues are so complex and sensitive that it was not possible to arrive at detailed, consensus-based recommendations. Rather, the Conference participants developed broad principles, which hopefully will provide the basis for further dialogue and development into detailed strategies that can be implemented at a national, State, institutional and professional level. This report provides a summary of selected presentations at the Conference, and draws together the important themes into a broad overview of the issues. My sincere thanks go to all who took part in the Conference and helped make it such a success. I would like to particularly thank the organising committee, the South Australian Minister for Human Services for opening the Conference, and all the speakers. Thanks also for the support provided by United Medical Protection. A special tribute should be paid to the Commonwealth Department of Health and Aged Care, which, through the Medical Training Review Panel, provided much support to early postgraduate training in Australia, and not only strongly supported this Conference and the publication of these Proceedings, but also funded medical students and junior medical officers from all States and Territories to attend. Conference recommendations Recommendation 1 The medical profession has a duty of care to colleagues. There is a need to promote significant cultural change within the medical and other professions, and within workplaces, to encourage an improved acceptance and management of doctors and students in distress. This change needs to heighten the awareness of stressors in the medical profession and workplace. It also needs to encourage a sympathetic and caring approach to the person involved and to deal with the issues in a non-punitive manner. Everyone has a responsibility to identify and assist the student and doctor in distress. Recommendation 2 For people involved in managing students or doctors in distress Each institution should have a clearly identified person as the point of contact, who ideally should be independent of the student or doctor's career and studies. Further consultations with other people or bodies, such as the Director of Clinical Training, supervisors, peers, and medical administration, should be on a "need to know" basis. They should occur only with the individual's consent, unless patient or colleague safety is at risk. The importance of timely, regular and positive feedback for students, junior doctors, teachers and supervisors is paramount. When there is concern about patient safety, the Medical Board should be informed. The person who made the initial identification should be informed that the matter is being managed. Recommendation 3 Strategies for preventing distress in students and doctors should be implemented nationally, and should include: An emphasis in the student curriculum on maintaining health and wellbeing. The education of the profession and students about behaviour patterns and warning signs, especially in "at-risk" groups. A comprehensive orientation of students, junior medical officers and registrars, with clear definition of the roles and responsibilities of each. The Medical Education Officer and Director of Clinical Training actively seeking to recognise the character of the individual units in all training locations, including community placements. Effective performance appraisals of junior doctors, and feedback incorporating registrar and/or nursing perspectives where appropriate. Adequate support and provision of resources for junior medical officers (JMOs) including: – adequate staffing to cover annual and sick leave; – continuing education, particularly in areas of stress management and time management; – dedicated weekday time to allow an annual visit to a general practitioner; – appropriate location and pager-free time for junior doctors to meet; and – provision for national meetings between State and Territory JMOs and students. Recommendation 4 There is a need for further consultation between relevant bodies regarding the transfer of information about distressed students between university and hospitals. This issue needs to be further explored with discussions by all parties involved — the universities, hospital administration and medical staff, postgraduate councils and medical boards. Recommendation 5 That the management of students or doctors in distress be: confidential; independent of training or studies; clear and well defined in all medical schools and hospitals in Australia; continually re-evaluated by all parties involved; and structured to include career counselling, if appropriate.

Geoffrey W Dahlenburg MD, FRACP

A recent article noting that "unhappy doctors are a worldwide phenomenon" imputes this to ongoing changes in relationships with patients and society.1 Despite this phenomenon, many young people, for a variety of reasons, still wish to study medicine. The reasons include: parental pressure — "you've got the marks" . . . "it's a secure income" . . . "doctors are well respected" . . . "you can always sing/write later"; the challenge — both academic and personal; and the wish to help people — "to do something meaningful". Here, I outline some of the issues in the student and early postgraduate years which may influence performance, summarise the effects of recent changes in medical practice, and, finally, explore impairment issues as they affect medical students and doctors. The student yearsSelection biasWhatever the prerequisites for medical school entry, there is a selection bias towards those who are conscientious, intelligent, able to delay gratification, and have high levels of personal drive and demands on self. But they may also be unassertive and fairly compliant. Another, frequently overlooked, group entering medical school are multitalented and curious ("they could have done anything"). This latter group may be restless and impatient with others less gifted. The interaction between these character traits and student expectations will affect medical students' performance, career choice and impairment. Changes in curriculaIn the past, despite the apparent academic nature of medicine, the old model of medical education (ie, preclinical "chalk and talk" followed by a clinical apprenticeship) relied heavily on rote learning. The newer medical curricula put greater emphasis on adult learning techniques and the acquisition of life skills. This is a welcome change2 and should challenge all students and lead to greater awareness of communication skills. Educational philosophyThe philosophy underlying medical education is an important factor affecting student selection as well as distress and impairment. There are two different views: 1. Medical education can be seen as a right — a broad education for those interested in health issues, which is open to anyone who can gain entry. In this paradigm, medical education is not linked to ability or fitness to practise medicine, and the role of universities is to produce graduates with a sound knowledge and appropriate basic skills, but they have little or no responsibility for their clinical conduct after graduation. 2. The role of medical education is to maintain a flow of well qualified doctors, with education linked to workforce requirements. Here we need to consider whether the goal is to produce potential interns, general practitioners, or specialists. Each of these goals implies different training needs and priorities: if the aim is to produce junior doctors, this paradigm acknowledges the significant subsidy by the taxpayer and the physically demanding nature of the work, requiring fitness standards akin to those of airline pilots; or if the aim is to produce doctors who become specialists (in primary or secondary care), then the course is pitched beyond the first few years, with an assumption that the Postgraduate Medical Council will be responsible for early training issues. Both of these views are valid — the choice of goals with their differing underlying philosophies will influence selection and "goodness of fit" of the student with the paradigm, and will indirectly affect stress and impairment issues. Ethical pressuresA recent study3 has explored the ethical pressures on final-year medical students, and noted three main types of ethical problems: conflict between requirements of medical education and patient care; responsibility exceeding student's capabilities; and involvement in communication or procedures with patients that were deemed to be substandard. These issues are important in themselves, but the authors also noted that the areas of conflict between medical education and patient care are rarely discussed. Student concernsAgainst a backdrop of upheaval in the health system, expectations of patients, their families and society in general, there is a need to identify the concerns of students and junior doctors and to keep them motivated and inspired. Box 1 lists the concerns identified by a recent survey of medical students at the University of New South Wales by our Student Support Working Party, and some of the responses to these concerns. The early postgraduate yearsRites of passageThe first two postgraduate years have traditionally been seen as a rite of passage, and a time to assimilate with the culture of "the harder I work, the better doctor I am". The system seems to reward self-sacrifice and "driving yourself into the ground", and to discourage time for self-reflection or self-care. We know we must tell patients about the need to exercise, to reduce stress, to have a balanced lifestyle and good, restful sleep, but doctors are presumably different from everyone else! Thus, in the past, the intern year provided a significant barrier — the assumption being that, if junior doctors are emotionally and physically resilient enough to complete the early postgraduate years, then they have "earned their stripes" and are able to continue. For the survivors, again, there used to be significant mentoring and social support through association with a particular hospital. The first few postgraduate years of a medical career are still just as physically and emotionally demanding. Thus, if the threshold is lowered by making provision for an increasing range of specific impairments in interns, it may be necessary to have other methods of screening physical and emotional resilience — or else to change the prevailing medical culture and public expectations of doctors. The following questions flow from this philosophy: Can people who cannot carry out a physical examination or basic medical procedures work as interns? Can they become doctors if they cannot fulfil an internship? How should interns who become very distressed by illness or sick people be catered for? Non-practising doctors?When these questions are posed, some proffer the idea that there could be special places for doctors who will not practise. This is a matter of whether the taxpayer is prepared to fund places for people who will never be doctors. This may cause considerable difficulties later if those who said they understood the conditions on entry change their minds after graduation. The alternative is to offer different courses, for example in medical ethics, for people who have valuable contributions to make, but cannot physically do the work of a doctor. Problems of perpetual changePreviously, doctors could expect autonomy, job security, deference and respect, and a reasonable balance between private life and work commitments. There are now growing imperatives towards patient-centred care, greater accountability, evaluation by others and a growing culture of blame.1 The medical indemnity organisations and the whole medicolegal environment are in a state of flux. There is also much greater rotation of staff around hospitals, leading to less "bonding" with particular institutions, less camaraderie for interns (who are no longer "residents"), and less access to mentors important for a future career. Overall, there are fewer solo-doctor general practices, and much more emphasis on working with multidisciplinary teams. There are more female doctors forging substantial careers, more doctors who are working parents, and reports of diminished income in general practice. The impact of corporatisation of medicine is still not clear, while provision of provider numbers means more political involvement in medical workforce issues. In clinical practice, there is less opportunity for meaningful contact with patients, with shorter hospital stays and less continuity of care. Particularly in emergency departments and with home visits, doctors can face potentially dangerous incidents involving verbal and even physical abuse related to drug misuse. Associated with all of these changes is greater voicing of dissatisfaction from junior doctors. There are also significant changes in the nursing profession, with greater staff turnover in hospitals leading to less continuity, and the newer roles of nurse practitioners and practice nurses, which offer potential but are yet to be fully explored in Australia. The far greater range of paramedical and alternative practitioners may be seen as allies or potential competitors. In terms of the broader health system, there is a greater demand for transparency, and, from the general community, rising rates of medical litigation, but also more opportunities for collaboration with "informed consumers". Over the past decade, there has been a move away from an emphasis on treating acute illness to managing chronic disease. A recent article, "Are we teaching the wrong things?",4 highlights the growing need for clinicians to promote greater autonomy in their patients with chronic illness, working with them in a collaborative relationship. The authors provide a set of specific interpersonal techniques to help doctors promote effective partnerships, leading to greater mutual satisfaction. This new paradigm contains the seeds of the answers to many of the problems facing both doctors and patients. In the next decade, new ethical issues confronting medical students and young doctors will concern the Human Genome Project, the impact of pollution, the increasing burden of chronic illness and an ageing population (within the constraints of a shrinking health budget), and the prospect of an increasing role for doctors (particularly general practitioners) as budget holders and "gatekeepers". In coping with these issues, informed consumers may prove to be welcome allies. Impairment issuesStress, distress and impairment are defined in Box 2. Distress, while not necessarily linked to academic failure, is often associated with a fall in academic performance. Impairment implies some effect on performance. Many students or doctors may have short periods of distress, but they are usually not impaired. The distress is often related to some identifiable cause that can be dealt with by holiday leave, or personal or administrative change. Others may be impaired, but not distressed. For impaired doctors and students, the impact of a disorder can vary with the age of onset relative to the stage in a medical career, and may present different issues for junior doctors and for students in undergraduate and postgraduate medical courses. For many psychiatric disorders, the age of onset is in the late teens and early 20s–30s (eg, psychotic illnesses and eating disorders tend to present in late teens and early 20s, while anxiety disorders and bipolar disorders tend to present in the 20s and 30s). Furthermore, by virtue of their personality styles, their expectations of themselves and others, as well as sleep deprivation and the responsibility and nature of their work, medical students and young doctors constitute a vulnerable group for depression. There is a need for doctors involved with medical boards to have an understanding of current management of psychiatric disorders, and there may be a role for ongoing involvement of impaired doctors who have frequent relapses or severe impairment with medical board impairment programs. This in an acknowledgement that some disorders (such as bipolar disorder) may require long term, less intense monitoring during times of improvement. Medical studentsFor medical students in New South Wales, the criterion for NSW Medical Board involvement is impairment which impacts on patient welfare. Our Medical Board has developed a short, structured referral form for universities, and we are also having regular meetings with the universities to identify clear goals and feedback mechanisms. We also encourage early referral to ensure the smoothest possible arrangements for internship. The most difficult impairments to manage include intermittent psychosis, severe personality disorder and addiction. Moreover, these impairments may not be evident at a selection interview. It is also important to note that a few people will not be able to practise medicine because of their impairment. If so, there needs to be discussion about the acceptability of having these students continue in the medical course. This argument goes back to the underlying philosophy of medical education and whether it is ethical to allow someone to make the significant investment required in a medical course, knowing that they will not be able to practise medicine and that the course may not equip them for much else. If it is not considered ethical, such students should be encouraged to make other career choices and helped to do so. Using the airline pilot analogy, they would be counselled about their lack of suitability. If, on the other hand, these students are allowed to enrol in medicine and continue studying, despite significant impairment inconsistent with practising medicine, it is not sufficient to assume they will find a place in medical research — there needs to be more consideration of what appropriate, non-clinical career choices are available. DoctorsThe NSW Medical Board has recently developed a working definition of impaired doctors (Dr A Reid, Medical Board of NSW, Medical Director, personal communication). Impaired doctors are defined as those who "suffer from any physical or mental illness, disability, condition or disorder (including the misuse of drugs or alcohol) that detrimentally affects their physical or mental capacity to practise medicine, and results in risk or potential risk to the public that is not adequately managed by treatment or practice modification". The Medical Board's main interests lie in the maintenance of good standards and patient safety. A longitudinal assessment of possible impairment is important, with an accent on ability to communicate with patients and others, periods of absence from studies or work, degree of social support, and the amount of insight and personal responsibility taken by the impaired person. A recent article6 discussed the need for simple, well publicised access to a program for impaired doctors, which should include some crisis intervention. It also stressed the importance of peer support, ongoing supervision and monitoring for five subsequent years, together with frank discussions about future prescribing. An example would be doctors who have had problems with analgesic dependence, who might be required to demonstrate that they are better informed about prescribing. The NSW Medical Board requires such doctors to undergo education about pain management as part of their rehabilitation. A suggestion has been made that impaired doctors should be matched with other doctors with similar illnesses or impairments, who can assist them from their own experience.7 Other possible solutions for doctors with a chronic illness include proactive career counselling and guidance, secured funding for retraining doctors who can no longer practise, and ensuring attitudinal change as part of medical training.8 Positive trendsWe have the prospect of new graduates being a cohort of bright, interested young people with a much broader ethnic mix. They may be better placed in assisting those in distress, with more specific training, greater awareness of the stresses pre- and postgraduation and greater access to effective psychological management strategies. An article entitled "Promoting well being among doctors" has advocated moving from a disease model to focus on positive functioning.9 The authors advocate use of techniques from the growing field of positive psychology which aim to promote self-care, encourage peer support, challenge self-critical thoughts and foster optimism. This theme is also pursued in the "Career Focus" section of the British Medical Journal, with articles on looking after yourself and evaluating life roles.10,11 The goals are to help doctors influence their work environment and increase feelings of self-worth and effectiveness. Self-care techniques, combined with work practices, ensuring a balanced lifestyle and a growing focus on a more collaborative approach, both in the doctor–patient relationship and in clinical teamwork, have the potential to increase job satisfaction and resilience in doctors. Finally, I would like to pose a series of questions for us to answer at this Conference (Box 1). 1: Responding to medical students' concerns at the University of New South Wales Concerns the need to earn money; the requirement to travel between campuses; the lack of understanding by friends and family of the pressures involved; communication difficulties (especially for those from a non-English-speaking background); and the lack of an identifiable referral network for students with problems. The concerns of older students (who, with the advent of postgraduate courses, are now becoming more common) are slightly different — they may have taken a drop in income to study and already have families and mortgages. Responses Some of the responses to these concerns have included a decision to establish scholarships for those who are financially burdened (so that they can study and have a balanced lifestyle); encouraging students to have their own general practitioner; and the appointment of a Student Support Officer (who is a working general practitioner) –to improve liaison for those students in distress, –to improve the referral network for those in need, and –to coordinate services for those requiring remediation and counselling. There has also been an initiative involving mentor groups (students in Year 3 mentoring those in Year 1, and students in Year 6 mentoring those in Year 4) which has been very successful. Finally, medical students in New South Wales are registered with the Medical Board and paths for referral and review have been improved. 2: Distress and impairment "Stress" and "distress" are often used interchangeably Stress results from an event which produces physical or psychological pain.5 Stress is also applied to the autonomic arousal associated with such events. Distress is the external sign that all is not well and assistance is required. It is usually related to specific events or illness, and is understandable and acknowledged as appropriate, or considered inappropriate in the context. It may temporarily affect performance, but should be a signal for action to reverse the cause of the distress. Impairment Impairment may be acute, episodic or longstanding — the course is related to the underlying disease, condition or disability. The term implies that performance is affected by the course of the underlying physical or mental condition. An impaired but insightful student or doctor may be able to practise safely under specific conditions. 3: Questions for the Conference to address Do the universities need a statement about their goals for provision of medical education and preparation for a medical career? Should medical students be made aware of these goals at entry into medical studies? Should they be required to declare any problems in meeting the requirements? What is the purpose of identifying students in distress or with impairments? What can we offer them? Are these goals being realised? Can we provide transparent, supportive, proactive processes for those who are impaired? Is medical training consistent with current medical workforce requirements? Are we doing enough to emphasise positive functioning (at all stages of a medical career)? How much impairment will society tolerate in doctors? How much will the profession tolerate? What are the workforce implications of impairment? What is role of the Medical Registration Boards? Should boards deal with only the most impaired doctors or should they be more proactive? Can we produce some acceptable Australian policy and good documentation on proactive strategies for dealing with stress and impairment in medical students and young doctors?

Kay A Wilhelm MD, FRANZCP

It has been long recognised that the practice of medicine is stressful and that doctors are prone to anxiety, depression, drug and alcohol problems, and even suicide.1,2 Similarly, the process of medical education is stressful and medical students, too, are at risk of psychological problems.3 In New South Wales, in 1997, after a report on doctors' mental health, the NSW Medical Board convened an independent Doctors' Mental Health Implementation Committee, with wide-ranging representation from the profession. This Committee produced the NSW Doctors' Mental Health Policy to provide a framework for the NSW Doctors' Mental Health Program.4 Separate policies were developed for rural practitioners, area health services, specialist medical colleges, and for medical schools. Mental health policies for medical schoolsThe policies for medical schools included: promoting the importance of mental health — by embedding it in the curriculum; encouraging a caring culture within the medical school; identifying suitable personnel to provide assistance to students with social and psychological problems; and assisting students to obtain good medical and psychological care. Many factors may contribute to stress and distress in medical students. These include not only the intrinsic stressors within medical education, but also significant changes and conflicts in lifestyle. For example, students in graduate programs, who are often older and married with young children, may have great financial pressures placed upon them. Implementing the policies at Sydney UniversityThe policies were implemented primarily in two ways: by incorporating the theme "Personal and Professional Development and Ethics" in the curricula; and by establishing a Student Welfare Committee. Personal and Professional Development and Ethics is one of the four teaching themes in the graduate medical program, which are integrated both vertically and horizontally. The others are Basic and Clinical Sciences (pre-clinical sciences), Patient–Doctor (diagnostic and clinical skills) and Community–Doctor (epidemiology and social medicine). The Personal and Professional Development and Ethics theme is integrated into all aspects of the students' learning program, which is centred around "problem-based learning" in small groups meeting twice weekly. These groups focus each week on a specific clinical problem. The students are encouraged to develop good listening and communication skills and to be aware of the functioning of the group. In the context of these clinical problems, they are exposed both to the multiple roles of doctors — as clinicians, educators, supervisors, and patient advocates — and to the professional and ethical issues in the clinical case. Larger lecture or seminar teaching sessions cover healthy lifestyle, stress and stress management, anxiety and depression, and substance misuse. Other sessions deal specifically with mental illness and stigma in mental health, and students are encouraged to understand the political, financial, legal, and ethical impacts of these disorders. In addition, they understand the duty of care in relation to mental health problems in their colleagues and their own mental health. The Personal and Professional Development and Ethics theme is assessed at several points during the medical course, in both a formative and summative manner. (A formative assessment does not involve a pass or fail, but, if unsatisfactory, may require some remediation. A summative assessment is a pass/fail assessment). A Student Welfare Committee was established with basic principles of confidentiality regarding student information, a duty of care to students, and, in some instances, a duty of care to hospital staff and to patients. The Committee comprises the coordinators for the first two, non-clinical years of the medical course and the Associate Deans of the teaching hospital clinical schools, with the chair being a psychiatrist on the university staff. If appropriate, a member of the Medical Board is invited to attend. Information about individual students discussed in the committee is de-identified. The importance of collecting detailed information about problems has been emphasised, particularly as the Medical Board requires detailed information to be able to make the most appropriate decisions if and when students are referred. The Committee has established appropriate processes for referring students to appropriate clinicians — counsellors, psychologists and psychiatrists — outside the faculty. Other options available are referral to the Medical Board, for establishing and maintaining psychological care for the student, for placing specific requirements on the student for registration, or for deregistration. (In New South Wales, medical students are registered in a similar way to medical graduates.) Students with problems tend to come to the Committee's attention in two ways. Firstly, students may self-present to the year coordinator or to the Associate Dean's office with either social or psychological problems. Initially, a supportive identified member of that office screens the problem. The matter can then be referred to the Associate Dean or the year coordinator and discussed at the Student Welfare Committee meeting. Appropriate documentation is kept. Secondly, students may be reported to the Associate Dean by other concerned students or staff, usually when they appear quite psychologically disturbed or have significant behavioural problems. In the early days of this Committee, there were often differences of opinion, particularly in considering, firstly, duty of care to patients and other staff, and, secondly, confidentiality within the faculty. For example, should relevant university staff be notified of a student who was distressed or not coping so they could be of support and assistance in the student's next rotation? As the committee progressed, these issues were largely resolved. It was agreed that one key staff member in a rotation would be made aware of a student needing support. ConclusionsThe pressures placed on medical students during their education, which can lead to significant psychological problems, are increasingly being recognised. The consequences for the student — in distress caused, and in interruption to their education — are considerable. The problems may also adversely affect others. Medical faculties need to be aware of these problems and identify and deal with them as soon as possible. Structures should be in place to accomplish this.

Chris C Tennant MD, MPH, MRCPsych, FRANZCP

Medical courses are inherently stressful because of the nature of the course, the workload and, for some students, financial issues. These stressors can lead to impaired judgement, reduced concentration and self-esteem, and increased anxiety, manifesting in turn in depression and even suicide. In 1997, as a first-year medical student of the graduate program at Sydney University, I attended the conference of the Australian and New Zealand Association of Medical Education. The conference explored facets of stress for medical students and found that medical students were indeed stressed. However, the causes of the stress were not explored, and neither were the ways of managing this stress. I decided to examine the level of stress in students in my year. There are fundamental differences between the undergraduate and graduate medical courses and in the type of students enrolled. As opposed to the predominantly lecture-based, didactic undergraduate courses, the graduate course emphasises self-directed learning in problem-based, small-group tutorials. Graduate students have an advantage in that they have had previous experience of university education. In 1997 the average age of the students in my year was 24.5 years. They therefore had different life experiences to younger undergraduate students. I hypothesised that stress in the first year of the graduate course would reflect financial, personal and living issues; time management problems; the new format of the course and the problem-based learning structure; using computers; and, for some students, the requirement to move residence to study. Examination pressures were not applicable in the first year. The studyA study was devised to assess overall stress and the effect of these eight potential stressors. MethodsEach parameter of stress was assessed by a retrospective questionnaire, using a four-point scale ("stressed", "very stressed", "unstressed", and "very unstressed"). Students were assessed twice in their first year, at enrolment and six months later. Stress at these two time points in first-year students in 1997 was compared with that in first-year students in the two subsequent years, when an intrafaculty support network, the "Buddy Program", had been established. For this program, the medical faculty encouraged students to be involved, and supported the development of this student support network. Students finishing first year were asked to volunteer to take part in peer support — to be a "buddy" for the next year's first-year students. Volunteers were introduced to two or three students at an informal morning tea. Contact between the buddy and first-year students was maintained using the tutorial rooms, telephone and email. The students were encouraged to approach their buddy with questions, or for support, whether on an academic, social or personal level. All interactions were confidential, with support from the honours supervisors (trained in psychology and counselling) if situations demanded their intervention. The Statistical Package for the Social Sciences (SPSS) was used for all analyses of results: χ2 analyses were used to test relationships between categorical variables, and descriptive data were compared using t-tests. Because of very small numbers in sections of the four-point scale, rates for "stressed" and "very stressed" were combined, as were rates for "unstressed" and "very unstressed". Stressor frequency in the intervention years was compared with the baseline year (1997) using 95% CIs. ResultsAll students in 1997, 1998 and 1999 were included in the study. Response rates of students to the questionnaires were as follows: in 1997, 115/132 (87.1%); in 1998, 131/154 (85.1%); and in 1999, 166/201 (82.6%). The results are presented in the Box. Students in 1997 had higher stress levels than those in the two subsequent years. Across the three years, the main stressor was time management: between enrolment and six months later, the proportion of students with stress from time management problems did not decrease significantly. Financial issues also caused significant stress. There were temporal changes in overall stress. In the intervention years when the "Buddy Program" was operating, more students were not stressed at enrolment and remained so six months later ConclusionsA substantial proportion of graduate medical students find the course stressful, with the main stressors being related to time management and financial issues. Stress levels fluctuate throughout the academic year. Starting a course which acknowledges inherent stresses and has an established support network for this creates a less stressed group of students at enrolment. The "Buddy Program" maintained low stress levels in individuals who started the course unstressed. However, students commented that there was not enough access to buddies, despite the high rate of buddy volunteers for the program. Medical students need to be taught structured time management skills, and given access to financial support. Rates of overall stress and factors causing stress, by year, at intake and at six months. Data are number and proportion of first-year students in a graduate medical course, with 95% CIs for comparison of rates — 1997 v 1998 and 1997 v 1999 At intake At six months 1997 (n = 115) 1998 (n = 131) 1999 (n = 166) 1997 (n = 115) 1998 (n = 131) 1999 (n = 166) Overall stressed 60 (52.2%) 46 (35.1%) 72 (43.4%) 50 (43.5%) 52 (39.7%) 77 (46.4%) 95% CI 4.8%, 29.3% – 15.7%, 8.0% – 8.5%, 16.1% – 14.7%, 8.9% Individual stressors Time management 82 (71.3%) 75 (57.3%) 103 (62.0%) 85 (73.9%) 104 (79.4%) 123 (74.1%) 95% CI 2.2%, 25.9% – 1.8%, 20.3% – 16.1%, 5.1% – 10.6%, 10.2% Financial issues 66 (57.4%) 60 (45.8%) 88 (53.0%) 67 (58.3%) 68 (51.9%) 84 (50.6%) 95% CI – 0.8%, 24.0% – 7.4%, 16.2% – 6.1%, 18.8% – 6.9%, 22.2% New format of the course 65 (56.5%) 59 (45.0%) 80 (48.2%) 28 (24.3%) 48 (36.6%) 60 (36.1%) 95% CI – 1.0%, 23.9% – 3.5%, 20.2% – 23.7%, – 0.9% – 22.5%, –1.1% Personal issues 56 (48.7%) 51 (38.9%) 74 (44.6%) 58 (50.4%) 45 (34.4%) 73 (44.0%) 95% CI – 2.6%, 22.2% – 7.7%, 16.0% 3.8%, 28.3% - 5.4%, 18.3% Problem-based learning 51 (44.3%) 42 (32.1%) 54 (32.5%) 27 (23.5%) 31 (23.7%) 32 (19.3%) 95% CI 6.1%, 18.5% 0.3%, 23.4% – 10.8%, 10.4% – 5.6%, 14.0% Using computers 40 (34.8%) 36 (27.5%) 23 (13.9%) 9 (7.8%) 17 (13.0%) 8 (4.8%) 95% CI – 4.3%, 18.9% 8.2%, 33.6% – 12.7%, 2.4% – 2.9%, 8.9% Living conditions 36 (31.3%) 25 (19.1%) 47 (28.3%) 29 (25.2%) 18 (13.7%) 37 (22.3%) 95% CI 1.4%, 23.0% – 7.9%, 13.9% 1.6%, 21.4% – 8.0%, 12.4% (n = 44) (n = 73) (n = 82) (n = 44) (n = 73) (n = 82) Moving residence to study 28 (24.3%) 21 (16.0%) 44 (26.5%) 12 (10.4%) 10 (7.6%) 18 (10.8%) 95% CI 7.9%, 43.7% – 17.3%, 19.1% – 10.0%, 20.7% – 10.6%, 21.2%

Gisele M L Mouret MB BS (Hons), BAppSc(Physiotherapy)

The Tasmanian University Medical Students Society (TUMSS) and the Tasmanian Branch of the Australian Medical Association (AMA) have jointly run a mentor scheme linking students with doctors since 1994. However, the scheme was not meeting the needs of students. In particular, there was a lack of support for students who were distressed or affected by adverse life events, such as mental or physical illness and loss of family support. The impact of such problems was seen to contribute to the average annual loss of 11 students for the academic years 1999–2000. Here, I focus on the history and development of this model for helping students in distress. History of the schemeThe Tasmanian Branch Council of the AMA started the mentor scheme in 1992. Mentor doctors were paired with students on a one-to-one basis, and the scheme was run by a committee of doctors. In 1994, the running of the scheme was passed to the student representative on the AMA Council. As a consequence, the scheme waxed and waned for a few years, depending on the amount of time the student representative had available. In 1998, the model was altered to involve six students, one from each year of the course, with one doctor. As a final-year student left, a first-year student would be added to the group. The aims of the scheme, which have remained consistent from the beginning, are: to develop integration between the years in the course; to link students with doctors to help them appreciate the bigger picture beyond medical school; to facilitate student networking in both giving and receiving support; to provide doctors with insight into the current medical course; and to allow doctors to have a role in shaping the future for current medical students. Problems with the group formatThe most recent format — groups of one doctor and six students — did not meet these aims as successfully as hoped and many of these groups eventually foundered. Participant representatives of each group in the scheme were contacted and feedback was sought on their experiences. Some of the reasons given for the scheme's shortcomings were: The long-term commitment demanded of doctors by the continuous replacement of final-year students with first-year students gave no natural break point for mentors to "bow out gracefully". The model, being predominantly face-to-face, was not practical in the fifth and sixth years of the course, when students study in remote parts of the State. This made it very difficult for them to maintain their involvement with a group. While the group model was good for networking, it could also be restrictive for those unwilling to raise issues in a group setting. Some students indicated that they did not feel they could contact the mentor for a one-to-one meeting because the scheme was defined as a group event. Consistent contact was not maintained with each group and no central point of leadership existed to motivate the groups, or assist in resolving problems within groups. Group members were selected by a third party and demographic characteristics were used to match members. However, this system was not always as successful as hoped in finding compatible group members and mentors. Entry was limited to the start of the year, when students did not feel they had any problems. Later in the year, when they were confronting problems, students had to single themselves out to gain entry to the scheme, and often had to join established and even full groups. In summary, anecdotal evidence indicated that the scheme was a good opportunity for networking, but the number of people to network with was limited. Furthermore, the scheme provided limited scope for linking students with a suitable mentor to help them cope with a particular difficulty they were experiencing at the time. The result was that the scheme could do little to address the needs of the handful of students who were lost from the course each year for want of appropriate support. Current direction of the schemeIt was decided that this gap in student support could best be met through a model based on the Tasmanian Doctors' Health Advisory Service. Ailing students will be linked with appropriate clinicians, primarily via a web-based referral system. This system will enable "mentors" with an interest in student health to be drawn from a relevant specialty for a specified period of time on an "as-needed" basis, with confidentiality maintained. The proposed changes to the scheme present several advantages. Rather than dictating a long-term contact with a mentor, it allows for students to make brief contact with a mentor to deal with problems as and when they arise. Students are not discouraged from forming ongoing relationships with their mentors, nor from building up a network of contacts with a number of doctors. Students may approach each mentor in a selective fashion to deal with a range of issues, including health, career, medical politics and study, and do so in the way they feel most comfortable with. The use of the web in this scheme also allows rural and remote doctors and students to participate, and no longer disadvantages fifth- and sixth-year students at teaching sites far from the main campus. Instead, the opportunity now exists to locate a mentor in their local area and build new networks that should make their stay in the north or north-west of the State more enjoyable and fulfilling. International students, who have been identified as one group having particular difficulty during their time in rural areas, may gain more support and guidance from the new scheme. For doctors, the new scheme provides various categories of involvement to choose from. They are able to dictate just how much or how little they would like to be involved and the types of information or advice they feel comfortable providing. While such a model is theoretically simple, its development has highlighted a number of issues. These include: Protecting the interests of doctor mentors and preventing their being misused (or abused); Developing an adequate network of mentors to meet a range of student needs; Defining the limits of confidentiality and indicators for disclosure when student ailments prevent satisfactory ward work or study practices; and Identifying an acceptable avenue for disclosure and action by a medical school given the lack of an independent regulatory body for medical students. Features of the modified schemeSome aspects of the current one-doctor-to-six-students structure of the scheme are being retained and new components are being introduced. Face-to-face meetings are still encouraged. Technology is not being promoted as a substitute for personal meetings, although it will help to lessen the impact of distance. It is anticipated that a blend of email and telephone contact and face-to-face meetings will make this scheme invaluable for students remote from the main campus. Rather than attempting to duplicate the Doctors' Health Advisory Service, links will be developed with the service. This will allow students for whom the mentor scheme is not sufficient to draw on the expertise of professionals experienced in dealing professionally with people who are not coping well. To maintain some cohesion and motivation for the scheme, regular social gatherings and educational forums are planned. In addition to doctors acting as mentors, some senior students are being encouraged to act as mentors for more junior students. Students have a lot to offer their peers: help with understanding the direction of the course and how to survive it; how university works; and where to find practical assistance. Constraints of the schemeFor the scheme to be a success, its scope must be limited to providing effective assistance with small problems. Students with chronic problems or ailments requiring active therapy will be referred to their general practitioner or other appropriate healthcare provider. Thus, the scheme is not seen as a "bypass" for fee-for-service healthcare and students will need, and be encouraged to have, their own GP. Future directionsThe web-based mentor scheme I have described is still at its fledgling stage. Future improvements will increase the efficiency of providing mentors and decrease the level of maintenance required. Other improvements are: The gradual upgrading of the website so that it is largely self-administering. One of the burdens of the scheme to date has been the huge workload required to maintain the electronic and telephone service. The involvement of mentors from other States and overseas to represent specialties or interests not available in Tasmania. The involvement of junior doctors in the scheme, with a gradual transition as their confidence and experience grows, from being mentored to being mentors. This scheme has the potential to be valuable to students and doctors in the support it offers and in the networking opportunities it provides. However, there is a need for other structures. An independent regulatory body associated with medical student registration is required to assist when a student is no longer able to functional appropriately in a clinical setting, and requires more direction and support than mentoring can provide.

Lisa M Barrow BSc(Hons), MPsych (Clinical), MAPS

Most members of the medical profession feel stressed at some time. If stress is ongoing, impairment may occur (defined as being unable to safely or reliably perform one's role). A continuum appears to exist between functioning well, being distressed and becoming impaired, with external (environment-related) and internal (personal-related) stressors determining where an individual will lie on the continuum. We are conducting a study which aims to determine whether distress in new medical graduates can be predicted before the graduates become impaired and unable to safely or reliably perform their role. Study commencementOur study, which commenced in 1997, initially looked at predictors for "troubled" and "troublesome" interns. Hospital-based focus groups comprising interns (postgraduate Year 1), resident medical officers (postgraduate Year 2 and above), ward-based nursing staff and medical administrators reported on internal and external stressors for junior medical staff. Residents and nurses reported similar external stressors, whereas the internal stressors reported by the two groups were quite different (Box 1). Residents tended to report issues relating to "troubled" interns (eg, poor support, few outside interests), whereas nurses identified factors relating more to "troublesome" interns (eg, poor attitude, unprofessionalism). In other words, resident staff seemed to be able to identify their stressed and at-risk peers before effects on performance were observed (Box 1). Our study has subsequently moved through three distinct phases. Phase 1In Phase 1 (1997), 151 interns from seven primary allocation centres (centres which employ first-year postgraduate doctors) around New South Wales were approached and specific tools were administered, at orientation and at mid-year, to assess "burnout",1 alexithymia (not being emotionally sensitive or expressive, and having externally oriented thinking),2 and social support.3 General demographic characteristics were also obtained. These data were correlated with "assessed performance" data for the interns in the study, as determined from term evaluations by their supervisor. Results from this pilot cohort suggested that alexithymia was a possible predictor of a resident in difficulty, ultimately leading to poor performance. Phase 2In Phase 2 of the study (1998), the entire NSW cohort of interns (482) from all primary and secondment allocation centres across the State were approached and the same questionnaire tools administered. Scores for two of the subscales of the Maslach Burnout Inventory — "a sense of personal accomplishment" and "emotional exhaustion" — indicated an overall moderate level of burnout among interns at mid-year (as defined in the normative data for medical practitioners supplied by the instrument publishers). This was not surprising given the high level of emotional stress traditionally associated with the intern year. However, measurements of the third subscale, "depersonalisation", indicated a high level of this component of burnout. Furthermore, significant correlations were noted between alexithymia at mid-year and both "a sense of personal accomplishment" and "emotional exhaustion". There was a negative correlation between alexithymia (mid-year) and "personal accomplishment" (r = – 0.35; P < 0.001) and a positive correlation between alexithymia (mid-year) and "emotional exhaustion" (r = 0.25; P < 0.001) (ie, alexithymia was associated with higher levels of emotional exhaustion and lower perceived levels of personal accomplishment). This larger cohort also confirmed the presence of primary and secondary forms of alexithymia: Primary alexithymia is postulated to represent a personality trait; and Secondary alexithymia is postulated to represent a "state" characteristic relating to an induced state of alexithymia. Secondary or induced alexithymia possibly indicates a coping mechanism midway through the stressful internship year. Primary alexithymia seemed to be particularly predictive of higher burnout and poorer performance, although induced alexithymia was also associated with a lower assessed level of performance than was the case for interns who remained non-alexithymic (Box 2). Phase 3Phase 3 of the study is currently under way. One hundred and twenty students from the University of Sydney are being tested at six different times across their final medical school year (Year 4) and the internship year. The core measurement tools have again been administered and, in addition, the General Health Questionnaire,4 the International Personality Disorder Examination (IPDE, ICD-10 module) screening questionnaire5 and the Sheehan Quality of Life questionnaire.6 A key difference from previous studies is the inclusion of a one-on-one Life Events and Difficulties Scale (LEDS)7 interview at six-monthly intervals over the two-year period. Preliminary findings from the mid-internship LEDS interview indicate some issues that appear to promote stress mid-internship. Poor-quality supervision is a common issue and appears to relate to the unsupportive, "burnt-out" or overworked registrar or term supervisor providing inadequate supervision. Similar issues arise in situations where appropriate levels of supervision are lacking, including at some rural allocation centres, and particularly in emergency situations or at night. Lack of debriefing measures after a critical incident was another common theme, as was dealing with emotionally difficult situations, such as giving bad news. Above all, administrative support issues appear to be very significant. A sympathetic administration ameliorates many of the other problems, but an unsympathetic one heightens the level of stress experienced. Summary of findingsIt would appear that the performance of new medical graduates is affected by their personal responses to the experience of internship. A supportive environment potentially ameliorates this performance effect. To help students progress into the internship and minimise stress we need to: Provide good registrar and supervisory support; Have a sympathetic medical administration; and Promote awareness of burnout and personal emotional needs. 1: External and internal factors predicting distress in interns 2: Presence of alexithymia* at orientation and mid-year during internship, and related performance and burnout * Not being emotionally sensitive or expressive, and having externally oriented thinking.

Michele G Daly MSc · Simon M Willcock MBBS, FRACGP

Medical Boards throughout Australia are considering amending their respective Medical Acts so that all students in each State or Territory are required to be registered with their Medical Board as a prerequisite for studying medicine. Such amendments have arisen from the increasingly litigious environment, the growing role of clinical education in traditionally preclinical years, and the recognition that medical students enjoy many of the doctor–patient privileges of fully qualified medical practitioners and must therefore assume appropriate responsibilities. New South Wales was the first State to introduce this requirement, having done so in 1992 after broad consultation. The Board's sole concern is with impairment, not misconduct or improper behaviour. In NSW this requirement has been well accepted and is perceived as an additional support mechanism for students. Victoria passed legislation in 2000 for registration to start in 2002, but precise details are not available (at the time of the Conference). This followed extensive consultation with students over the preceding years. The model is not dissimilar to the NSW model. Again, the Board's role relates solely to impairment. In South Australia, at the time of the Conference, legislation is before the upper house of parliament. There is a perceived lack of recent student consultation on the proposal. The proposed model possesses somewhat stronger teeth than the NSW or Victorian models in that it applies to medical students the same conditions of registration as currently exist for doctors. [This Act has lapsed. There was a change of government in South Australia before the Act was passed.] In Western Australia, there is strong student opposition to universal registration. The current proposal is that the Medical Board would have jurisdiction only over students referred by the University of Western Australia Faculty of Medicine, but negotiations are continuing. The concept has been mooted in most other States and Territories. Specific time frames are unknown. The aim of registration is to facilitate early detection of impairment that would compromise patient welfare; to encourage impaired students to seek support; to facilitate alternative arrangements for medical students to enable disabled or impaired students to complete their degree; and to minimise risk to the public. The Australian Medical Students' Association (AMSA) recognises the potential value of registration of students. It should be viewed as an additional support mechanism, as a way of supporting impaired medical students through their course, or assisting them in finding another career path should medicine prove to be unsuitable. If it is perceived as punitive or adversarial, it will not be accepted by students. AMSA believes that the precise purpose of medical student registration needs to be very clearly defined given the significant additional powers that such an initiative would bestow upon State medical boards. Recognising the scope for its misuse, it is vital that the registration of medical students only be used for the initially intended purpose: to minimise risk to patients; to develop an impartial mechanism of notification and investigation of complaints against students, independent of the university; and to allow recognition of medical students by any public hospital, teaching or non-teaching, in that State. The medical boards should only initiate investigations if they believe that the ability of a registered medical student to have direct patient contact may be affected by the student's physical or mental health; if the student has an impairment; or if the student has exhibited unethical conduct. Complaints made on other grounds, such as academic performance, should not be investigated by the Board, but should instead be referred to the university. AMSA recommendations for medical board registration of medical studentsMedical student registration should be introduced only after a thorough consultative process, with endorsement from local student bodies and medical faculties. NSW and Victoria did this, and it should also be done in other States. The medical boards' role should be passive, so that they only have the right to investigate a student in the event of a complaint. In most circumstances, complaints about a medical student should only be made to a medical board when all other appropriate avenues have been exhausted. This represents a significant difference from the registration of medical practitioners. Medical board registration should not require students to prove their capacity to undertake clinical studies; this would be an unnecessary burden and an invasion of privacy. Medical board registration should be contingent solely upon enrolment in an Australian Medical Council accredited medical school. Any changes to medical board registration, such as conditions or suspensions, should only be brought about as a consequence of an investigation into a complaint or the cessation of enrolment in a medical school. Most people likely to make complaints against students will have several other avenues open to them. Academics and clinical officers can use existing university procedures in the first instance, and would only need to progress to the medical board in exceptional circumstances. On the other hand, a patient in a rural setting who identifies an impairment in a medical student, and feels obliged to report it, has few options but to approach the medical board directly. Any changes to medical board registration should have an appeals process that should not involve any financial cost to the student, and should be conducted promptly. Medical board registration should be nationally recognised by boards in other States. There is potential for the national registration of medical students in line with current proposals for practitioners. Medical boards should not charge for medical student registration, counselling or investigation or make medical indemnity a condition of registration. Finally, there is a profound need for confidentiality. Personal data should not be publicly available in that part of the register open to the public.

Stefan C Kane

Identifying the characteristics of doctors with health problems that disrupt their ability to practise medicine may help to identify young doctors and students at risk. I describe here the experience of the Health Committee of the South Australian Medical Board, which has been active for 18 years, in the hope that this might assist in formulating a prevention and early intervention program. Four main types of health problems are encountered in doctors. drug misuse, particularly narcotic drugs such as pethidine; mental health problems; general health problems that threaten vocational status; and infection with blood-borne viruses, such as hepatitis B and C and HIV. Here, I will concentrate mainly on drug misuse and mental health problems. NotificationThe Board hears of doctors with potential problems in several ways. The most common is notification by the doctor's practice partners. In addition, members of the doctor's family may seek advice or a doctor's patients may contact the Board, usually saying that their doctor seems "to be behaving strangely" or "to have changed". The Pharmacy section of the South Australian Department of Human Services often detects abnormal prescribing practices, especially in relation to pethidine, and routinely notifies the Board. Finally, about 20% of health-impaired doctors self-notify. It is perhaps reassuring that it is very unusual for a health-impaired doctor to come to the attention of the Board because of a medical misadventure or an adverse event. Procedure after notificationWhen the Health Committee is notified about a doctor with a potential health problem, it writes to the doctor (and quite often also contacts the doctor by phone) and invites him or her to meet with the Health Committee. The letter stresses that the doctor may bring his or her spouse or a friend, and informs the doctor that the Medical Defence Association lawyers are very used to working with these types of problems with the Health Committee. The aim of this initial communication is to emphasise that the interview will have the qualities of intervention, treatment and rehabilitation rather than being a disciplinary activity. Confidentiality is given very high priority and the doctor's identity is only divulged to the members of the Board's Health Committee. There are a lot of subtle issues involved in contacting doctors. It is unwise, for example, to contact on a Thursday or Friday, because this leaves them the whole weekend to worry. Indeed, there have been instances of suicide as a result of this period of isolation and concern. About half the doctors who come to the Committee meeting are accompanied by their spouse, about half by a lawyer, and about 40% come on their own. When these doctors are interviewed, it is relatively rare for them to deny that they have a problem, for example with drugs or with depression. Health Committee's responseThe Health Committee is responsible for coordinating a response to the problem. This usually involves arranging for advice from specialists, such as psychiatrists; arranging for a general practitioner for the doctor; and, in the case of drug misuse, arranging for urine tests three times a week. A health-impaired doctor usually takes at least three months' leave from work. Voluntary undertakingsVoluntary undertakings are signed at the initial meeting and include permission from the health-impaired doctor for the specialists to send their assessments to the Health Committee. The voluntary undertakings are gradually changed over time. When doctors return to work, the undertakings often include that the doctor will not prescribe S8 drugs; will not work in a solo practice; and will not prescribe for themselves or their families. OutcomesAs it has developed and matured, this program has had increasingly good outcomes — and this particularly relates to earlier detection. Relapse rates have fallen considerably and suicide has been reduced. Pethidine misuse: About half the doctors have a relapse in the course of their "first round" of treatment. In the second round, again about half relapse, and this relapse rate also applies to the very small number who go on to a third treatment program. Mental health problems: The vast majority of these involve depression or post-traumatic stress disorder, and this group of doctors generally does well in treatment and complies very well with the management program set out by their treating specialist. The program is particularly useful in the case of hypomania. The backing of the Board for the specialist's management program goes a long way towards ensuring compliance with medication in doctors with this condition (which is characterised by poor medication compliance). Some of the characteristics of health-impaired doctors that may assist in early intervention and education programs are given in the Box. Drug misuseIt is not unusual for a doctor to be introduced to the effects of pethidine during the course of a medical procedure, commonly orthopaedic procedures. The doctor comes to see that pethidine (which is by far the most abused drug) gives the patient a profound sense of relief and a false sense of objectivity. Many of the doctors misusing drugs obtain wider benefits from the Health Committee program than merely achieving abstinence. In the context of psychotherapy, it is common for them to rethink their approach to medicine and to their families. They may achieve a more mature relationship with their wife or husband, although, equally, it is not uncommon for relationships to break up at this point. Follow-up and long-term supportI have emphasised findings which might be called demographic or sociological in nature because they are easy to recognise. It is not hard to see that some special support might be provided to doctors who come from a different culture, or who have found themselves in solo practices, or whose families are struggling in the context of setting up life in a new culture. I would like to especially note here that, at least in South Australia, doctors in the community and in hospitals and other institutions are generous in providing support and help for impaired doctors, and later when they are trying to return to work. The role of the Board in this context is to facilitate the doctor's return to work; to help often new medical partners to understand the problems commonly faced; and to support the doctor concerned. It is essential for the doctor's new colleagues to feel that the Board remains interested in the long-term future of a previously health-impaired doctor. Thus, long-term follow-up is the rule. The Board's Health Committee has noted that, with long-term follow-up, the number of doctors who bring their spouse or partner with them increases as time goes on. This appears to be a good prognostic sign. SummaryWe have found that it is possible to set up a system which has the powerful backing of the Medical Board, but which is, at least in the first instance, non-punitive; to identify risk factors for drug misuse and mental health problems; and to detect these problems early if the system, especially the medical system, is made well aware of possible avenues of help. A result of the Health Committee activity, as described here, is that there is less stigma associated with the notion of impairment and therefore the opening up of more opportunities for helping impaired doctors. Assisting doctors who are isolated or not part of the culture to integrate in an atmosphere of collegiality seems to be an important part of achieving long-term favourable outcomes. Some characteristics of health-impaired doctors Working style: When these doctors describe their working style (and this is often supported by information from colleagues and their family), they appear as very conscientious people who work very long hours. They often have few friends within the medical profession and do not attend continuing medical education sessions. Sometimes an impression is gained that they have reached a point where "their only friends are their patients". Family relationships: At the time of presentation, it is common to find that the doctor's family relationships have become disturbed and dysfunctional. Isolation and alienation: A common finding is that more than half the doctors presenting with drug misuse did not train in Australia. In addition, there are a number who are sons or daughters of first-generation Australians, who are often by far the most highly educated of the extended family, and a great deal of faith has been put in their futures. In addition, solo practice is often over-represented, as is rural practice. As these doctors tell their stories, it becomes clear that they feel isolated, and perhaps even alienated, from Australian-trained doctors, and Australian customs and cultures. Their main solace as a doctor is in the actual practise of one-to-one medicine, and they do not share their experiences with their partners or in the wider setting of medical societies. They are often depressed or at least dysthymic. In the wrong career: Some doctors feel isolated and estranged because they have come to recognise that they have made a mistake in going into medicine and do not know what else to do. Some of these doctors come from families with a strong medical tradition.

Ross S Kalucy AM, MB BS, FRANZCP

There is compelling evidence that doctors are an at-risk group. Their high rates of mental illness and stress-related illness are of particular concern, and are reflected in tragically high suicide rates, high levels of drug abuse, and decreased job satisfaction and "burnout".1,2 All of these are powerful indicators of poor self-care. Junior medical officers, in particular, are at risk. The New South Wales Medical Board has only incomplete data, but these show an alarming increase in suicides of doctors in recent years, with 21 known doctor suicides occurring between 1992 and 1997 (one in 1992 and eight in 1995).3 The increase is mainly accounted for by junior doctors. In response to the increasing suicide rates and doctors' high rates of stress-related illness and depression, the NSW Doctors' Mental Health Working Group was formed in May 1997. This was a joint initiative of the NSW Health Department and the NSW Branch of the Australian Medical Association. Its policies and recommendations emphasise that doctors should be aware that they are at risk of stress and mental health problems, and that they have a responsibility to care for themselves and to seek appropriate professional medical care. Further, the Doctors' Mental Health Working Group encourages all doctors to have, and to regularly consult with, their own general practitioner and not to prescribe for themselves or their families. However, there are considerable barriers to be overcome. A NSW survey found that 26% of doctors who reported suffering from a medical condition warranting a medical consultation had not sought that consultation because they were doctors themselves. Only 42% of doctors surveyed had their own GP, and even fewer usually consulted a GP for health problems.4 Why do doctors neglect their own health and self-care? Can we identify barriers and facilitate a process for doctors to seek appropriate care? Healthcare and junior medical officersTo answer these questions, a project was initiated to determine healthcare behaviours and attitudes to healthcare among junior medical officers (JMOs). The project was supported by the Hornsby Ku-ring-gai Ryde Division of General Practice, Hornsby Ku-ring-gai Hospital and the Northern Sydney Area Health Service. The project received funding from the Innovative Projects Grants scheme for Divisions of General Practice. The aims of the project were to identify: healthcare behaviours of junior medical officers; barriers to the use of general practice services; educational needs of GPs to assist them to provide an appropriate service for other doctors as patients; and ways in which area health services could facilitate access of JMO staff to GP services. The project involved focus groups of JMOs and GPs, the development and implementation of a questionnaire survey for JMOs in the area health service, and educational sessions for GPs and JMOs. The questionnaire was developed from issues raised in the focus groups. The General Health Questionnaire (GHQ 28)5 was also administered. The survey was issued to 300 junior medical staff across the area health service from postgraduate years 1–4. The response rate was 52%. Preliminary resultsThere are high levels of self-prescribing and self-diagnosis, reliance on hospital registrars for advice and referrals, and frequent neglect of preventive health issues. Doctors are prescribing medications, for themselves and others, ranging from contraceptives, antihypertensives and sleeping tablets, up to and including narcotic analgesics and antidepressants (see Box). Doctors are legally able to write prescriptions for themselves, but these prescriptions are, of course, not part of a consultation where ongoing care is considered. Rates of self-prescribing and prescribing for colleagues among 158 junior medical staff Have prescribed or would prescribe Drug class For self For a colleague Antibiotics 81% 78% Sleeping tablets 38% 36% Antihypertensives 15% 22% Antidepressants 7% 14% Narcotic analgesics 7% 18% "Corridor consultations" are common, with 22% of respondents admitting to requesting a prescription from a work colleague. Interestingly, more than 50% of respondents said they felt uncomfortable about being asked for a prescription by a colleague. Half of the respondents indicated that they self-referred to consultants or treated themselves for conditions that warranted a medical consultation; and 30% agreed that they had suffered from a medical condition they would like to have discussed with a doctor, but had not done so because they were doctors themselves. In focus group discussions, JMOs indicated that young professionals such as themselves should have a medical checkup at least once a year; and 83% of respondents thought that all hospital doctors should have an annual health check. The survey results indicated that 30% of respondents were too busy to have a general health check, 70% could only justify seeing a doctor if they were really ill, 20% indicated that they looked after their own health needs, and 39% were overdue for some aspects of their preventive healthcare. Conclusions and recommendationsYoung doctors give their own healthcare a low priority. They feel great pressure not to miss shifts due to ill-health — as if this were not a valid reason. They have to be sure they are really sick enough before they would consider asking for help. This attitude to healthcare means that it is even more difficult for young doctors to seek help for a stress-related illness, a mental health issue or for substance misuse, as these are not seen as "real" illnesses. Some of the recommendations that have come from this research may help to overcome these barriers to appropriate healthcare. For example, 82% of respondents felt that hospital administrations should allow doctors time to have an annual checkup, while 42% of respondents agreed that it would make it easier for them if the checkup was compulsory. Certainly, the information we have indicates that hospitals should be actively encouraging their medical staff to have regular medical checkups. This would act as a reminder, create an environment in which medical checkups were seen as the norm and not requiring a reason, and perhaps set up life-long patterns of behaviour. SummaryThis short overview of our project does not include the data from the General Health Questionnaire. However, notable links with levels of stress in particular groups of doctors have emerged. This preliminary research indicates that patterns of inappropriate healthcare behaviours develop very early in doctors' careers. We have a responsibility to care for JMOs, who appear to be more vulnerable to stress and its consequences. While we have focused on this group, our results can clearly be extrapolated to the medical profession as a whole. Perhaps the culture of poor self-care that appears to be ingrained in the medical profession comes from within.

Narelle E Shadbolt MB BS, FRACGP, MFM

The training of junior doctors requires a delicate balance between "on the job" experience and quality training. . . . The preregistration year is a time in which training, skills and working role are consolidated under supervision, and it has been suggested that it may be the most stressful period in medical practice.1 In South Australian teaching hospitals, the education and training of doctors in their prevocational years is currently the domain of a team comprising a Director of Clinical Training (DCT) and a Medical Education Officer (MEO), in conjunction with a general clinical training committee. The overarching aim of the DCT–MEO team is to ensure high-quality patient care by guiding and supporting the developing junior doctor. To achieve this, the team works both in and on the system of the public teaching hospital. The DCT–MEO teamThe DCT and the MEO have different, but complementary, roles. The DCT is a senior practising clinician and mentor, whose involvement is of necessity part-time, because of clinical responsibilities within and outside the teaching hospital (Box).2 The MEO, on the other hand, can be more focused on prevocational medical education and, especially if full-time, can provide a consistent presence in the hospital for junior medical officers (JMOs) during their training. The MEO has a range of skills in healthcare education, evaluation and counselling, and gives educational credibility to the team (Box). This team is more effective than each individual acting alone. The complementary skills and roles of members of the early postgraduate medical education and training team Director of Clinical Training Medical Education Officer Multifaceted role Focused role Part-time Full-time Clinical insights Educational insights Patient care expertise Evaluation expertise Clinical teaching Quality monitoring Career advice Counselling skills The MEO in South AustraliaIn mid-1999, MEO positions were established at each teaching hospital by the South Australian Council for Early Postgraduate Training. This model was adapted from one previously developed in Queensland by the Queensland Medical Education Centre with Queensland Health. At this time, the five foundation South Australian MEOs undertook informal needs analyses at the hospitals to gain objective insights into the local system. We asked the questions "What is happening now for JMO education and training?" and "What needs to be done?". From the results of these analyses, we could tailor appropriate strategies for quality improvement of education and training in response to the particular and current needs of the JMOs at individual hospitals. Quality management and evaluation of JMO education and trainingQuality-monitoring and improvement systems are vital in a structure which is responsible for staff development, as the teaching hospitals are for JMO education and training. Quality management is an important role for the MEO with educational evaluation experience. MEOs adopt a wide range of evaluation strategies, including questionnaires, interviews and participant observation, resulting in both quantitative and qualitative data. The MEO encourages and coordinates assessment and feedback from supervisory staff on, for example, JMOs' clinical competence, but also vice versa from JMOs about their supervisors on individual term rotations. The gathering of evaluative data about the individual terms, and on the hospital's education and training program as a whole, is essential for quality improvement. Evaluation must be a continuous processEvaluation must be part of a continuously cycling process that can be managed by an MEO to ensure rapid responses to needs as they arise in a changing environment. All aspects of JMO education and training programs, and the context in which they operate, need to be monitored. De-identified data are then fed back to the program coordinators, and used to inform the process of implementing change, which, in turn, must also be evaluated. The continual gathering of data can provide evidence of systemic problems which could cause excessive workloads, dissatisfaction with rosters, and reduced training opportunities, all of which may affect JMO development and performance.3 Evaluation must result in outcomesEvaluation undertaken because it seems to be "the thing to do" is doomed to failure. People will not engage in evaluations if they never see any results, and failure to demonstrate outcomes will lead to lack of trust in the evaluators. Evaluation must be confidentialIt is difficult for a busy DCT to undertake comprehensive, continuous and confidential evaluation processes unassisted. By definition, an MEO in South Australia is not medically qualified and is thus perceived to be outside the "medical establishment". This is an advantage, enhancing his or her capacity to obtain free and frank responses to questionnaires and interviews, and increasing response rates and the usefulness of the data. An MEO is well placed to demonstrate and maintain confidentiality in evaluative processes and objectivity in reporting evaluation results to the DCT and the hospital management. Support systems for JMOsWhile formal administrative structures can be designed to facilitate the successful progress of JMOs through their service and training commitments, additional, less formal systems are also necessary. Another role for the MEO is to advocate for, initiate and organise professional, personal and educational support for JMOs. This can include: Weekly intern meetings, providing a collegial atmosphere, peer support and debriefing opportunities in a private, relaxed and caring environment;4 A program of intern tutorials specifically for and responsive to the needs of JMOs; and A JMO lounge, which is a private space for relaxation, recuperation and meetings with colleagues away from the ward environment. Provision of a supportive system and atmosphere within the teaching hospital can be facilitated by the DCT–MEO team, giving junior doctors opportunities and encouragement to support each other and themselves.4 A wider role for the MEO beyond JMO trainingA background in education and training means the MEO can help support not only doctors in training, but also their supervisors. This can be achieved through the quality improvement process described above, and by offering practical support and advice, providing, for example, skills in "Teaching-on-the-run" or "How to give constructive feedback". In South Australia, the MEOs as a group offer a wide range of skills, including expertise in education, counselling, management, project development and research. They are a resource that can be called on across campuses and along the continuum from medical school through to specialty training programs. ConclusionEmployment of an experienced postgraduate medical educator by a teaching hospital demonstrates a commitment to medical education and training of JMOs. The DCT and MEO can enhance the profile of JMO education and training within the hospital by active engagement in the work of hospital committees, encouraging mutual feedback between management and junior medical staff, advocating for education and training within the hospital environment, and helping to maintain the "delicate balance between 'on-the-job' experience and quality training" to reduce the potential for distress in junior doctors.1

Anne A Martin BSc(Hons), PhD

Despite our best efforts to create systems and organisational supports to facilitate optimal development for all junior medical officers (JMOs), some will continue to perform suboptimally and experience distress. It then becomes necessary to take an individualised approach to these JMOs. It must be emphasised that there is a clear distinction between distress and impairment. Distress does not imply impairment, although prolonged and unalleviated distress may eventually lead to impairment. North Western Adelaide Health Service (NWAHS) allocates about 50 interns (mainly from Adelaide University Medical School and from the graduate-entry program at Flinders University School of Medicine) between two main public teaching hospitals — The Queen Elizabeth Hospital, which serves a predominantly ageing multicultural population in Adelaide's western suburbs, and the Lyell McEwen Health Service, with an expanding, younger client base in the north. These two hospitals are 25 km apart and together serve some of the poorest socioeconomic areas in Adelaide. This, together with the politically uncertain future of The Queen Elizabeth Hospital, puts NWAHS low on the list of preferred placements for newly graduating medical students. (For the Year 2001 intake, only one of the top 90 graduates indicated NWAHS as first preference.) This means that NWAHS, an already stressed system, may receive a disproportionate share of JMOs at risk of poor performance. Here, I present a step-by-step overview of the processes and insights gained since the medical education officer (MEO) role was introduced at NWAHS in June 1999. Who alerts the MEO and what prompts the alert?Once the support component of the MEO role becomes known, concern about a particular JMO may be raised by the supervising registrars or consultants, the nursing staff, allied health staff, other JMOs, and, at times, a JMO contacts the MEO directly. There is often a sense of relief that there is someone in the system who can deal with these concerns. Most alerts are prompted by concerns about clinical performance. However, pastoral concerns are sometimes implicated (Box 1). Establishing the drivers of distressFollowing an alert, a wider context needs to be established. There is a need not only to check the information, but also to look beyond the obvious (eg, a seeming inability of the JMO to prioritise may disguise an avoidance issue and a host of other factors). Fact finding may involve talking with other members of the unit, or being aware of a particular unit's history with JMOs, and/or the "track record" of the person who initiated the alert, and of the JMO concerned. Of course, there is a need for discretion, whether enquiries are made directly or at a more casual level. Usually, an informal interview is conducted with the JMO to detail the issues raised and note any additional pertinent information. Once the facts are established and a picture begins to emerge, the underlying issues can be more clearly identified, and then decisions can be made and actions taken. The key drivers of JMO distress that have emerged at NWAHS are listed in Box 2. Stressors may be external (ie, to do with the outer environment), or internal (ie, to do with inner processes at a personal level). An example of an important external stressor that is crucial to a JMO's experience is the quality and continuity of registrar presence on a unit. For example, how organised is the registrar? Does the registrar involve the JMO in patient management decisions? How willing is the registrar to teach and extend the JMO? How willing is the registrar to assist and support the JMO during busy periods? And, finally, how available is the registrar when needed? In this regard, the lead-up to physicians' examinations is a particularly stressful time for JMOs. Other external stressors of note include bullying and harassment, particularly the way in which nursing staff can undermine a JMO (or a student). Once covert, these issues are now beginning to be more openly discussed. Having a supportive medical administration, too, can make a big difference to JMOs' sense of wellbeing. This has been clearly documented by end-of-year intern surveys conducted at NWAHS in 1999 and 2000. Highlighted issues included perceived unfair rostering and leave allocation, general unhelpfulness and discourtesy, and bullying and harassment issues. One of the internal stressors listed, professional ethics, has emerged from interviews and end-of-year surveys of JMOs. Issues related to the constant pressure for early — sometimes perceived as too-early — discharge of patients; how "not for resuscitation" orders are interpreted by nursing staff on some wards; and, more generally, the way patients are routinely treated by some health professionals. By the end of the year, some JMOs report disillusionment with a system which they perceive is forced to practise "conveyor belt" medicine. Given that many JMOs entered medicine for altruistic reasons, these ethical issues are a source of distress. Assessment of stressorsBefore proceeding directly to an intervention, an assessment of the stressors is useful. The distinction between external and internal stressors clearly indicates different intervention strategies, although the stressors often involve a combination of external and internal factors. Other aspects of the stressors are useful to consider as well. For instance, has the distress been triggered by a critical incident that has gone unrecognised by the unit and so the JMO has not been debriefed and supported? Also, would the stress be classified as short term, medium term or long term? Periods of short-term stress (a few days to perhaps a fortnight) tend to resolve themselves without causing any lasting problems or major performance concerns; medium-term stress, perhaps for the duration of a particular attachment, may require substantial support; and long-term stress demands attention. Tailoring individual interventionsThese assessments will influence decisions on how to tailor individual interventions to best manage each situation. Listed below are some of the strategies that have been implemented at NWAHS. Clinical learning contract (Box 3)When a JMO's difficulties are related to personal performance, it is most important that this is identified within the first month of an attachment. This allows time for the problems to be discussed by all concerned, a plan of remediation to be constructed, and a performance review to take place before the final assessment. Those involved include the supervising consultant and unit registrar, together with the JMO, and, at times, the MEO or DCT acting in a facilitating and supportive role. The clinical learning contract forms the basis for this process and serves as a simple, documented record of the JMO's progress. Focused coachingIf the medical knowledge base of a JMO is considered inadequate, research registrars can be recruited and paid to provide one-on-one tutoring. Defusing and debriefing after critical incidentsCritical-incident stress is far more prevalent among JMOs than is commonly realised. New doctors may be more affected than their more senior colleagues by the painful events they experience. Their colleagues, who may have become inured to this aspect of the profession, may fail to acknowledge this stress and give adequate support to junior doctors at these times. Often there is a delayed response. A distressing event will occur, and then perhaps a subsequent, relatively minor event will unexpectedly trigger an overwhelming stress reaction. Besides the need for professional intervention at the individual level, this also shows the need to heighten awareness at a systems level and implement training for registrars and supervising clinicians in critical incident defusing and debriefing. Panic promptsSome JMOs temporarily freeze when confronted with an unexpected clinical emergency. I have coined the term "panic prompts" for a small card carried by these JMOs which has a checklist of basic procedures that a JMO would be expected to have worked through before seeking registrar assistance and back-up. At a minimum, this means anticipating the basic information that a registrar would demand. Crisis interventionAt times, MEOs feel like they are operating as a mobile triage service. A JMO may be in such distress that immediate crisis intervention is required. For example, a JMO may need to be taken off duty at once, and the MEO must ascertain whether outside support is available within a short time span, and whether the JMO is able to drive safely or if a taxi may be required. To date there have been four such occurrences at NWAHS. First-line counselling strategiesSome of the first-line counselling strategies are listed in Box 4. The first few relate to general skills that are available to most mature and reasonably sensitive people willing to spend time with another person in distress. The second group applies to people trained in counselling. ConclusionIntegral to the whole process, and the real strength of MEOs, is their independence from medical power structures and from direct involvement in JMOs' evaluation. The MEO, however, should be able to "network" and access hospital and medical authorities. To this extent, the trust placed in MEOs by all concerned (junior doctors, registrars, senior clinicians, and administrators), and the need for confidentiality and discretion, are complex and crucial factors. Professional integrity on the part of the MEO is paramount. The Conference has focused on students and junior doctors in distress. However, it is artificial to consider the problems of students and JMOs in isolation from senior practising clinicians. To what extent are senior clinicians' performances and sense of wellbeing also affected by varying levels of distress; and of course this begs the question — does their distress have an impact on medical students' and junior doctors' wellbeing? We need answers to these questions. 1: What prompts an alert to the Medical Education Officer about a junior medical officer (JMO)? Performance-related concerns Problems with time management (eg, discharge summaries not completed in a timely manner or not adequate; working hours too long; difficulties prioritising). Problems in situations when JMOs provide cover for medical and surgical emergencies, such as during change of shift (short calls). Problems with clinical competence in a specific setting or situation. Interpersonal problems (conflicts and difficulties relating to others). Pastoral concerns Observably high levels of anxiety and tension. Inclined to "self put-down". Crying episodes. Clinical depression. Problems with attitude (eg, perceived arrogant and patronising behaviour; short-tempered, impatient outbursts; or shirking a fair share of the workload). 2: Factors affecting stress levels in junior medical officers External stressors Quality and continuity of registrar presence Helpfulness of nursing staff Nature of the work Type of working environment Medical knowledge Exhaustion — caused by long working hours, intensity of workload, and entry into full-time employment from student lifestyle Supportiveness of medical administration Internal stressors Anxiety, lack of confidence Lack of interpersonal skills (assertion) Physical illness Psychiatric illness Unresolved critical incident stress Professional ethics Personal, non-work-related problems Belief that they have chosen the wrong career 3: Clinical Learning Contract to document assessment of a JMO's performance 4: First-line counselling strategies Non-professional counselling Listening, giving emotional support and clarifying issues. Providing a confidential opportunity for pressure release — "gripe dumping". Reality checks — checking that perceptions are valid. Reframing – reorienting a skewed perception to a more positive perspective. Encouraging the JMO to ask for help and having him or her rehearse doing so confidently. Professional counselling Using problem-solving strategies and skills from a variety of psychological frameworks. Building centring and anchoring triggers which help to maintain confidence and a calm demeanour. Self-awareness and skills coaching in responsible assertion. Self-awareness and skills coaching in anger management.

Karen Grace BA, MSSc(Counselling)

All medical boards have as their primary objectives protection of the public; and maintenance of the highest possible standards of medical care. The Boards are state-based and constituted under Acts of Parliament. However, they are independent, operating at arm's length from government, and are self-funded through medical registration fees. While it is often stated that the medical profession is self-regulated, the reality is that the profession, community groups, politicians and departments of health all have input into the Acts which the medical boards administer. Therefore, it is probably more accurate to say that the medical profession is self-administered rather than self-regulated. There is a widespread misconception about medical boards — that they are populated by grey-haired, eminent, elderly men, long retired from their field of medicine. This is most certainly not true of the New South Wales Medical Board, which also recognises the vital importance of community representation: five of the 22 members of the current NSW Board are from non-medical backgrounds. Activities of medical boardsRegistration of medical practitioners (and, in NSW, medical students): The core activity of all boards is the registration of medical practitioners, ensuring that their qualifications meet a required minimum standard. In NSW, medical students are also registered. This came about when the Board recognised that, each year, a number of young doctors coming to the Board's attention because of illness had problems dating back to their student years. The Board recognised that if it could have been involved earlier the transition of these students to the workforce may have been much smoother. Student registration has been in place in NSW since 1992. The only provisions of the NSW Medical Practice Act 1992 that apply to students are those relating to impairment. Managing poorly performing practitioners: The second domain in which medical boards are active is in managing poorly performing practitioners though a variety of disciplinary and non-disciplinary processes. It is in this area that there is the most variation in the approach of the various medical boards. In NSW, there are 25 000 registered doctors. Every year about 1200 complaints are made against them. Only 20% of these are formally investigated, and less that half of the investigations proceed to a disciplinary hearing. Each year, the NSW Medical Board holds 25–30 Medical Tribunals, with about half these doctors being deregistered. Contrary to popular belief, deregistration is the outcome for only about 1% of doctors about whom complaints are made. Management of "impaired" practitioners: The third domain, and the most important in the context of this Conference, is the management of "impaired" practitioners. While the definition varies from State to State, a practitioner is generally considered to be impaired if he or she suffers from any physical or mental condition which detrimentally affects, or is likely to detrimentally affect, his or her capacity to practise medicine. It is important to recognise that doctors and students may be unwell or disabled without being "impaired", according to its statutory definition. Impairment is very specifically related to risk to the public. For example, if a surgeon develops Parkinson's disease and gives up procedural practice, then he or she is clearly unwell, but not impaired. The single most important factor in determining impairment is the practitioner's insight into his or her illness and its effect on practising medicine. The objective of impairment programs is, like all Board activities, to protect the public. However, a strong secondary objective is to maintain the doctor in safe practice whenever possible. Health ProgramDoctors: Of the 25 000 registered doctors in NSW, about 130 are currently involved with the Health Program. Half have problems with drugs or alcohol, 40% have a mental illness, and the remaining 10% have other medical problems. In the drug-dependent group, pethidine is very much the drug of choice because of its ease of access for medical practitioners. Medical students are more likely to use illicit drugs. In NSW, these registrants would be required to undergo an extended period of urine drug screening, along with other Board monitoring and treatment requirements. Other States have different approaches, and it seems that NSW and Queensland require a much longer period of monitoring than other jurisdictions. Medical students: Of the 25 medical students involved with the NSW health program, 20% have drug or alcohol problems, 70% have a mental illness, and 10% have other conditions, such as motor disability. Criteria for notification of medical studentsThere is still uncertainty in the three medical schools in NSW about which students should be referred to the NSW Board, and when. There are two important criteria: Public protection — is there a risk or a potential risk to the public? An individual with bipolar disorder may pose no risk if the condition is stable, but there is significant potential risk if the individual becomes floridly manic. The needs of the student — if the student is likely to require support or special consideration in their transition into the medical workforce, then early notification is essential. The Board does not want to know about every distressed, unwell or disabled student. Clearly, most of these students are not impaired within the Board's definition. However, if the individual has special needs, there is great value in early notification, as the Board needs time to ensure that a suitable internship can be devised. The NSW Medical Board's approach to impaired students is illustrated by the case study given in the Box. Need for a culture changeNotification of both students and doctors requires a shift in culture. The profession is historically reluctant to "dob in a mate", and problems are frequently "swept under the carpet" or poorly managed in "corridor consultations". Some States and Territories have legislated a statutory obligation to notify impaired practitioners to the Board. There are pros and cons to this approach. Of greatest concern is the potential for mandatory notification preventing unwell doctors from seeking treatment. Flexible approaches to internshipsInternships used to be extremely regimented and prescriptive. In NSW, and I believe in most other jurisdictions, there is now a much more flexible approach. Internships can be individualised in terms of hours, terms, location and duration, provided that the core competencies of internship are achieved. However, flexibility does raise important employment issues. Unimpaired interns have expressed concerns about favouritism and reverse discrimination. In addition, hospitals do not have a limitless capacity to accommodate interns with special needs. In NSW, some hospitals are very good at looking after impaired interns, but it is unfair to overload them. ConclusionsMedical boards discharge their responsibility for public protection in a variety of ways. The structured, compassionate and fair management of impaired practitioners is an important component of a board's work. The NSW Medical Board has 10 years' experience with student registration, and commends it to other jurisdictions, and to students themselves, as a valuable and mutually beneficial approach. Case study — a medical student referred to the NSW Medical Board Dr A was a final-year student when first referred to the Medical Board. He was a mature-age student in an undergraduate program who had been displaying inappropriate behaviour in his clinical terms, and had refused all offers of help by the Faculty. When he was notified by the Faculty, he was in a manic episode of bipolar disorder. The student was independently assessed by a psychiatrist nominated by the Board and placed in a monitoring program. He had a further manic episode, but it was detected early because of the support structure around him. We were able to intervene rapidly and his condition stabilised quite quickly with treatment. We required him to have a treating psychiatrist, and we had his authorisation for the psychiatrist to let us know if he did not comply with treatment or if his health deteriorated. He attended for regular review by the Board-nominated psychiatrist and for Board review interviews on a six-monthly basis. On graduation, we notified his employer of his conditions of registration, as it was important that his internship was conducted in an informed and supportive environment. He did very well, and is now in specialist training. (All colleges have stopped denying specialist training to doctors with conditional registration.)

Alison M Reid MB BS, MHA, FAFPHM

[The comments made in this article and given at the conference were appropriate at the time. Since then, the South Australian Parliament was prorogued and an election held. The proposed new Medical Practitioners Act had not passed both Houses of the Parliament and has therefore lapsed. At this time, I am not aware of what the new Government may include in a Bill it may wish to introduce.] The South Australian Medical Practitioners Act 1983 is currently being reviewed and the new Bill is before Parliament. The new Medical Practitioners Act will call for the registration of medical students with the South Australian Medical Board, and will aim to be supportive of medical students. It will also contain new provisions for protecting the public. Registration of medical studentsRegistration of students has several important pluses for students. It clearly brings them into the ambit of the profession with some status, and it helps identify students who, because of ill-health, may not be able to enter certain areas of clinical practice after completing their studies. Early counselling and input into those professional pathways that will be available can only be of benefit to all concerned. Registration of students is not a new concept. New South Wales has already adopted this approach and it is currently on the agenda of several other States. New provisions for protecting the publicThe approach of the Medical Board in South Australia has always been to support both individual members and the medical profession in general while retaining its statutory requirement of public protection. Under the new Act, the SA Medical Board will require much more information on the health of individual doctors and students, particularly in relation to infectious diseases. While transmission rates of bloodborne viruses from healthcare professionals to patients are low, such transmissions do occur, with potentially serious consequences for patients. As part of the Board's role of public protection, it is appropriate that the Board is made aware of practitioners who are infected with bloodborne viruses so that appropriate protective steps can be put in place. It should be emphasised that these steps would not necessarily or routinely mean denying the right to practise medicine. There is already a requirement in the current Act for a treating doctor to report to the Board, in writing, the details of patients who are medical practitioners, and are suffering from a condition which impairs or may impair their ability to practise medicine safely. The new reporting requirements now place a responsibility on the patient who is a doctor to also report his or her own health status to the Board. Overall, the SA Medical Board will maintain a careful balance of confidentiality, support for the medical profession, including medical students, while looking after the best interests of the general public.

David H Wilde BA(Hons), JP

The Medical Board of Queensland, through its Health Assessment and Monitoring Program, provides active support to the medical profession, particularly to doctors recovering from impairment (ie, illness which has been serious enough to affect their capacity to practise). There are about 50 new referrals to the program each year — 37% have a psychiatric illness, 45% involve drug misuse (other than alcohol), and 7% alcohol misuse. At least 60% of practitioners who come to the Board's attention have a dual diagnosis (eg, depression and drug misuse). Board databases do not specifically collect information on the stage that the doctor has reached in his or her career at the time of illness. However, approximations can be made through manual collation of recent data, with the rough figures on diagnoses in junior doctors being 17% alcohol misuse, 17% other drug misuse, 25% depression, 8% post-traumatic stress disorder, and 17% bipolar affective disorders. Case historiesThe following case histories illustrate the work of the program with doctors recovering from drug misuse and/or mental illness. Identifying details have been altered in the interests of practitioner confidentiality. However, details pertaining to significant events, milestones, Board intervention and outcomes have been reported as accurately as is compatible with maintaining confidentiality. Case 1This young doctor (less than two years after graduation) was rostered to cover ICU alone, with a consultant on remote call. In an endeavour to control stress-related symptoms, he treated himself with benzodiazepines. Their use escalated, as did his symptoms of poor sleep, poor appetite, weight loss and social withdrawal. Recognising that his symptoms were worsening, he sought relief in S8 drugs, which he obtained from the operating theatres (adjacent to ICU). His drug misuse continued (varying in severity) over several years. He was eventually found unconscious in the theatre change rooms. The Board was notified. His primary and most urgent need was for detoxification because of long-term misuse of benzodiazepines and opiates. Once this had been undertaken, an assessment of his fitness to practise was arranged by the Board. A minimum of three months off work was needed, but he had no income protection. Showing considerable initiative (particularly given the severity of his illness), he started a dog-grooming business, and managed to support himself through a lengthy period of time out of the medical workforce. When his medical condition had stabilised, he secured a new medical post with Board support. He was required to fully disclose his medical history to his supervisor, to undergo random urine drug screening (up to 16 tests per month), and was subject to monthly workplace reports from his supervisor to the Board. With the passage of time, reporting and testing requirements have been gradually reduced. He is progressing very well, and there has been no relapse. ChallengesHe needed time off without income protection. He needed to overcome the label of "impaired doctor". Once he had left the hospital he had been working in, there was no sense of duty of care elsewhere. His vulnerable position with his employer necessitated intervention and advocacy even after he was employed. LessonsThere is a need for education of peers to monitor junior doctors and, if necessary, initiate early intervention. If this doctor's drug misuse had been detected earlier, the escalation in drug taking would probably never have occurred. Income protection is essential for all medical practitioners, and should be taken out as early as possible in a career. Insurers are increasingly stringent in refusing insurance or insisting on exclusion clauses for those with a history of mental illness. There is nothing wrong with doing non-medical work for a while, and it can even assist in the recovery process. Long-term stability in the profession can be achieved after an apparent disaster. Case 2This intern developed bipolar illness in the intern year. She was absent from work for three months, and then attempted re-entry. She relapsed and, on medical advice, abandoned her internship. When referred to the Board, she was working in an unskilled, casual position in the hospitality industry. Five years had elapsed and she had been stable for three of those five years. The Board organised a three-month placement for a training clerkship. The hospital was so impressed they offered her a job. She is now in her Senior House Officer year, and has been receiving excellent reports — "She is the best resident I have ever had". As with most practitioners with bipolar affective disorder managed by the Board, it has been necessary to have a long-term prohibition on night duty. After so long "in the wilderness", this young woman has so much to contribute. There have been intermittent relapses, but she has the insight to manage these, and appropriately withdraws herself from the workforce. ChallengesDeskilling — she was away from medicine for five years. She didn't fit in anywhere — she was not a student, but, as she had not completed her internship, she was not really a doctor. There was no apparent benefit to the hospital in taking her on, so organising the initial clerkship took a lot of advocacy. Special rostering needs have remained a long-term issue — she can not do night duty. LessonsSometimes it is just too much to become a doctor and deal with illness at the same time — time out is OK. Even a protracted period away from clinical work does not mean the end of a career and may in fact save it. Sometimes an illness helps doctors bring special empathy to their work. Having been a patient and in hospital can add an extra dimension to doctoring. Case 3This student developed a psychotic illness in sixth year. He took antipsychotic medications for four months and then withdrew at the beginning of his intern year. He then had a relapse and took nine months off. The hospital was very supportive, but when he started his internship again he received very negative reports. He tried a new placement with a different employer so he could get a more objective assessment, but the negative reports continued. After six months, he had a meeting with the Director of Clinical Training, the Medical Education Officer and the Consultant. He decided to abandon internship, disclosing a dulling of cognition when taking antipsychotics. Three weeks later he phoned, relieved and grateful to be off the treadmill. He planned to resume his previous passions for mathematics and languages. His family needed debriefing, which, although outside the Board's brief, was provided with the doctor's consent. They experienced great difficulty coming to terms with what had happened to their wonderful, talented son. The Board staff continued to provide support for job seeking (ie, they continued to engage in advocacy with prospective employers and to help him with his curriculum vitae). He found part-time work in a field in which his excellent interpersonal skills were an asset, and is now studying for an alternative career. ChallengesUltimately, this doctor was just too sick with a chronic illness to embrace the challenges of internship. A small community can be supportive, but can also result in labelling, whether real or perceived. A doctor who is perceived to have "failed" may not be particularly "saleable" to other prospective employers. His family had an enormous emotional investment and no appropriate support or forum. LessonsSometimes it is not worth the personal and institutional cost of continuing to juggle a medical career with serious illness. Sometimes a "good outcome" is the appropriate redesign of career goals. Families of young doctors need support when the goals they have all worked towards are not achievable because of an illness that may not be externally visible. It is not inappropriate to hope that new medications and/or remission of illness may make it possible to revive a stalled medical career. Even when a junior doctor must abandon the profession, the profession should not abandon him or her. The following cases illustrate the need to provide support to an individual to withstand family pressures or pressures from employers, and the damage that can come from breaching confidentiality. Case 4This intern developed a psychotic illness during internship. She presented as very well after the episode, but subjectively felt very fragile, and was certain she was vulnerable to relapse should she return to work. Her family, noting the absence of symptoms, and probably fooled by the coping mechanisms adopted by this very able young woman, became quite impatient after she had taken a month away from work, and started demanding that she return. Likewise, her employer, facing staffing problems, was in regular contact, wanting to know when she would be able to resume work. When she came to the Board's attention, the acute episode had resolved, but she continued to feel vulnerable to relapse. She had not re-established a normal sleep pattern, and continued to feel somewhat dysphoric. At an initial meeting with Board staff, she outlined a timeline for return to work that she felt she could cope with. Board processes were timetabled to coincide with her timeline, allowing her to refer employer and family to the Board in the event of further disagreement about a return to work. The timeline proceeded uneventfully and on schedule. No relapses have occurred to date, and she has become a very valued member of the hospital staff. Assessments are consistently in the range "very high" to "excellent". ChallengesMaintaining a good rapport with hospital administrations, while not necessarily delivering what they need or want, can be very difficult! Dealing with families raises complex issues of confidentiality, boundaries and professional identity. For example, consider the implications of a doctor's mother ringing the Board to argue the case in favour of a return to work! LessonsIn the absence of significant secondary gain associated with prolonging work absence, a doctor who insists that he or she is not fit to return to work should be deemed not fit to return, unless assessment unequivocally refutes that assertion. Empowering a vulnerable return-to-work candidate to control his or her own timetable (with appropriate input from treating health professionals) maximises the chance of a successful return. The normal boundary which would apply to family issues (of not needing to deal with these or become involved) may not be appropriate when dealing with very young doctors still tightly enmeshed in their family of origin. Case 5This intern experienced a single episode of psychosis against a background of depression after using cannabis. She voluntarily withdrew herself from the workforce, and resigned from her intern position. When she was again well enough to return to work, she approached the hospital from which she had resigned (Hospital A), but was told that they had a full staff complement. Another hospital (Hospital B) was approached, and was interested in offering a trial clerkship. This was suddenly cancelled at short notice. Some weeks later, the Medical Superintendent of Hospital B disclosed that the Medical Superintendent of Hospital A had approached him, and had made several statements about the intern's suitability, which resulted in the withdrawal. By this time, the Medical Superintendent of Hospital A had had no association with the intern for over five months. He was not in possession of any current medical reports and, by any description, the statements he made were inaccurate and frankly defamatory. A period of protracted unemployment followed. Eventually, a third hospital was persuaded to offer a trial clerkship. They were very impressed, but unable to offer employment on the basis that they had a full staff complement, and no reserve funding. However, because of the positive reports from the placement, the intern successfully competed for a position in a subsequent open-selection process. Reports have been extremely positive, and there has been no recurrence of either depression or psychosis. ChallengesOnce this intern resigned, nobody felt she was their responsibility. Significant deskilling had occurred, making her even less attractive to prospective employers. A single ill-informed breach of confidentiality had catastrophic consequences for this young doctor, resulting in long-term unemployment and deskilling. LessonsSome senior colleagues still don't understand confidentiality. A breach of confidentiality, even made in good faith, can have unintended implications. A person should not make a comment if he or she is not prepared to put it in writing! Encourage tenacity and self-belief, even in the face of disheartening failures. It pays off in the long run.

Jillann F Farmer MB BS, FRACGP

The first two breakout groups comprised medical students and prevocational trainee doctors, and the third delegates from medical boards, postgraduate councils and hospital administrators. The groups reported back on student issues, prevocational and trainee doctor issues and medical board issues. This is a condensed summary of the reports from each group. Student issuesIdentifying the distressed or impaired student is not the problem; peer groups are usually the first to be aware of this, but don't know what to do about it. We need a "Dummy's guide to helping a mate" — a simple flowchart outlining who to contact for each particular problem. A structured process of identification and notification of distressed or impaired students is needed. All students could be interviewed, perhaps annually, and the same questions asked. If the time can be found to interview recent graduates for selection for hospital placements, then it should be possible to find time to interview students to identify distress. An independent body is needed to assist distressed or impaired students at every medical school (an example is the general practitioner program at Melbourne University). This should be completely independent of the assessment process, and should only report back to the Faculty if there is a problem that needs to be addressed. Such a GP program would need to be well advertised. The more people who become involved, the less the stigma. Visiting an independent GP is then seen as positive rather than punitive. Confidentiality is a major issue. Career prospects should not be endangered. Medical schools should develop a database of mentors or people to contact (eg, GPs or social workers who are not members of the academic staff). They should be available at all campuses, hospitals and rotations, and should provide feedback about global issues for the student cohort — not individual students' problems. This would allow for prevention. Students would also need to constantly evaluate such a system. There would be no advantage if the GP appointed was not up to the task. Mentoring eases problems during transition periods (eg, going from Year 12 at school to first year at university, and during the final two years of the medical course when clinical work predominates (Years 3 and 4 for graduate courses and Years 5 and 6 for undergraduate courses). There are logistical issues to resolve. If mentoring is voluntary for both mentor and mentoree, the "lurkers" may still miss out. Special programs are needed for high-risk groups, including non-English-speaking students. They may need extra courses, but not special courses, as this can be alienating. The Personal and Professional Development tool (ie, using course interviews and essays to identify problems) is not the answer if used in isolation. Prevocational and trainee doctor issuesWho should identify the student and junior doctor in distress? Everyone. A cultural change is needed. There is a culture in medicine of not admitting faults, and of weakness being seen as failure. Confidentiality is the key. Reporting systems should be independent of career prospects. Referral can be self-referral, or referral by peers, resident medical officers, registrars, consultants, or nursing staff. There should be a transparent pathway of events and the implications of reporting which is independent of career pathways. Who should be informed or involved in the management of those in distress? Hospitals should have a list of people available for first contact (ie, staff GP, medical education officer, and others). Management could involve the Doctors' Health Advisory Service and the junior doctor's own GP. Directors of clinical training or clinical supervisors need to be aware of individual doctors' needs, but do not need to be aware of the problem itself. It is important that those providing help are trained and have some background in the kinds of services needed. What action should be taken? Prevention. First point of contact outside of the medical framework. Independent follow-up. Half a day's paid leave each year for consulting a GP, with consideration given to making it mandatory. Regular pager-free forum for debriefing. Support and resources for JMOs (ie, adequate staffing and cover for leave or sick leave. Others should not have to take up the slack). Education of supervisors, registrars, consultants. Education about junior doctors' responsibilities. Education about time management. Comprehensive orientation. Resources, such as common room and dictating room. Management. Must be confidential, independent of training, and involve a clear pathway of processes to be followed. Information about students should be transferred from the medical school to the hospital medical administration, but this is complicated by privacy regulations. In response to a question about whether it would be defamatory if universities passed on information which might affect a doctor's career, a medical school dean said the individual student should be involved. It would be easier if the student was aware that the university was going to ask the hospital to give him or her an appropriate internship environment. Comment was made about the importance of a supportive administration. This support should extend beyond working conditions and rosters to social activities, housing and other matters. The role of medical boardsWho should identify the student and junior doctor in distress? Everyone, but colleagues have a professional responsibility for doing so. The medical board's role is not punitive; it must be seen to be supportive. Who should be informed or involved in the management of those in distress or impaired? Medical boards — but only if the student or doctor is impaired. The boards intervene when public safety issues are involved. The matter can usually be resolved at a local level. What action should be taken? There is a huge role for medical boards in promoting a culture change by providing information on the support they provide to impaired doctors, and by influencing employers to provide support and mechanisms for assisting junior doctors. Most of the profession hopes that their only contact with the medical board will be to obtain registration and to pay their annual fee; they hope never to hear from them again. Medical boards need to be more proactive in promoting their image as caring and supportive, not punitive. It was pointed out that universities need to be more aware that the faculties of medicine are training people to be doctors, with all the implications of providing safe medical care for the community. Faculties of medicine are not just producing medical graduates. With imminent registration of medical students with medical boards in other States besides NSW, there needs to be a dialogue established between medical boards and university councils.

Simon M Willcock MB BS, FRACGP

Live stronger live longer: An exercise and lifestyle program for over 40s Mark Awerbuch. Sydney: McGraw-Hill, 2001 (xviii + 230 pp). ISBN 0 074 71087 7 This is a timely book on progressive strength training for older people which is made doubly useful because the program can be modified for people with arthritic conditions. The book is divided into two sections. The first provides a foundation for understanding changes to the body caused by ageing and arthritis. It discusses the impact of these changes on physical and psychological health, and presents the evidence supporting the benefits of strength and cardiovascular fitness training programs. Issues of nutrition and the importance of ensuring an appropriate diet are also discussed. Information is provided in an easy-to-read style, a user-friendly manner, and it is suitable for either health professionals or the interested layperson. A particularly useful chapter focuses on the barriers and motivators to starting and sustaining ongoing participation in exercise programs. The second section provides a step-by-step framework for conducting a strength and/or cardiovascular fitness training program — the book argues that these programs are complementary. Exercises are simply described, with many photographs. One criticism is that all of the photographs show only two participants, who appear quite fit. To older people, or people with mild to moderate arthritis, the photos may make them think the program is not suitable for them. (The book argues strongly that the program is appropriate for these groups as long as the framework is followed.) There is a very useful list of contact details on where to find further information (such as Fitness Australia-accredited gymnasiums), and a comprehensive bibliography of recent research in the area of exercise training for older people and people with arthritis. Overall, the book is a useful text for health practitioners, older people generally, and those with mild arthritic problems. People with more severe arthritis should discuss the issues with their medical practitioner, specialist or physiotherapist before beginning this type of program, as there is a need in this group to closely monitor initial response to exercise to avoid aggravation of joint pain.

Keith Hill

The 2001 MJA/Wyeth Award was awarded to the authors of “The effects of quality improvement interventions on inhospital mortality after acute myocardial infarction” (MJA 2001; 175: 465-467). At the recent AMA National Conference Dr Ian Scott accepted the MJA/Wyeth Research Award from Dr Kerryn Phelps, AMA President, and a cheque from Professor Deborah Saltman, Medical Director of Wyeth Australia. Dr Ian Scott is from the Department of Internal Medicine, Princess Alexandra Hospital, Brisbane, and his co-authors, Dr Michael Coory and Dr Catherine Harper, are from the Epidemiology Branch of Queensland Health. They received the award for their clinical research into reducing in-patient mortality from myocardial infarction. Each year approximately 20 000 Australians suffer an acute event from coronary artery disease — mostly myocardial infarction — and of people with this malady admitted to hospital about one in eight died. Dr Scott and his co-investigators showed that the implementation of quality improvement interventions produced a 50% reduction in in-hospital mortality. With the use of locally generated, evidence-based clinical guidelines, audit of outcomes and feedback to clinicians — the classical tools of quality improvement — the in-hospital mortality was reduced from 12.5% in 1994-95 (pre-intervention) to 8.8% in 1996-99 (post-intervention). Indeed, the post-intervention mortality rates from acute myocardial infarction were lower in the test hospital — a district hospital — than in hospitals with coronary revascularisation facilities or those treating larger numbers of patients with infarcts. Professor Saltman warmly congratulated the recipients and noted that for quite some time now the profession has viewed guidelines with some scepticism; however, Dr Scott and his team have elegantly demonstrated the efficacy of locally generated and approved guidelines and their study was “a courageous one with remarkable results of interest to all clinicians”.

Sustained relief The results of the multinational ACCENT randomised trial have just been published, with encouraging results for sufferers of Crohn’s disease. Current treatment of moderate or severe Crohn’s disease includes long-term steroids (with a host of adverse side effects), and purine metabolites and methotrexate (which have a slow onset of action). Infliximab, a monoclonal antibody with a rapid onset of benefit, has now been shown, in responders, to give sustained relief with repeated doses. It was effective in some patients who had failed other treatments, and allowed patients taking steroids to either reduce their dose or stop taking steroids altogether. Lancet 2002; 359: 1541-1549 Shortsighted Perhaps mother was right when she said holding books too close or reading in the dark would damage our eyes. A review of myopia, an increasingly common condition in which images focus in front of the retina, gives evidence that prolonged near work can cause myopia, and that overcorrecting myopia can make the condition worse. Genetic factors contribute to myopia, as does early deprivation of formed vision (such as untreated infants with congenital cataract) by causing elongation of the eye. Current theory is that prolonged near work leads to myopia via the blurred retinal image that occurs during near focus. The retinal blur initiates a biochemical process in the retina which stimulates biochemical and structural changes in the sclera and choroid, leading to axial elongation of the eye, and thus movement of the retina away from the eye’s focal point. BMJ 2002; 324: 1195-1199 Bent backs Decreasing the physical load at work, especially for workers with low-back complaints, may be an important tool in preventing sick leave due to low back pain. This recommendation comes from a prospective study of sick leave (≥ 3 days) involving workers from 21 companies in a variety of industries throughout the Netherlands. A physical examination was completed at baseline, and videos were made of each worker to enable analysis of work-related physical factors. Three-year follow-up was available for 732 workers (mean age, 36.4 years; 25% female), of whom 149 had taken leave because of back pain. Trunk flexion, as well as trunk rotation and lifting, were significantly associated with sick leave for low back pain. A dose–response relation was found for trunk flexion, with those spending 15%–20% of their work time with their trunk flexed ≥ 30° being 3.2 times more likely to take leave than those whose job involved minimal flexion. Occup Environ Med 2002; 59: 323-328 Secret messengers Changes in myocardial gene expression, which would account for clinical improvement, have been found in the endocardium of patients with dilated cardiomyopathy who responded to beta-blockers. The study, from the United States, recruited patients who were being treated with digoxin and an ACE inhibitor, then randomly assigned them to additional treatment with metoprolol, carvedilol or placebo. Levels of messenger RNA (mRNA) in the endocardium for three categories of contractility-regulating genes were measured at baseline and after six months’ treatment. Patients who responded to beta blockers had an increase in sarcoplasmic-reticulum calcium ATPase mRNA and alpha-myosin heavy-chain mRNA and a decrease in beta-myosin heavy-chain mRNA, indicating molecular remodelling. N Engl J Med 2002; 346: 1357-1365 A drink a day . . . Postmenopausal women who are looking for a healthy alternative to weak tea or low-fat milk may need to look no further than their vodka and orange. In a randomised controlled, crossover trial conducted in the United States, moderate alcohol consumption reduced insulin concentration and improved insulin sensitivity in 51 healthy women (mean age, 60 years). Each was supplied with a full diet intended to maintain current weight, and was not told whether her daily orange juice contained 0, 15, or 30 grams of ethanol. Fasting insulin, triglycerides and glucose were measured at the end of each eight-week dietary period. Consumption of alcohol 30g/day reduced fasting insulin by 19.2%, and increased insulin sensitivity by 7.2%, independent of body mass index, thus potentially reducing the risk of type 2 diabetes and cardiovascular disease. Unfortunately, as well as exceeding Australian guidelines for daily alcohol consumption, increased serum levels of two steroid hormones known to be risk factors for breast cancer were detected in those given alcohol. JAMA 2002; 287: 2559-2562

Med J Aust 2002; 177 (1 Suppl).