Volume 178 Issue 4

As medical curricula and the competencies required of new graduates evolve, evidence-based evaluation of these curricula should become routine Over the last two to three decades, many universities and medical schools have initiated curriculum reforms. The factors cited as drivers of this worldwide reform include the ever-increasing knowledge base, shift in the burden of disease, advances in technology, changing expectations of patients and societies, easy access to healthcare information via the Internet, need for cost-effectiveness, the quality movement and awareness of medical errors, and changes in the learning environment. As desired competencies of physicians have gone beyond factual knowledge and clinical skills, training programs need evaluation methods that measure these competencies As societies struggle with their healthcare systems and re-examine the question "What is a good doctor and how do we measure it?", medical schools, teaching hospitals, professional societies and regulatory bodies try to provide guidelines, answers and leadership. As a consequence, there has been a proliferation of competency lists, and the movement towards "outcome-based education".1 One of the more meaningful lists of competencies was developed as part of the Education of Future Physicians of Ontario (EFPO) project2 (Box) — the first six of the eight competencies in this list resulted from patient input. Competencies required of medical graduates*2 Medical expert–clinical decision maker Communicator–educator–humanist–healer Collaborator Gatekeeper–resource manager Learner Health advocate Scientist–scholar The physician as a person * Developed for the Education of Future Physicians of Ontario project. Medical educators have therefore been asked to redefine the required knowledge base, set of skills, attitudes and experiences of physicians at all levels of training, while devising outcome metrics (assessments) that would allow meaningful feedback to individuals, schools, training programs and the system as a whole.3,4 The design and identification of these outcome metrics continue to be a challenge and reflect to a certain extent the diverse missions of medical schools: As university students, medical students receive an advanced scientific degree, implying a depth of knowledge and mastery of scientific skills. Assessments and outcome metrics have traditionally concentrated on the scientific aspects of medicine, which appear narrow in light of the above-listed competencies. Medical schools prepare their students to function as doctors for the rest of their lives. In most parts of the world, the government or a professional body certifies and licenses doctors, endorsing them as competent practitioners of medicine. Reliable metrics of the quality of medical practice remain a major challenge. Non-adherence to accepted medical guidelines has many reasons.5,6 However, awareness of and use of guidelines has been a measurable effect of one recent curricular change, involving problem-based and self-directed learning along with regular assessments of skills and attitudes.7 Medical schools also prepare their students to function as interns and junior medical officers after graduation. In essence, the directors of house-officer training programs and their colleagues are some of the earliest sentinels of medical student performance. In this issue of the Journal (page 163), Dean and colleagues use the last aspect to collect performance data about recent graduates of the University of Sydney graduate-entry medical program.8 Using a self-assessment tool and collecting data from supervisors, they found that graduates of the new curriculum had better communication and teamwork skills, and that they approached patient care in a more holistic manner, while being more confident and willing to continue to learn. The graduates of the new program assessed their knowledge base as weaker than that of their traditionally trained colleagues, a fact that was supported by some, but not all, of their supervisors. Despite the weaknesses of the study design acknowledged by the authors, these results reaffirm the value of follow-up studies as outcome metrics of medical education.9 As the "officially" desired competencies of physicians have gone beyond factual knowledge and clinical skills, training programs need to institute evaluation methods that measure these competencies.10 While more quantitative measures are developed, and increasing numbers of new curricula are introduced, better communication and feedback is needed between the various levels of medical education to guide this process. Medical education is a continuum and a lifelong endeavour, and all its components — secondary schools, colleges, medical schools, training programs, practices, hospitals and professional societies — need to work together.5 As in any complex, interdependent system, frequent feedback is absolutely necessary; we need intermediate and surrogate markers to assess progress and allow us to take corrective steps. The present study provides one such marker, albeit limited.8 Similar data collection should be encouraged as a matter of routine to inform the system and improve the training of physicians.

H Thomas Aretz MD

First, let's decide what we really mean by phimosis Circumcision remains a topic of significant debate in Australia, even though there has been a marked reduction in the rate of circumcision in this country, which has reflected that of England, where 95% of boys were circumcised in the 1930s, declining to 6.5% in the early 1980s.1 In this issue of the Journal (page 155), Spilsbury and colleagues report that many boys are circumcised for phimosis before the age of five years, despite phimosis being rare in boys of this age.2 They reviewed all circumcisions in Western Australian hospitals between 1981 and 1999, recording that the rate of medically indicated circumcisions increased during that period, and that, if the 1999 rate remains stable, it would be seven times the expected incidence of phimosis in the group of boys aged less than 15 years. These findings imply a high rate of unnecessary surgery, similar to the findings from studies conducted in England.1,3 Spilsbury and colleagues define phimosis as "narrowing of the preputial orifice leading to non-retractability of the prepuce". Such a definition would result in many boys under the age of five years being diagnosed with a condition for which surgery is considered to be justified. Their use of the term phimosis seems to mean pathological phimosis. To clarify, the prepuce is regarded as normal in boys if non-retractable because of preputial adhesions, or if the skin is physiologically non-retractable because of narrowing (ie, physiological phimosis). Figure 1 shows a normal foreskin that is non-retractable. The terms phimosis and non-retractable are not sufficiently clear in isolation, and need to be qualified. Rickwood and colleagues have recently given a succinct definition, stating that the ". . . normality, with an unscarred and pliant preputial orifice, is clearly distinguishable from pathological phimosis [shown in Figure 2], a condition unambiguously characterised by secondary cicatrisation of the orifice . . .".1 The addition of the word "pathological" or "physiological" is necessary to differentiate the different prognoses for phimosis, and, if the foreskin is not retractable because of adhesions to the glans, that information needs to have been included in the definition and documentation. Thus, rewriting the extract from the article by Spilsbury and colleagues, "many boys are circumcised for (pathological or physiological) phimosis before the age of five years, despite (pathological) phimosis being rare in this group". Why does the rate of circumcision for phimosis exceed the expected rate of phimosis?Clearly, the word "phimosis" in isolation does not have sufficient power to separate disease from a normal condition. Further, if parents feel there will not be support from the general practitioner, they may complain of symptoms in their child for the purpose of avoiding the debate about the appropriateness of circumcision for cosmetic reasons. Alternatively, the GP may support the parents' desire to have their boy circumcised, but expect resistance from the surgeon, and thus tend to present the child as having a pathological diagnosis. Such manipulation is not surprising when dealing with such an emotive topic. Nor is it necessarily improper given the differing cultural and medical views on the value of circumcision. A further explanation for the high circumcision rate for (pathological) phimosis might be a reluctance to record non-medical circumcision as such, using the appropriate International classification of diseases codes.4,5 What is the optimal treatment for phimosis?A wide body of evidence shows that most boys can be treated successfully with steroid cream, and that circumcision is required only infrequently.6-9 Unfortunately, almost all of these studies lack the distinction between pathological phimosis, as defined by Rickwood et al,1 and other foreskins that are non-retractable either as a result of preputial adhesions or because they are physiologically non-retractable. However, clinical experience suggests that most cases of pathological phimosis can be successfully treated with steroid cream, provided the steroid cream is applied to the partly retracted prepuce three times daily. After 4–6 weeks the prepuce should be retracted at the time of bathing and after voiding.10 It also appears that even balanitis xerotica obliterans can be successfully treated without circumcision,11 particularly if steroid treatment is supplemented with the minor operation of preputioplasty, in which the distal end of the prepuce is widened.12 Unfortunately, because the use of the term phimosis does not recognise the variations of the normal foreskin, the roles of observation, steroid cream and circumcision have not yet been compared in a study that has used a rigorous definition of pathological phimosis. There remains debate about the care of the normal prepuce in infant males. Parents are usually advised not to touch it, whereas the normal hygiene approach to body parts is one of not hurting, but keeping clean. The latter policy may help prevent skin irritation at the end of the prepuce, which may be part of the cause of pathological phimosis and balanitis (although this needs to be supported by appropriate studies). Evidence-based discussion about circumcision with parents will only be able to occur once we have undertaken prospective studies of the care of the prepuce and the use of steroids for treating phimosis. Parents will then be confident that their uncircumcised boy will not develop disease attributable to the nature of the foreskin. However, we should first focus on integrating a standard definition of phimosis into the study protocols. In the meantime, we should respect the view of parents who regard circumcision as good treatment for their child, given certain provisos. One is that they have been made aware of other options. The other is that they are making an appropriately informed decision about the management of their boy's prepuce because they are aware that "phimosis" does not equate to "pathology", and "pathology" does not always need surgery. Finally, Van Howe et al warn that physicians who perform "involuntary" circumcision are required to provide full disclosure. However, they also warn that, "with current legal precedent, this may not be enough" to protect the doctor from legal action,13 further emphasising the need to develop sound definitions on which to base our treatment of the prepuce. 1: A normal foreskin that is non-retractable, with pouting of the most distal portion when gentle retraction is attempted. 2: This foreskin shows the dome configuration of a boy with "true" phimosis. The fibrosis and pinhole meatus are also seen.

Paddy A Dewan PhD, MD, FRACS

Despite the risks to unvaccinated children, compulsory vaccination is not the answer In a pluralistic society, there are many views on what constitutes acceptable child-rearing. In Australia and other Western societies, parental discretion is limited primarily by legislation against abuse or neglect. In treatment decisions, the legal starting point is that the united view of both parents is correct in identifying the child's welfare. A court will usually only override the parents' decision if the judge is convinced the child's life is endangered, such as when a child needs transfusion.2 Administration of a vaccine is never immediately life-saving in this sense, except in the case of post-exposure rabies vaccine,3 but vaccination satisfies ethical criteria for preventive interventions in children: it is effective, minimally invasive, and associated with significant societal benefits.3 Indeed, the highly favourable benefit-to-risk ratio of childhood vaccination is so well documented that healthcare professionals are understandably frustrated when faced with what seems to be an irrational decision by parents to refuse vaccination. This is especially so when this decision has resulted in failure to prevent a life-threatening illness, as in the tetanus case presented by Goldwater et al (page 175).4 This case raises issues for both the clinician and society. How do healthcare professionals understand and best respond to a conscious decision not to vaccinate? In a highly immunised population, what is the balance of risks and benefits to individual children and their contacts from refusal to vaccinate? Should a case such as this propel us towards compulsory vaccination? In Australia, vaccination is not compulsory, but various incentives and reminders aim to promote it. First, payment of the maternity allowance at 18 months and the childcare benefit requires up-to-date vaccination according to the Australian Childhood Immunisation Register (ACIR),5 unless a medical practitioner has notified the ACIR of a contraindication or serologically confirmed immunity, or has discussed conscientious objection with a parent. Second, at school entry, documentation of full vaccination is required in most Australian jurisdictions, with children who do not have such documentation or serological proof of immunity to specific diseases, such as measles, able to be excluded from school attendance if suspected cases occur. Although the United States is often quoted as having laws for mandatory vaccination, the practical effect of these laws is also limited to exclusion of unvaccinated children from school during outbreaks, although preschool attendance for such children can be barred altogether.6 Italy is one of a few countries where there is compulsory vaccination, but only for diphtheria, tetanus, polio and hepatitis B. However, this has not been enforced for many years.7 To find examples of truly compulsory vaccination, it is necessary to go back to the 19th century. In England, the Vaccination Act of 1853 made smallpox vaccination compulsory for all infants in the first three months of life, on pain of fine or imprisonment. Its enactment spawned riots in several towns and an active anti-vaccination movement. In 1898, a new Vaccination Act removed these penalties and introduced the concept of "conscientious objector" into English law.8 In present-day Australia, most parents whose children are not fully vaccinated are not conscientious objectors, but rather face practical barriers such as recurrent minor illness, work commitments, large family size or social disadvantage.9,10 Parents who are strongly opposed to vaccination comprise a much smaller group. Of a large sample of 1779 Melbourne children in childcare in 1997, only 13 (0.7%) had not received any vaccines.10 This is similar to the proportion of all children Australia-wide registered with Medicare for whom there is a registered conscientious objection.5 In general, such parents tend to be well educated, older, female and of Anglo-Saxon background.11,12 Qualitative data suggest that conscientious objectors fear possible but unknown, especially long term, adverse effects of vaccines, believe that lifestyle measures to improve general immunity are viable alternatives to protection from vaccines, and often mistrust the motives of healthcare providers.9,12 This limits the ability of healthcare professionals to present pertinent counterarguments. Indeed, there is some evidence that parents philosophically opposed to vaccination may have their objections reinforced by factual information about risks and benefits, because these facts do not accord with their beliefs about health and illness.13 In contrast, parents who are merely doubtful about vaccination are much more likely to be amenable to presentation of relevant factual information.9 Healthcare professionals communicating with such doubtful parents need to have their facts well prepared and be sure that they have ascertained the parents' specific concerns, particularly whether these arise from personal or family experience. This is all potentially achievable within a realistic timeframe for a standard consultation, using readily available material specific to Australia.14 In the current Australian environment of high immunisation rates, does refusal of vaccination pose risks to either the individual or the community? In the case of tetanus, the risk is limited to the individual, as the disease is not transmissible. The risk to the individual is highlighted by the US experience, where, with very high immunisation rates, 15 reported cases of childhood tetanus occurred between 1992 and 2000.15 Children unvaccinated because of their parents' beliefs accounted for 9/11 cases in school-aged children,15 although objecting families represent only 0.6% of families with children attending school in the US.16 For other transmissible vaccine-preventable diseases, such as measles, pertussis and poliomyelitis, the risk goes beyond the individual. In Colorado, schools with a higher percentage of objectors were more likely to have a pertussis outbreak, and at least 11% of vaccinated children in measles outbreaks acquired measles from contact with an unvaccinated child of objecting parents. In addition, there was a 22-fold (measles) and sixfold (pertussis) increased risk for the individual unvaccinated child.16 Similarly, in Germany, almost all cases of Hib meningitis occur in unvaccinated children of objecting parents.17 In closed communities of vaccination objectors, such as certain religious groups, very high levels of morbidity from diseases not present in the general community can occur, such as in polio outbreaks in the Netherlands.18 Although there are few such communities in Australia, there is a tendency for conscientious objectors to cluster in certain geographic areas, so the risk of transmission is amplified. Measles cases in Australia now arise exclusively from imported strains and the unvaccinated children of conscientious objectors have recently been highlighted as at risk.19 Parents should be made aware that a decision not to vaccinate, made on their children's behalf, exposes their child to significant risks, even in 2003. Persuasion, at both the clinical level14 and the societal level,5 is appropriate, but truly compulsory vaccination is not an option, either in Australia or in other comparable countries.6,7

Peter B McIntyre FRACP, FAFPHM · Alison H Williams MB BS, FRACGP · Julie E Leask RM, MPH

The Australian and New Zealand Association for Medical Education (ANZAME) was established in 1972 as a medical education society, but has gradually evolved into an association for health-professional education. In July 2002, ANZAME held its 30th Annual Scientific Meeting in Sydney in a collaborative arrangement with the Australian Postgraduate Federation in Medicine (APFM). There were about 150 registrants, the majority from the medical and nursing professions. There were many health-professional educators, as well as delegates from South-East Asia and the United Kingdom. The formal conference was preceded by workshops on qualitative research, university departments of rural health and the challenges of continuing medical education (CME). Ronald Harden opened the pre-conference workshop session with a stimulating exposition entitled "Challenges for continuing medical education in the new millennium". He highlighted the pressures on the health practitioner that accompany a busy clinical life and the need to keep up to date — a "pressure cooker" existence that persists for at least 30 years after graduation. These pressures give rise to the desperate feeling that "I have so much to learn that I have no time to learn". Harden elegantly expanded on "CRISIS" in CME, which ought to be Convenient, Relevant, Interactive, based on Self-assessment, Individualised and Systematic (outcome-based). The aim of CME, as for all medical education, should be "doing the right things, doing the things right, by the right person". The following day, Harden opened the conference with the Australian Postgraduate Federation in Medicine's Coppleson Oration. The theme was "The changing scene in health professional education: the past, present and future". He stressed the need for curriculum planning to be outcome-oriented to produce the best graduates. Medical schools must keep up with the latest information technologies, and "virtual medical schools" (run via computer networks) are in the (cable) pipeline. These schools will employ reusable modules (like "Lego blocks") that can be applied anywhere in place and time, with study guides and task lists to enable learners to plot their way through the course. Assessment in medical schools should be evidence-based, and both "formative" and "summative": The aim of formative assessment is to encourage learning and understanding among students. The learning environment should be relevant and non-threatening, and should foster the application of knowledge, skills and attitudes. The aim of summative assessment (done at the end of each year and the end of the course) is to determine whether educational objectives have been achieved. It should involve analysis of evidence from as many sources as possible, including answers to multiple-choice questions, reports of performance and supervisors' reports. Harden discussed the usefulness of the Objective Structured Clinical Examination (OSCE), portfolio learning and progress tests. Portfolios have been in use for some years to assess students in other disciplines. They are literally "a collection of papers" that incorporate evidence of learning, how that learning relates to the course, objectives and the aims of further learning. Portfolios encourage independent and reflective learning as well as critical thinking and professionalism. Progress tests are part of the formative assessment. They should be used as checklists by students themselves to see how they are progressing. Harden argued that lateral thinking should be encouraged, quoting Einstein's statement that "If the first idea is not absurd, there is no hope". He highlighted the issue by expanding on the model of a core curriculum with special study modules. This approach is a key recommendation of the General Medical Council's report to UK medical schools to tackle the issue of information overload in the curriculum.1 In a typical program, about 70% of the curriculum should be core information and the rest special study modules. All students should have competency in the core curriculum, which contains the basic minimum information required to practise as a doctor and forms the foundation for further learning. The special study modules allow students to study topics of their choice in greater depth, encourage them to take responsibility for their own learning, and help them develop lateral thinking and critical appraisal skills. Changes in the health professions, including medicine, were the theme of the first plenary session. Jenny Graham (Executive Dean, Southern Cross University, Lismore) argued for patient-related outcome and evidence in education. Rosemary Roberts (Director, National Centre for Classification in Health, Sydney) argued for patient-related diagnoses as well as medical diagnoses. The patient should be far more important than the disease itself. Unless the profession does the right thing by patients, their confidence cannot be retained or regained. Eva Cox (Senior Lecturer, Discipline of Humanities and Social Sciences, University of Technology, Sydney) spoke about the social changes influencing health-professional education. She pointed out that six major health determinants — clean water supply, nutrition, sanitation, public health, education and equity of access — are just as important as physiology and pathology. Cox urged that university ethics committees go beyond deliberation on research activities to oversee how the universities conduct their business in other areas, such as research and publications. She argued that trustworthiness is the social capital of universities. Universities should have ethical guidelines on publications and authorship as well as research-fund distribution. Most business organisations are now "locally responsible" (ie, sensitive and responsive to the needs of local communities), and must be mindful of the "triple bottom line" of money, energy utilisation and ethical responsibilities. Universities should follow suit. In another keynote address entitled "Change in education methods that influence health-professional learning", Harden explored changes in educational methods. He reminded the conference that it is a "new world", and universities that do not deliver electronic educational programs will wither. He illustrated this fate with the metaphor of ice-suppliers in Scotland, who were forced to close up shop with the advent of refrigerators because they failed to appreciate the implications of the new technology. Information overload, student diversity, and the explosion in Internet use have all rocked the world of graduate education. Harden said educationalists range from pessimistically intimidated to irrationally enthusiastic about "e-learning". However, e-learning must be complemented with face-to-face learning — even when the "virtual medical school" starts operation it must be customised for individual sites. Adrian Lee (Pro-Vice Chancellor of Education, University of New South Wales, Sydney), in his keynote address on changes within the university structure that influence health-professional education, continued the theme of e-learning. He highlighted the need for face-to-face learning, social bonding, small-group learning and hands-on learning, which are beyond the scope of the virtual curriculum. Lee stressed that globalisation is a major force and, unless we change to keep up with it, it will be imposed on us. One of the innovations in his university is the Fellowship in Innovative Teaching using Educational Technologies. Faculty members are freed from normal duties to learn theory and practice of learning and to develop teaching and assessment materials. This has been a great success and has brought the teaching faculty together. The University of New South Wales is a member of "Universitas 21", a network of 18 universities in 10 countries. Shared resource materials are available online. Students of universities in the partnership will be able to undertake degrees in a range of programs online. Another change implemented at the University of NSW is the introduction of online formative assessment in some disciplines. Julie Wells (Strategic Consultant in Higher Education, Royal Melbourne Institute of Technology, Melbourne) looked at the big picture in her presentation on "Changes in political and social policy that influence health-professional education". She emphasised that research and scholarship are integral parts of effective teaching and that there are dangers in separating these elements for funding purposes. Educationalists need to engage the community and the government in driving changes. If we want to be a clever country, we must put more money into learning. Heather Alexander (Senior Lecturer, Medical Education, University of Queensland, Brisbane) discussed changes in assessment methods. She highlighted the need for communication, ownership and staff development in medical schools and stressed that teaching and learning are a continuum. Assessment is becoming broader, with new instruments being developed to ensure flexibility, reliability and validity. Error in medical practice is a major problem, and the challenge is to minimise this by recognising and measuring error as part of undergraduate education. Error has rarely been addressed in teaching and learning, but as medical schools are asked to certify a student's "fitness to practice" the issues of safety and medical error come to the fore. Students of all abilities make errors, and deciding on the consequences for students who do so is problematic. ANZAME is renowned for its informal, innovative meetings, which include the very popular "PEARLS" (Personally Arranged Learning Sessions). During these sessions, a speaker is allowed up to 10 minutes to present a topic. This is followed by 30 minutes of discussion and debate. At this year's conference, there were 85 PEARLS on health-professional education topics. Most participants in these sessions highlighted the need for learning (active) rather than teaching (passive). As Rufus Clarke (Professor of Medical Education, University of Sydney, Sydney) noted, "students are now passive cross-sectional observers, but they should have longitudinal participatory roles". The main take-home message from the conference was that change is constant and that education should be outcome-oriented. This involves fundamental rethinking in curriculum development and planning. Educators have a societal contract and we should be sensitive to this. Electronic learning is here to stay, and more and more universities are embarking on e-learning. However, the most important message is that education should be student-centred and we should focus on learning rather than teaching. Conference participants returned home with a strong feeling that our region of the world is at the cutting edge of many educational innovations. There is a vibrant group of committed people who are making changes, be they imposed or desired.

Balakrishnan R Nair FRCP, FRACP · Ian Hardie MB BS, FRACS

Objective: To investigate the incidence rate of circumcision for phimosis and other medically indicated reasons in Western Australian boys from 1 January 1981 to 31 December 1999.Design and setting: A population-based incidence study using hospital discharge data of all circumcisions performed in all WA hospitals during the study period.Main outcome measures: Changes in the incidence rate of circumcision for medically indicated reasons.Results: The rate of medically indicated circumcisions increased in boys aged less than 15 years during the study period. Phimosis was the most common medical indication for circumcision in all age groups. The rate of circumcision associated with phimosis was eight times that associated with balanoposthitis and 21 times that of balanitis xerotica obliterans. Boys aged less than five years had the highest rate of circumcision to treat phimosis, at 4.6 per 1000 person-years, representing about 300 circumcisions per year. Boys aged less than five years living in country areas were 1.5 times more likely to be circumcised for phimosis than boys living in metropolitan Perth.Conclusion: The rate of circumcision to treat phimosis in boys aged less than 15 years is seven times the expected incidence rate for phimosis. Many boys are circumcised before reaching five years of age, despite phimosis being rare in this age group.

Katrina Spilsbury BSc, PhD · James B Semmens MSc, PhD · C D'Arcy J Holman MB BS, MPH, PhD · Z Stan Wisniewski MB BS, FRACS

Objective: To assess iodine status and goitre prevalence in a sample of schoolchildren in Melbourne.Design: Cross-sectional study of urinary iodine excretion and presence of goitre in a sample of schoolchildren from Years 5–12 attending two urban schools.Participants: 607 children aged 11–18 years consented to thyroid gland palpation and 577 provided a urine sample on the day of examination in August 2001.Outcome measure: Iodine status of the study population, based on median urinary iodine values categorised as normal (≥ 100 μg/L), mild (50–99 μg/L) or moderate–severe (< 50 μg/L), and classified according to sex, school year and presence of goitre.Results: 76% (439/577) of students had abnormal urinary iodine values, with 27% (156/577) having values consistent with moderate–severe deficiency. The median urinary iodine excretion for the total group was 70μg/L, with values for school years 5–12 ranging from 62 μg/L (Year 12) to 76 μg/L (Year 9). The median urinary iodine value in girls was lower than that in boys (64μg/L v 82 μg/L), and girls had significantly lower urinary iodine values overall (P < 0.002). There was no association between goitre grade and moderate–severe (< 50 μg/L; P = 0.39) or mild (50–99 μg/L; P = 0.07) urinary iodine deficiency.Conclusions: We found mild iodine deficiency in a cohort of schoolchildren in Melbourne. Our results support other data showing mild iodine deficiency in Sydney and Tasmania and the argument for a national study of iodine nutrition.

Ciara M McDonnell MB, MRCPI · Mark Harris MD BS, FRACP · Margaret R Zacharin MB BS, FRACP

Objective: To compare preparedness for hospital practice between graduates from a problem-based, graduate-entry medical program and those from other programs (undergraduate problem-based and traditional).Design: Survey of graduates (by mailed questionnaire) and organisers of clinical training (by semistructured interview); results were compared with published results of surveys of graduates from other programs.Setting and participants: All graduates of the first intake of the University of Sydney graduate-entry medical program were surveyed at the end of their first intern year (2001), along with the director of clinical training or intern manager at each of the New South Wales hospitals that employed the graduates.Main outcome measures: Graduates' self-reported level of preparedness in the eight domains of the Preparation for Hospital Practice Questionnaire; and organisers' opinions of their strengths and weaknesses.Results: 76 of 108 graduates from the graduate-entry program (70%) and organisers of clinical training at all 17 hospitals participated. Graduates from the program felt more prepared than did those from other programs in five of the eight domains assessed (interpersonal skills, confidence, collaboration, holistic care, and self-directed learning) and no less prepared in any domain. Organisers rated the graduates highly, especially in clinical competence, confidence, communication and professional skills. Opinions of interns' knowledge of basic sciences conflicted, with strengths and weaknesses mentioned with equal frequency.Conclusion: Graduates from the graduate-entry, problem-based program are at least as well prepared for their intern year as graduates from traditional and undergraduate problem-based programs.

Sarah J Dean BA(Psych Hons) · Alexandra L Barratt PhD, FAFPHM · Graham D Hendry BA(Hons), PhD, GradDipEdStud · Patricia M A Lyon MEd, PhD

Teacher-clinicians are not always adequate role models In 2000, the Australian Medical Council highlighted the place of clinical ethics in the education of medical students.1 A similar appreciation of its relevance has grown in the UK, North America and Europe.2-4 Recently, a working group of the Association of Teachers of Ethics and Law in Australian and New Zealand Medical Schools (ATEAM) produced a core curriculum for the subject5 that encompasses the knowledge, skills and attitudes required for students to appreciate the range and complexity of ethical issues permeating medicine and the moral principles required to deal with them. Who should teach ethics to medical students remains debatable, with some advocating a role for ethicists and others seeing the clinician as more appropriate. ATEAM argued that an optimal program embodies "multiple perspectives and multiple teachers".5 As the working group put it: "Teachers of ethics can play an important role in modeling the very nature of ethics: the teaching process should be perceived as being emotionally supportive and academically encouraging, should be tolerant of multiple perspectives, should be interdisciplinary and should actively involve clinicians as code-instructors and as role models for students. This also underscores the responsibility of teachers to develop as an ethical community and be alert to, and respond to, unethical behavior among themselves."5 Clinicians who are specifically recruited to teach clinical ethics are invariably selected on the basis of their sensitivity and commitment to the ethical dimension of the doctor–patient relationship; they are likely to serve as appropriate role models. Regrettably, during the course of their training, students may encounter other clinicians who lack sensitivity and manifest a disregard of ethical principles. In a survey of Canadian medical students, half reported pressure to act unethically and 60% had observed unethical conduct in a clinical teacher.6 Moreover, they had felt impotent in the face of these circumstances because of the teacher's intimidatory attitude. Having taught clinical ethics for almost three decades and on three continents, I have compiled a body of evidence of clinicians demonstrating wholly undesirable qualities and behaviour to medical students. In the context of case-centred teaching programs in ethics, students are requested to observe ethical aspects of practice during their attachment to a medical or surgical unit and then select an experience which has provoked their curiosity, generated concern or affected them in some way. The narrative of this experience is shared with a group of fellow students, one of whom serves as a scribe. As a result of this process, I have files containing dozens of ethically challenging scenarios (Box 1). The student dilemmaA recurrent theme in these scenarios is the students' powerlessness either to challenge the clinician or to intervene on the patient's behalf: "How can I, when placed at the very bottom of the hierarchy, voice my disapproval?" . . . "How can I come to the aid of patients when I am not directly responsible for them and this could be construed as acting beyond my remit?" . . . "How can I inform the Dean given that my quandary may well be divulged to the clinician himself?" Although these sorts of questions have been posed many times, I have always found it difficult to provide a rational response. After all, any advice to take action could well place students in professional jeopardy.7 When asked what factors inhibit students from speaking out, fear heads the list. Teacher-clinicians exert a strong influence over the student's future. They may be examiners or a source of references. Another commonly cited factor is the dominance of a professional culture which makes it taboo to question the clinical or professional conduct of a senior colleague. Mention is often made of an ethos whereby doctors should protect one another, especially in the face of a censorious environment and a siege mentality regarding the legal profession. Students note that "whistle blowing" is frowned upon and that the discloser of "medical secrets" is often ostracised.8 Students may not always feel confident that their critical reaction to an unethical clinician is justified: "Perhaps I am not able to tease out all the aspects?" . . . "Surely consultants with much more clinical experience and knowledge than myself must know what they are doing." . . . "Perhaps it is the best way of dealing with the situation." Other factors are probably rationalisations to justify retreating from a potential confrontation. For instance, are students justified in levelling criticism when they themselves may act unethically in the future, whether deliberately or inadvertently? Leeway is also given to the common plight which doctors, especially junior staff, face — working under great pressure with limited resources. Is it not understandable that a doctor may sometimes, in a state of frustration or fatigue, fail to maintain optimal ethical standards? Finally, questioning a consultant's clinical decision is akin to a student asking a teacher to clarify an objective position, but raising questions about an ethical judgement may penetrate more deeply and imply an attack on the personal qualities of the clinician. In minor instances, issuing this challenge may not seem worth the offence it may cause. In extreme cases, where a student surmises that a teacher is habitually unethical by dint of inherent deficiencies, the corollary may follow that "Such doctors unfortunately do exist and we have no choice but to tolerate them". If a series of teachers fail as ethical role models, students may well become disillusioned with their chosen profession. Instead of having an eager, energetic approach to medical life, they may become cynical and embittered. If insufficient good role models are available, students may miss the opportunity, at a formative period in their development, to enhance their own ethical capabilities. Students are well placed as members of an observant, intelligent peer group to contribute to the promotion of ethical standards by raising issues with their teachers. By not speaking out, avoidable patient distress may persist. The distress may be amplified by a sense of disillusionment that the "next generation" of doctors merely imitates the undesirable behaviours of their seniors. Students' acquiescence could be seen to maintain the status quo. James Dwyer7 captures the essence of the problem: "... the failure to speak up in certain situations is a failure of learning and caring." Moreover, the risk prevails that moral sensibility becomes eroded. Suggestions for changeGiven the adverse repercussions of negative ethical role modelling, I have sought the views of student groups over recent years as to how they may act. What follows is the product of these discussions. The cardinal change required is to remove the taboo on students "speaking up". Dwyer7 encapsulates this appositely by calling on students to subscribe to the Socratic maxim primum non tacere ("first, do not be silent") to fulfil their responsibilities to patients, colleagues and the medical profession. Abolishing the taboo depends on a number of overlapping factors. Altering the nature of the teacher–student relationship is paramount. The traditional hierarchical character of not only that association but of all the tiers of medicine embodies so many limitations that it ought to be ditched at the earliest opportunity. A more equitable link, similar to a partnership, is bound to be much more rewarding to both parties by permitting everyone to learn from each other's perspective.9 Here, the teacher must obviously modify well-entrenched habits and come to regard students as creative and curious. The learning process can be so much richer when it encompasses this interactive quality. The host environment, whether it be a hospital, a clinic or general practice, is another crucial variable in enabling the student to raise ethical questions. An institution whose ethos encourages ethical enquiry and is open to the challenge of optimising clinical care will listen carefully to the student's voice. The student may contribute to this spirit of ethical openness in at least two ways. Firstly, questions about ethical aspects of a clinical situation should be raised respectfully, avoiding judgementalism or personal denigration. Secondly, students should take care to broach delicate matters, which may well involve patient care, in a suitable setting. Thus, if distressed by an encounter between doctor and patient, they should refrain from questioning the teacher until in the private surroundings of the tutorial room. In proposing these two requirements of students, we have depicted them as individual protagonists. They may hesitate to raise an issue lest they are "out on a limb", their views stemming from an idiosyncratic source. Students would therefore do well to ventilate their concerns to their fellows and then share the task of questioning the clinician. The advantage of fellowship can be reinforced by reference to a code of ethics. A draft code for medical students published in 2002 by the Australian Medical Students' Association is an exemplary document comprising eight principles (Box 2), each of which is elaborated upon and clarified in a series of annotations.10 In the event of an experience with a negative role model, students can readily compare what they have observed with corresponding principles in their code. This comparison can then embolden them to challenge the teacher. If students experience difficulty because the teacher resists their enquiry they may feel helpless. The third annotation of Principle 6 of the AMSA code anticipates this by stipulating that: "When medical students experience difficulty with staff, they should discuss this with their academic mentor or supervisor." This is sound advice, although the student may be reluctant to follow it lest he or she be labelled a "whistle blower". Again, the notion of "security in numbers" applies. Fellow students who share a concern would no doubt find it easier to raise this as part of a group with a clinical dean or clinical supervisor. ConclusionNo matter how comprehensive and systematic the teaching of medical ethics, the acquisition of relevant skills and the cultivation of desirable attitudes will take place mainly in the clinical arena and be influenced by doctors who model an appreciation of the myriad ethical questions that pervade medical practice. Role models of good ethical conduct will always loom large in guiding the student to acquire a sense of moral integrity.11 Clinician-teachers share a duty to do all they can to expedite the process. Negative modelling is a destructive force which has no place in the learning environment. We all have a responsibility to confront and eradicate it. 1: Examples of ethically challenging situations faced by medical students The jocular doctor: In an effort to introduce each patient in a clinic to the observing students, a consultant either joked about them or referred to an amusing quality in them. Although the content and tone were not malicious, the students wondered whether this did not undermine the principle of respecting the dignity of the person. The students were sensitised given their experience not long before of a pair of surgeons talking indelicately about an anaesthetised patient under their joint care. The slanging match: A group of students were unnerved when witnessing a feud between a consultant and a ward sister, conducted in the passage and well within earshot of the patients. The pair had virtually come to blows over the issue of truth-telling. The nursing staff were convinced that a patient with advanced cancer sought the truth about her prognosis, whereas the consultant was of the view that she would be emotionally harmed if given an explicit prognosis. The students felt immobilised in the face of the increasingly acrimonious exchange. The scolding doctor: During the course of a consultation, a patient complained of a burning sensation in her legs. The clinician briefly reassured her that this was of no consequence. The pain appeared to worsen, the patient becoming tearful and distressed. Expecting further reassurance by the doctor or cessation of the examination, the students were staggered to hear his litany of criticisms of the patient for her not exercising or eating adequately. Later in the staff office, the doctor complained further about the patient, seemingly insensitive to her suffering. "All must palpate": Having examined a patient with an abdominal mass who was obviously in severe pain, the doctor instructed all eight students in the tutorial group to palpate her abdomen after the ward round. Half the group felt so intimidated by the clinician's "overbearing personality" that they examined the patient despite her request for the process to cease. The others felt it disrespectful to impose on the patient, but then had to lie to the teacher that they had "felt the mass". The "difficult" patient: The patient screamed out in pain when the doctor examined her pelvis. The observing student was startled to hear the doctor then reprimand the patient for acting "hysterically" and losing control. Later, but still at the bedside, he explained to the student that she was a "difficult personality" and had always responded in this "exaggerated" way. 2: Principles from the Australian Medical Students' Association Code of Ethics — preliminary draft Medical students should: respect the needs, values and culture of patients they encounter during their medical training; never exploit patients or their families; hold clinical information in confidence; obtain informed consent from patients before involving them in any aspect of training; appreciate the limits of their role in the clinical setting and in the community; respect the staff who teach and assist them in their clinical training; when involved in clinical research adhere to the ethical principles in the appropriate national and international guidelines; maintain their personal integrity and well being.

Sidney Bloch PhD, FRANZCP

Before I visited the Department of Forensic Medicine in Glebe, my concept of an autopsy lacked insight. I now realise that autopsies have many roles and affect us at as many different emotional levels. My first impression was that a very strong "impersonal" aura prevailed in the autopsy suite. Two rows of cold, steel tables laden with bodies were surrounded by uniformly dressed pathologists and technicians — opening bodies, removing organs, examining organs, replacing organs, restoring bodies. As I observed this routine, I became aware of the social chatter, similar to the conversation that takes place in operating theatres. Here, the chatter seemed to trivialise the situation. The emotional spectrum then shifted dramatically when I focused, not on the body, but on the person that the body represented. Each person has a history and it was at this level that the concept of death became very personal. I found myself studying their facial expressions and becoming immersed in the circumstances surrounding their death. For people who had died by suicide, I tried to comprehend the terrible anguish and hopelessness they must have felt before taking their own lives. For those who died in accidents, I realised that they would not have expected to die that day. The face of a motorcyclist killed in an accident did not show pain, although the reports indicated that death was not instantaneous. Did he have any last thoughts or reflections as he lay dying on the side of the road? Then I wondered how the families would deal with the devastating news of these deaths. I witnessed a young man who had survived surgery and then died of a massive pulmonary embolism at home. I reflected on the pain that his family, girlfriend and friends must have been feeling. The fact that he was well loved was obvious from all the graffiti on his plaster cast and the tattoo of his girlfriend's name on his abdomen. These incidents impressed on me how precious and unpredictable life is and how I so readily take it for granted. I found that what disturbed me most was not, as I had anticipated, that a person was "dead", but rather the emotions involved in death. I found that I could not detach myself from the profound feelings of sadness that the deceased person's family would be feeling. A powerful compounding factor was the short time frame between death and autopsy. In most autopsies, the person had died in the past 24 hours. I would go home each night knowing that someone alive right now would die, and I would see them in the morgue in the morning. At the end of each day I was exhausted. I had moved through a kaleidoscope of emotions, from sadness to helplessness, from anger to frustration. I became aware of the extent to which I was personalising each case and of the toll this was taking on me. I needed to detach. It was at this point that I began to understand the "impersonal aura" that I had initially felt was inappropriate. The social chatter and humour provided protection from a narrow focus and draining emotions. On a daily basis, one could not survive this high emotional intensity without such a coping mechanism. Even knowing this, I still found it difficult to stay detached, especially during an autopsy. The body is opened by a series of incisions in the head, neck and trunk, then the internal organs are removed for dissection and examination. I felt this intermediate presentation of the body (with empty chest, abdominal and cranial cavities) to be a violation of that person. I imagined the distressing reaction of the family if they could see what was happening to their loved one. I asked the questions "Was it not enough that they had already lost their loved one? Was an autopsy really necessary? How do we justify this added pain?". These questions played on my mind all through the week. I learnt that family consent is not needed for a coronial autopsy in New South Wales, although a family does have a legal right to object to the examination. The pressure of having to make such a decision at a time of great emotional distress and vulnerability doesn't seem fair. This decision could also conflict with the family's religious or other beliefs. On the other hand, an autopsy is clearly a valuable procedure. Determining whether a person died of natural causes, or as a result of unnatural interference by others, is necessary both for the emotional recovery of family members and the maintenance of justice in our society. Autopsies also provide information about diseases that may directly affect relatives, and, cumulatively, aid in the prevention of future deaths. I learnt a lot during my week at the morgue — particularly about my "personal and professional development". I had never experienced death on a personal level, and my reactions to death were not what I expected. I had experienced a similar inability to detach during hospital rounds. I realise now that it is a trait that I must confront, particularly if I want to remain sane in the medical field. I need to find a balance between becoming what I perceive as too impersonal and becoming too involved.

Tina Kastowsky BSc (Biomed)

Imprecise language and deliberate confusion of important ethical and legal concepts are clouding our understanding of controversial end-of-life issues. This could affect our decision about whether or not to legalise euthanasia. In postmodern societies, the euthanasia and physician-assisted suicide debate is an important forum for the "death talk" through which we accommodate — with as much comfort as possible — the reality of death into the living of our lives.1 Recently, I debated Dr Philip Nitschke, at the Australian Medical Association's Annual General Meeting in Canberra, 24–26 May 2002, on whether euthanasia and physician-assisted suicide should be legalised. Dr Nitschke advocates such legalisation; I oppose it. In this article, I discuss my impressions of the discussion of euthanasia that took place at that AMA meeting and respond to it. Euthanasia is "a deliberate act that causes death undertaken by one person with the primary intention of ending the life of another person, in order to relieve that person's suffering."1 Throughout, I use the word "euthanasia" to include also physician-assisted suicide (although I recognise that in some situations, not discussed here, they must be differentiated). Language mattersLanguage is not neutral, especially in the euthanasia debate. We must choose and use our words carefully and precisely if we are to avoid inadvertently opening the way for the legalisation of euthanasia. For instance, saying that patients must be offered all treatment necessary to relieve their pain, even if that treatment could or would shorten life, or they must be offered all treatment necessary to relieve their suffering, may seem the same. But, properly interpreted, the former statement does not open up the possibility of legitimating euthanasia; the latter could do so and could affect the law accordingly. The language used in some of the resolutions passed by AMA delegates at the meeting can be interpreted several ways, thus creating confusion as to whether delegates had moved from opposing euthanasia absolutely towards approving it. Consequently, the media produced front-page headlines stating that the AMA had switched its policy on euthanasia and had "cleared [doctors] to 'hasten death'."2 Resolution 3Take, for instance, Resolution 3, which stated: National Conference recommends . . . that AMA policy be amended to read "that the AMA support doctors whose primary intent is to relieve the suffering and distress of terminally ill patients in accordance with patients' wishes and interests, even though a foreseen secondary consequence is the hastening of death." Most doctors to whom I spoke at the meeting said they saw this resolution as nothing more than a reaffirmation of the AMA's current position, which, consistent with current ethics and law, rejects euthanasia and supports offering patients all necessary pain-relief treatment, even if it could or would shorten life. However, this resolution might inadvertently go well beyond that. First, the resolution is not limited to pain relief: it refers to relief of "the suffering and distress of terminally ill patients" — a much broader category of symptoms and situations than just pain. Language to better reflect the present AMA position would be "the relief of pain and other symptoms of serious physical distress of terminally ill patients." Secondly, Resolution 3 implies that "the patient's wishes and interests" justify the life-shortening treatment — a key argument of the pro-euthanasia lobby. They argue that competent individuals' informed consent to euthanasia justifies giving them lethal injections. Opponents of euthanasia believe that a person's consent to having death inflicted does not justify another person inflicting death. This latter belief is enshrined in contemporary criminal law, except in countries such as the Netherlands and Belgium, which allow an exception for euthanasia. Further, Resolution 3 could be taken as legitimating the pursuit of death as a secondary consequence, not simply tolerating it as an unavoidable, unwanted consequence. In ethics and law, the difference between these two situations is reflected in the very significant distinction drawn between justifying an unwanted consequence (here, death) and excusing it. "Double-effect" doctrineThe legal doctrine of "double effect" justifies giving pain-relief treatment, provided it is given with the primary intention to relieve pain, and excuses any unavoidable, but unwanted, life-shortening effect of doing so. In short, the act of pain relief is justified — it is a right act; its unwanted consequence of shortening life is excused (ie, tolerated) in the circumstances. Let me explain why the distinction between a justification and an excuse is important in this context: an excuse carries the message that shortening life is wrong, but the person who does so will not be prosecuted (ie, he or she will have legal immunity). The message of a justification — as implied by the wording used in Resolution 3 — is that the conduct of shortening life is right. When considered as a justification, Resolution 3 can also support another pro-euthanasia line of argument: given that doctors have now accepted that hastening death is acceptable and justifiable as a secondary effect, it should not be unacceptable and unjustifiable as a primary intention. In contrast, interpreting the doctrine of "double effect", as suggested above, would not be open to such reasoning. It says that the secondary effect of hastening the death of the patient in providing necessary pain-relief treatment is unwanted and must never be a desired consequence, but, to the strict extent necessary to relieve pain, it is excused in law. That approach also reflects many people's moral intuitions that we must relieve pain, but it is wrong to kill. The doctrine of "double effect" requires, first, that the act resulting in a bad consequence (such as the shortening of life) is morally neutral. Providing pain-relief treatment would qualify as at least a morally neutral act. Second, the pain relief must not be achieved by shortening life (ie, through a bad consequence). Third, the bad consequence, the shortening of life, must not be primarily intended as either an end or a means; rather, the primary intent must be the legitimate aim of relieving pain. Fourth, there must be no other reasonable way of achieving the pain relief without involving the undesired effect of shortening life. Lastly, the proportionality of good and bad consequences required to justify the bad ones must be present. Providing necessary pain relief, even if it shortens life, fulfils all of these conditions; euthanasia fulfils none of them. ConfusionThat the delegates might themselves have been confused about the possible meaning of Resolution 3, which they passed (65 to 48 votes), could be indicated by their rejection (34 to 79 votes) of Resolution 4. That resolution proposed . . . that the AMA "work towards . . . adopt[ing] a neutral position on the issue of voluntary euthanasia." The 31 doctors who voted for Resolution 3, but against Resolution 4 (assuming the same 113 doctors voted in each case), obviously had no idea that Resolution 3 could be interpreted as moving towards acceptance of euthanasia, because they opposed even a neutral stance on it. A neutral stance would be, in fact, not only a move away from opposing euthanasia, but a move towards euthanasia. Its message is that, in principle, there are no moral, ethical or legal reasons to oppose euthanasia; rather, its acceptability is a matter of personal conscience and whether any associated potential abuse can be prevented. Yet another indication that the doctors might not have understood the ambiguity of the language of Resolution 3 and the inconsistency between voting for it and against Resolution 4 is that Resolution 1 was passed with only four against votes. It expressly rejects euthanasia: "[T]he AMA . . . absolutely reject[s] any intervention whose primary intent is to bring about the death of a patient . . ." This resolution distinguishes acting with such an intent — euthanasia — from the justified withdrawal of life-support treatment that results in death, and advocates educating the community about palliative care and ensuring that its provision is given high priority. In short, the resolution outlines a comprehensive anti-euthanasia approach to caring for terminally ill people. Confusion compoundedAfter the AMA conference, a well-known euthanasia advocate posted an email on the Deliverance (Voluntary Euthanasia Australia) chat line commenting on its outcome (List Member, Friday, June 21, 2002). The email stated that one of the participants at the meeting: ". . . got it absolutely right when he said that the principle of double effect allows doctors and others to hide behind it [to carry out euthanasia]. In light of the AMA's plan to (re-)educate doctors on the difference between "ethical care" and "euthanasia" this has particular significance : what the AMA "education" campaign is likely to amount to is to tell doctors to keep their minds off the foreseen consequences of what they do — to aim at pain-relief, not death." This email reflects an important modus operandi of euthanasia advocates — to work for the acceptance and legalisation of euthanasia by intentionally creating multiple confusions between it and other conduct that is ethically and legally acceptable in treating terminally ill patients. I call it "euthanasia by confusion".1 Disputed distinctionsPain-relief treatment versus euthanasiaA key target in creating this confusion is the doctrine of "double effect". It is attacked through allegations that the doctor's goal — his or her intent — and the cause of the patient's death — the causation — are the same in giving pain-relief treatment that could shorten life and in euthanasia. In other words, euthanasia advocates claim that the doctrine of "double effect" is just legal sophistry and that pain-relief treatment that could shorten life is really euthanasia. Those who oppose euthanasia argue that provision of pain-relief treatment is different in kind, not just degree, from euthanasia, because the intent is different. Necessary pain-relief treatment, even that which could shorten life, does not involve a primary intention to kill the patient; euthanasia does. Profound ethical and legal differences hinge on whether such an intent is present. As the Deliverance email demonstrates, euthanasia advocates also claim that doctors are hypocritically hiding behind the permissibility of giving pain relief under the doctrine of "double effect" — in fact, to carry out euthanasia. That is, they claim that, in practice, in giving pain-relief treatment, many doctors are acting with a primary intention of killing patients, not of relieving their pain. Often these claims are made on the basis of the large amount of pain-relief treatment given. But provided the dose (even if it is very large) is necessary to relieve the patient's pain and given with the primary intention of doing so, that is not euthanasia. Where it is clear that these conditions are not fulfilled, it would be euthanasia. There are serious harms in arguing that giving necessary pain relief is euthanasia: it could make doctors frightened to provide it. They must be reassured that they will not be legally liable; indeed, as the law is now developing, they are more likely to be liable for not doing so. Withdrawal of life support versus euthanasiaEuthanasia advocates also deliberately confuse withdrawal of life-support treatment with euthanasia. They argue there is no difference in either intention or causation between withdrawing life-support treatment when it results in the person's death and giving that person a lethal injection. They say that in both cases the doctor kills the patient (ie, causes the patient's death). This commonality of causation means they argue that, if we agree to respect refusals of life-support treatment, we must also agree with euthanasia. Moreover, they claim that, if there is no moral or ethical difference between refusals of treatment that result in death and euthanasia, there ought to be no legal difference. Those who oppose euthanasia disagree. They argue that refusals of treatment are morally and ethically different from euthanasia and ought to remain legally different. There are long-established, well understood, profound and important differences between allowing people to die, when it is ethically and legally justified, and making them die (ie, putting them to death). Respecting people's refusals of life-saving treatment belongs in the former category, euthanasia in the latter. The right to refuse treatment flows from a right to inviolability — a right not to be touched, including by continuing treatment, without one's consent — not from a right to die. There is therefore a right to have treatment withdrawn, which means that death will result from (ie, be caused by) the patient's underlying illness, but there is no right to be killed. Causing a patient's death through administering a lethal injection is different in kind from death resulting from refusal of treatment. The same line of pro-euthanasia argument is also constructed through a confusion of means and ends. This argument is that when death is the inevitable outcome, the means used to achieve that — whether withdrawing life support or a lethal injection — are morally irrelevant and ought to be legally irrelevant. But the means through which we die matter morally and should continue to matter legally. The issue is not if we die — we all die; it is how we die. Deep moral intuitions have long informed us that there are important distinctions between "letting nature take its course", including by refusal of life-support treatment, and killing a dying person. Death: purely private or societal impact?Advocates of euthanasia also argue that that how we die is just a private matter. Opponents of legalising euthanasia reject that argument. They believe each person's death necessarily involves others, including healthcare professionals, and societal values and symbols. Moreover, if euthanasia is involved, how we die cannot be just a private matter of self-determination and personal beliefs, because euthanasia "is an act that requires two people to make it possible and a complicit society to make it acceptable."3 Impact of legalising euthanasiaChanging the norm that we must not kill each other would cause profound damage to society. There would also be serious damage to institutions — in particular, medicine and the law — that maintain respect for human life, especially in a secular, pluralistic society that no longer has a shared religion to carry such values. Fundamental valuesAmong the fundamental elements of the case against euthanasia is its contravention of the principle that to act with a primary intention of killing another person is inherently wrong (except in justified self-defence or defence of others). To legalise euthanasia would damage important, foundational societal values and symbols that uphold respect for human life. In fact, the prohibition on intentionally killing is the cornerstone of law and human relationships, emphasising our basic equality.4 To legalise euthanasia would be to change the way we understand ourselves, human life and its meaning. And a more pragmatic, but nevertheless very important, objection is that abuse of legalised euthanasia cannot be prevented, as recent reports on euthanasia in the Netherlands have documented.5,6 In response, euthanasia advocates argue, in support of legalising it, that doctors are secretly carrying it out anyway. They claim to have found a high incidence of secret euthanasia by healthcare professionals, for example in Australia.7 However, that study has recently been severely criticised on the grounds that the respondents replied to questions that did not distinguish between actions intended to shorten life — euthanasia — and other acts or omissions in which no such intention was present — pain-relief treatment or refusals of treatment — that are not euthanasia. Consequently, the researchers' estimates of the number of cases of hidden euthanasia may be grossly exaggerated.8 But, even if accurate, the fact that doctors are secretly carrying out euthanasia does not mean that it is right. (Further, if doctors were presently ignoring the law against murder, why would they obey guidelines for voluntary euthanasia?) Lethal impactWhat impact might legalising euthanasia have on society? In answering questions of impact we must not look at euthanasia just in relation to individuals or in isolation from the context in which it would operate: at a societal level, the combination of an ageing population, scarce healthcare resources and euthanasia would be a lethal one. And what impact might the consequent message — that suicide is an appropriate response to suffering — have on people who are suicidal? What impact would legalising euthanasia have on the profession of medicine? Euthanasia "places the very soul of medicine on trial".9 Doctors' absolute repugnance to killing people is necessary to maintaining people's and society's trust in them. This is true, in part, because doctors have opportunities to kill not open to other people, as the horrific story of Dr Harold Shipman, the UK physician-serial killer, shows. It would be very difficult to communicate to doctors a repugnance to killing in a context of legalised euthanasia. Harm to medicine also harms society. We need to protect the institution of medicine not just for its own sake, but also because it is a very important value-creating, value-carrying and values-consensus-forming institution, especially in a secular society. How would legalising euthanasia affect medical education? What impact would physician role models carrying out euthanasia have on medical students and young physicians? Would we devote time to teaching students how to administer death through lethal injection? Would they be brutalised or ethically desensitised? (Do we adequately teach pain-relief treatment at present?) Last wordsPhysician-assisted suicide and euthanasia are simplistic, wrong and dangerous responses to the complex reality of human death. For physicians to give lethal injections to their patients or to assist them to commit suicide is inherently wrong from the perspective of principle-based or deontological ethics. But even on a utilitarian or situational ethics analysis, it is ethically wrong — the risks and harms outweigh the benefits. Physician-assisted suicide and euthanasia involves taking people who are at their weakest and most vulnerable, who fear loss of control or isolation and abandonment — in a state of intense "pre-mortem loneliness"10 — and placing them in a situation where they believe their only alternative is to kill themselves. Nancy Crick, a 69-year-old Australian grandmother, was Dr Nitschke's patient. Mrs Crick committed suicide in the presence of over 20 people, eight of whom were members of the Australian Voluntary Euthanasia Society. She explained: "I don't want to die alone." Another option for Mrs Crick should have been to die naturally with people who cared for her present. Was she offered that option? Of people who requested assisted suicide under Oregon's Death with Dignity Act, which allows physicians to prescribe lethal medication, 46% changed their minds after significant palliative-care interventions (relief of pain and other symptoms), but only 15% of those who did not receive such interventions did so.11 How a society treats its weakest, most in need, most vulnerable members best tests its moral and ethical tone. Thus, what doctors decide about euthanasia will play a very large part in determining Australia's moral and ethical tone — far into the future.

Margaret A Somerville AM, FRSC, LLB, LLD (Hon)

Refusal of a parent to have a child vaccinated against tetanus raised ethical issues for the treating clinicians. The clinicians felt their duty to the child was compromised, but recognised that our society leaves the authority for such decisions with the parents. As there was no reason, other than different beliefs about vaccination, to doubt the parent's care for the child, the clinicians limited their response to providing strong recommendations in favour of vaccination. Other issues raised by this case include community protection, and the costs to the community of treating a vaccine-preventable disease.

Paul N Goldwater FRACP, FRCPA · Richard G Power FRACP, MRCP(UK) · Paul H Henning FRACP · Terence G Donald FRACP · Jon N Jureidini PhD, FRANZCP · Christine F Finlay RN, RM · Annette J Braunack-Mayer BMedSci(Hons), PhD · Mike S Gold FRACP, MD

Although many 19th-century misconceptions about the foreskin have been dispelled since it was shown that infantile phimosis was not an abnormality, the ideas that ritual or religious circumcision arose as a hygiene measure, and that circumcision makes no difference to sexual response, have persisted. The first idea should be dismissed as a myth and the second has been seriously questioned by modern research. Owsei Temkin, renowned medical historian, has written: ". . . we are all apt to accept a historical myth where we cannot rely on historical knowledge. Where history is lacking, mythology takes its place, and those who disdain history are among the foremost victims of mythology."1 This is most certainly true when we consider male circumcision. Although much progress has been made since 1949 in dispelling 19th-century myths about the male foreskin (for example, that infantile phimosis was a pathological abnormality; that circumcised men were immune to syphilis; that the foreskin was a "cesspool"; and that circumcised boys did not masturbate), others have proved more persistent. Among these are the idea that ritual circumcision, as practised by certain tribal peoples, arose as a hygiene measure; and the assertion that the removal of the foreskin makes no difference to sexual function. There is no evidence that customary circumcision originated as a hygiene measure. Many primitive cultures carried out a variety of mutilating procedures on different parts of the body, including the genitals of both boys and girls, but the reasons for these practices are obscure and contested. These cultures also practised cannibalism, human sacrifice, infanticide, widow-burial, foot-binding and other traditions not endorsed today. Conflicting theories have been advanced to account for the rise of ritual operations on the male and female genitals, among which are the following: 2 a propitiatory sacrifice or sign of submission to a deity (probably a milder form of a ritual which began as human sacrifice); an offering to the god or goddess of fertility to ensure children; a mark of tribal identification; a rite of passage from childhood to adult responsibility; an attempt to emphasise feminine or masculine characteristics in girls and boys by removing the parts of the genitals (clitoris and foreskin) believed to resemble the genitals of the opposite sex; and a means of humiliating and marking defeated enemies and slaves. The only point of agreement among proponents of the various theories is that promoting good health had nothing to do with it. In the days before aseptic surgery, any cutting of flesh was the least hygienic thing anybody could do, carrying a high risk of bleeding, infection and death. None of the ancient cultures which traditionally practised circumcision have claimed that the ritual was introduced as a hygiene measure: African tribes, Arabs, Jews, Muslims and Aboriginals explain it differently, but divine command, tribal identification, social role, respect for ancestors and promotion of chastity figure prominently.3 It was only in the late 19th century, when mass circumcision was being introduced for "health" reasons, that doctors sought legitimacy for the new procedure by claiming continuity with the distant past and reinterpreting its origins in terms of their own hygiene agenda.4,5 Although the policy statement recently issued by the Royal Australian College of Physicians reaffirms earlier statements that there is no medical indication for routine circumcision, it does suggest that tribal circumcision arose as a hygiene measure in desert environments, and it is disappointingly silent on the significance and role of the foreskin itself as a normal and prominent part of the male genitals.6 Despite the assertion of most contemporary advocates of circumcision that circumcision makes no difference to sexual response, there is a vast medical literature on the significance of the foreskin. In the Graeco-Roman world doctors considered the foreskin so important that they devised treatments to lengthen those which did not provide generous coverage of the glans.7 During the Renaissance and 18th century the centrality of the foreskin to male sexual function and the pleasure of both partners was recognised by anatomists Berengario da Carpi, Gabriello Fallopio and William Harvey, in popular sex manuals like Aristotle's master-piece,2,8 and by physicians like John Hunter, who also appreciated the importance of the foreskin in providing the slack tissue needed to accommodate an erection.9 In the 19th century the role of the foreskin in erotic sensation was well understood by physicians who wanted to cut it off precisely because they considered it the major factor leading boys to masturbation. The Victorian physician and venereologist William Acton (1814–1875) damned it as "a source of serious mischief",10 and most of his contemporaries concurred.11 Both opponents and supporters of circumcision agreed that the significant role the foreskin played in sexual response was the main reason why it should be either left in place or removed. William Hammond, a Professor of Mind in New York in the late 19th century, commented that "circumcision, when performed in early life, generally lessens the voluptuous sensations of sexual intercourse",12 and both he and Acton considered the foreskin necessary for optimal sexual function, especially in old age. Jonathan Hutchinson, English surgeon and pathologist (1828–1913), and many others, thought this was the main reason why it should be excised.13,14 In the 1970s, a United States physician who had himself circumcised was so pleased with the result that he wrote an article urging everybody else to have it done, but even he acknowledged the loss of sexual sensation: "The change in sensation during intercourse a few weeks later was surprising. The sharp pleasurable sensation was noticeably lessened, as it is when topical anaesthetics are used to delay ejaculation. . . The overpowering erotic sensation has been dulled, and with it some of the immediate pleasurable sensation. Initial excitement has decreased. . . [When fully erect the penis presents] a smooth shaft with a piston-in-cylinder-like action during coition. Friction and therefore sensation are diminished."15 It is difficult to put numbers on so subjective an experience as sexual satisfaction, but contemporary Canadian researchers who have identified the complex innervation of the penis, the ridged bands and the frenular delta16,17 have provided physiological confirmation of the 18th-century folklore that a man's foreskin was "the best of your property".18

Robert J L Darby PhD

Trial: Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346: 393-403. QuestionCan treatment with lifestyle modification (changes in diet and physical activity) or metformin reduce the conversion from impaired glucose tolerance (IGT) to type 2 diabetes? Do these treatments differ in effectiveness? Trial details Design: A three-arm multicentre, stratified, randomised controlled trial. Setting: 27 centres in the United States. Patients: 3234 (mean age, 50.6 years; 45.3% non-white; 67.7% female). Inclusion criteria were age 25 years or older; body mass index 25 kg/m2 or more if white, 24 kg/m2 or more if Native American, or 22 kg/m2 or more if Asian; fasting plasma glucose level of 5.3–6.9 mmol/L or < 6.9 mmol/L if Native American; a 2-hour plasma glucose level of 7.8–11 mmol/L after a 75 g glucose tolerance test (GTT); and no previous history of diabetes except gestational diabetes. Patients taking medication affecting glucose tolerance or with a disease which would affect life expectancy or participation in the activity recommendations were excluded. Intervention: The three groups were standard lifestyle recommendations plus twice-daily placebo (control group); intensive lifestyle program plus twice-daily placebo (lifestyle group); and standard lifestyle recommendations plus metformin (metformin group). The intensive program aimed to reduce patients' weight by at least 7% by dietary means and to have them engage in physical activity of moderate intensity for at least 150 minutes a week.1,2 The program was taught in 16 one-to-one lessons followed by individual and group sessions. The standard lifestyle intervention included similar information to the intensive program, but this was given as a written brochure and advice at the annual visit. Patients taking metformin were given one 850 g tablet plus one placebo per day for the first month and two metformin tablets daily thereafter. Main outcome measures: Progression from impaired glucose tolerance (IGT) to diabetes on the basis of six-monthly fasting plasma glucose measurements and an annual 75 g oral GTT. If a result met the 1997 American Diabetes Association (ADA) definition of diabetes,3 the test was repeated within six weeks. If the repeat result also met the ADA definition, the primary endpoint was reached. Otherwise, the patient continued in the assigned group. Main results: The trial was stopped one year early after an average follow-up of 2.8 years. Compared with the control group, the rate of type 2 diabetes was reduced by 58% (95% CI, 48%–66%) in the lifestyle group and by 31% (95% CI, 17%–43%) in the metformin group. The three-year cumulative incidence was 14.4% in the lifestyle group, 21.7% in the metformin group and 28.9% in the control group. The general pattern of the results did not vary by age, sex or race. At the final visit, 38% of the lifestyle group had reduced weight by 7% or more, average fat intake had declined by 6.6% from a baseline of 34.1% of total energy, and 58% were achieving the activity goal. More than 70% of patients took at least 80% of their medication. Hospitalisation and death rates were not different among the three groups. Conclusion: Both lifestyle modification and metformin reduce progression rates from impaired glucose tolerance to diabetes but lifestyle changes were more effective than metformin. The number needed to treat to prevent one case of diabetes in three years is 6.9 for lifestyle and 13.9 for metformin. CommentaryRationale for the trialThe prevalence of type 2 diabetes and its precursor stages is increasing. In 1999, the prevalence of diabetes was 7.4% and of impaired glucose tolerance (IGT) and abnormal fasting blood glucose (FBG) level was 16.4% in Australians aged 25 years and older.4 People with IGT have an increased risk of macrovascular disease, but not of microvascular disease. IGT is associated with obesity, sedentary lifestyle and increasing age, and is more common in some racial and ethnic groups. The only well conducted previous study of lifestyle modification was smaller and included only white people.5 Previous studies of pharmacological agents to reduce the conversion rate had been underpowered.1 Trial methodsThis was a well-conducted study with great attention to detail. For example, the requirement that an endpoint was diagnosed based on the results of two GTTs or two FBG tests was a potential source of bias and unblinding for participants and trial staff. This was addressed by retesting a sample of patients with normal results on these tests and not disclosing the result until progression to diabetes was confirmed.1 Patients were randomly assigned to groups only after completing an extensive run-in phase. An intention-to-treat analysis was done. Sample size for the trial was based on having a 90% power to detect a 33% reduction in the expected incidence of diabetes (6.5% per year). Greater methodological detail is available elsewhere.1,2 Although the focus was on progression to diabetes, reversion to normoglycaemia was also reported. At one year, more than 20% of the control group and 40% of the lifestyle group had normal values for both fasting and post-load glucose levels, and this declined to about 20% and 30%, respectively, at three years' follow-up. This highlights the need for a control group when evaluating interventions. Without this, most of the reversion in the intervention group might have been attributed to the intervention. Instead, it is clear that much of the reversion is related to "regression to the mean".6 That is, when a group defined using a cut-off point in a measure with substantial intra-individual variability is retested, the average value on the second test will be closer to the total population mean.6 New informationThis study is the first to test lifestyle against pharmacological prevention for type 2 diabetes and also the first to include groups that are often under-represented — the elderly, women and non-white people. The results confirm the findings of the previous lifestyle trial5 and extend their generalisability. Whether the interventions actually prevent diabetes, or simply delay its onset, or what happens if the interventions stop, cannot be answered by either study. The variability of glucose levels has been previously described. However, the size of this trial means that the magnitude of the reversion to normal is probably a good estimate of what would happen in the clinical setting in patients who were retested. The size of the variability also has implications for interpreting the results of national surveys such as AusDiab,4 as it means that the proportion of people with abnormal glycaemia found on a single test overestimates the proportion who would have had the abnormality confirmed on a later test. Implications for clinical practiceThis study shows that 5–6 kg weight loss combined with dietary modification to reduce fat intake to less than 30% of energy and increasing activity for 150 minutes per week will halve the conversion rate to diabetes in people with IGT. Because the mean baseline body mass index (BMI) was 34.0 kg/m2, losing 5–6 kg reduced this to about 31.5 kg/m2, which is still in the obese range. Patients should not be given the false impression that they must achieve a body weight in the healthy range (BMI of 18.5–24.99 kg/m2) before any benefits occur. As Native Americans and Pacific Islanders were included, it is reasonable to conclude that the results of this study would apply to Indigenous Australians, who have high levels of diabetes and cardiovascular mortality.7 At present, it is not possible to separate the effects of dietary and activity change on the outcomes, so both need to be recommended together. The intervention for the control group was similar to what a general practitioner might do during a consultation. A lot of support was given to help the lifestyle group patients achieve their lifestyle changes,2 which means that this is not a cheap intervention. The challenge for clinical practice is to provide this support either directly or by referral to community groups and to advocate for environmental changes that support beneficial lifestyle changes.

Dorothy EM Mackerras BSc, MPH, PhD GradDipNutrition

Appropriate statistical methods for analysing trial data are critical for the correct interpretation of the results. Item 12 of the CONSORT statement (Box 1) relates to the statistical methods used in the reporting of trials, together with scientific and statistical principles concerning analyses of subgroups, endpoints and appropriate statistical tests. These issues need to be carefully considered before beginning a study and should be outlined in a standard trial protocol, which may be supplemented by a more extensive statistical analysis plan.1 1: CONSORT checklist of items to report when reporting a randomised trial1 Section and topic Item no. Descriptor Statistical methods 12 Statistical methods used to compare groups for primary outcome(s); methods for additional analyses, such as subgroup analyses and adjusted analyses. Primary outcomesBoth primary and secondary endpoints should be clearly described in the objectives sections of the trial protocol.2 Statistical considerations appropriate to the design of the trial, including sample-size calculations, timelines for any interim analyses and a sketch of a proposed statistical plan for analysing these endpoints, should be detailed in the statistical section of the protocol and reported in subsequent publications.3 The analysis principle for the primary outcome must be that of intention-to-treat, where the data are analysed according to the treatment group to which they were randomised.4 Statistical analysis planKey components of the statistical analysis plan for the primary endpoint or endpoints include: Specifying how the outcome will be measured. Common measures are: Binary (whether or not an event has occurred) — for example, whether or not the subject has experienced a complete or partial response from cancer treatment at 12 months. Typical measures of the event are proportions (risk), rates or odds, and measures of treatment effect include odds ratios and differences in the proportions (or rates) between the intervention and control groups. Count (the frequency of an event in a set time period) — for example, the number of episodes of epilepsy experienced by patients in a 30-day period. A typical unit of measurement would be the rate (count per unit time), and measures of treatment effect include incidence density ratios (similar to odds ratios) or differences between the rates in the groups being compared. Time to event (how long it takes to observe the outcome of interest) — for example, the survival time of patients with advanced breast cancer. Endpoints of this type usually contain censored data (ie, the event of interest has not been observed by the end of the follow-up period), and analyses would involve comparing "averaged" relative risks or hazard/risk ratios (pooled across the time period of the study) between the groups. Measurement on a continuous scale. Examples include blood pressure and temperature measurements, and analyses involve comparing the difference between the means of the intervention and control groups. Other measurements include ordinal scales (eg, quality-of-life ratings, 5-point trauma scales) and non-ordered scales (eg, patient preferences between oral, intravenous or combination treatment delivery). Outcomes measured on these scales require specialised statistical methods. Any transformations on the data likely to be required before analysis. This includes possible groupings or classifications of data (eg, into good, acceptable and poor quality of life), as well as mathematical transformations (logarithms, square root, etc) needed to "normalise" the outcome variables. Typically, these transformations are used if the distribution of the outcome exhibits skewdness, and where, after transformation, this distribution is symmetrical and thus satisfies the assumptions of the statistical method being used to make comparisons.5 If statistical or graphical methods will be used to examine the distribution of the outcome, such as boxplots, histograms and scatterplots,6 these should be detailed. Appropriate statistical tests which will be used to analyse the data. While the underlying assumptions of common statistical tests vary, underpinning all these tests is the assumption that either the outcome (or some transformation of the outcome) or other calculated measures (such as correlation coefficients, hazard or odds ratios) will be "normally" distributed. The normal distribution underlies most statistical inference for most continuous outcomes (and is the basis of χ2, F and t-tests, as well as comparison of odds, hazard and incidence density ratios). If the assumptions of proposed statistical tests do not apply (eg, the data are known to be bimodal), then alternative statistical approaches (eg, classifying the outcome into categories) for analysing such outcomes should be described. How missing data will be accounted for in the analyses (both scientifically and statistically). For example, missing data are sometimes omitted, assigned the baseline value or the group average, or imputed using statistical theory.7 Whether statistical inference be will drawn using one-tailed or two-tailed tests (with appropriate justification) and if any statistical adjustments for multiple comparisons will be performed. In reporting the results of randomised trials, an unadjusted analysis for the primary outcome will provide a consistent, unbiased estimate of underlying treatment differences; this is guaranteed by the randomisation process. This analysis should usually be the primary comparison. However, if the randomisation was stratified, a primary analysis stratified by the stratification factors may be equally appropriate. Subsidiary analyses, which adjust for stratification factors, other potential confounders, or both, can further define the effect of treatment and may provide more efficient statistical comparisons. Parametric tests are based on specific distributional assumptions such as the normal distribution.8 Common misconceptions in analysing clinical data are that a non-parametric analysis (eg, Wilcoxon rank-sum test) is appropriate if the sample size is small (< 30), the data appear skewed (ie, may not be normally distributed) or that the medians are being compared. Whether the distribution of the data departs significantly from the normal distribution may be formally tested; if no departure from normality is indicated, comparisons based on the normal distribution are usually still preferable. Tests based on the assumption of normally distributed data can also be statistically valid for small sample sizes (as low as three per arm). Of course, if there is clear evidence that the data are not normally distributed, the appropriate statistical tests (eg, "exact" tests or non-parametric tests) or appropriate data transformations are required. Finally, even non-parametric tests require some assumptions with respect to the underlying populations from which the samples are drawn.8 If there is a choice of statistical method (ie, assumptions of a parametric test are satisfied), non-parametric methods are generally not as powerful (ie, do not have the same ability to detect a significant difference if it actually exists) as their parametric counterparts. A checklist for a statistical analysis plan is provided in Box 2. 2: Checklist for a statistical analysis plan for clinical trials Provide a detailed description of the primary and secondary endpoints and how they are to be measured. Provide details of the statistical methods and tests that will be used to analyse the endpoints. The analysis of the primary outcome must follow the principle of intention-to-treat. Describe the strategy to be used (eg, alternative statistical procedures) if the distributional or test assumptions are not satisfied. Detail whether comparisons will be one-tailed or two-tailed (with appropriate justification if necessary) and specify the level of significance to be used. Identify whether any adjustment to the significance level or the final P values will be made to account for any planned or unplanned multiple testing or subgroup analyses. Specify potential adjusted analyses with a statement of which covariates or factors will be included. Identify any planned subgroup or subset analysis along with justification for the relevance of this analysis (eg, biological rationale) before commencement of the trial. Specify planned exploratory analyses, justifying their importance. Support claimed differential subgroup effects with biological rationale and supporting evidence from within and outside the study. Provide statistical evidence of interaction between the overall treatment effect and that observed in the subgroup(s) of interest. Remember that prespecified subgroups will have more interpretive value than those defined on an ad-hoc basis or as a result of multiple comparisons. Changing the primary outcome during the conduct of the studyCircumstances can arise where, after a trial commences, the primary outcome is deemed to be suboptimal. This most commonly occurs when the observed rate of the primary outcome is substantially lower than anticipated, reducing the ability (power) of the study to evaluate the effects of treatment on this outcome. This could be the result of a recent change in non-trial background therapy or to recruitment of a more healthy subset of the patients of interest. In these instances, it is possible to modify the primary outcome, provided the reason for so doing is not based on knowledge of interim results of the effect of treatment in the study. Thus, if study data indicate that the rate of myocardial infarction (the primary outcome) is much lower in the intervention or control arm than originally anticipated, it would be highly inappropriate to modify the primary outcome to, for example, include stroke, as this choice is potentially influenced by a knowledge of interim results of the effects of treatment in the study. However, using the overall event rate for myocardial infarction in the whole study cohort (blinded — not differentiated by treatment) could provide justification for endpoint modification in a valid way. Any change in primary outcome during the study requires careful thought, planning and documentation. Secondary outcomesAnalysis of the secondary outcomes needs to be described in the same way as that for the primary outcome, with sufficient documentation in the analysis plan as to how they will be analysed. Where possible, further exploratory analyses should be identified before the completion of the study, with a clear scientific rationale for the reason and value of such analyses. Subgroup analysisIt is essential that potential subgroup analyses are specified before the commencement of a study to guard against data "dredging" or "trawling". Applying many different statistical tests to the same data (eg, on subgroups or different outcomes) has the effect of greatly increasing the chance that at least one of these comparisons will be declared statistically significant even if there is no real difference. This practice is often termed data dredging.9 However, simply specifying a subgroup analysis in advance does not necessarily add scientific legitimacy to the interpretation. A number of strategies exist to ensure the credibility of subgroup analyses, and a checklist proposed by Simes (personal communication) suggests that the following criteria should be satisfied. That there is a biological rationale for considering the subgroup separately from the rest of the patients in the study. Lack of strong biological or clinical evidence for why the treatment should have different effects in a particular subgroup would detract from support of a true underlying differential effect, even if a conventionally significant difference were found. That there is prior evidence or belief that a differential treatment effect in a subgroup is plausible. Lack of prior evidence suggests that differential treatment effects observed in subgroups become hypothesis-generating observations rather than firm conclusions. That there is statistical evidence (ie, a significant interaction) of a difference in the effect of treatment for the subgroup in question compared with the other patients. For example, if there is an apparent advantage of treatment in younger compared with older patients, then careful (clinical and statistical) examination of this difference is required before it can be confidently concluded that a true differential treatment benefit exists in the subgroup of younger patients. Studies are frequently underpowered to detect such interaction effects; nevertheless, lack of statistical evidence of such interaction should prohibit firmly concluding any differential treatment effect in the subgroup. That there is independent confirmation from other factors in the study of the possible differential treatment effect in the subgroup. For example, if, in a trial examining the effect of chemotherapy in gastric cancer, it is observed that women survive longer after an intervention than men, supporting evidence could be to observe that the response rate to treatment was higher and time to disease progression was also longer in women compared with men. Common pitfalls with subgroup analysis are focusing on the size of the P value and of the treatment effect in any subgroup, ignoring the play of chance. Other issues, such as the total number of subgroups examined, also play a major role in determining the credibility of any observed differential subgroup effect. Subgroups defined before initiating the study would be more credible in terms of true differences in effect on the study findings than those determined only at the time of analysis.

Val J Gebski MStat · Anthony C Keech FRACP, MSc(Epid)

To the Editor: We are writing to add our wholehearted support to the plea made by Carapetis et al1 for a simplified ethical approval process for multicentre studies. We are conducting two national case-controlled studies of cancer in Australia, funded by grants from the National Institutes of Health and the Department of Defense in the United States, as well as the National Health and Medical Research Council (NHMRC). Our ability to achieve full population coverage was a major competitive advantage in terms of securing international funding. However, to realise this objective, we have spent more than a year obtaining ethics approval from the myriad institutions controlling access to patients and the public. We have been required to make more than 60 separate ethics applications, lodging about 550 copies of the proposal (a total of 40 000 sheets) at a cost of more than $7000 for paper and printing alone. When labour is included the cost of the initial submissions escalates to $16 000 (excluding substantial investigator time). Other costs include the extraordinary requirement of one ethics committee in Victoria that an investigator from Queensland personally attend a 10-minute interview at which no substantive issues were raised. The ethical benefit of this investment must be questioned when the majority of changes required by committees have dealt with minor issues such as grammatical style that have little to do with patient protection. Inevitably, such directives are inconsistent across institutions. It is thus impossible to comply with all requests while maintaining a standard set of study documents. These problems are accentuated for the increasing number of Australian researchers relying on overseas funding. For example, regulatory authorities in the United States insist that all ethics committees reviewing US-funded projects involving humans must have US federal approval to do so. In our experience, few Australian hospital ethics committees have this approval. Therefore, in addition to fulfilling standard institutional ethics requirements, we have also had to help several committees go through the lengthy process of securing US accreditation simply to approve our study! For all the above reasons, we strongly believe that Australian researchers and patients would be best served by a single national ethics committee for large multicentre studies. This would also reduce the enormous burden currently placed on the individual committees. In the meantime, we thank Breen and Hacker2 for their reminder to institutional ethics committees that the NHMRC national statement "empowers ethics committees to minimise unnecessary duplication".

David C Whiteman · Penelope M Webb · David M Purdie · Adèle C Green

To the Editor: Both adult and paediatric hospital emergency departments (EDs) are subject to inappropriate use.1,2,3 Some families use the ED as a primary care provider,4,5 often claiming that they have no regular general practitioner.6 Such families may experience poorer overall health.7,8 We hypothesised that providing such families with information about GPs in their area and emphasising the benefits of having a GP responsible for their long term healthcare might: facilitate the establishment of ongoing relationships between patients and GPs; and encourage families to use GPs more as their primary source of care. We conducted a controlled trial (week-on, week-off randomisation) of families identified as having no regular GP who presented to the Royal Children's Hospital ED over four months. Information about the GPs interested in seeing children was located on a computer database. Medical staff were able to search for a GP whose surgery was close to the patient's street address. Families were provided with detailed information about the GP's practice (eg, opening times, languages spoken, etc). Parents were given a list of GPs and a map showing the locations of their surgeries, together with a letter of introduction; the families decided which GP they would attend. Families in the control group were just treated as usual. Families were then contacted after two months to see if they had visited a GP and whether regular contact had been established. Over the four months, 216 families were enrolled; 96 were allocated to the intervention group. Despite our active encouragement, the ED medical staff provided the intervention material to families in the intervention group on just 49% of occasions. We found that, two months after the initial ED visit, intervention-group families were no more likely to have established an ongoing relationship with a GP than control families (46 [38.3%] and 41 [42.7%], respectively; P = 0.5), irrespective of whether or not they received the intervention material. In summary, this single intervention was not sufficient to alter healthcare-seeking behaviour of families with no regular GP. It seems the motivation to obtain a GP lies with the family. Thus, it would seem necessary to design and deliver an intervention that addresses the beliefs of families about the roles of various facets of the healthcare system. With time and work pressures, ED medical staff may not be in the best position to provide such intervention.

Michael K Marks · Daniel Steinfort · Peter LJ Barnett

In reply: We agree with Johnson and Lassere about the value of longitudinal studies, especially clinical trials, in assessing healthcare benefits and costs. They are critical to informing clinical practice and health policy. If it were possible to conduct these studies across a wide variety of settings, representing the range of "real life" practice, then there would be little need for epidemiological modelling. However, this is not possible. Clinical trials (with or without cost components) will only ever be conducted over relatively short durations, on circumscribed populations and under tightly controlled conditions. A key, but often overlooked, issue is whether the results of studies are externally valid (generalisable). Indeed, the evidence base that dictates clinical practice and health policy should comprise data that are both internally and externally valid. We do not suggest that epidemiological modelling replace longitudinal studies (in fact, modelling depends critically on robust prospective data); rather, it complements these studies by providing a means to assess their external validity. We are also mindful of the limitations of epidemiological modelling, as outlined in our article,1 and acknowledge the importance of ensuring rigour in the methods. Our article dealt with generating the data needed for sound economic evaluation, by taking into account the long-term benefits, risks and costs of treatment strategies, and "real-life" health service conditions. This is distinct from the issue of whether "conditional listing" on the Pharmaceutical Benefits Scheme should be implemented for drugs that are yet to be proven cost-effective.

Danny Liew · John J McNeil · Anna Peeters · Stephen S Lim · Theo Vos

To the Editor: In a recent letter in the Journal,1 Rodger writes that breast screening is unlikely to affect overall mortality and notes that this "gives the lie to the conclusions of Olsen and Gøtzsche's overview, which are based only on overall mortality". English is not my first language, but according to my English–English dictionary "give the lie to" means either "to disprove" or "to accuse of lying", and a related adjective is "mendacious". In actual fact, however, in our Cochrane Review,2 we carefully analysed both breast cancer mortality and all-cancer mortality. We found breast cancer mortality to be an unreliable outcome that is biased in favour of screening. For deaths ascribed to any cancer, including breast cancer, we found a relative risk of 1.02 (95% CI, 0.95–1.10) for the two trials with medium-quality data,3-5 and a relative risk of 1.00 (95% CI, 0.91–1.10) for the only trial with poor-quality data that reported all-cancer mortality.6 If it were true that screening reduced breast-cancer mortality by 30%, as some Swedish researchers have claimed,7 then the expected relative risk for all-cancer mortality should not be greater than 0.95. These findings should raise concern rather than complacency. Another, recent indication that things are not what they purport to be is provided by the results of the large Two-County study. A Swedish overview of the randomised trials reported a 10% reduction (95% CI, 0.73–1.11; absolute reduction, 5.0/1000 to 4.5/1000) in breast-cancer mortality for one of the two counties,8 whereas the authors of the Two County study reported a 24% reduction (95% CI, 0.62–0.93; absolute reduction, 5.7/1000 to 4.3/1000),9 with the same type of statistics, within the same age group of women (40–74 years), and after a similar follow-up (1.2 v 1.3 million women-years). The conclusion in our Cochrane Review is: "The currently available reliable evidence does not show a survival benefit of mass screening for breast cancer (and the evidence is inconclusive for breast cancer mortality)." I would not have expected Rodger, as an editor of the Cochrane Breast Cancer Group that approved and published our Cochrane Review, to talk about "giving the lie" to our results.

Peter C Gøtzsche

In reply: In his letter, Gøtzsche is clearly under the misapprehension that, in using the figure of speech "gives the lie to", I am accusing him of lying. Nothing could be further from the truth. As he quotes, I applied that phrase to his conclusions. In my Australian Oxford Dictionary1 to "give the lie to" can mean — and it is this meaning that I was applying — "serve to show the falsity of a supposition". I was replying to Gough's response2 to my editorial3 on breast screening. He clearly showed that breast screening was unlikely to reduce overall mortality. I agree. I believe, therefore, that Olsen and Gøtzsche are wrong in supposing that analysis on the basis of breast cancer mortality is inappropriate, and that only overall mortality should be considered. Gough argues for this better than I can. Being an editor of the Cochrane Breast Cancer Group does not require me to accept every supposition or conclusion in a Cochrane review. The whole point in publishing a scientific paper — as part of the Cochrane Library or in a peer-reviewed journal — is to open it, after appropriate review, to public scrutiny, scientific comment and even criticism. Their Cochrane review4 has succeeded in achieving all of this.5 Lastly, I reiterate my comments in the editorial3 that mammographic breast screening detects breast cancers that are "smaller, less likely to involve nodes and, if node positive, more likely to involve fewer nodes." In other words, if the TNM (tumour–node–metastasis) system means anything, there is a better prognosis with such breast cancers than with those detected clinically. Perhaps Gøtzsche needs to add a clinical oncology perspective to his undoubted expertise in the finer details of trial methodology analysis.

Alan Rodger

Comment: The expression "give the lie to" has shifted its emphasis over the centuries, from the very direct "accuse (someone) of lying" to the much more abstract "show or imply (something) to be false". Some modern dictionaries, such as the Macquarie Dictionary (1997) and Merriam-Webster (2000), still give both meanings; others, such as the New Oxford Dictionary (1998), only the second. Large British and American databases, such as the British National Corpus, show that the phrase is usually used abstractly: one "gives the lie to" propaganda/a claim/an argument/a theory — whether in the context of academic discussion or political debate. The validity of an intellectual position is questioned, not the integrity of the person(s) associated with it. Yet, the simplicity of the phrase "give the lie to" probably gives the lie to the complexity of the challenge it expresses.

Pam Peters

To the Editor: The articles by Reid1 and Paterson,2 former bureaucratic leaders of the New South Wales and Victorian health systems, respectively, on the process for developing the 2003–2008 Australian Health Care Agreements (ACHAs) are disappointing. They offer few original conceptual insights or clear proposals. Reid's dream is that the 2003–2008 ACHAs will see "a new expression of national health policy on which funding decisions can be based". However, he presents only old ideas, such as "ACHAs will need to extend beyond public hospital issues to incorporate primary care", and, on the perennial cost-shifting between the two levels of government, "clearer lines of financial management of care and appropriate incentives are needed". Reid laments that the focus of all previous agreements has been "narrowly limited to one aspect of healthcare . . . the maintenance of universally accessible public hospital care free of charge". Paterson does propose something radical, and the core of his proposals is that "the payer must stand behind the patient and not between the patient and the provider". The way to Paterson's "outcome-enabled health system" is to "relieve the constraints that bind inputs and distort the 'production' system". Does he mean we need more doctors and nurses, or does he mean substitutes should perform some of their current activities? Patterson proposes more investment in "information and communications technology" to facilitate a gradual move to "patient-based funding". Does this mean capitation, medical savings accounts, or is he proposing non-insurable copayments? Whatever it means, there will be "no outcome-driven healthcare until the system recognises the whole patient", and this will only be achieved with "electronic patient record systems in routine and ubiquitous daily use by providers". Given their experience as senior health system administrators, it is a pity neither Reid nor Paterson provides any explicit suggestions that recognise the key factor that will determine the outcome of the ACHAs. This is the policy gridlock that any federal system almost inevitably imposes. A recent issue of the Journal of Health Politics, Policy and Law was devoted to health politics and policy in a federal system. The editor, Petersen, concludes with a view relevant to Australia: "You can love it, you can hate it, but . . . federalism thwarts uniformity and universalism, frustrates responsiveness and policy analysis, limits large scale innovation while churning more localized mills of idea generation and promotion, and offers a permanent employment plan for health policy researchers".3 Parts of Australian health arrangements certainly need an overhaul. An example is general practice. This sector, differently organised and financed, could deliver much more to the community, the rest of the healthcare system, the Federal Government and to general practitioners themselves. Change in this sector would not depend on improbable cooperation between levels of government, and would be more manageable than the multifarious whole-of-system reforms about which Reid and Paterson speculate.

William Coote

To the Editor: In their article describing an outbreak of Bordetella pertussis infection, Spearing and colleagues report an adult contact who was infected with B. pertussis and was treated with roxithromycin.1 In our experience, this is common practice in Australia, where roxithromycin is a frequently used macrolide antibiotic. We are currently preparing a systematic review (registered with the Cochrane acute infections group) of the effectiveness of antibiotic therapy for treating pertussis. We have found no studies of the effectiveness of roxithromycin for either treatment or contact prophylaxis for pertussis infection. B. pertussis is sensitive in vitro to roxithromycin but 2–4-fold less so than to erythromycin. While relying on the class effect of macrolides in eradicating B. pertussis and using roxithromycin in preference to erythromycin because of its lower side-effect profile may seem logical, there is no evidence to support this practice. In contrast, there is at least one study showing the efficacy of clarithromycin as an alternative to erythromycin for the treatment of pertussis.2

R John Massie · Sultan Altunaji · Renata Kukurozovic · Nigel Curtis

In reply: As we mentioned in our article, erythromycin is the drug of choice for treatment and prophylaxis of pertussis in people of all ages.1 Several statements can be made about the use of macrolides in this condition.2 Firstly, erythromycin has been shown to decrease the duration of illness when given early in pertussis infection and to eliminate Bordetella pertussis from the nasopharynx. Secondly, erythromycin therapy for index cases has been shown to reduce the rate of secondary cases of pertussis in households in uncontrolled studies.3 However, in a recent randomised placebo-controlled study, while erythromycin reduced the incidence of culture-positive pertussis in household contacts there was no reduction in respiratory symptoms.4 Thirdly, clarithromycin and azithromycin have been shown to be at least as effective as erythromycin in treating pertussis in two small comparative studies.5 As Massie et al point out, there are no clinical studies of the use of roxithromycin in this condition, and laboratory in-vitro sensitivity studies suggest roxithromycin may be inferior to erythromycin. Roxithromycin is the most widely used macrolide in Australia, but it requires a leap of faith and extrapolation to prescribe this drug for prophylaxis or treatment of pertussis. In the one case in our series where roxithromycin was prescribed, this was not our decision. We would have recommended erythromycin on the basis of the available clinical evidence. Vaccination is preferable to antibiotic prophylaxis for long-term control of pertussis.

Joseph G McCormack · Natalie M Spearing · Robert L Horvath

To the Editor: Van Der Weyden has asked a provocative question about the relevance of what he calls "medicine's homage to health".1 In so doing, he pays his own homage to a world where boundaries are sharp and healing becomes reduced to a matter of applying "bioscience to matters of mind and body". While I daresay many editors of biomedical journals would share his view, he is only highlighting an age-old tension. Indeed, Crookshank wrote in 1926 about the Ancient Greek schools of Cos and Cnidus, and of their debate about doctrines of the natural/descriptive and the conventional/academic approaches to medical knowledge.2 The Coans promoted the importance of the influence of the individual and society on the presentation of illness, and managed illness holistically with regimens oriented towards the needs of the individual, while the Cnidans oriented their practice around the distinctions between diseases, treating specific diseases with specific remedies.3 These differing approaches to illness and disease highlight the conflict between cybernetic and linear thought which has underpinned medical history ever since. It is rarely understood that the linear doctrine of biomedicine has only become dominant in the last century or so. Medicine's isolation from contemporary scientific thought explains our long delay in confronting the challenges of systems thinking — challenges that the basic and applied sciences took on in the early years of the 20th century.4 Our contemporary error is in assuming that the accumulation of data that passes for modern medical knowledge is sufficient to deal with the tasks of medicine. The disquiet expressed by Van Der Weyden is only a symptom of the continuing inability of a mechanistic view of medicine to deal with caring for patients in the real world.

Grant M Russell

In reply: Russell implies that my recent column on the boundaries of medicine1 conveys the premise that medicine is a defined and discrete discipline underpinned by biomedical science. So it did, but the contention is not mine, it is that of Seldin.2 However, no one would deny that biomedical knowledge is the best developed and most powerful component of modern medicine; nor would they deny that there are other intrinsic components, such as the art of caring.3 My argument is that the boundaries between medicine and health have become blurred with modernity's overwhelming homage to health.4 Furthermore, the very nature of health is difficult to define, shaped, as it is, by variable psychological, socioeconomic and cultural factors. If, in fact, health is the World Health Organization's utopian "the complete [my emphasis] physical, psychological and social well being", then most of us are unhealthy.5 My purpose was to question the boundaries of medicine and health. In particular, to question where the responsibility for attaining the modern Shangri-La of health rests — with the individual, society or medicine?

Martin B Van Der Weyden

An elderly patient with diabetes presented with oesophageal obstruction after taking a regular dose of metformin. A lateral neck radiograph confirmed the presence of an obstruction in the upper oesophagus. The patient underwent rigid oesophagoscopy, at which time the tablet, complete with packaging, was removed (see Box). The patient went on to make a full recovery.

Peter A Monksfield MRCS · Olivia JH Whiteside MRCS · Stuart CA Winter MRCS · Nicholas B Steventon FRCS · Graham J Cox BDS FRCS

Physical signs of child abuse. Christopher J Hobbs and Jayne M Wynne. London: W B Saunders, 2001 ($271.15, 401 pp). ISBN 0 70202582 8. This is the second edition in five years of this rather expensive atlas by two reputable British paediatricians who specialise in the investigation and management of child maltreatment. It is a distressing catalogue of the injuries deliberately inflicted by caregivers on children and young people. The book covers the full spectrum of child abuse as well as providing over 300 pages of photographs (with up to five photographs per page). It provides good guidance on conducting physical examinations, colposcopy and photography. The authors emphasise that the diagnosis and management of abuse requires an interdisciplinary approach, where different professionals and systems bring together different pieces of the jigsaw. There are sections and subsections that cover each type of abuse and its differential diagnosis, and each section starts with a brief overview of the salient points. The contents of many of these sections are in note form (as if they have been made up from teaching slides which were orally expanded). This can be occasionally confusing — for example, under a section on retinal haemorrhages is a dot point “vaginal birth (30%)”. It is unclear if this refers to the proportion of vaginal births having this abnormality, or whether it refers to the fact that only 30% of retinal haemorrhages occurred in infants born vaginally. References for some of these assertions would also have been helpful. Nevertheless, the format is clear and user-friendly. I do have a number of criticisms. The book is somewhat unevenly balanced with head and abdominal injuries sharing a chapter, while superficial integumental injuries are divided among four chapters and burns among three. There are occasional typographic errors, and some references are misspelled. Some of the advice given is not consistent with best evidence for practice in teaching hospitals — for example, CT scans are a more sensitive investigation for head injury than plain skull x-rays, and the role of radioisotopic bone scans as the initial approach to screening for skeletal injuries is underemphasised. The authors note the value of digital photography for exchanging images electronically. In Australia, this advice is problematic, as digital images have been ruled out for evidentiary purposes owing to the ease with which they can be manipulated. Despite these reservations, and considering the fact that the authors are going to produce a complementary slide set (presumably on CD-ROM), I believe that access to this reference book would be helpful to many. It is particularly suitable for those training as general and community paediatricians and for those working in hospitals with a large paediatric patient load. Graham V VimpaniPaediatrician Child, Adolescent and Family Health Services Wallsend, NSW

Graham V Vimpani

Practical guide to geriatric medicine. Ranjit N Ratnaike (editor). Sydney: McGraw-Hill, 2002 ($109.95, xxv + 958 pp). ISBN 074710338. The elderly consume an increasing amount of the health care dollar, hospitals are under pressure to discharge patients early and, increasingly, care is provided in the community. For these reasons Practical guide to geriatric medicine is a useful addition to the reference library of any general practitioner, general physician or geriatrician. The book comprehensively covers a wide range of topics relevant to the clinical care of the elderly. It has a lot of practical tips on the management of common problems such as psychiatric illness, neurological disorders and dementia, and includes lots of relevant validated screening tools. Whole-body systems are well covered, with an emphasis on screening and prevention. The chapter authors are experts from various international backgrounds and almost half are Australian. This balance is a bonus, as it ensures that the information is relevant to clinical practice in Australia. For example, there is a chapter on the functional assessment of the over-75-year-old as part of the enhanced primary care package. For the academically minded reader it would have been helpful to cross-reference the text with the bibliography and further reading references that appear at the end of each chapter. This book is well written and easy to read, with a wealth of useful information. The presentation is excellent, with paragraph headings and useful tables, as well as figures highlighting the important points. It is excellent value for money and highly recommended for the busy clinician. George SzonyiGeriatricianBalmain Hospital, NSW Order this book

George Szonyi

Football fan fatalities When Argentina beat England in a penalty shoot out in the 1/8th finals of the 1998 World Cup, the English fans were heartsick — some of them literally! A recent survey of the English Department of Health’s health episodes statistics database examined hospital admissions on the day of and the two days after each of England’s four 1998 World Cup matches. The month before the matches as well as the same periods in 1997 and 1999 were used for comparison. The Cup matches were not associated with any change in admissions for stroke, road traffic injuries or deliberate self-harm, and there was no significant difference in the number of acute myocardial infarctions (AMIs) after England’s first-round games (two wins and a loss). The period following the fateful game with Argentina, however, was associated with a 25% increase in admissions for AMI, suggesting that intense emotional response to the suspenseful game may have taken its toll on some fans. BMJ 2002; 325:1439-1442 Breast risk clarified The finding of atypical lobular hyperplasia (ALH) on breast biopsy has long been identified as a risk indicator for breast cancer, but it was thought that both breasts were equally at risk in women with the condition. Not so, say British researchers whose study shows that the breast in which ALH has been diagnosed is at much higher risk of developing invasive cancer than the other breast. Of 252 women who had breast biopsies showing ALH between 1950 and 1985, 50 (20%) developed invasive breast cancer: 34 in the breast with ALH, 12 in the other breast, two bilateral, and in two the side was not known. Thus, the breast with ALH was three times more likely than the other breast to develop cancer. The finding is of particular importance to women who are considering preventive breast surgery. Lancet 2002; 361: 125-129 Always with us? Debate continues about whether autism is actually on the increase or whether the disorder is simply becoming more likely to be recognised. Researchers in Atlanta, USA, used the records of the Centers for Disease Control and Prevention’s Metropolitan Atlanta Developmental Disabilities Surveillance Program to identify possible cases of autism in children aged 3–10 years in the city. Experts then reviewed the children’s medical and educational records and used DSM-IV criteria to determine which children displayed behaviours consistent with autistic disorder, pervasive developmental disorder — not otherwise specified, or Asperger disorder. They identified 987 children, giving a prevalence for autism of 3.4/1000 children, with a male to female ratio of 4:1. The prevalence rose between the ages of three and five years, fell after age eight, and was similar in all racial groups. It was much higher than that reported in studies conducted 10–20 years ago, but was consistent with more recent studies in the United States and the United Kingdom. JAMA 2003; 289: 49-55 Weight of the world In our part of the world, weight loss is on almost everyone’s agenda, from individuals to drug companies and public policy planners. Researchers from the Netherlands, however, provide further evidence for the growing international call for urgent measures to prevent obesity. In an analysis of data from 3457 participants in the Framingham Heart Study who were aged 30–49 in 1948, they found an association between overweight or obesity at age 40 and decreased life expectancy, regardless of weight in later years. Non-smokers lost an average of just over three years if they were overweight (body mass index [BMI] 25–29.9 kg/m2), and 7.1 years (women) and 5.8 years (men) if they were obese (BMI >30 kg/m2). Obese smokers lived 13–14 years less than their non-smoking, normal-weight peers. Although the applicability of this 50-year-old cohort is uncertain in today’s populations, the results suggest that identifying and treating obesity in middle-age may be “missing the boat” and that prevention should be a public health priority. Ann Intern Med 2003; 138: 24-32 Victims of fashion Australian commentators have complained about the current trend for wearing “hipster” pants, with much of the distress centred around obligatory glimpses of unsightly back bulges, belly buttons and even pubic hair. One Canadian physician, however, has reported the phenomenon of “hiphuggers’ tingly thighs”. He describes three young, mildly obese women who presented with tingling or burning of the lateral aspect of the thigh due to compression of the lateral femoral cutaneous nerve (meralgia paraesthetica). Apparently tight hipsters can cause compression of this nerve as it passes under the inguinal ligament. The cure? Avoid the offending garments and wear loose-fitting dresses! CMAJ 2003; 168: 16